The thought of the living must take from the living the idea of the living.Georges Canguilhem
To what extent might one consider Georges Canguilhem a scholar of social medicine? Defined as a field of study that examines health and disease from a social science perspective, social medicine has a long and complex history. It has changed over time and has taken different forms in different parts of the world. Social medicine has relevance and significance today as an interdisciplinary endeavor that includes anthropological, sociological, historical, and philosophical modes of inquiry. This piece is not an attempt to reconstruct the transnational history of social medicine and compare and contrast its various manifestations. Rather, its aim is to explore how Georges Canguilhem’s essay “The Living and Its Milieu” might be useful conceptually for contemporary work in social medicine. Given his concern with the social and the vital, we can easily see Canguilhem’s importance for the question of what social medicine might be as a field of study concerned with questions of health and disease.
At the heart of Canguilhem’s essay is the relationship between living beings and the milieu. One might say that for some scholars in social medicine, the social operates as a milieu. The social is the milieu of the human; it refers to a set of “influential circumstances” that impact people and their lives. This is expressed, for instance, in the concept of “social determinants of health,” a foundational notion that considers the social as a general and almost mechanical cause of disease.
As many have argued, categories such as gender, race, and class are often taken as self-evident entities that exist in the world like trees or stones. But these categories are concepts with a complex role in people’s lives. This makes the tracking of the effects of the social extremely difficult. One cannot talk about gender, for instance, independent of the ways in which gender is understood and put into practice in everyday life. This means that scholars of social medicine need to move beyond a naturalized understanding of the social as milieu of the human. The kind of analytic violence that scholars commit by assuming that certain people “belong” to a “gender” or “race” or “class” is stunning, given the amount of critical social science work that has gone into showing that none of these categories are self-evident. They are neither self-evident nor uncontested. As Veena Das and Ranendra Das underscore, “an individual cannot be said to ‘belong’ to her kinship network, community or neighborhood as, say, water belongs to the bottle or clothes belong to the wardrobe” (2006, 81). Any “belonging” to the social is fraught with tensions. And the struggles that we witness are often struggles around normative sociality, normative understandings of roles and relations.
As Canguilhem points out in his New Reflections on the Normal and the Pathological, people refuse the needs and norms of society and challenge them—“a sign that the needs and norms are not those of the whole society” (Canguilhem 1991, 256). Similarly, he argues that the concept of adaptation “implies a concept of society which surreptitiously and wrongly assimilates it to an environment, that is, to a system of determinisms when it is a system of constraints which, already and before all relations between it and the environment, contains collective norms for evaluating the quality of these relations” (1991, 282). This means that taking seriously the social requires a rigorous epistemological foundation that avoids the reproduction of normative sociality and that refuses the very understanding of “society” as an “environment.” Paradoxically, the concept of “social determinants of health” has expelled the social from social medicine. There is no social in this form of social medicine. There is only an environment.
This is where Canguilhem’s essay becomes incredibly inspiring. For the question that he poses is precisely a question of relation, the relation between living beings and milieu. As Canguilhem notes, it is a fundamental “characteristic of the living thing that it makes its milieu for itself, that it composes its milieu” (Canguilhem 2008, 111). The milieu is not a given; it is the result of a constitution: “The milieu proper to man is the world of his perception—in other words, the field of his pragmatic experience, the field in which his actions, oriented and regulated by the values immanent to his tendencies, pick out quality-bearing objects and situate them in relation to each other and to him. Thus the environment to which he is supposed to react is originally centered on him and by him” (Canguilhem 2008, 118).
Similar to his account of the relation between life and knowledge (see Marrati and Meyers 2008), Canguilhem proposes a reciprocal relation between living being and milieu: living beings have an impact on the milieu just as the milieu has an impact on living beings. However, despite the fact that Canguilhem underscores the openness of both terms, and thus their non-totalizeable nature, he continues to consider living beings and milieu as distinct entities. Furthermore, he starts from the premise that there is an individual who constitutes her milieu. This is perhaps the most important limit in Canguilhem’s approach. It is partly due to his emphasis on the “problem of individuality,” a problem that has always been central for Canguilhem and his existentialist philosophy. However, it is a particular kind of existentialism, one that—at least in some formulations—refuses to consider individuality as a given. Canguilhem writes: “To live is to radiate; it is to organize the milieu from and around a center of reference, which cannot itself be referred to without losing its original meaning” (Canguilhem 2008, 113-114). Individuality, one might say, is a central reference point that only works as long as it is not referred to.
Throughout his essay, Canguilhem emphasizes the relative nature of the milieu. “The notion of milieu is an essentially relative one. When we consider separately the body that receives an action transmitted by the milieu, we forget that a milieu is a medium, in between two centers, and we retain only its function as a centripetal transmitter, its position as that which surrounds a body” (Canguilhem 2008, 100). The key question is how to think this relation between two centers. What would it mean to start from the relation rather than from one or the other center?
Here one can perhaps go one step beyond Canguilhem. Relation is a question of movement. Gilles Deleuze’s approach is helpful. In his work on Hume he argues that relations are not internal but “external to their terms” (Deleuze 1991, 37). A relation is a movement, a passage, a transition from something that is given to something that is not given. It is in the nature of a relation to “go beyond the given.” This also means that the success of a relation cannot be determined in advance.
Highlighting the precarity and fragility of relations would be one way of avoiding an understanding of the social as taken for granted entity, a thing surrounding living beings like a physical environment. But the social is not a milieu. What, then, is the social? Where is it located? The social, we might say, is in the relation between human beings and the milieu.
How do human beings “belong” to the milieu, if not like water in a bottle or clothes in a wardrobe? “The relation between the living and the milieu establishes itself as a debate (Auseinandersetzung), to which the living brings its own proper norms of appreciating situations, both dominating the milieu and accommodating itself to it. This relation does not essentially consist (as one might think) in a struggle, in an opposition. That applies to the pathological state. A life that affirms itself against the milieu is a life already threatened” (Canguilhem 2008, 113).
The relation that Canguilhem highlights has a life, a life of its own. We might say that this life is what we mean by the social. Consequences are often unintended and unpredictable. New things happen in the world. This form of social medicine makes the question of the social not a question of context, but a question of relation. And it considers this relation in a vital and not mechanical way. A vital—but also precarious and fragile—quality characterizes the relation between human beings and milieu. No one will ever be able to determine completely all the conditions and consequences of that relation. Human beings respond, and even the milieu responds. And the response will always be a response and not a mechanical reflex. The result can never be known in advance (see Han and Das 2015).
The German word Auseinandersetzung has a broad range of meanings. It can mean “to consider” but also to “take apart” or “place apart.” The vital quality of any consideration and mutual undoing will only come to the foreground once we follow Deleuze and make the relation between human beings and milieu external to both terms, allowing the relation to have a life of its own. Only by affirming the exteriority of relations will the social retain its relative meaning and avoid the fate of the milieu when it appeared as a reality in itself. This, perhaps, is Deleuze’s philosophy of life, where life is that which passes through us in ways that we do not always fully understand.
Read another piece in this series here.
Canguilhem, Georges. 2008. “The Living and Its Milieu.” In Knowledge of Life, edited by Paola Marrati and Todd Meyers, translated by Stefanos Geroulanos and Daniela Ginsburg, 98-120. New York: Fordham University Press. First published in 1952.
Das, Veena and Ranendra K. Das. 2006. “Urban Health and Pharmaceutical Consumption in Delhi, India.” Journal of Biosocial Science 38, no. 1 (January): 69–82.
Deleuze, Gilles. 1991. Empiricism and Subjectivity. An Essay on Hume’s Theory of Human Nature. New York: Columbia University Press.
Deleuze, Gilles. 2001. Pure Immanence: Essays on a Life. New York: Zone Books.
Han, Clara and Veena Das. 2015. “Introduction: A Concept Note.” In Living and Dying in the Contemporary World: A Compendium, edited by Veena Das and Clara Han, 1-37. Berkeley: University California Press
Marrati, Paola and Todd Meyers. 2008. “Foreword: Life, as Such.” In Knowledge of Life, edited by Paola Marrati and Todd Meyers, translated by Stefanos Geroulanos and Daniela Ginsburg, vii-xii. New York: Fordham University Press.