Critical epidemiology of Jaime Breilh

A dialectical response to cartesian reductionism and its connection to the critique of political economy

Abstract

The work Critical Epidemiology and the Health of Peoples (2024), by Jaime Breilh, a central figure in Latin American collective health, emerges in a context of a “multiple pandemic-syndemic crisis” of the global hegemonic capitalist system. Organized into three chapters, the book stands out as a tool for forging an “ethical and courageous science in a sick civilization.” At the core of this endeavor lies the dispute over the category of the “social determination of health,” derived from the analysis of the social reproduction process but often co-opted and reduced to a functionalist synonym of the “social determinants of health” (SDH). This review analyzes the entire work, arguing that Breilh’s contribution goes beyond a critique of Cartesian reductionism. The author presents a robust and structured methodology grounded in Marxist dialectics, which re-establishes a fundamental connection between collective health and the critique of political economy through the categories of “social reproduction” and “subsumption,” providing the theoretical and methodological tools necessary for the praxis of an emancipatory science.

The book’s argumentative construction unfolds in movements that establish the “why” and the “how” of the paradigmatic rupture. After historically recovering the emergence and development of critical Latin American epidemiology within the field of Collective Health in Chapter 1, Chapter 2 begins with the deconstruction of the “Cartesian bubble”, the linear empiricist thought that dominates health science. Breilh criticizes Cartesian research for its “superficial” character and its focus on “isolated factors,” which result in a “functionalist pragmatism” serving the maintenance of power. He extends this critique to the epidemiology of the “social determinants of health,” notably Marmot’s approach. He classifies this model as “institutional reformism” and a “neo-Cartesian scheme of causality” which, although it postulates the “causes of causes,” remains within the linear logic of factors and therefore fails to transcend the analysis of the “tip of the iceberg.” By reducing the complexity of reality to an “incomplete arrangement of evidence and factual relations,” the social determinants of health model becomes a fetishism that dissolves the dialectical interrelation among the different levels of social reality.

In direct opposition to the functionalist epidemiological model, Chapter 3, “New Method and Intercultural Awakening”, presents the “how,” grounding the alternative proposal in the critique of political economy. Breilh positions the central Marxist category of “social reproduction” as the foundation of his methodology, defining it as the “movement of production and distribution of life,” inseparable from the “logic of capital accumulation” and “social power relations.” Within this framework, health (or illness) becomes an embodiment of the contradictions generated in this process. The connection with Marx is deepened through reference to Bolívar Echeverría and to the contradiction between use value and exchange value as the core of the social substance to be transformed. To explain how this determination operates, Breilh revisits another fundamental Marxist category: subsumption. Rather than the positivist “linear conjunction,” he proposes the “subsumption of the biological-natural within the social” as the dialectical mechanism that explains how the social encompasses and transforms the biological. The author demonstrates theoretical sophistication by historicizing the concept, from Marx’s formal and real subsumption of labor to contemporary forms—sociobiological, of consumption, and finally, the “fifth subsumption” (cybernetic).

Based on these foundations, Breilh structures his “metacritical methodology.” The analysis of determination is organized into three dialectical dimensions: General (G), Particular (P), and Individual (I). The movement G → P → I (subsumption) is counterbalanced by “relative autonomy” (I → P → G). To operationalize this analysis, he proposes the “Matrix of Critical Processes,” which evaluates the “4 S’s” (Sustainability, Sovereignty, Solidarity, Security) and dialectically integrates qualitative evidence (Metanarrative) and quantitative evidence (Metainference). Metainference, crucially, redefines the use of statistics and the very concept of the “variable,” freeing it from its Cartesian prison (as the measure of an isolated factor) and re-signifying it as a “measurable dimension of a concatenated process.” The Metanarrative, in turn, transcends inductive cultural relativism by contextualizing voices within the structure of power. Thus, the methodology is conceived as praxis, articulated with Matus’s “triangle of action” and the need for an intercultural science, serving as a tool for the “awakening of the people” and the struggle of the working class.

It can therefore be concluded that Breilh’s work represents a fundamental contribution to critical thought in health. It not only denounces the erasure of social determination and its reduction to positivist “determinants,” but also offers a robust and detailed methodological alternative. By grounding his critical epidemiology in the Marxist categories of social reproduction and subsumption, Breilh provides a powerful tool for praxis in collective health, enabling a materialist, historical, and dialectical analysis that reconnects human illness to the contradictions of capital accumulation. Finally, we consider that the author establishes a potent paradigmatic landmark, indicating the direction that epidemiology and the health sciences in general must take in their endeavor toward the radical transformation of society.