Manuel Zapata-Olivella's Medical Dialectics: Renewed clinical thinking and social medicine

Dialéctica Médica de Manuel Zapata-Olivella: pensamiento clínico renovado y medicina social

There is scant information regarding the author Manuel Zapata Olivella, who obtained a Doctor of Medicine and Surgery degree from the Universidad Nacional de Colombia in the mid-twentieth century. Although his dissertation for obtaining the degree was defended in 1949, it remains unpublished, indicating that this document could expand the author's contributions in a relatively underexplored area: scientific medical writing. Moreover, while literary critics see the influence of contemporary social medical philosophy in Zapata Olivella's work, he is not acknowledged in the writings of thinkers associated with that movement in Latin America.

Upon retrieving the dissertation from the historical archives of the Gabriel García Márquez Central Library at the Universidad Nacional de Colombia, and subsequently analyzing its form and content, it was determined that it is a scientific essay aimed at reformulating social medicine discourse through a dialectical framework, thereby reevaluating contemporary medical practice, an objective that remains pertinent today. In view of the foregoing, the objective of this reflection article is to describe the main characteristics and perform a thematic analysis of the unpublished essay by Manuel Zapata Olivella, entitled Dialéctica Médica, while discussing the potential contributions of his dialectical approaches to Latin American social medicine to reformulate clinical medicine.

Sobre el escritor Manuel Zapata Olivella poco se comenta que a mediados del siglo XX recibió el título de Doctor en Medicina y Cirugía en la Universidad Nacional de Colombia. Aunque su tesis para optar a ese título fue sustentada en 1949, aún permanece inédita, por lo que este documento podría completar la obra del autor desde una faceta poco explorada: como ensayista científico en medicina. Además, si bien la crítica literaria reconoce en Zapata Olivella las huellas del pensamiento médico-social de su época, los recuentos sobre pensadores de tal corriente en Latinoamérica no lo mencionan.

Una vez recuperada la tesis en los archivos históricos de la Biblioteca Central Gabriel García Márquez de la Universidad Nacional de Colombia, y analizadas su forma y contenido, se pudo establecer que se trata de un ensayo científico escrito con la intencionalidad de reformular el pensamiento médico clínico desde la dialéctica y replantear así la práctica médica de su época, siendo esta intención aún vigente en la actualidad. Teniendo en cuenta lo anterior, el objetivo de este artículo de reflexión es exponer las principales características y realizar un análisis temático del contenido del ensayo inédito de Manuel Zapata Olivella, titulado Dialéctica Médica, examinando los potenciales aportes de sus planteamientos dialécticos al pensamiento médico social latinoamericano, encaminados a renovar la clínica médica.

REFLECTION PAPER

Zulma Consuelo Urrego-Mendoza1

1 Universidad Nacional de Colombia - Bogotá Campus - Faculty of Medicine - Department of Public Health - Bogotá D.C. - Colombia.

Open access

Received: 29/01/2024

Accepted: 28/10/2024

Corresponding author: Zulma Consuelo Urrego-Mendoza. Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional de Colombia. Bogotá D.C. Colombia. E-mail: zulcurregom@unal.edu.co.

Keywords: Social Medicine; History of Medicine; Philosophy, Medical; Literature, Modern; Knowledge Discovery; Social Sciences (MeSH).

Palabras clave: Medicina social; Historia de la medicina; Filosofía médica; Literatura moderna; Descubrimiento basado en la literatura; Ciencias sociales (DeCS).

How to cite: Urrego-Mendoza ZC. Manuel Zapata-Olivella's Medical Dialectics: Renewed clinical thinking and social medicine. Rev. Fac. Med. 2024;72(3):e112675. English. doi: https://doi.org/10.15446/revfacmed.v72n3.112675.

Cómo citar: Urrego-Mendoza ZC. [Dialéctica Médica de Manuel Zapata-Olivella: pensamiento clínico renovado y medicina social]. Rev. Fac. Med. 2024;72(3):e112675. English. doi: https://doi.org/10.15446/revfacmed.v72n3.112675.

Copyright: Copyright: ©2024 Universidad Nacional de Colombia. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Abstract

Resumen

Introduction

Manuel Zapata Olivella is renowned as a writer, folklorist, anthropologist, and thinker, whose work focused on the Afro-Colombian community and culture. However, little is said about his role as a physician.

In commemoration of the centenary of his birth on March 17, 1920, his works were republished, and some of his unpublished texts such as “La maraca embrujada por Jibaná”1 and various poems,2,3 were made public in research works. Still, his dissertation to obtain the degree of Doctor of Medicine and Surgery from the Universidad Nacional de Colombia (UNAL) remains unpublished. The thesis was allegedly entitled La dialéctica aplicada al diagnóstico clínico (Dialectics Applied to Clinical Diagnosis),4 El método dialéctico y las ciencias modernas (The Dialectical Method and Modern Sciences),5 or Dialéctica Médica (Medical Dialectics),6 and reportedly included a treatise on the physiologist Claude Bernard.1

While initially considered a lost work because it had not been found in the historical archives of the Gabriel García Márquez Central Library of the UNAL,6 several months of investigation into the library’s old thesis collections led to the discovery of the document in early 2020. It was stored in a section different from the Corporis Fabrica Collection, which contains the old medical theses produced at the university.7 Given that it is an old and protected manuscript, the thesis could only be studied within the library premises and taking manual notes; however, due to the onset of the COVID-19 pandemic a few weeks after the thesis was found, it was not possible to continue with this work. The review was resumed at the end of 2022 and completed in 2023, confirming that the thesis is entitled Dialéctica Médica and that it is a scientific essay that aims to contribute to the renewal of the classical view of clinical medicine.

The analysis of this thesis is part of the research project Pensamiento médico social colombiano a mediados del siglo XX: el caso de Manuel Zapata Olivella (Social medicine in Colombia towards the second half of the twentieth century: the case of Manuel Zapata Olivella), which was approved by the Council of the UNAL Faculty of Medicine (Resolution 2245 of 9/12/2022) and the Ethics Committee of the same academic department (Act 001 of 26/01/2023).

In order to retrieve a document that complements this writer’s lesser-known role as a scientific medical essayist, the purpose of this reflection article is to describe the main characteristics and perform a thematic analysis of the unpublished essay written by Manuel Zapata Olivella entitled Dialéctica Médica. It is intended to look into the potential contributions of his dialectical approaches to Latin American social medicine, with the goal of reformulating clinical medicine.

To this end, some aspects of the author’s medical career will be outlined, current dialogues between social medicine (SM) and clinical medicine will be introduced, and the contents will be reviewed using the thematic analysis method, focusing on contents that, from a dialectical materialist perspective, are a potential contribution to a clinical medicine that is in line with Latin American social medicine (LSM).8-10

Manuel Zapata Olivella, a social physician for literary minds and a literary mind for medicine

Zapata Olivella pursued a medical degree at the UNAL from 1940 to 19496 (Figure 1), was the monitor of basal metabolism in the physiology laboratory in 1942, and completed his internship in 1943 during which he acted as the physician for students residing in the university dormitories located on campus at the time.10 Between 1943 and 1947, he interrupted his medical studies to traverse Central and North America,11 where he conceived three of his first literary works: Tierra Mojada (Wet Land), Pasión vagabunda (Wandering Passion), and He visto la noche (I Have Seen the Night).12-14

Figure 1. Headline of Manuel Zapata Olivella’s record at the Faculty of Medicine of the Universidad Nacional de Colombia. 1940.

Source: Original picture of Manuel Zapata Olivella’s Kardex from the medical school. Historical institutional archive, Universidad Nacional de Colombia.

During his journey, he served as a “trauma and maternity” intern at the clinic run by Mexican orthopedist and opera singer Alfonso Ortíz Tirado,10,15 provided medical services to painter Diego Rivera,15 was an intern at the Floresta Sanatorium for the “nervous and mentally ill” in Mexico City,10 and worked as a nursing assistant at Los Angeles General Hospital, USA.15

When he resumed his medical studies, he became an intern of “syphilography and pathological anatomy” at the Asilo de Locas (Insane Women’s Asylum) in Bogotá in 1948 and then submitted his thesis in October 1949,10 receiving his medical degree on November 7 of the same year at the UNAL (Figure 2).

Figure 2. Close-up of Manuel Zapata Olivella’s graduation certificate as a physician, manually recorded in the minutes book of the Universidad Nacional de Colombia’s Faculty of Medicine, following the customs of the time.

Source: Original image of the degree certificate No. 2514 of 1949. Historical institutional archive, Universidad Nacional de Colombia.

After graduating, he held public health posts in Bogotá between 1960 and 1965 and even worked as chief physician of the Health Education Section.6 Literary critics equate him with SM,16 but Latin American social medical thinking has not introduced him into its canons.9

When he wrote his thesis to obtain his medical degree, Zapata Olivella was already a writer and nurtured his novels with medical experiences. For example, La Calle 10 (Tenth Street) includes his experiences in the old Faculty of Medicine of the UNAL located in downtown Bogotá,5 while Detrás del rostro (Behind the Face) is a fictional work based on psychoanalysis and his social medicine activities with marginalized people.16

Professor Alfonso Esguerra Gómez, president of the graduate thesis (equivalent today to thesis director), was responsible for introducing the first experimental physiology laboratory at the Faculty of Medicine of the UNAL, as well as Pavlov’s theories.17 He, together with the dialectical European experimental medical thought of the time, probably influenced the methodology used in Zapata Olivella’s thesis, as physiology constitutes a crucial component of the work.

Furthermore, Zapata Olivella’s interactions with leftist intellectuals, both at the UNAL and during his travels and political work, undoubtedly brought him closer to the knowledge of the Soviet Union at the time, which he also incorporated into the text. It should also be noted that during his stay in Mexico, nationalist dialectical biology was a dominant ideological current.18

Just as the physician lays the foundation for the writer’s endevours, it is to be expected that the writer, in his capacity of a scientific essayist, would make valuable contributions to the physician’s work from a dialectical point of view.10

On Latin American social medicine and clinical medicine: a pending approximation

SM began to consolidate in Latin America in 1968,19 with regional records dating back to 1884, at least in Chile.20 Even though the initial promoters of LSM were specialists, such as the pediatricians Salvador Allende and Juan César García and the cardiologist María Isabel Rodríguez,9,21 the LSM movement questioned the hegemonic biomedical model, thus distancing itself from clinical medicine,9 which is a trait that is not shared by other versions of SM.22

LSM has been engaged in conceptual debates on the subject of health, the study of the health-disease process, and the social determinants of health (SDH), with an emphasis on social class. The main topics addressed are the study of health conditions in specific population groups, the relationship between violence and mental health, the analysis of the health-work relationship, and primary health care.8,9 However, LSM has made few concrete advancements in clinical practice that could serve as an alternative to the hegemonic medicine it criticizes.

In fact, although some LSM authors claim that its objective “is not to build new schemes within scientific knowledge and clinical approaches to disease, but to enhance the image and experience of health as a socially determined element”,9, p.111 others make a call to carry out “a constant clinical activity, influenced by a large amount of theory inherent to social sciences”23, p.23 to transform the modern medical paradigm, connecting clinical knowledge with social medicine and community knowledge to achieve mutual enrichment24 or a hierarchical coexistence where social medicine knowledge predominates over clinical medicine knowledge.25

The demarcation of LSM and clinical medicine is supported by arguments claiming that clinical medicine has an individualistic and decontextualized nature;26 intrinsically focuses on biological phenomena without connecting them to the social order;23,27 is more interested in resource rationalization rather than focusing on the health-disease process;27 and conforms only to the values of the ruling class.25 Nevertheless, it promotes the exploration of community health knowledge to enrich the health care of individuals and groups, aiming to “transform the simple functionalist vision of the current hegemonic model”,9, p.111 without developing specific and effective approaches to “responding to the needs of patients”,9, p.244 and “influencing official medical practice”.23, p.22 The foregoing prompts us to reflect on clinical medicine as a necessary complement to the activities usually carried out by SM, advocating for an “engaged clinical medicine” that both informs and is informed by action.22

When he wrote his thesis, Zapata Olivella was a member of the Colombian Communist Youth,5 a Marxist-Leninist organization in which he was undoubtedly in contact with the historical-dialectical materialism that permeates his thesis. Actually, by that time, he had already founded the first Center for Afro-Colombian Studies28 and had expressed his concern about problems afflicting this community such as hunger, discrimination, and exploitation.29,30 Based on this, it could be said that Zapata Olivella was a politically active leftist intellectual, whose medical degree thesis constituted another link in his search for a clinical medicine that would allow him to “foresee illness and, what is even more precious for the scientist, to influence, transform and direct man’s health, not through the shortcuts of his own mechanisms, but through the healthy and beautiful source of nature”.10, p.137

Dialectics put into action through text structure and its sources

Regarding the physical characteristics of the retrieved document, Dialéctica Médica is a 140-page document with a red cloth hard cover. Corrections in both form and content can be seen between the lines and were made by hand in a handwriting that resembles that of the author, although this needs to be verified (Figure 3).

Figure 3. Cover of the thesis Dialéctica Médica by Manuel Zapata Olivella.

Source: Original image of the cover page of Manuel Zapata Olivella’s Doctor of Medicine and Surgery Thesis.

In terms of content, the document does not include a table of contents and goes directly from the preliminary sections to the main text of the essay, which consists of two major sections and a general conclusion. The last section contains the references, which do not include the title of the works cited, only the author’s last name and initials and the citation page. It should be noted that standardized referencing in scientific and academic studies began to be developed at the international level in 195531 and that this practice became generalized in Colombia in 1990.32

The thesis begins by exposing the general laws of dialectics and how it intertwines with medical issues, dialectically redefining key concepts of medicine such as disease, treatment, or prognosis. The second part analyzes specific cases of human diseases, linking them with the approaches discussed in the first part. Thus, networks of meaning are interwoven throughout the text, and their conception as a whole is a dialectical feature.

As for the theoretical foundation of the thesis, Zapata Olivella resorts to 142 authors of various ideological currents, such as Hippocrates and Galen, Francisco José de Caldas, physiologist Claude Bernard, Frederick Engel, Karl Marx, the Russian behaviorist Ivan Pavlov, the Soviet agronomist Trofim Lysenko, and the naturalist Ivan Michurin, and all of them are dialectically related: “That is why wise men seem, in their disagreements, to be irreconcilable madmen, but it is the clash of their opposing conceptions that has determined the progress of science”.10, p.2

The most cited author is Trofim Lysenko, who addresses evolutionary materialist approaches to Soviet biology. The next most cited author is Claude Bernard, who discusses French experimental medicine and applied dialectics. In contrast, the thesis only cites Hegel three times, and he does so to refer to dialectics. In the case of Marx and Engels, these authors are cited twice each, the former when the thesis deals with dialectics in history and the latter when discussing the dialectical method in exact sciences.10 Concerning Rudolph Virchow, he is only mentioned once, in the section on dialectics applied to medicine, describing him as an empiricist clinician to be imitated in his scientific approach to patients because the physician should “rely on bedside observation and experimentation to provide satisfactory therapeutics”,10, p.13 but there is no mention of his controversial role as the inspirer of LSM.20

Considering the foregoing, it can be stated that, in Dialéctica Médica, Zapata Olivella based his formulations on materialism and the dialectical method applied to medicine knowing Virchow’s ideas, but without considering him as a referent social physician, which is similar to what has been described about Allende’s work, who also did not consider Virchow as a referent in the field of social medicine.20 Instead, he turned directly to the Soviet literature on genetics and physiology and to the French literature on experimental medicine, as well as to Engels, Marx and Hegel, and to Marxist biologists of various backgrounds.

Dialectical continuum between human beings and their environment

In his thesis, Zapata Olivella accepts the “dialectical feature that says that all things are related to each other and that they are influenced in such a way that the variations of one (environment) necessarily influence the others (living beings)”.10, p.7 He also takes up Bernard’s understanding of internal environment, accepts the continuum between internal and external factors, following Lamarck’s postulates, and deals with the constant transformation of inert matter into organic matter through metabolism.10,33

Moreover, he argues that the characteristics of the external environment influence internal biological organization, noting that “applying the dialectical method to heredity [vernalization experiments] has shed definite light on the appearance of new features in living beings as a consequence of variations in the environment or alterations in metabolism”,10, p.65 referring to Lysenko’s vernalization experiments based on the traditional knowledge of Russian peasants. For Lysenko, no characteristic was totally hereditary or acquired: an inherited genetic aspect would have a variable development depending on the environment. Therefore, Lysenko embraced the approach of inheritance of acquired traits, without denying Mendelian genetics, as did other contemporary biologists such as Goldschmidt in Germany, Sonneborn and Sager in North America, and Waddington in England.33,34

In response to LSM’s criticism of biological determinism in clinical medicine, Zapata Olivella presents his approach of totality and continuity between the human being and his environment, grounded on general dialectical theory, concrete developments of dialectical biology, formulations on metabolism, and empirical evidence regarding extranuclear and Mendelian inheritance. As a result, he is able to contextualize clinical medicine in accordance with the ideas of SDH, which would later be used by LSM.35

On the other hand, by choosing Lysenko, a Soviet technical agronomist who developed experimental practices rooted in traditional Russian peasant knowledge, as a reference instead of some of the scientific biologists who also endorsed the theory of acquired inheritance, Zapata Olivella shows his tendency towards the values of the popular classes as the foundation for his dialectical clinical approaches, as opposed to an alignment with the values of the dominant classes.

Viewpoints on health: between completeness and fragmentation

Distancing himself from the prevailing model of clinical medicine of his time, and even of the present time, in which disease is considered a specific phenomenon determined by specific causes, circumscribed to a developmental framework, and implicitly associated with external factors in its causality, Zapata Olivella in his thesis proposes to consider disease as a process occurring simultaneously with health. He argues that “disease and health appear united by a multitude of relationships that penetrate each other to such a degree that it is impossible to differentiate one from the other”,10, p. 53. as is the case of life and death, given that, in Zapata Olivella’s view, living beings are permanently “evolving from the old to the new, [in] a constant journey from life to death, a vital rebirth from the ashes of death. This unstable balance lies at the essence of life.”10, p.53 These ideas are in line with what some decades later LSM would suggest regarding the health-disease process within the framework of the human life process (HLP).24,35

Dialéctica Médica also reflects a resistance to mechanistic materialistic models, which are embedded in the dominant medical thought and are expressed through probabilistic methods in research and clinical practice.36-38 In this sense, in his essay, Zapata Olivella alternatively proposes a dialectical model that considers the functioning of the human body as a whole, both intrinsically and in relation to its environment.10 This was clear, without denying the advances in medicine of the time stemming from other epistemological approaches, bearing in mind that the author makes the following remark about dialectics: “the application of this method to contemporary sciences and particularly in the field that interests us, medicine, does not imply the revaluation of proven scientific knowledge, but rather a better method for interpreting it”.10, p.8

Unity and struggle of opposites at the patient’s bedside

When approaching the understanding of diseases such as endocrine disorders, cancer, and psychosomatic diseases from his views on the health-disease process, Zapata Olivella emphasizes that “we are approaching disease as a struggle of opposites, a process of various intrinsic and extrinsic factors that, while determining a complex phenomenon, also define its uniqueness”.10, p.50 Therefore, the author places the health-disease process in a context of dialectical interaction between conditions extrinsic to the human being and his internal realities, in which these aspects are constantly changing and maintaining health or causing disease: “the causes that can determine alterations in physiology must have their origin in the dilated external environment”,10, p.72 an idea that is in line with the SDH proposed by LSM.39

In addition, based on the scientific knowledge of his time, Zapata Olivella provides an analysis of the continuous relationship between the external determinants of HVP, including social determinants, and the contradictory biological and psychological processes that occur in human beings: “this mutual permeation is common to all biological phenomena, from the simple incorporation of a water molecule by a cell to the assimilation of an idea by our consciousness”.10, p.55

Unlike biomedicine, which is committed to fragmenting the human body to study each of its parts,40 Zapata Olivella calls for a comprehensive clinical medicine approach, in which the patient is assessed and their condition is inferred based on the data collected at the patient’s bedside, considering “the exact development of his self-dynamics as a whole and not separately, in accordance with the laws of contradiction and the exchange of quantity for quality”.10, p.137 In his statements, the author partially agrees with the recommendations to modify medical education promoted at the Faculty of Medicine of the UNAL in 1948, which attempted to promote clinical medical education with the patient.41 However, he differs by suggesting an analysis of human vital processes as a whole, instead of making an analysis fragmented by the specialization of knowledge, as it was also promoted in Colombia at that time based on the North American medical model.40,42

Of quantitative changes and qualitative leaps in medicine

For Zapata Olivella, any symptom or its exacerbation is the materialization, in a qualitative leap, of a series of previous quantitative changes that usually go unnoticed in traditional medical practice, even though these changes would make it possible to establish how and when “a new acute syndrome will explode with fatal consequences, with the same accuracy with which an astronomer is able to predict the orbit and volume of a star that has not yet been seen through his lens”.10, p.47

In Dialéctica Médica, Zapata Olivella supports this by giving examples of various physiological alterations in the number of certain parameters that can be detected using various technological devices and laboratory tests available at the time to determine functional changes, resulting in clinical manifestations that are qualitatively different from the previous clinical state, such as seizures or pain syndromes.10 In doing so, the author captures the trend in Colombian medicine in the 1940s, a time when medical education was undergoing a transition from the French anatomo-clinical model42 to the biomedical model (pathophysiological and etiopathological),41 but he also contributes his particular view from the perspective of dialectics.

At least a decade prior to Leavell and Clark’s approaches to the natural history of disease,43 Zapata Olivella proposed that clinical medicine should focus on identifying the subtle changes in quantity that always precede the onset of perceptible qualitative changes, either as symptoms or as syndromes, in order to carry out interventions aimed at timely rechanneling the human organism toward an optimal state of health, noting that “the good clinician must develop his research in the context of preventive medicine”.10, p.32 Notwithstanding the above, it is worth mentioning that such emphasis on prevention was already being introduced into medical practice in Colombia in line with the precepts of the North American school of public health,42 but with an epistemological approach different from the one presented by Zapata Olivella in his essay.

With respect to LSM, some authors have made specific progress based on critical epidemiology, emphasizing the usefulness of laboratory and imaging test findings alongside clinical diagnoses to broaden the understanding of the singular or individual domain of SDH, situating it within the contexts of community (specific) and society (general),44 thereby connecting the analysis of biological processes, genotype, and phenotype with SDH.45,46 However, this is not a generalized trend in LSM, and therefore no similar proposals have been made in relation to clinical medicine. In this sense, Zapata Olivella’s proposals, updated in the light of current knowledge, could serve as a bridge between the knowledge of LSM and clinical medicine.

Conclusions

Dialéctica Médica is a key unpublished work by Manuel Zapata Olivella, which illustrates his role as a scientific medical essayist and in which he presents various applications of the dialectical method in fundamental issues of clinical medicine.

Based on the laws of dialectics, the author conceptualizes the interactions between the individual and the environment, the health-disease process, as well as medical action, pointing out possible routes to bring together the collective knowledge of LSM and the individual knowledge of clinical medicine. Such proposals, nurtured by current scientific advances such as epigenetics, which has renewed interest in the relationship between environment and heredity,47 could be a point of convergence between these two bodies of knowledge.

In conclusion, Dialéctica Médica provides a useful starting point to reformulate clinical medicine theories and practices, so that they are epistemologically compatible with LSM. In addition, the recovery of this unpublished document is a contribution to the scientific and literary heritage of the Faculty of Medicine of the UNAL and of the author.

Conflicts of interest

None stated by the author.

Funding

The Universidad Nacional de Colombia provided financial support for developing the project.

Acknowledgments

To the staff of the Historical Institutional Archive and the Gabriel García Márquez Central Library of the UNAL, for their cooperation during the search for primary sources for the project.

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