I. The Question Nobody Asks
There is a question that haunts every encounter between a person and a healthcare system, but that almost nobody working inside that system is trained to ask. It is not: Does this intervention meet the clinical threshold? Not: Is this cost-effective? Not: What does the evidence say? The question is far simpler, and far harder. Will this actually make this person's life better?
The simplicity is deceptive. Behind it lies a whole theory of what life is, what value is, and what medicine is for. Developing that theory is what Living Value Theory (LVT) sets out to do. This article presents LVT's answer to the question of value in health and healthcare, drawing on two keynotes given in Tromsø in May 2025 and the discussions they generated. It argues that existing frameworks, whether economic, epidemiological, or anthropological, systematically mislocate where value resides, and that this mislocation is not merely an academic problem. It produces real harm: diagnoses that damage the lives they claim to improve, screening programmes that install illness where none was felt, clinical encounters that do the right thing by medicine's standards and entirely the wrong thing by the patient's.
The core claim can be stated in a sentence: value is not what is measured, exchanged, categorized, or symbolically recognized. Value is what sustains, repairs, or improves the ongoing coordination of a living being with its world. Where that coordination is going well, where life is simply working, value is present in its most powerful form. And it is precisely there that it leaves no trace, resists measurement, and falls outside every existing account of what makes healthcare worthwhile.
The Tromsø seminars brought together medical anthropologists, clinicians, and social scientists from the Nordic welfare states. That setting, the most developed and genuinely egalitarian version of organized healthcare the world has produced, turned out to be theoretically crucial. The Nordic welfare state, LVT argues, is not an exception to the distortions that affect modern healthcare. It is their most refined and legible expression. Understanding why requires beginning at the beginning: with what life actually is, before anything goes wrong.
II. Life Before the Clinic
Consider what health feels like from the inside, not when you are ill, but when you are well. It feels like nothing in particular. You move through your day. You sit, stand, eat, talk, think, sleep. You are not narrating your kidney function or monitoring your blood pressure. You are not, as Hans-Georg Gadamer famously observed in The Enigma of Health, aware of being healthy at all. Health, Gadamer wrote, hides itself. The more completely it is present, the less it appears.
This hiddenness is not an accident. It is the signature of what LVT calls Level 1 coordination, or L1: the state of seamless engagement with the world in which actions are performed without deliberation, skills enacted without awareness, bodies metabolize, orient, and sustain themselves without needing to become visible to themselves. L1 is not unconsciousness. It is what Heidegger called being-in-the-world: the absorbed, practical engagement with things and people that is the primary mode of human existence. You pick up a glass without thinking about your grip. You navigate a staircase without calculating each step. You breathe.
This is the vast, vast majority of what keeps us alive. It is also the vast majority of what constitutes health. The immunological surveillance, the metabolic regulation, the postural adjustment, the overnight cellular repair, none of this is monitored, measured, or managed by a healthcare system. It proceeds in what LVT calls the mesocosm: the lived field in which reality becomes available to living beings through mediation. The mesocosm is not a philosophical abstraction. It is the actual world as experienced from within a body, among others, in a place, surrounded by materials, using symbols. It is where life happens.
Just below L1 coordination lies what LVT calls L2, or felt misalignment: the pre-symbolic sense that something is off. Not yet named, not yet narrated, just felt. A stiffness. A slight wrongness. A pull of hunger or fatigue. Most such states are remediated immediately and spontaneously. You shift in your chair. You reach for water. You pause and look away from a screen. No clinical encounter occurs. No data trace is produced. No entry appears in any record. And yet something with genuine health significance has happened: a disruption was sensed and repaired. The body has kept its coordination intact.
There is Kleinman's estimate that perhaps eighty percent of health episodes are treated in the household. But that number misses the deeper point. LVT is not making a claim about proportions. It is making an ontological claim: the level at which health is primarily lived, L1 and L2, seamless coordination and felt misalignment, is not merely underserved by healthcare systems. It is structurally invisible to them. It cannot, in principle, be tracked, measured, or symbolically represented without already having left the level at which it operates. To understand why this matters, we need to understand what symbolic representation is actually doing, and where it sits in the architecture of living.
III. From Living to Language: The Levels of Recursivity
Living Value Theory describes five levels of recursivity, five ways in which coordination becomes available to itself, to others, and to institutions. They are not a simple hierarchy from primitive to sophisticated; they are a description of the different forms in which living engagement with the world can fold back on itself.
L1, as we have seen, is seamless coordination. L2 is felt misalignment. The third level, L3, is the point at which something becomes symbolically articulated: given a name, shared with another person, spoken aloud. "I am tired." "Something doesn't feel right." "I have pain here." L3 is where the transition from the pre-symbolic to the symbolic occurs. It does not require abstraction from many cases. It requires only that something be named as this thing, this feeling, this situation, available within the lived world.
L4 is where symbolic articulation moves into abstraction, generalization, and what LVT calls stabilization. L4 produces general categories, disease classifications, diagnostic thresholds, institutional protocols, the symbolic infrastructure of organized healthcare. "You have major depressive disorder." "Your bone density falls within the osteopenic range." These are not simply descriptions. They are actionable stabilizations: they exist, in their institutional form, precisely to drive decisions. The diagnosis enables the prescription. The classification enables the protocol. The risk category enables the screening programme.
L5 is the meta-recursive level: reflection on the entire system of levels themselves. This article is operating at L5. L5 asks: what are these categories actually doing? What do they make visible? What do they hide? What forms of coordination do they enable or damage?
Now here is the structural problem that LVT identifies, and that it regards as one of the most consequential unrecognized features of modern healthcare: L1 and L2 are strictly pre-symbolic. They cannot be captured by any form of symbolization without already having shifted levels. The moment you describe a state of felt health, you are at L3. The moment you diagnose it, you are at L4. The phenomenological tradition in medicine came tantalizingly close to grasping this. Gadamer saw that health hides itself. Heidegger saw that absorbed practical engagement is primary. But even phenomenology tends to assume that a sufficiently careful description can capture the pre-symbolic state. LVT's claim is more radical: the representation is always already something other than what it describes. L1 and L2 are not difficult to symbolize. They are beyond symbolization in principle.
This creates an ontological gap at the centre of all health research, clinical practice, medical anthropology, health economics, and epidemiology. Every method we have, interviews, surveys, clinical examinations, biomarkers, outcomes data, qualitative fieldwork, randomized controlled trials, operates at L3 and above. Every form of data is already a symbolic transformation of the mesocosm. This is not a methodological limitation that better methods might overcome. It is a structural feature of what symbolization is. The implication for value theory is direct: if the most important dimension of health lives at L1 and L2, then any value framework that measures, counts, or symbolically represents its subject will systematically miss the most valuable thing.
IV. Five Ways of Being in the World
Coordination does not happen in a vacuum. It happens through five irreducible mediations, the actual modes through which living beings engage with their world. LVT calls these embodiment, being-with, dwelling, multimateriality, and multisymbolization.
Embodiment is the lived body as the ongoing condition of all experience: sensation, proprioception, interoception, metabolism, fatigue, pain, hunger, arousal, skill. You value a glass of water more acutely when you are parched than when you have just drunk three litres. This is not a psychological preference. It is embodied coordination, the body's own assessment of what the mesocosm currently requires.
Being-with is coordination with other living beings. Social life does not begin with explicit norms, contracts, or symbolic agreements. It begins with co-presence, attunement, dependency, care, shared attention, imitation, and rivalry. You value things differently when they concern your children than when they concern strangers.
Dwelling is the mediation that health research has most systematically ignored. It names the spatial and temporal conditions of inhabitation: landscape, altitude, climate, seasons, light cycles, ecological patterns, and distance. The midnight sun of Tromsø is not background to human experience there. It is a constitutive feature of the mesocosm, shaping sleep, mood, seasonal economy, the rhythm of the academic year, the very logic of the city's founding at the precise intersection of certain fishing routes and navigational conditions. No medical anthropology textbook takes dwelling seriously as a factor in health. It is simply backgrounded, treated as container rather than constitutive condition. LVT argues this is a profound error.
Multimateriality names coordination through materials and artefacts: tools, medicines, infrastructures, food, devices, buildings, and the built environment. Multisymbolization names coordination through symbols, language, number, image, code, narrative, classification, law, money, and it is the mediation most prone to overreach: the mistake of treating symbolic representation as if it were the coordination it represents. All clinical measurement scales, statistics, and biomarkers are forms of symbolization that take on a life of their own, and are routinely mistaken for the embodied realities they were meant to represent.
The five mediations are irreducible. None can be derived from another. Any account of health that proceeds exclusively through one mediation will systematically misrepresent what it studies. Biomedicine works primarily through multimateriality and multisymbolization, largely ignoring dwelling. Epidemiology works almost exclusively through multisymbolization, treating statistical abstraction as if it captured embodied life. The result, in both cases, is poor mesocosmic fit.
V. The Hidden Core of Health
LVT's account of what health actually is before it enters a clinical setting is one of its most provocative contributions. Health is not a state of verified normality established by biomedical measurement. Health is L1 coordination: the seamless, pre-symbolic engagement of an embodied being with its world across all five mediations. It is the condition in which, as Gadamer observed, nothing comes to attention, not because there is nothing there, but because everything is working.
This means that the vast majority of what keeps us healthy is invisible to healthcare systems by structural necessity. The coordination of our immune response, our postural adjustments, our metabolic rhythms, our social attunements, our felt sense of whether the season, the temperature, the quality of sleep, and the state of our relationships are adequate, all of this proceeds at L1 and L2, continuously, without generating any data trace. L1 coordination is not merely the most common mode of health. It is health in its primary form. Everything else, clinical encounter, diagnosis, prescription, trial enrolment, outcome measurement, is secondary to it, derivative of it, and potentially disruptive of it.
This framing allows LVT to name a form of harm that has no adequate conceptualization in existing medical anthropology or clinical medicine: preventive iatrogenesis, the damage done by installing an L4 category into a life that had no L2 ground. There was no felt misalignment. There was no disruption requiring repair. The disruption was produced by the diagnosis itself. An ethnographic case from Jønsson (2024) illustrates this with particular clarity: a man who goes to a routine health examination, feeling well and living normally, is told he has cancer. The cancer may never have caused him symptoms. But from the moment of the diagnosis, the moment the L4 institutional category enters his life, his L1 coordination is irreversibly changed. He worries. He undergoes treatment. The treatment has side effects. His relationships change. His sense of himself changes. He lives in the shadow of the diagnosis until he dies, of something else entirely. The clinical system records this as a successful detection of pathology. There is no code for what was actually done to the coordination of a life that was, before the examination, simply working.
The overdiagnosis literature in clinical medicine and epidemiology has developed related concepts, evidence synthesis showing net harm from certain screening programmes, choosing wisely campaigns, frameworks for distinguishing beneficial from low-value care, and these are genuinely valuable contributions. The analysis of overdiagnosis could add a sharper critique of how biomedicine believes that what is valuable (or not valuable) is always fully measurable. It could also add an analysis of how preventative diagnostic iatrogenesis can emerge from imposing L4 classifications on a mesocosm that had no felt misalignments.
VI. Transactive Dualism and the Welfare State
Modern healthcare is not organized through LVT's five mediations and levels of recursivity. It is organized through what LVT calls transactive dualism: a value cosmology that crystallized in the Enlightenment period between roughly 1770 and 1820, and that has structured how value is recognized, measured, and distributed ever since.
Transactive dualism begins from a particular image of the social world: two parties, A and B, of equal standing, freely entering an exchange in which X passes from A to B and Y passes from B to A. This diagram, familiar from any introductory economics or anthropology course, encodes a whole cosmology. Value shows itself in transactions. It is produced in exchanges. What has not been transacted has not, in this cosmology, generated value at all. The Lockean premise that labour on something makes it yours, the Smithian premise that the market is where value is realized, and the Cartesian premise that A and B are fundamentally separate, sender and receiver, self and other, with nothing shared in advance, are all versions of this same underlying structure.
The Enlightenment version of transactive dualism was, in many respects, a genuine advance. Feudalism did not have it. In a feudal system, transactions were not entered freely, parties were not of equal standing, ownership was not transparent, and exit from exchange was not possible. The Enlightenment's insistence on equality before the law, on the transparency of exchange, on individual rights that no lord could override, these were real achievements. What LVT argues is that transactive dualism, however much it improved on feudalism, remains a value cosmology that systematically misses the most important things: the coordination that precedes any transaction, the value that never becomes visible, the life that is simply going well.
The Nordic welfare state is, in LVT's analysis, the most benign and fully realized articulation of transactive dualism ever constituted. The fundamental transaction is clear: citizens pay taxes, and the state redistributes these fairly to provide universal access to health, education, housing, and social security. In return, citizens fulfil their obligations: they attend screenings, accept diagnoses, comply with treatment protocols, and perform what might be called pharmaceutical citizenship, going to the osteoporosis check not because they feel anything is wrong, but because they understand that this is what a good citizen in a welfare state does. The welfare bargain is genuine and deeply valued. It expresses a real commitment to equality and solidarity.
But it also has a structural consequence that is harder to see precisely because it is so well-intentioned. The welfare state can only recognize value that is symbolically visible and transactionally traceable. The number of screening appointments attended, the number of prescriptions issued, the number of diagnoses confirmed, these are what can be counted, compiled, audited, and reported. They are what the state can demonstrate it has provided. The most fundamental states of health, seamless bodily coordination, felt ease of engagement with the world, the quiet background functioning of a life that is simply going well, cannot appear in this account at all. They are not transactions. They leave no trace.
This creates what LVT calls a redistribution of recursivity. The recognized authority to define what counts as health has been moved away from the person's own L1 and L2 coordination and relocated in authorized institutional sites. If you feel fine but your bone density scan says otherwise, you are, by the logic of the welfare state, ill. If you feel unwell but every test comes back normal, you are, by that same logic, healthy. The felt sense of one's own coordination no longer counts as evidence. What counts is the biomedical L4 category.
Contemporary social life amplifies this redistribution through diffuse social surveillance. As biomedical L4 categories spread through everyday life, through public health campaigns, news media, digital health nudges, and the interventions of well-meaning neighbours, people are increasingly expected to self-monitor in clinical terms. The person who doesn't get out much is no longer simply living as they choose. They are, in a world that has absorbed the epidemiological literature on social isolation and mortality risk, failing to perform healthy living correctly. The person who eats a biscuit and feels guilty is not responding to a felt bodily misalignment. They are responding to an L4 category that has been installed in the space where L1 felt sense used to operate. This is the hollowing of L1: the progressive replacement of pre-symbolic, embodied self-assessment by institutionally sanctioned category.
VII. Three Clinical Portraits
Nothing in LVT's theory of value becomes fully concrete until it meets actual clinical practice. The three portraits from fieldwork in Kolkata, documented in Living Worth (Duke University Press, 2022), illuminate from the inside what mesocosmic fit looks like in action, and what happens when it is absent.
The first portrait is a moment of near-perfect clinical art. It turns on the Bengali concept of moner khabar, literally, food for the mind. A patient comes to a psychiatrist's office and refuses psychiatric medication outright. He does not recognize himself as having a mental illness. He describes what he calls "artificial drugs" as something foreign to his body and his sense of himself. His framework for health is shaped by the deep Bengali cultural attunement to food, digestion, and the relationship between bodily nourishment and mental state, a relationship captured in the popular Bengali saying mon kharap lagle, sharir kharap lage: if the mind is bad, the body is ill. The psychiatrist does not correct this framework or escalate to an L4 psychiatric label. Instead, he inhabits it. What is really going on with you, he tells the patient, is that your mind is starved. It is not getting the nourishment it needs. I am giving you moner khabar, food for the mind. Just as you feel the misalignment of hunger in your body, your mind is experiencing the same lack, and I am simply supplying what it needs to recover. With that reframing, staying at L3, at the level of the patient's own symbolic world of food and bodily care, rather than ascending to the psychiatric L4, the psychiatrist achieves what a direct clinical translation could not: the patient accepts the medication. The mesocosmic fit is excellent. The symbol preserves the patient's existing coordination rather than rupturing it with an alien category.
The second portrait involves not an individual consultation but an institutional scene: the Pfizer PRIME-MD workshop, described in detail in Living Worth. The scene is a lunchtime event at a fancy restaurant in one of South Kolkata's wealthier areas. Twelve general practitioners with private practices have been invited. Pfizer has hired Dr. Mullick, a high-flying psychiatrist who travels several hours daily across the city to practice in different clinics, as its key opinion leader for the event. After a fifteen-minute teaching video, lunch is served, and then Dr. Mullick gives a PowerPoint presentation on the epidemiology of depression, culminating in the recommendation that the best available treatment is Pfizer's own drug Daxid, the Indian version of Zoloft (sertraline). The declared goal of the workshop is to introduce the GPs to a diagnostic questionnaire called PRIME-MD Today, Primary Care Evaluation of Mental Disorders, developed by Robert Spitzer, the architect of symptom-based diagnostics in the DSM-III. The questionnaire is meant to be handed to patients in the waiting room, with the doctor then using it to arrive at a rapid depression diagnosis in under two minutes. The teaching video demonstrates the system through the case of Mrs. Rao, a poorly educated woman whose husband is an unemployed alcoholic and who must support the whole family on her own. She presents with backaches and headaches. The doctor, reviewing her PRIME-MD responses, detects "underlying depression" and persuades her, against her protests that she just has a headache and is not going mad, to accept that her problems come not from her dire family situation but from this underlying psychiatric condition.
The actual outcome of the workshop is the opposite of what Pfizer intended. Dr. Mullick himself instructs the GPs not to give the questionnaire to patients, it will make them resist the diagnosis. The Pfizer representatives have not even brought Bengali-language versions of the questionnaire, as if they knew it would never be used. The GPs need no instruction in any of this. They already know, without needing to articulate it, that sitting down with a patient and walking through a questionnaire that ends with "you have depression" would destroy the clinical relationship, generate refusal, and probably cause more harm than it prevented. They know this because they live in the same city as their patients, have often known them for years, and understand the worlds into which a psychiatric diagnosis would land. They will continue prescribing antidepressants when they judge it right to do so, but they will do it by staying in the patient's own mesocosmic register, as the psychiatrist did with moner khabar, bypassing the L4 articulation entirely. In LVT's terms: they know that the PRIME-MD system has terrible mesocosmic fit. Dr. Mullick, who does not share his patients' worlds, does not see this.
The third portrait is the most consequential, and the most important for understanding what happens when mesocosmic fit is absent at its most catastrophic. Mrs. Saha is a woman of around forty whose son Neel, then twelve years old, had been struggling at school. Mrs. Saha brought Neel to see Dr. Mullick at an outpatient psychiatric clinic. Dr. Mullick diagnosed Neel with attention deficit hyperactivity disorder (ADHD) and prescribed methylphenidate, Ritalin. The effect on the family was not the one intended. Mrs. Saha's husband and in-laws were appalled. In their view, there was nothing wrong with Neel. If someone in the family was mad, it was Mrs. Saha, and if someone was responsible for Neel's problems, it was her. They turned on her. They pushed her to seek psychiatric treatment herself. Four years after Neel's diagnosis, Dr. Mullick diagnosed Mrs. Saha with manic depressive psychosis. Her husband and his brother began to beat her. Eventually she was exiled from the inner rooms of the house to sleep alone under the stairway.
By the time Ecks observed her consultation with Dr. Mullick, Mrs. Saha had one goal: to persuade the psychiatrist to authorize a brain scan. She was convinced that if she could produce objective biomedical evidence that her symptoms had a neurological origin rather than a psychiatric one, she might regain some standing in the family. She was not taking her medications regularly because they did not help. "I'm having this fear all the time," she said. "I am not able to talk properly with other people." Dr. Mullick eventually agreed to sign the referral for the scan, saying simply: "Come back with the results."
Dr. Mullick later explained the entire trajectory of Mrs. Saha's case in detail. He knew the facts: the ADHD diagnosis, the family's reaction, the deteriorating domestic situation, the beatings, the exile under the stairs. And yet he had no framework for recognizing that any of this had anything to do with what he was doing. He was practicing by the book. He had made the correct diagnoses. He had prescribed the appropriate drugs. The harm that had followed was, in his account, an unfortunate side effect of the family's superstitions and stigmatization of good psychiatric care. He knew the facts. He did not know the mesocosm.
Dr. Sen, by contrast, practiced from a small chamber right at the edge of a slum, a short walk from the outpatient hospital where Dr. Mullick operated. Almost all his patients came from the slum. His own home was nearby. He had known many of his patients for years and often treated several members of the same families. When he considered a severely depressed female patient whose husband was an unemployed alcoholic and who had to maintain the whole family on her own, his refusal to prescribe antidepressants rested on three interlocking reasons. First, the financial burden: drugs bought out of pocket for months or years would strain a household already on the edge. Second, the drowsiness effect: antidepressants would make the woman too sleepy to get up in the morning and go to work, and she was the family's only provider. Third, and most fundamentally: pills could destroy the fragile coordination holding the family together. "It would bring down the house," he said. The most valuable clinical act Dr. Sen performed for this patient left no trace whatsoever in any clinical record. No diagnosis. No prescription. No data. And yet, by the measure of what actually makes life better, it was the right thing to do.
LVT reads these three portraits through the concept of mesocosmic fit. Dr. Sen knows the mesocosm of his patients because he inhabits it: he lives nearby, sees the same families across generations, and understands the economic and social coordinates of lives in that slum. Dr. Mullick does not know the mesocosm of his patients because he does not share it: he travels several hours daily across the city, practices in different clinics for a few hours at a time, and relates to his patients through their symptom profiles, all of which look the same, regardless of what world the patient goes home to. The comparison is not a moral one. Dr. Mullick is a good psychiatrist by all institutional standards. The point is ontological: good clinical judgment requires mesocosmic knowledge, and mesocosmic knowledge requires mesocosmic exposure, actual, metabolic, embodied presence in the world of the patient.
VIII. The Paradox of Invisible Value
This is LVT's central paradox, and it is not confined to clinical medicine. Every form of value theory that exists, economic, anthropological, phenomenological, philosophical, focuses on moments of articulation, exchange, or measurement. They are theories of visible value: value that leaves a trace, value that can be recognized, named, contested, and measured.
David Graeber, in his sustained attempt to develop a general anthropological theory of value, saw that value had something to do with life, with what makes life meaningful and worth living. But he could not answer what life itself was. LVT is, in part, an attempt to supply that answer. Life is L1 coordination. It is the seamless, pre-symbolic engagement of embodied beings with their world across the five mediations. When that coordination is working, when nothing demands attention, when the world fits, value is present in its most fundamental form. And it is precisely then that it is least visible.
The practical consequences of this invisibility are severe, and they operate at every level. In clinical medicine, the interventions that are most visible, the diagnosis, the prescription, the procedure, the referral, are the ones that are counted, funded, studied, and rewarded. The interventions that are most valuable, knowing when not to diagnose, knowing when not to prescribe, supporting L1 coordination rather than disrupting it, are uncountable, unfundable, and largely unstudied. They disappear precisely because they work. Dr. Sen's most important clinical decisions are nowhere in the data. The moner khabar reframing leaves no record of a psychiatric encounter at all.
In public health policy, the symbolic bias runs equally deep. Ivan Illich came closer than most to recognizing it when he noted that the greatest improvements in population health in the nineteenth and twentieth centuries came from sanitation, clean water, and better nutrition, things that people themselves maintained as a matter of ordinary L1 coordination, rather than from the spectacular interventions of high-technology medicine. LVT goes further: the greatest contributions to health are often contributions to the conditions under which L1 coordination can simply proceed, conditions of dwelling, embodiment, and being-with that never appear as healthcare expenditure at all.
In medical anthropology, the bias is equally structural. The tradition founded by Kleinman begins with illness narratives, explanatory models, and the patient's symbolic articulation of their experience. This is already L3. The doctor's response is L4. The entire framework, however sensitive to cultural difference and patient subjectivity, operates entirely within the symbolic register. And when it characterizes the relationship between patient articulation and physician diagnosis as two competing explanatory models, it misses the most important thing that is actually happening: the doctor is not replacing one symbol system with another. The doctor is escalating from L3 to L4, shifting recursivity levels, not substituting frameworks. This has not been recognized in medical anthropology before, and its recognition changes the terms of the critique.
Health economics is even more directly constrained. Its objects of analysis, numbers of consultations, prescriptions issued, quality-adjusted life years, days of hospitalization, are all symbolic data traces that have already undergone at least one transformation away from the lived mesocosm. Health economists are not studying health. They are studying the symbolic record of health encounters. This is not a criticism of their methods within their own terms. It is an observation about what those methods, however sophisticated, structurally cannot see.
Psychiatry's crisis is partly a crisis of mesocosmic fit. Heart rate quantifies well because the phenomenon is largely non-recursive: a measurement does not significantly change the heart rate. Depression quantifies badly because depression is deeply recursive: a diagnosis of depression is itself an event that changes the course of whatever is being diagnosed. The placebo effects, the context-dependence, the shifting efficacy of unchanged drugs across decades, all these puzzles dissolve when it is recognized that any sufficiently recursive phenomenon resists quantification in principle, not merely in practice. Once you can quantify something, it is no longer fully recursive. That is why the most important things in healthcare, the mesocosmic coordination of actual lives, will never show up in a clinical trial.
IX. The Ontological Argument Against Relativism
LVT's insistence that mesocosmic fit cannot be reduced to universal rules, that what makes life better for Mrs. Saha in Kolkata is irreducibly different from what makes life better for a retired schoolteacher in Tromsø who attends an osteoporosis screening she does not feel she needs, inevitably raises the spectre of relativism. If there are no general norms that apply across contexts, are we not saying that anything goes?
LVT's answer is firm: no. And the reasoning is important. LVT is not making a cultural relativist argument. It is not saying that different cultures have different frameworks that are equally valid. It is making an ontological argument: this is what life and coordination actually are. The mesocosm is not a perspective or a framework. It is the field of actual coordination in which living beings exist. What makes something good for Mrs. Saha is not what her culture says is good for her, understood as a symbolic system. It is what actually sustains her embodied, social, material, and spatial coordination, what allows her to live in a way that is not disrupted by avoidable harm.
The difference between Dr. Mullick and Dr. Sen is not that they have different cultural frameworks. It is that one of them knows the mesocosm of his patients and the other does not. One understands what his actions will actually do to the coordination of the life they are entering. The other does not, and produces catastrophic harm as a result. This is not relativism. It is the recognition that good clinical practice requires mesocosmic knowledge that cannot be captured in universal protocols, not because universalism is philosophically wrong, but because the mesocosm is too irreducibly particular for any protocol to anticipate in advance.
The discussions in Tromsø pushed hard on this point. Several participants noted the tension between LVT's emphasis on situational judgment and the Nordic welfare state's commitment to equal care, the principle that everyone in Norway, whether in Oslo or in Kirkenes, deserves the same quality of healthcare. LVT's response is to accept the principle of equality while challenging its ontological foundation. People are not equal because they are interchangeable units in a transactive system. They are equal because each is a fully multimediated living being whose coordination deserves recognition and support across all five mediations and all levels of recursivity. That is a more demanding form of equality, one that requires understanding the mediational diversity of actual lives rather than applying standardized protocols as if that diversity did not exist.
Similarly, LVT does not dismiss the critical tradition in medical anthropology that has exposed healthism, pharmaceutical marketing, and the colonization of everyday life by biomedical categories. But labelling everything "neoliberalism" is itself an L4 flattening move that strips away empirical complexity and makes critique politically pointless. When researchers characterized people experimenting thoughtfully with vitamins and supplements as being brainwashed by pharmaceutical companies, they missed what the data actually showed: careful, intelligent, embodied engagement with the question of what makes one feel well. Slapping an L4 category onto the richness of that engagement is not critique. It is the same move that Dr. Mullick makes: imposing a label and losing the mesocosm.
X. Implications for Research and Practice
If LVT is right, the implications for how we study and practise medicine are significant, but they are not nihilistic. The point is not that measurement is worthless, that trials are useless, or that symbolic articulation should be abandoned. The point is that measurement, trials, and symbolic articulation have a specific and limited domain, their mesocosmic fit, and that the damage comes from extending them beyond that domain without acknowledging the extension.
Heart rate has excellent mesocosmic fit with quantification. The phenomenon itself comes in a form that numerical representation captures well. Blood glucose levels have reasonable fit. Kidney stone removal is a paradigm case: the intervention is discrete, the outcome is measurable, and the phenomenon does not care what it is called. Depression has terrible mesocosmic fit with quantification, because depression is deeply recursive. A PHQ-9 score can only partially represent this. A randomized controlled trial, which averages across recursive effects, cannot represent them at all. And this is not a failure of current trial design. It is a structural feature of the domain. The same logic applies across psychiatry: all of the strange puzzles about why psychiatric drugs seem to work less well outside the trial setting, why their efficacy shifts across decades even for the same drug in the same population, why placebo responses are so large and so variable, all of these dissolve once it is understood that psychiatry is dealing with irreducibly recursive phenomena.
The recognition of mesocosmic fit as the key evaluative criterion opens new questions for research. Instead of asking only whether an intervention produces measurable benefit, we might also ask whether it improves or disrupts L1 coordination. Instead of counting diagnoses issued, we might ask what proportion of diagnoses, in a given context, have genuine L2 ground, whether there was a felt misalignment that the diagnosis articulates accurately and helpfully. Instead of measuring adherence to treatment protocols, we might ask whether the treatment, in this patient's mesocosm, actually improves their life.
For clinical training, the implication is that what is currently devalued, apprenticeship in mesocosmic attention, time spent in patients' communities, the cultivation of the capacity to ask with each patient whether this will actually make their life better, needs to be recognized as the core of good clinical judgment. Being in Tromsø in May, experiencing the quality of the light, the distances, the particular sociality of a city at the edge of the world, generates knowledge about dwelling that no textbook could supply. A week of actual presence in a Kolkata slum would have told any questionnaire designer why their instrument made no sense for this population. That is what mesocosmic exposure means. It is the same for clinicians: you cannot know whether moner khabar will work, or whether pills will bring down the house, without knowing the world your patient goes home to. This is not something that can be reduced to cultural competency training or additional modules in the medical curriculum. It requires a different understanding of what clinical knowledge actually is, and where it lives.
XI. Value Where Life Actually Is
The Tromsø seminars ended without resolution, with discussion still running when the formal session closed, spilling into corridors as the language shifted between English, Norwegian, and Danish. Participants recognized in LVT's framework something their own work had been reaching for without quite finding the words. That incompleteness is appropriate. LVT is not a finished doctrine. It is a set of conceptual tools for a reorientation that has barely begun.
But the reorientation itself is clear. Value is not what is measured, exchanged, represented, or symbolically recognized. Value is what sustains, repairs, intensifies, or improves coordination in the mesocosm. The most valuable health states are those that never need to prove their value. They are working, and so they are invisible, and so they appear in no ledger of healthcare achievement. The most valuable clinical acts are often the ones that leave no trace: the decision not to diagnose, not to prescribe, not to install an L4 category into a life that has no L2 ground for it, Dr. Sen knowing that pills would bring down the house; the GPs knowing that PRIME-MD had zero mesocosmic fit in the lives of their patients; the psychiatrist who framed an antidepressant as moner khabar rather than as a drug for a disorder the patient refused to recognize.
The Nordic welfare state, the most sincere and generous institutional expression of the Enlightenment's commitment to equality and collective provision, is simultaneously the arena in which transactive dualism's limitations are most visible. Because it is so committed to making care visible, trackable, and fairly distributed, it structurally cannot recognize value where it lives most powerfully: in the seamless coordination of ordinary lives that are simply going well. The challenge LVT poses to welfare state medicine is not to abandon universalism, equality, or solidarity. It is to build those commitments on a better account of what life actually is, one that begins not from the transaction, but from the coordination; not from the symbol, but from the mesocosm; not from what can be measured, but from what actually makes things better.
That is a long way from where contemporary healthcare systems stand. But it begins from a recognition that is available to any practitioner who has ever sat with a patient and understood, without being able to document it, that the most valuable thing they could offer in that moment was not a diagnosis or a prescription. It was simply to see the person in front of them, to understand the world they were living in, and to leave that world, as far as possible, intact.
The most important intervention the health system could sometimes offer is the one that does not occur. The most valuable health states are those that never need to prove their value. And any theory of value that cannot account for this, that can only see what is measured, transacted, and symbolized, has already missed the most important thing.
References
Ecks, S. 2022. Living Worth. Durham: Duke University Press.
Jønsson, A.B.R., 2024. Medicalization of old age: experiencing healthism and overdiagnosis in a nordic welfare state. Medical Anthropology, 43(4): 310-323.