During the Covid crisis, we were summoned to “believe in science”. Yet medicine is not a science but an art of care, and health is not the absence of disease but a capacity. Here I untangle this double confusion, I show who has an interest in maintaining it, and I draw from it a concept, the care of the milieu, with concrete gestures, from one’s own body to the collective body.
Believing in science is a misunderstanding
During the Covid crisis, and still today, I hear that we should “believe in science”, trust it as something objective and immutable, and that any questioning of official data would amount to conspiracy thinking. The people who hold this discourse are often well-intentioned; they think they are defending critical thinking against sectarian drifts that do exist. But asking people to believe in science is to misunderstand its nature.
Gaston Bachelard, in The Formation of the Scientific Mind (1938), describes the scientific approach as a permanent break with our certainties. “Opinion thinks badly; it does not think: it translates needs into knowledge.” Nothing can be founded on it, it must first be destroyed, for “we know against previous knowledge”. For a scientific mind, he writes, all knowledge is an answer to a question, and without a question there is no scientific knowledge. Science is therefore not a stock of truths to adhere to but a process of testing, made of competing hypotheses, controversies, deep disagreements between scientists, and it is from this organised dispute that consensus, always provisional, is born. The theory of relativity seemed mad in 1905, since it made space, time and energy interdependent, when they had always been held to be distinct, and yet it is this counter-intuitive understanding that made possible the computers we use every day. Whoever asks for adherence without questioning is no longer speaking of science but of belief, and I have described in the article Truth and truthful religion the scientistic religion that took hold during this period, with its dogmas, its heretics and its excommunications.
An art at the crossroads of several sciences
Georges Canguilhem, philosopher and physician, defended in 1943 a medical thesis that became a major book, The Normal and the Pathological (1943, expanded edition 1966). From the introduction onwards, he explains why he came to medicine, which appeared to him “as a technique or art at the crossroads of several sciences rather than as a science in the strict sense”. A physician draws on biology, chemistry and physics, but the object of this art is not knowledge, it is the care of a singular person, and this care precedes knowledge: “It is first because men feel sick that there is a medicine.” Canguilhem refuses to confuse the plane of concrete life with that of abstract science. The disease of a living being, he writes, “does not lie in parts of the organism”; it is an experience lived by a whole being, within a whole life.
Other medical traditions show this in their own way. Chinese medicine was built over centuries of observation, of ways of living, of an education of attention to one’s own body. These are not scientific approaches in the Western sense but approaches of care, through which people take charge of their own health.
The assimilation of medicine to a belief, for its part, is nothing new. In Dom Juan (1665), Sganarelle, disguised as a doctor, protests: “What, Sir, are you impious in medicine too?”, and Dom Juan replies that medicine is “one of the great errors that exist among men”. Molière establishes the equivalence between religious faith and medical faith, since one can be “impious” towards either. Three and a half centuries later, we have not moved past it, except that the injunction to believe now comes from the institutions themselves.
Health is not the silence of the organs
In 1936, the surgeon René Leriche proposed a definition that remains famous: “Health is life lived in the silence of the organs.” Canguilhem discusses it at length, for Western medicine is still organised according to this conception. In it, health exists only negatively, as the absence of symptoms, and the body appears only when it hurts. Within this frame, health is known only through disease, only repair gets funded, and “prevention” still means averting a pathology, never cultivating a vigour.
Canguilhem proposes something else. “To be in good health is to be able to fall sick and recover; it is a biological luxury.” Health is not conformity to a statistical average, it is a capacity, which he calls normativity: what characterises health is the possibility of tolerating deviations from the habitual norm and of “instituting new norms in new situations”. A healthy organism is not an organism without deviation, it is an organism capable of inventing its own norms when its milieu changes. Restoring Hippocratic medicine, Canguilhem even recalls that “the organism develops a disease in order to cure itself”: fever, inflammation and fatigue are reactions with an intention of healing, which should first be accompanied rather than silenced.
Seeking the origins of health rather than those of disease
The medical sociologist Aaron Antonovsky (1923-1994) gave a name to the reversal this conception calls for. In Health, Stress and Coping (1979), he observes that medical research keeps asking why people fall ill, and he turns the question around: why do so many people remain healthy, when stressors are everywhere and life spares no one? For this inquiry he coined the word salutogenesis, the study of the origins of health, which he opposes to pathogenesis, the study of the origins of disease. His surveys, conducted notably among women who had survived the concentration camps, led him to an answer: health depends to a large extent on what he calls the sense of coherence, that is, on living in a world one understands, on which one has a hold, and which is meaningful to oneself. Health is thus also produced outside the medical field, in the conditions of life and in the bonds that give hold and meaning to existence. Prevention remains turned towards the disease to be averted; Antonovsky invites us to seek, and to cultivate, what produces health.
The expropriation of health
Ivan Illich opens Medical Nemesis. The Expropriation of Health (1975) with this sentence: “The medical establishment has become a major threat to health.” The medical colonisation of everyday life, he continues, alienates the means of care, and the professional monopoly on knowledge prevents its sharing. His demonstration, supported by hundreds of studies, rests on three levels of what he calls iatrogenesis, the production of harm by medicine itself: the diseases caused by treatments, the medicalisation of all of life, from birth to death, and, deepest of all, the destruction in people of the capacity to face suffering, disease and death by themselves. Illich also recalls that the great health gains of populations came from hygiene, food and housing far more than from medication. The expropriation he speaks of is literal: a good that belonged to everyone, the capacity to care for oneself, has been transferred to an institution that sells it back.
This institution is not economically neutral. Pharmaceutical companies and device manufacturers fund a large part of medical research and clinical studies, yet these industries profit from disease, not from health: healthier populations buy fewer treatments. Paul Feyerabend, in Against Method (1975), showed that scientific “facts” are always laden with interpretations, and he argued that research priorities should be debated by citizens rather than set by experts funded by industry, a position I have presented in Truth and truthful religion. During the Covid crisis, this mechanism became visible: products that could protect against severe forms were presented as protecting against transmission, which was false and known to be false, and it is on this confusion that the authorities based coercion. I analysed this period in What fear did to us, and the necessary nuance about the actual efficacy of these products in Presence and nuance of thought, so I will not return to it here. When medicine is presented as pure science, what should be debated is made indisputable, and any care that does not go through its products is disqualified in advance.
Healing eyes without selling glasses
William Horatio Bates (1860-1931) was no outsider. A 1885 graduate of the College of Physicians and Surgeons of Columbia University, an ophthalmologist in New York, a practitioner in several hospitals including Harlem Hospital, where he held free consultations for the poor, he published some thirty articles in recognised medical journals. Examining his patients in different situations and emotional states, he observed that the visual acuity of one and the same person varies through the day, with fatigue, stress and activity. From this he drew a method that treats the eye as a living organ whose health can be maintained, through movement, relaxation, central fixation, memory and imagination. From 1903, at the request of the superintendent of schools of Grand Forks, North Dakota, teachers applied his method of myopia prevention in the classrooms, for eight years. Bates then repeated it in five public schools of New York, published the results in the New York Medical Journal (1911, 1913), and gathered them in Perfect Sight Without Glasses (1920).
Aldous Huxley put it to the test. Having become nearly blind at sixteen following keratitis, he lived for almost thirty years with severely deficient vision despite very thick glasses, then discovered in 1939 the Bates method, taught by Margaret Corbett, and recovered within a few months the ability to read without glasses. In The Art of Seeing (1942), he drew from it a theory in which seeing is an act of the brain and the mind as much as of the eye, an act that stress and emotions degrade. He wonders why the eyes should be held to be the only part of the body incapable of re-education: for damaged legs, everything is done so that the person walks again without crutches, whereas for the eyes crutches are prescribed for life.
Clients who recover their sight buy fewer glasses, and the optical industry therefore had nothing to gain from the spread of this method. Bates’s work was violently attacked. In 1952, the professor of optometry Elwin Marg concluded that almost all of his theories had been judged false by vision scientists, and the method was removed from the medical curriculum. To this day, practitioners of the art of seeing are not allowed to say that their practice heals, on pain of illegal practice of medicine. Bachelard named epistemological obstacle the refusal, within us, to examine data that contradict our certainties; with the Bates affair, we see a dimension Bachelard did not envisage: the obstacle can have interests, and shareholders.
I have been practising this art of seeing for several years. I took off my glasses, I see better and better, I drive without correction, which once seemed unimaginable to me. It is a slow path, and it is a path of care. My vision may not be “normal” in the statistical sense; it is normative in Canguilhem’s sense: I have instituted my own norms of vision, suited to my life, and I keep making them evolve.
Caring for the milieu rather than repairing breakdowns
I propose to call care of the milieu the reversal that the thoughts of Canguilhem, Antonovsky and Illich, taken together, make possible. Canguilhem showed in Knowledge of Life (1952) that a living being can never be understood in isolation: an organism lives in and through its milieu, and health is the quality of this relation. Caring for the milieu means maintaining what makes a living being capable, rather than repairing its breakdowns one by one. The milieu is first one’s own body: sleep, food, movement, the attention paid to it, the practices through which one knows it and regenerates it. It is also the collective body: the bonds, which count among the primary determinants of health and longevity, as I developed with regard to the blue zones in Présence et expérience sociale; the material conditions of life, water, air, housing, food, which did more for the health of populations than medication, as Illich recalls; and organisations themselves, whose robustness Olivier Hamant helped me think through in Robustness, antifragility, resilience, for a living system holds through its margins, its redundancies and its fluctuations, not through its optimisation.
Within this frame, medicine keeps its full place. When disease occurs, it is treated, with all available means, including those of the most advanced science. But the person being treated then lives in a well-tended milieu, which makes them more capable of coming through what happens to them, and health ceases to be the exclusive domain of medicine. Even the word prevention falls short of saying this, for to prevent is still to avert an ill, whereas in caring for the milieu one cultivates a capacity.
The gestures of the care of the milieu, on three scales
On the scale of discernment, faced with any health discourse that claims the authority of “science”, I propose asking three questions:
- Is this about knowledge or about care? Knowledge belongs to science and its controversies; care belongs to medicine, to people and to their experience.
- Who funded the study, and who sells the solution? A study funded by the seller of the product is not worthless, but it must be read differently.
- Where are the controversies? In a living scientific field they are visible, and a field without apparent disagreement is most often a field where the questions have been closed.
On the scale of the body, the point is to learn to listen to one’s own and to practise what maintains its capacity: movement, rest, food, and proven self-care practices such as the art of seeing or meditation, whose effects, known and cultivated for millennia, Jon Kabat-Zinn ended up confirming through the clinical studies he launched in the late 1970s. Discernment works in both directions: those who claim to hold science are not right about everything, and neither are those who promise miraculous cures beyond all critical scrutiny. Each of us has the responsibility of cross-checking sources and of making our own way with our own critical mind.
On the scale of the collective, caring for the milieu becomes a politics: maintaining social bonds as a health determinant in their own right; guaranteeing material conditions, water, air, housing, food; detaching medical training and research from industrial funding, for a medicine funded by those who live off disease is structurally pulled towards disease; and opening to citizens, as Feyerabend proposed, the debate on research priorities.
In untangling science and medicine, neither is weakened: the first is a questioning, the second an art of care, and health is what Canguilhem teaches us to see, the capacity of a living being to institute its norms within its milieu and to recover. This capacity, each of us can cultivate in our own body, and all of us can cultivate in the common body, that of our bonds and our organisations.
