Introduction
The author expresses skepticism towards clerical forms of power that monopolize interpretation, dictate truth, and turn rituals into tests of obedience. This perspective was reinforced while reading Javier Cercas’ “The Madman of God in the End of the World,” which emphasizes the distinction between belief and obedience, and a promise versus the apparatus that administers it. Here, “clerical” refers to a category of power, not faith.
The Relevance of the Topic
This skepticism helps analyze contemporary scenarios, such as the relationship between medicine, public health, and protocols. Neither is inherently clerical, but both can transform knowledge into authority when they become strong institutions. In medicine, the risk arises when clinical knowledge becomes unquestionable, reducing patients to mere recipients of instructions. In public health, the risk emerges when norms replace competence, and compliance replaces responsibility. In both cases, the discussion shifts from technical to political: who defines correctness, who distributes responsibility, and who bears the cost?
Public Health Protocols: Balancing Standardization and Judgment
Public health was created to limit arbitrariness and make care a collective good. It requires tools like programs, norms, guidelines, and indicators to standardize and reduce unjustified variations, prevent predictable errors, and protect both patients and professionals in an unequal system. However, standardization can also transform a tool into a dominant criterion of legitimacy, silencing context and reducing practical experience to “noise.”
Mexico’s National Medical Care Protocols (PRONAM)
In Mexico, PRONAM illustrates this point. They don’t aim to cover everything but rather organize medical practice, focusing on adult chronic diseases, childhood cancer, and two preventive activities. The issue lies in their implicit logic: they cater to those already engaged with the system, neglecting those who can’t access it due to various barriers like time constraints, transportation issues, costs, fear of losing a day’s work, bureaucracy, or simply an inconsistent system.
The Duality of Protocols
Protocols can be beneficial when they reduce unjust variations, but problematic when they replace practical judgment with textual dominance. In a system lacking continuity, resources, clinical time, and functional networks, protocols can operate contrary to their promise, turning compliance into a criterion of legitimacy instead of fostering conditions for care.
Prevention and the Tension Between Risk Management and Holistic Care
Prevention is a prime example of this tension. Identifying risks and anticipating harm is prudent, but expanding preventive measures without the public health capacity to sustain them can transform everyday life into a “potential patient” scenario and consultations into risk management without a care horizon.
The Case of the “1000 Days”
The “1000 days” concept, based on biological and epidemiological grounds, emphasizes early intervention, protecting critical windows, and preventing irreversible damage. However, its success depends more on the moral and material infrastructure that enables it than on the document itself. If this support fails, adherence to the protocol may occur without achieving its intended outcome.
The Clericalization of Protocols: From Technical Solutions to Institutional Obligations
In institutional discourse, protocols appear as technical solutions; however, in practice, they often become new obligations. This shift introduces a clerical element: evaluation focuses on whether personnel followed the protocol rather than if the system genuinely cared for individuals.
Michael Foucault’s Perspective
Foucault’s insights shed light on this issue: protocols don’t just guide decisions; they govern practice, producing normality, classifying deviations, and redistributing responsibilities. They make clinical uncertainty manageable—valuable when correcting abuses but potentially devastating in contexts where clinical practice resembles negotiation with scarcity, comorbidities, and social life rather than a linear sequence.
Consequences of Clericalization
Clericalization doesn’t require malicious intent; it can arise from high demand, low capacity, political pressure for results, and administrative needs to demonstrate order. Under these conditions, protocols function as substitutes for infrastructure: where continuity is lacking, follow-ups are prescribed; where supplies are insufficient, treatments are prescribed; where networks are absent, referrals are prescribed. The norm takes the place of what doesn’t exist.
The Central Paradox
Protocols aim to protect patients from individual arbitrariness but can end up safeguarding institutions from reality when they transform into tribunals. Compliance with the document becomes a declaration of order where genuine care is lacking, shifting responsibility from effective care to document compliance. One form of arbitrariness is reduced while another, structural, emerges from demanding what isn’t guaranteed.
Vulnerable Populations
This issue becomes more delicate with vulnerable populations. Protocols assume a patient who can return, relocate, understand instructions, and afford costs. Adherence isn’t a moral disposition but a logistical and social outcome. When overlooked, protocols morally judge inequality: if the patient or doctor “failed” to follow the route, the obvious—the flawed system architecture—is rarely acknowledged.
Reducing Patients to Cases, Risks, Codes, and Adherence
As a result, patients are reduced to cases, risks, codes, or adherence measures rather than being seen as whole individuals. This reduction occurs unintentionally but effectively, as biographies are truncated to fit formats, and what doesn’t fit becomes noise or an exception. In this context, Giorgio Agamben’s concept of “naked life” serves as a warning: when systems prioritize demonstrating compliance over care, life tends to become managed rather than lived.
Conclusion: Reclaiming the Protocols’ True Purpose
This analysis doesn’t suggest abandoning protocols or dismissing evidence but rather reclaiming their rightful place. Protocols should be adaptable, supporting clinical judgment without replacing it and holding institutions accountable for enabling genuine care.
If PRONAM expands—as it might—two key considerations for design are crucial: considering those who don’t access the system and distinguishing documentable routes from real capacities. A just protocol not only prescribes behaviors but also mandates minimal operational standards (supply, reasonable time, continuity, functional networks) and allows explicit margins for adaptation without penalty.
Public health’s promise remains essential: without it, social chance dictates outcomes. Being “anticlerical” here means remembering that document compliance shouldn’t outweigh the obligation to improve, balancing two forms of responsibility: one satisfied by compliance and another measured by care.
References
- Agamben, G. (1998). Homo sacer I. El poder soberano y la nuda vida. Valencia: Pre-Textos.
- Cercas J. El loco de Dios en el fin del mundo. Ed. Random House. México 2025. Decimotercera edición.
- Foucault M. Foucault, M. Seguridad, territorio, población (Curso, 1977–1978). Fondo de Cultura Económica. Buenos Aires, Argentina 2006
- Portal oficial de los Protocolos Nacionales de Atención Médica (PRONAM). pronamsalud.csg.gob.mx. <
*The author is a Tenured Professor in the Department of Public Health, Faculty of Medicine, UNAM and Emeritus Professor in the Department of Health Measurement Sciences, University of Washington.
The opinions expressed in this article do not represent the position of the institutions where the author works. [email protected]; [email protected]; @DrRafaelLozano
