13 - CISAS

Transcripción

13 - CISAS

PEOPLE’S HEALTH ASSEMBLY 2
GLOBAL HEALTH WATCH
THE PEOPLE’S MOVEMENT
INTERNATIONAL PEOPLE´S HEALTH COUNCIL
RESEARCH MATTERS
SCHOOL OF MEDICINE – U. OF CUENCA
NACIONAL PEOPLE’S HEALTH FRONT
Siiri Morley,Weej Mudge,Arden O´Donnell, Chris Onken,Tommaso
Pacini,Talya Ruch, Eve Moreau
Spanish Edition:
Reviewers: Arturo Campaña, Francisco Hidalgo.
Translation:: Gaby Mansfield Borrero.
Pre-diagramming :
Edith Valle
CENTER FOR HEALTH RESEARCH AND ADVISORY (CEAS)
LATIN AMERICAN HEALTH WATCH
Alternative Latin American Health Report
© Global Health Watch – CEAS - 2005
Asturias N2402 y G. de Vera
[email protected]
Phone-fax: 593 2 2506175 mobil : 099707682
Quito – Ecuador
Editor general: Jaime Breilh
ISBN-9978-44-258-8
English Edition:
Translation: Gaby Mansfield Borrero.
General Reviewers: Jeremy Ogusky.
Specific texts reviews: Pete Dohrenwend, Brian Epstein, Jessica
Flayer, Diana Grigsby, Jon Hartough, Emmanuel Hipolito, Garrett
Hubbard, Jaime Jones, Lynda Lattke, Ann Miceli, Amber Middleton,
Printed in: Cuenca , Ecuador
"Imprenta Hernández"
Cuenca
Global Health Action is a campaign tool based on the first Global Health Watch, published in July 2005.
The Watch is a broad collaboration of public health experts, non-governmental organizations, civil society activists, community groups, health workers and academics. It was initiated by the People’s Health Movement, Global Equity Gauge Alliance and Medact.
This alternative world health report is an evidence-based assessment of the political economy of health and health care – and is aimed at challenging the major
institutions that influence health.
The Watch is available for free download at the website www.ghwatch.org, and on CD, available by contacting [email protected]. It will be published by Zed
Books in December 2005.
Acción Global de Salud es un instrumento de campaña basado en el Primer Observatorio Global de Salud (Global Health Watch) publicado en julio del 2005.
El Observatorio es una amplia colaboración de expertos, organizaciones no gubernamentales, activistas de la sociedad civil, grupos de comunidades, trabajadores
de salud y académicos en el campo de la salud pública. Fue iniciado por el por el Movimiento de Salud de los Pueblos ("People’s Health Movement"), la Alianza
Global Gauge para Equidad ("Global Equity Gauge Alliance") y Medact.
Este Informe Alternativo sobre la Salud Mundial es una evaluación basada en evidencias de los servicios de salud y la economía política de la salud y constituye un
desafío hacia las instituciones mayores que con influencia en el campo de la salud.
El Observatorio está disponible en el portal www.ghwatch.org y también en formato de CD al que puede accederse contactando [email protected] y será
publicado por Zed Books en diciembre del 2005.
2
AUTHORS
(Order of appearance -edition):
Jaime Breilh; María Eliana Labra; Gerardo Merino; Adolfo Maldonado; Saúl Franco; Mariano
Noriega / Angeles Garduño / Cecilia Cruz; Arturo Campaña / Francisco Hidalgo / Doris Sánchez
/ María L. Larrea / Orlando Felicita / Edith Valle / Juliette Mac Aleese / Jansi López / Alexis Handal
/ Paola Maldonado / Jorgelina Ferrero / Stella Morel; Alex Zapatta; Walter Varillas; Laura Juárez;
Miguel Cárdenas / Luz Helena Sánchez / Martha Bernal; Sofia Gatica / Maria Godoy / Norma
Herrera / Corina Barbosa / Eulalia Ayllon / Marcela Ferreira / Fabiana Gomez / Cristina Fuentes
/ Isabel Lindon; Ary Miranda / Josino Moreira / René Louis de Cavalho / Frederico Pérez; Catalina
Eibenschutz / Marcos Arana; Charles Briggs / Clara Mantini; Elizabeth Bravo; Miguel San Sebastián
/ Anna-Karin Hurtig / Anibal Tanguila / Santiago Santi; Francisco Armada ; Asa Cristina Laurell;
Miguel Márquez / Francisco Rojas / Cándido López; Mónica Fein / Déborah Ferrandini;Mario
Hernández / Lucía Forero / Mauricio Torres. Julio Monsalvo / Frente Nacional por la Salud de los
Pueblos; Miguel Fernández / Sergio Curto; Jorge Kohen / Germán Canteros / Franco Ingrassi;
Paulo Capella / Edgard Matiello.
INSTITUTIONS/ORGANIZATIONS OF AUTHORS
(Order of appearance,edition):
Centro de Estudios y Asesoría en Salud (CEAS, Ecuador); Fundación “Oswaldo Cruz” (FIOCRUZ,
Brasil); Comisión Ecuménica de Derechos Humanos (CEDHU, Ecuador); Acción Ecológica
(Ecuador); Universidad Nacional de Colombia; Universidad Autónoma Metropolitana de
Xochimilco (México); Red Trabajo Infantil (Perú); Universidad Obrera (México); Fundación
Friedrich Eberth (FESCOL, Colombia); Asociación Colombiana para la Salud (ASSALUD,
Colombia); Escuela para el Desarrollo (CESDE; Colombia); Organización de Madres del Barrio
Utuzaingo (Argentina); Universidad Federal de Río de Janeiro (UFRJ, Brasil); Sistema de
Investigación sobre la Problemática Agraria (SIPAE, Ecuador); Defensoría del Derecho a la Salud
(México); centro de Estudios Ibero Hispano Americanos (Universidad de California, EUA);
Instituto de Epidemiología y Salud Comunitaria "Manuel Amunárriz" (Amazonía, Ecuador); Umea
Internacional School of Public Health (Suecia); Asociación de Promotores de Salud "Sandi Yura"
(Amazonía, Ecuador); Ministerio de Salud de la República Bolivariana (Venezuela); Secretaría de
Salud del Gobierno del Distrito Federal (México, D.F.); Universidad de La Habana; Academia de
Ciencias (Cuba); Ministerio Salud Pública (Uruguay); Secretaría de Salud Pública de la
Municipalidad de Rosario (Argentina); Secretaría Distrital de Salud de Bogotá (Colombia);
Consejo Internacional de la Salud de los Pueblos; Frente Nacional por la Salud de los Pueblos
(Ecuador); Universidad Nacional de Rosario (Argentina); Universidad Federal de Sta. Catarina
(Brasil); Colegio Brasileño de Ciencias del Deporte (Brasil).
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4
LATIN AMERICAN HEALTH WATCH
Alternative Latin American Health Report
Jaime Breilh
CEAS (Editor)
5
6
D
E
D
I
C
A T
I
O
N
To all the women of Ciudad Juarez,
which have been murdered since the start of neoliberalism.
May the memory of their violent disappearance
bloom in multiple forms of struggle
against this inhumane and genocidal social system,
that is sold to us as "modernization" and "progress".
RECOGNITION AND WORDS OF GRATITUDE
To the "Research Matters" Program of the
International Development Research Center (IDRC, Canada)
for their support of this project that attempts to show
the World some relevant evidence about the health
situation of Latin America
To the Provincial Council of Pichincha
for their support of the Alternative Reports´
launch and promotion.
To those that made possible this Alternative Report with
their invaluable testimonies of the struggle for health
built together with our people.
More than authors we consider them true allies that have honored
this collective memory about the peoples´health in hard neoliberal times.
For them and the academic and social organizations they represent,
our warm feelings and gratitude.
7
"Our elders taught us that the celebration of memory
is also a celebration of the future.
They told us that memory is not turning our faces and heart to the past,
its not a sterile remembrance of our tears and happiness.
Making memory, they told us, is one of the seven guiding inspirations
the human heart can apply in his life long journey.
The other six being: truth; shame; loyalty; honesty;
self respect and respect to others; and love.
That is why, it is said that memory is always facing tomorrow
and that paradox is what makes possible to avoid
the same nightmares and that to recreate happiness."
Subcommander Marcos, Marzo, 2001
"Science is not a mirror held up to reality,
but a hammer with which to shape it"
Paraphrasing Bertolt Brecht´s
famous definition of Art
C O NT E NT S
Introduction
1. Alternative Health Report: A Tool for the People. Jaime Breilh.
13
Section I:
THE HEALTH DIVIDE:THE PEOPLES’ PERSPECTIVE
Economic Dispossession (Assault) and Health
22
Monopoly, Inequity and Health
2. Neoliberal Reinvention of Inequality in Health in Chile. Maria Eliana Labra.
3.The Right to Health and the Free Trade Agreement with the United States. Gerardo Merino .
Institutionalization of Violence and the Hazards of Hemispherical Security
4. Military Occupation, Militarism and Health. Adolfo Maldonado.
5. Social and Political Violence in Colombia: A Social-Medical Approach. Saúl Franco.
Economic Fundamentalism, Legal Regression,Work Degradation
and the Ecosystem
24
25
34
40
41
52
62
6.The Impact of Neoliberalism in the Health of Latin-American Workers. Mariano Noriega,
Angeles Garduño and Cecilia Cruz
63
7. Floriculture and the Health Dilemma:Towards fair and Ecological Flower Production Jaime Breilh,
Arturo Campaña, Francisco Hidalgo, Doris Sánchez, Ma. L. Larrea, Orlando Felicita, Edith Valle, Juliette Mac Aleese,
Jansi López, Alexis Handal, Alex Zapatta, Paola Maldonado,Jorgelina Ferrero and Stella Morel.
8. Aspects of Hazardous Infant Work in Latin America. Walter Varillas
Life and Health As Commodities
9. Latin America: Neoliberalism And Survival. Laura Juárez
10. Regression of Health in Neoliberal Colombia. Miguel Eduardo Cárdenas, Luz Helena Sánchez
and Martha Bernal.
70
84
94
95
00
11. Destruction of Urban Space: "Concealed Genocide" In the Ituzaingo District.María Godoy,
Norma Herrera, Sofía Gatica, Corina Barbosa, Eulalia Ayllon, Marcela Ferreira, Fabiana Gómez,
Cristina Fuentes and Isabel Lindon.
10
110
12. Neoliberalism, Pesticide Use and the Food Sovereignty Crisis in Brazil.
Ary Carvalho de Miranda, Josino Moreira, René Louis de Cavalho and Frederico Peres
13.The Water Policies in Latin America: Between Water Bussines and Peoples´ Resistance. Alex Zapatta
Cultural Agression, Uniculturality and Health
14.The "Zapatista" Struggle and Health: Cultural Aggression, Discrimination and Resistance as
Triggers of Indigenous Potentialities. Catalina Eibenschutz Hartman and Marcos Arana Cedeño
15. Communication Hegemony and Emancipatory Health: An Underestimated Contradiction (The Case
of Dengue). CharlesBriggs and Clara Mantini
16. Despair in Latin America: Evidences for a psychosocial autopsy of suicide. Arturo Campaña
Biodiversity: Destruction and Monopoly
17. Control Over Nourishment:The Case of Transgenics. Elizabeth Bravo
18. Oil Exploitation in The Amazonic Region of Ecuador: Emergency in Public Health.
118
128
138
139
148
158
170
171
Miguel San Sebastián, Anna-Karin Hurtig, Anibal Tanguila and Santiago Santi
180
Section II:
THAT OTHER HEALTH POSSIBLE
Action from Democratic States
19. Health Program Achievements of the Bolivarian Venezuelan Republic. Francisco Armada
20.The Health Policy of the Government of the City of Mexico: for the Social Rights and
the Satisfaction of Human Necessities. Asa Cristina Laurell
21. Cuba Breaks through the Siege of the Imperialist. Miguel Márquez; Francisco Rojas; Cándido López
22. Uruguay: Community Participation in Health and the Role of Epidemiology. Miguel Fernández
and Sergio Curto
190
192
193
200
206
214
23. EReal Equity in the State´S Supply of Public Health:The Target of a Democratic Municipal Government.
Mónica Fein, Déborah Ferrandini
220
24.The Experience of Bogota D.C.: A Public Policy to Guarantee The Right To Health. Mario Hernández,
Lucía Forero, Mauricio Torres.
226
Action from the Peoples
242
25. Health: A Human Right. Frente Nacional por la Salud de los Pueblos.
26. Self Determined Peoples´ Proposals on Local Knowledges and Doings. Julio Monsalvo.
27. Work, Health and Self-Management an Experience of Articulation Between Self-Managed Companies
and Public University in Argentina. Jorge Kohen, Germán Canteros, Franco Ingrassia.
28. Sports and Human Liberation. Paulo Capela and Edgard Matiello.
243
248
258
270
11
Introduction
1
Alternative Health Report :
A Tool For The People
Jaime Breilh
Health reports are supposed to be knowledge and monitoring tools of public health (collective health) for the promotion and defense of life. If their information is realistic, they make evident the deep wounds of inequality in peoples’
current health situation.
Unfortunately, most of the renowned reports on regional health, ones that
are amply disseminated through institutional health offices, allow neither a clear
understanding of the profound deterioration that characterizes Latin-American
peoples’ health, nor of the relation between that decline and the unprecedented
wealth concentration that our societies experience. Despite being elaborated in
fancy editions and supported by important data bases, they are not conceived to
unveil reality, and with the mass communication media that masks or conceals
evidence of political and social inequity, official health reports hide the devastating effects provoked by market fundamentalism in the quality of life of our people. Likewise, human and health rights have been converted in the last two or three decades into commodities. So beyond their authors´ goodwill, and regardless
of their frequently robust solid mathematical and formal fundaments, official
health information and conclusions are commonly restricted to a logic that disguises reality. From a positivist paradigm, they obscure the health situation, since they magnify insignificant average health outcomes of national programs, while concealing major problems, or presenting these problems in a manner impossible to determine their structural origins.
Several examples might help us appreciate these types of fallacious constructions, which mislead our interpretation of the true health picture of our re13
INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA
gion.To illustrate our argument we could mention the
fact that official health registers of countries with growing inequities and social abysses are full of statistical
tables and graphs, showing a discrete improvement of
various average health indicators, such as mortality in
early age. In the eyes of the specialist these do not
constitute any proof of sound improvement of children’s living and health standards, as these averages
can be found stable or even declining slightly despite
aggravation of living quality contrasts among regions
and social classes in many places. Further, these discrete improvements can induce the false image of sustainable health development. For this reason, I have in
the past thoroughly analyzed these types of fallacies in
official reports [Breilh, 1990]. As I have frequently argued, it is not intellectual mercenaries –like Carlos
Montaner- who perform these calculations. They are
well-intentioned technicians, even some with progressive ideas, who by applying a lineal reductionist methodology and thus end up contributing to the reproduction of hegemonic interpretations of our reality. Just
to reaffirm our line of reasoning we could add another
illustrating finding. The so called human development
index (HDI) of the United Nations (UN) has been
used to provide a mathematical image of social wellbeing, in manifestly unfair countries. That amply cited
index elaborated by the United Nations Development
Program (UNDP), including compound indicators that
portend to reflect according to its authors "a long
healthy life, knowledge and a decent living standard"
[PNUD, 2001], showed an ascending trend, suggesting
a significant human development improvement
(r>0.94; p=0.00) in countries such as Argentina and
Ecuador from the years 1984 to 200, precisely when
the neoliberal model was unmercifully affecting their
peoples, provoking a clear social decline and massive
malaise, all of which operated as a source of growing
dissatisfaction that triggered violent outbreaks and the
overthrowing of presidents blamed for introducing
14
these voracious policies and further fostering inequality [Breilh, 2002].
Certainly, in the last few decades of neoliberal
economic policy, the magnitude of impoverishment
and expansion of social contrasts often rule out those
discrete statistical maneuvers, and data cannot conceal
social corrosion. However, when deteriorated health
indicators are registered, these appear disconnected
from the social unjust relations that generated them.
Correspondingly, the categories and variables chosen
to picture health, and the way they are associated, dissolve systematically their structural determinants,
such as economic concentration and social exclusion,
institutionalization of repressive violence and aggression, legal deregulation and reduction of public norms
for social security, which leaves citizens and working
population unprotected and at the service of greedy
labor arrangements, loss of human rights and their
transformation into merchandise, cultural aggression
and imposition, and big business destruction of biodiversity and appropriation of vital resources such as
water, energy, genetic resources.
The Alternative Health Report in Latin America
thus recovers these types of categories and relations
that tend to be overlooked by "dominant science", in
order for epidemiological analysis to become impregnated with reality, and so that our people can benefit
from an analytic tool which penetrates the roots of
their suffering, and allows for projecting, on reliable bases, a strategy to transform an inhumane and pathogenic social order.
Alternative Reports´ Brief History
Starting with the recognition of the insignificant
health achievements in the world population’s health
in the last two decades, voices arouse demanding a different type of health monitoring and reporting system.
Observatorio Latinoamericano de Salud.
Social forums demanded a focus on the dramatic
health problems of the socially excluded, the workers
and the marginal urban masses thronged in cities, the
rapidly increasing rural populations submitted to extreme impoverishment, and above all, that they be aided by dependable organizations not representing the
biased perspective of the powerful.
To begin with, specialized scientific organizations
with research experience were summoned. Facing the
middle of the 1980’s, different movements of civil society initiated discussions on the necessity to inject
"reality" into international health policies and information required to evaluate the situation of peoples’
health. Following several preparatory events held in
different places of the World, the First Peoples’ Health
Assembly was convoked in Bangladesh in December of
2000 with the participation of 1.500 delegates from 75
countries.They represented civil society organizations,
nongovernmental organizations, social activists groups,
health professional associations, and academic and research nucleuses.The main issue of the first assembly,
still envisaged as an urgent need, was, "listening to the
ignored".
Within this fundamental meeting the well-known
"Declaration for Peoples’ Health" emerged, which
summarizes the principles of our health struggle.
Briefly, it is to fight for the highest level of human
health under equitable access to care and preventive
resources; the conquest of an integrated and democratic health system, with solid high-quality primary
care; to promote the right to health, as such and not
as a commodity; the implementation of an integral system conducted by collective and communitarian organizations to their own benefit; and finally the ethical
and sanitary responsibility of understanding health development as a process determined by socioeconomic, cultural and political conditions, and not only by
the provision of medical care services, which hitherto
continue to be a privilege of affluent social groups. In
view of these antecedents, the organization of the Second World Assembly was made possible.
This urge for an alternative analysis to the
World Health Organization’s "World Health Report"
was proclaimed. There was a clamor for a type of report to be issued independently of official power
structures and not influenced by the agendas of international cooperation agencies. The need was for a
tool to assist the Peoples Movement on views of
health, an instrument for their struggle for equity and
human/social rights, and the need to monitor international health institution policies. In short, a tool for
social justice in the health field. The idea of an alternative report culminated in the initiative of Global
Health Watch.
The Watch has been coordinated by internationally renowned organizations, such as "Global Equity
Gauge Alliance" and "Medact", and has been projected
in working groups throughout all the continents. A
whole set of organizational efforts will now converge
in the introduction of a First World Alternative Health
Report, during the Second Peoples’ Health Assembly
in Cuenca, Ecuador, on Wednesday, July 20th of 2005,
before delegations of all continents, and simultaneously echoed in ten cities throughout the world.
The complementary publishing of a Regional Alternative Report for Latin America was decided on
this year, not only for the fact that the Second Assembly is taking place in a Latin-American country, but
also in recognition of valuable contributions made by
this region´s researchers and health organizations in
innovational research and successful alternative health
programs. The International Committee and Global
Health Watch designated the Center for Health Research and Advisory of Quito (CEAS) as the central
organizer and editor of the report. CEAS is now celebrating 25 years of scientific production dedicated to
the development of critical thinking, and the fostering
of emancipatory health programs.
15
Equity Forsaken:
Conventional Reports Methodology
The flaws of conventional reports cannot be fully
understood solely from an ethical perspective. Though
a number of conservative governments conceal inefficacy, or even corruption with biased statistics, the problem is that even well-intentioned experts generate
flawed reports, as I have noted above, not because
their calculations are mistaken in themselves, but because biased analysis models are applied, which merely
display health outcomes, without evidencing the social
processes that generate them, or substantiating the
power relations that provoke scarcity and suffering in
health and constitute the very barriers hindering the
achievement and recognition of human rights.
How can we understand the fact that conventional health reports comprise a form of renunciation of
equity, when they occasionally refer to inequitable
conditions? Actually, the construction of health evaluation or epidemiological models is based on concrete scientific ideas organized under specific paradigms.
Experts who design and plan health reports, whether
they are cognizant of it or not, apply specific interpretative frameworks or paradigms. What does this signify? On assembling diagnoses, we use concepts, we
make viable or prioritize various facts and relegate others, we choose several variables and not others, we
demonstrate relations among variables in a particular
manners, and we recognize certain values. This set of
methodological decisions and operations form a matrix from which we describe and interpret reality. Here, I will not dwell upon an explanation of the interpretative models commonly used to describe health, as it
is sufficient to recognize that lineal and reductionist
(positivist) methodologies have posed an extremely
negative influence on health thinking.
Elucidating positivist operations to readers not
familiar with the debate on scientific ideas, epistemo16
logical analysis of scientific work, is not an easy task to
be undertaken within this short paper. But some basic
reflections are indispensable. In the first place, positivism is neither the only paradigm, nor does it always
appear in evident visible forms. Nevertheless, it is important to highlight the interpretative consequences
of its application and its conservative nature, which
contradict the views of the Peoples Movement. The
positivist approach, as rigorous as it appears, presents
facts in a fragmented or disconnected manner that separates health phenomena from its social historical
context.Variables are placed out of context, reality is
atomized in many variables or factors, all of which are
separately assumed as causes of illness, although detached from the processes that explain their appearance and movement. In sum it is the outlook of a reality
crushed into pieces, mechanically associated.
The Analysis of Inequality Without Inequity
is a Flaw
To the ruling groups, the fact that health report
information is shown in pieces deprived of their social
origin is not a problem. On the contrary, it is a desirable procedure. This type of diagnosis dissolves historical health determinants and produces the illusion
that illness factors can be rigorously dealt with one by
one, when in fact, those fragmented pieces of reality
cannot be assembled in an integral explanation of societal health, and thus the image we are able to elaborate from that viewpoint, reality in fact, ends up being
veiled and obscured in statistical tables and sophisticated mathematical models.
On the other hand, people interested in understanding thoroughly their reality in order to be capable
of transforming it, must overcome this reductionism
and specific interpretation of problems. They must
emphasize the slants that constitute the health situa-
tion core and never neglect the association of those
problems with wide-ranging social relations derived
from the power structure and social domination relations which characterize hierarchical societies such as
ours.
Referring to inequality and allowing tables and
indicators to pervade our experience on urban-rural
social inequality, among "social strata" and genders,
etc, may result in solely rhetoric if we fail to connect
knowledge of the mentioned inequalities with studies
on inequities and the specific social contrasts that generate them. Hence, usually displaying inequality numbers without an inequity analysis is an illusion, and an
operation perfectly acceptable to those not interested
in changing the world, but merely modifying its most
negative and evident facets. The dissemination of superficial inequality indicators does not threaten the
hegemonic health prescriptions of the powerful.To the
contrary, their acknowledgment of certain social differences can convey an image of magnanimity. On the
other hand, the announcement of clearly unfair social
relations and the existence of an economical, political
and cultural system of dominance, that operates as a
fundamental health determinant is for them intolerable, since it discloses the essentially inequitable nature
of our societies, and points to real changes that imply
demolishing those domination structures.
Within Latin America, perhaps on account of historical proximity of progressive scholars and researchers with grassroots struggles, a renewed view on
collective health emerged as early as the 70’s in public
health writings. Epidemiology, for instance, and the
consequent health diagnoses and reports of this discipline.Accordingly, in conjunction with the activation of
a Latin-American Movement named Social Medicine, at
present known as Collective Health, renovation began
concerning studies on the evaluation of health1, which
several authors appreciate as one of the most vital
movements toward science oriented in social justice
and rooted in a creative renovation of health paradigms [Waitzkin; Iriart; Estrada & Lamadrid, 2001].
In recent years, signals of openness to a social
approach based on health determinant processes have
resounded in First World academic nucleuses and international agencies. Events such as the "Conference
on Health Impact Assessment and Human Rights" at
the Harvard School of Public Health2, where attention
was drawn to the need to open health interpretations
to socioenvironmental determinants, and further link
them to human rights and inequity; or the configuration of the Commission on Health Social Determinants by the WHO3 in March of this year, with the express mandate to surmount approaches restricted to
particular illnesses, and tackle general problems derived from social inequality, confirm a reaction against
positivist schemes for which Southern movements have called attention for decades.
In the last Health Research World Forum4, the
existing distortion of the health research priorities
allocation system was discussed a propos the "10/90
research gap", since only 10% of resources are assigned to the bulk (90%) of peoples’ health problems.
The "10/90 gap" has been proclaimed as a result of
commercial reasoning that prevails within institutions
that conduct health research investments and have the
economic power to assign resources.The minor significance conceded to problems affecting social masses
depicts the implicit recognition that their research is
1. In the Internet site of the Health Sciences Center of the University of New Mexico (http://hsc.unm.edu/lasm), a bibliographic database may be found on the scientific production of Latin-American Social Medicine and its innovating view.
2. Harvard School of Public Health (2002). Conference on Health Impact Assessment and Human Rights. Boston, august 16-19.
3. OMS - Comisión sobre Determinantes Sociales de la Salud (http://www.who.int/social_determinants)
4. Foro Global de Investigación en Salud. México, 16-20 Noviembre del 2004.
17
not considered as "highly profitable". Within the same
event, an international commission put forward a
"combined approaches matrix" [Ghaffar; De Francisco;
Matlin, 2004] to prioritize investments in research based evidences. The flaws of the model depicted cannot be fully discussed here; I can only underline that,
albeit the cited matrix proposes a broader analysis
field that acknowledges the impact of macroeconomic
policies, the health system, and other sectors such as
labor, legal standards, education, and ecological problems as health determinants. It nevertheless reproduces the conventional reduction of interventions to the
institutional sphere, without putting forward any serious critique of the consequences of social dominance and the associated inequitable power structure.
The Alternative Report:
Critical Thinking and Liberating Action
The Alternative Health Report for Latin America
presupposes a critique of the pathogenic effects of social inequity and the need to transform the prevailing
power structure as a way to achieve a healthy and dignifying quality of life for our people, and as a basis for
sustainable institutional and technical changes in the
health field. Thus, the construction of an authentic alternative approach presupposes a critical knowledge
paradigm and transforming view of intervention in
health.
To fulfill its commitment, in its first part the Alternative Report penetrates the devastating effects of
the economic accumulation model applied within Latin America in the last decades. The idea is not merely
to speak of globalization, as there is no contemporary
forum in which problems are not interpreted and justified alluding to globalization, as an issue of worldwide economic and market system relations.The idea is
to visualize the new characteristics of our social sys18
tem which distinguish it from other epochs that have
immense weight and influence on health.
In late capitalism, the technological basis of digital communication and other technical resources are
crucial. Even if it is important to acknowledge the significance of this technological revolution, we must not
disregard the fact that the roots of present social domination reside rather in the structural processes of a
new capital accumulation system, defined by Harvey as
the accumulation by dispossession [Harvey, 2003]. According to this author, contemporary capitalist logic
not only exerts itself through the extraction of surplus
value from workers and the traditional market mechanisms, but it now depends heavily on truly predatory
forms of practice, fraud and violent exaction, which
are imposed by taking advantage of inequalities and
power asymmetries to dispossess weaker countries or
vulnerable groups directly.
Case studies rendered throughout the different
chapters of section I ("El Modelo de Acumulación por
Despojo y la Salud" - Accumulation Model by Dispossession and Health) examine the extreme impoverishment of peoples, the destruction of their living conditions, and the deterioration of environmental integrity.
They illustrate how the logic of large corporations
operate, whose profit increases demolishing living
conditions, while social mobilization struggles creatively to defend human rights and health. Distinct chapters interweave to illustrate the expansion of monopolies that permanently reinvent mechanism of social
and cultural subordination and inequity; the institutionalization of violence; the cases of deregulation of labor and social protection laws, with the ensuing degradation of working and living conditions; the gradual
transformation of human rights into commodities; the
cases of cultural aggression; and the varied manners of
biodiversity destruction.
In section II ("Esa Otra Salud Posible" - That Other Health Which is Possible), a more optimistic or
progressive side of Latin American health is presented
regarding the advances accomplished by national and
local governments of humane social nature, in spite of
the previously cited adverse conditions. Workers’ victories in defense of justice and living conditions are
documented and illuminated, like the case of recuperated factories in Argentina and successful self-managed community driven proposals are explained. Even
fields conventionally considered as tangent to health
are taken into account, like the case of emancipatory
sports programs in Brazil. And finally, experiences of
intercultural relations that tender bridges among peoples’ different knowledge bases and the liberating academic knowledge that is resultant to this interchange
is illustrated.
Creating this report from design to completion
in a short five month period, with Spanish and English
versions simultaneously prepared, CEAS (Health Studies and Advisement Center, Quito-Ecuador) defined a
fast moving strategy, identifying key issues and calling
for the contribution of specialists and social organizations with which it had developed fraternal work during its two and a half decades of institutional struggle
for collective health. Overall, our summon was positively responded to by 60 individual authors from ten
separate countries, and more than 30 organizations of
the region (among the most representative academic
nucleus or peoples’ organizations). Obviously, an effort
of this magnitude could not achieve in such a short time all the desirable characteristics of a complete Latin American Report; however, its representativeness
and authenticity are supported and justified by the
scientific and political relevance of the work its authors and their organizations have accomplished. The
Alternative Report coming from such a diverse set of
experiences attains unity in the emancipatory nature
of their resistance against the irrational, genocidal, and
inhumane social system in which we live.
We sincerely hope that the Alternative Report
will accomplish the two basic goals that inspired its devising: to become part of our collective memory in the
progressive sense that the celebration of memory acquires when, as Subcommander Marcos stated, memory faces tomorrow and "…that paradox makes it
possible to avoid the same nightmares and thus recreate happiness"; and secondly, to make clear the difference that Brecht established between conservative
rhetoric and emancipatory cultural works: not being "a
simple mirror held up to reality but a hammer with
which to shape it".
The Alternative Health Report reaffirms our
right to build our collective memory, without mediations of the powerful, as the peoples´ memory is only
liberating when it registers the substantial side of their
pains and happiness, when it nourishes and celebrates
a different tomorrow.
REFERENCES
●
BREILH, JAIME & AL (1990). Deterioro de la Vida: Un Instrumento para Análisis de Prioridades Regionales en lo Social y la Salud.
Quito: Corporación Editora Nacional.
●
BREILH, JAIME (2002) El Asalto a Los Derechos Humanos y el
Otro Mundo Posible. Quito: Espacios, 11: 71-82.
●
HALL, GILLETTE; PATRINOS,ANTHONY (2005) Pueblos Indígenas, Pobreza y Desarrollo Humano en América Latina. Washington: Banco Mundial.
●
GHAFFAR, ABDUL; DE FRANCISCO, ANDRÉS; MATLIN, STEPHEN (2004) The Combined Approach Matrix: A Priority Setting
Tool for Health Research. Geneve: Global Forum for Health Research.
●
HARVEY, DAVID (2003) The New Imperialism. Oxford: The Oxford University Press
●
WAITZKIN,HOWARD; IRIART, CELIA; ESTRADA, ALFREDO;
LAMADRID, SILVIA (2001) . Social Medicine Then and Now: Lessons from Latin America. American Journal of Public Health, October,Vol 91, No. 10 1592-1601
19
Section I:
THE HEALTH DIVIDE:
THE PEOPLES’ PERSPECTIVE
(Economic Dispossession -Assault- and Health)
Monopoly,
Inequity and Health
2
Neoliberal Reinvention of Inequality in
Health in Chile1
María Eliana Labra
The state of compromise and health policies
Under a conservative pressure in 1924, Mandatory Workers’ Insurance
(Social Security) was introduced in Chile. It was designed to protect the "manual" workers (blue-collars) of the formal market against the risks of old age, disability and illness. Consequently, the more affluent sectors and the public and
private employees (white-collars) were left with pension funds for individual capitalization.
Social Security offered ambulatory medical attention and hospitalization care in establishments of the so called Public Charity, a colonial institution for indigents. In terms of Public Health infrastructure, these programs were implemented by diverse state jurisdictions. The Armed Forces had (and still has) its
own prevention and assistance regimes. Private medicine lacked gravitation and
its later development was very limited.
The institution of Social Security in Chile coincides with the change from
oligarchy to the Modern State and the promulgation of the Liberal Constitution
of 1925, which assured civil, political and social rights, and established as a duty
of the State, maintaining a national public health service. This determination was
influenced by the Rockefeller Foundation and the Pan-American Sanitary Office
who felt that Latin-American governments should organize public health in a
centralized way, headed by a public health specialist.
By the end of the turbulent 20’s and the beginning of the 30’s, a political
party system conformed by right, center and left-wing forces took shape. These
were governed by means of delicate compromise arrangements until the brutal
rupture of 1973. From one perspective, the parties constituted the axis of the
23
State-Society correlation and social institutions which
overlapped with them; from another perspective, the
class bias, which differentiated them, left its mark on
social policies, especially those related to health.
The discrimination between workers and employees, instituted with Social Security, gave rise to a historic struggle, led, since the 30’s, by the socialist doctor Salvador Allende. He was minister in the social government era (1939-1941), notable parliamentarian,
and President of the Republic (1970). Allende pursued
the integration of the social previsional funds or the
unification of all health services in one institution, and
the rectification of geographical and class disparity.
Allende believed that health iwas a universal right and
that health status is determined primarily by factors
such as proper wages, housing, nutrition, education, leisure and culture [Allende, 1939].The disputes around
these issues emerged strongly during the "Socialist Republic" halfway through 1932.This occurred when progressive currents strove for socio-economical transformations along with medical groups that, influenced
by the soviet health system, defended the dissemination of "sanitary factories" ("usinas") throughout the
country. The objective was to form a universal, integrated, efficient and humane organization, directed by
a "technical commanding group", with centralized planning as its main instrument.
In the health sphere, these events re-created the
historic struggle between three ideological currents
that divided professionals and whose vestiges still persist: the right or conservative wing, defender of state
medical assistance for the poor and the needy; the
center wing, favorable to the maintenance of provision
of medical assistance separated from public health; and
the left wing, partisan of a unique system of health, integrated and universal, inspired by social medicine
principles. In the interim, the legal reforms of the system of social protection resulted in a hybrid of these
positions, due to the State of compromise.
24
The demands for more equitable social policies
were partially acknowledged when, after eleven years
of legislative transaction, the unification of the pension
funds brought about the modification of the regime of
benefits of Social Security in 1952. As part of the same
law, by means of parliamentary artifices, an article was
implemented that merged all the medical and hospital
services and the jurisdictions of public health of the
country in one institution – the National Health Service ("Servicio Nacional de Salud", SNS), inspired by the
National Health Service (NHS) created in 1948 in capitalist England, financed by the Treasure, and whose
coverage was universal. Nevertheless, this intention of
imitating the NHS was abridged as the SNS remained a
part of the Social Security and, as such, was subjected
to the same financial limitations, with restrictive coverage for the urban workers. Consequently, the relationship of the conjuncture revealed the power of the
landowners (right-wing) system upon impeding the inclusion of peasants, and of the center wing on opposing
the leveling of workers and employees. Thus, the health
coverage was preserved for the urban workers with
their dependents and for indigents who could certify
this condition. In spite of this, it should be stated that
the SNS was a pioneer in Latin America, a paradigm for
its institutional engineering, its technical competence
and territorial organization in "health zones"; for the
adoption of new planning and programming methods
and for the excellence of its leading members (all of
them educated at the Sanitary School, created in 1943).
In addition to these events, the foundation of the
Medical School in 1948 had an effect (presided over by
Allende). This institution gained monopolistic representation of the profession, the exclusive ethical pier
control and the rest of prerogatives of public status,
turning into a crucial national and sectorial actor. Attributable to this corporative power, doctors were
able to negotiate a privileged statute by which they
were converted into civil servants.
In 1960, the population reached 7.4 million, with
72% of the work force earning less than minimum wage. As far as the SNS, it had 95.5% of the beds in the
country and took care of 70% of the Chileans, which
illustrated that many people without legal rights used
these services as recourse to the indigence file.
The absence of a solution to the problem of universal access to the SNS and the chronic financial deficit provoked several disputes until 1968, when the
democratic Christian government, with the socialists’
support, decided to create a Unified Health System.
Nonetheless, the legal project was mutilated due to a
range of pressures: the employees’ associations insisted on conserving the schemes of free election administered by the National Medical Service for Employees ("Servicio Médico Nacional de Empleados", SERMENA), established in 1942; the doctors were looking
for an increase of their wages by way of the expansion
to private practice, in agreement with the continental
movement in favor of a higher status for the profession; the opposition parties viewed in this conflict the
opportunity to confront the government. As it was
not possible to reach more generous political agreements, the outcome was a very peculiar law that inserted the regime of the SERMENA (and its scanty resources) in the SNS only for employees,. These employees thus had access to the public services through
the professional’s free election and received co-payment for medical action, but in a different schedule
from traditional beneficiaries. In sum, within the SNS
two forms of management were instituted, removing
the existent unity and reinforcing the discrimination of
class, without solving the financial issue.
In 1971, president Allende raised the issue of the
Unified Health System ("Sistema Unificado de Salud",
SUS), whose design comprised fiscal financing, universal coverage, communitarian participation, equity in
the access to and quality of care, and a set of redistributive social policies. Even so, in the prevailing envi-
ronment of ideological polarization in 1973, the SUS
was blocked by the opposition, causing the Medical
School’s adherence to the President’s resignation.
The brutal military coup of September 1973
abruptly terminated the democratic path that had
been expanded throughout the country for 140 years.
It aborted any progressive initiative, sank the nation in
terror, and annihilated civil, political, and social rights,
arduously conquered, sowing insecurity among citizens.
The reforms of authoritarian neoliberalism
The pioneer neoliberal experiment undertaken
during the dictatorship in Chile, under the dogma of
market primacy and the failure of the Keynesian or
protector State, was formulated and implemented in a
short time (1978 – 1981) by the hegemonic nucleus
composed of Pinochet and economists that derived
from the Chicago School. In the social field, the proposition of "modernization" in prevention and health
relied on the active participation of the Medical
School, at that time in the hands of an ultra right-wing
group that had taken it by assault.
In the area of Prevention, the funds accumulated
by civil workers were transferred to lucrative mercantile societies – the Administrators of Pension Funds
("Administradoras de Fondos de Pensión", AFP). In
spite of the serious restrictions imposed by the international crisis of the time, the new system was feasible
through the massive transference of resources from
the social sectors to the Administrators of Pension
Funds and the decree of a mandatory 10% share of the
taxable rent, from which the employers and public
treasury were exempted. It is important to note that
via democracy and not by force, several countries are
adopting the Chilean model, despite its proven promotion of inequality.
25
Along with the privatization of prevention, there
was freedom to introduce reforms in the health sector, which totally switched directions, institutionalizing
the principle that inequality is a "natural" phenomenon
that can only be corrected with free mercantile competition along with individual endurance (meaning payment capacity).
Following this premise, the neoliberal changes in
health can be summarized in seven points: (1) the extinction of the NHS and the creation of the National
Health Service System ("Sistema Nacional de Servicios
de Salud", SNSS), regionalized in 27 services; (2) the separation among normative functions (Department of
Health), executive functions (regional services), and financial functions; (3) the formation of the National
Health Fund ("Fondo Nacional de Salud", FONASA), a
very important autonomous ministerial entity, but subordinated to the economical area, in charge of the financial administration and the free care choice; (4) the
introduction of a lucrative segment of health plans,
non-existent at the time, and mediated by the Health
Prevision Institutions ("Instituciones de Salud Previsional", ISAPRES); (5) the municipalization of the Primary
Care (6) the institution of a mandatory 2% contribution from the taxable rent for health, raised to 7% since 1987, from which employers and people affiliated
with the Health prevention Institutions were exempted; (7) the stratification of users, according to their income as a way of assigning them to different public services, under two modalities: institutional and free choice, since 1987 as well.
These changes aimed to institute in Chile different medical systems for the rich and for the poor. At
the same time, they produced a hecatomb expressed
by way of fragmentation, segmentation, and disorganization of services, devastation of hospital infrastructure, congestion in attention and, finally, workers’ demoralization due to dismissal, wage depreciation, loss of
rights and political persecution. The neoliberals also
26
fought against the associative world under the pretext
that it inhibits free competition. In this fashion, the ancient Medical School and the rest of professional colleagues had their privileges annulled, and were obliged
to turn into "labor-union associations" of voluntary affiliation. The traditional prominence of the institution
was affected by these facts and by the emergence of a
new powerful actor with whom it still rivals when it
refers to deciding: the Association of Health Provision
Institutions.
Hope and uncertainty in the "neodemocracy"
The "modernizations" just reviewed still persist,
in spite of the numerous measures democratic governments have taken since 1990, which tend to correct the problems mentioned in relation to health
and to attenuate the social inequalities in general.
As indicated by the Census of 2002, the Chilean
population reached 15.1 million, with an urban concentration of 86,5%. Analphabetism is estimated at
4%. The urban coverage of the water network is 100%
and that of sewers, 91%. It is important to mention
that poverty was 38,6% in 1990, and decreased to
18,8% in 2003. However, the concentration of income
is elevated: 10% of the rich retains 41% of revenue,
while 10% of the poor, barely 1.5%. This disparity was
confirmed in 2003 by the Human Development Report of the PNUD, indicating the distribution of family
income is 56.1 in Chile (measured with the Gini Index). With regard to the basic health indicators, the
Census of 2002 displays the following data: general
mortality rate per thousand inhabitants – .5.,3; maternal mortality per ten thousand inhabitants born alive –
1.7; infant mortality per thousand born alive – 8.3;
mortality in children younger than five per thousand
born alive – 10.2; general rate of fecundity – 2.2. These indicators are considered very good for an under-
developed country. It is on account of this that, despite the unequal distribution of income, Chile has been
classified in the PNUD Report as having a high HDI,
the 43rd position, with a coefficient of 0.831.
In the health system, the assistance and sanitary
coverage is currently as follows: the ministerial programs of public health reach 100% of the population;
public services offer medical and hospital care to
67.5%, and the Health Provision Institutions (ISAPRES)
cover 18.5% with their 16,000 health plans. The rest
is taken care of in the Armed Forces, Police or private
institutions [Ministerio de Salud, Fondo Nacional de
Salud, 2004]. On the subject of available hospital beds,
81.6% belongs to the SNSS and 18.4% to the ISAPRES.
These numbers illustrate that, regardless of authoritarianism and its getting out of hand; the role of the State in health continues to be important.
In the SNSS, two aspects of equity deserve special attention: the stratification of access and the financing. Concerning access, and based on the premise that every person is equal in the eyes of the market, the legal distinction between workers and employees was eliminated; but, all at once, the free election
co-payments were extended to the institutional care
system. In this modality, the co-payments depend on
monthly income and, for this, users are classified in this
manner: Group A: indigents – exempted; Group B: income close to 200 dollars – exempted; Group C: income between 200 and 300 dollars – they pay 10% of
the tariff; Group D: income superior to 300 dollars –
they pay 20% of the tariff. The admittance to groups A
and B is done by means of an indigence certificate. The
classification in groups C or D varies in proportion to
income and the number of dependents. In the last few
years, free consultation in Primary Care included users
who were older than 65 and those with catastrophic
illnesses. The private individuals that require assistance have to pay 100% of the total cost of the contribution, in accordance with the tariff annually established
by the Department of Treasury and the National
Health Fund (FONASA).
With reference to the distribution of users,
70,5% is concentrated in groups A and B, where the indigents are located. This is critical, as it was shown,
18% of the population is poor, and just 4% of it is indigent. That is to say, irrespective of the efforts of FONASA to eradicate the "false indigents", the majority
of the people prefer to assume a stigmatizing condition than to pay for attention.
Regarding free election, the co-payments cover
the difference between the improvement allotted by
FONASA and the cost of contributions, which vary in
line with their complexity. To this purpose, levels of attention 1, 2 and 3 were created; with Level 3 being the
one which best disburses to lenders, but the most expensive for users. It is no surprise, then, that the later
concentrates 98% of the doctors and 75% of all the
professionals [Ministerio de Salud, Fondo Nacional de
Salud, 2004].
In relation to the financing, the idea of neoliberals was that the contribution of the State to health
would become marginal as families progressively assumed its cost. In fact, from 1974 to 1989, the fiscal resources decreased 49% while the quotations increased
180% and the co-payments 50%, being that these represented, in 1989, 15% of the budget. Nevertheless,
this tendency has reverted. In 2002, the composition
of health expenditure was the following: fiscal contributions – 51%; quotations – 34.4%; co-payments –
8.4%; other earnings – 6.2%. These numbers also demonstrate that the co-payments did not have the expected impact, as their participation consisted of only
6.5% on average, between 1990 and 2002 [Ministerio
de Salud, Fondo Nacional de Salud, 2004].
It is essential to reiterate that the current form
of financing is characterized by two negative characteristics: on one hand, solidarity is very limited and circumscribed to the affiliates of FONASA, who are the
27
ones with less resources, and, on the other hand, by
extreme inequality in the health system as a whole, given that the beneficiaries of the ISAPRES do not contribute to FONASA. As they are the ones who possess the highest income, an effect named "descreme"
("whipping of the cream") is produced in the financing
of the public system. This occasions a series of distortions, mainly if we consider that public services take
care of 65.5% of the population and they also receive
those rejected by the ISAPRES (the elderly, the chronically ill, those who need complex treatments, etc.),
while these just cover 18.5% of the population. To
exemplify what was stated: 66,5% of the medical
hours corresponds to ISAPRES attention; FONASA
retains 54% of quotations, the ISAPRES, 46%; the annual per capita expenditure of the public sector is
equivalent to 210 dollars, the ISAPRES reach the 500
dollars; [Ministerio de Salud, 2001] in 1999 the country assigned 6,5% of the Gross National Product to
health, from which 2,5% was the share of the public
sector and 4%, of the private sector [González-Dagnino, 1999].
The new reform of health in perspective
On arriving at the government in 2002, the current president, Ricardo Lagos, undertook the task of
accomplishing a reform guided by five principles: the
right to health, equity, solidarity, efficiency in the use of
resources and social participation. To this end, the
subsequent projects of law were elaborated: Sanitary
Authority and Management; General Regime of Guaranties in Heath or Plan of Universal Attention with
Explicit Guarantees ("Atención Universal con Garantías Explícitas", AUGE); Regulation of the ISAPRES; Fi-
nancing of Fiscal Expenditure or Common Fund of
Compensation ("Fondo de Compensación Solidario");
Rights and Duties of Patients. Amongst these projects,
only the one related to Sanitary Authority is already a
law. Its general objectives are to equip the SNSS with
an assistance network capable of surmounting institutional fragmentation, integrating complex levels, fortifying the Primary Care and providing the establishments with autonomy of management.
A propos the AUGE Plan, we can consider it a
refinement of the regime of stratification of access
(mentioned earlier) or a "market basket" ("canasta básica"). It has as its center to guarantee the population
contributions associated with 56 primordial pathologies and will be mandatory for FONASA and the ISAPRES. Even if this constituted an important innovation, it reinforces current measures related to the contracting of private services, which now would serve to
take care of the AUGE patients. This would signify
great support to the ISAPRES in a critical moment of
involution. Regarding the access, the classification by
income for co-payment is maintained: groups A and B
continue to be exempted, but for groups C and D a
very complex formula is created. It is difficult to foresee the possibilities of administration (already extremely troublesome), of supervision of "false indigents"
and the amounts to be paid, and this is a fundamental
feature for the reason that it is expected that they increase to compensate the rise in costs1. Overall, it
could be agreed with the Medical School that the Plan
AUGE is a model of "administered health" already proven unsuccessful; inconvenient and unnecessary for
the country and will not solve the inequalities on the
subject of health [Colegio Médico de Chile, 2003].
With respect to the Common Fund, there was
an attempt of attenuating the "descreme" effect. It
1. The pilot plan AUGE has been functioning since 2003. It covers 17 health problems and it has raised fierce critics and exposed innumerable management and technical difficulties, along with elevated costs.
28
consisted of the collection of amounts proceeding
from a universal premium to be paid by each FONASA and ISAPRES payer, except those who would certify a situation of indigence. In any case, as the legislative discussion of this project was abandoned, the subject of solidarity in the absence of financing is still pending. It is likely, however, that the negotiations will be
recalled when the project of law related to the ISAPRES is discussed again, whose objectives are the rationalization of the chaotic and iniquitous current
market of health plans and the fortifying of the regulating authority of the Department of Health.
REFERENCES
●
ALLENDE, S. (1939). La Realidad Médico-Social Chilena. Santiago
de Chile: Ministerio de Salubridad.
●
COLEGIO MEDICO DE CHILE (2003). Reforma de Salud. Proyecto País. Propuestas del Colegio Médico. Santiago de Chile: Colegio Médico de Chile.
●
GONZÁLEZ-DAGNINO, A. (1999). La meta sanitaria para Chile
en el 2010. Cuadernos Médico Sociales, Santiago de Chile, 40:3650.
●
INSTITUTO NACIONAL DE ESTADÍSTICAS (INE) (2003). Chile: Censo de Población y Vivienda 2002. Santiago de Chile: INE;
Ministerio de Planificación y Cooperación, 2004. Pobreza y Distribución del Ingreso en las Regiones. Serie CASEN 2003. Volumen 2. Santiago de Chile: MIDEPLAN.
●
LABRA, M. E. (1985). O Movimento Sanitarista nos Anos 20 no
Brasil. Da "Conexão Sanitária Internacional" à Especialização em
Saúde Pública. Tesis de Maestría. Rio de Janeiro: Fundação Getúlio Vargas, Escola Brasileira de Administração Pública.
●
MINISTERIO DE SALUD (2001). Reforma del Sistema de Salud.
Santiago de Chile: Minsal.
●
MINISTERIO DE SALUD, CUENTA PÚBLICA (2003). Santiago,
MINSAL, p. 33. Cf. En 2003 Fonasa detectó 30.000 "falsos indigentes".
●
MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD
(2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile: Fonasa.
●
MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD
(2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile: Fonasa.
●
UNITED NATIONS DEVELOPMENT PROGRAMME (2003). Human Development Report 2003. Millennium Development Goals:
A Compact Among Nations to End Human Poverty. New York:
Oxford University Press.
Final Reflection
The trajectory of health policies presented here
demonstrates that in Chile an important tension persists between antagonistic currents, which, in the present conjuncture, can be summarized in two: one that
defends the fortifying of public service and social medicine and desires, basically, to rescue the best of the
former SNS, as a bastion of democracy and representing the duty of being a fairer, more efficient and effective health system. The other current, with a neoliberal orientation, is favorable to an even greater expansion of the private market in health, and the focalization of the action of the State in the poorest, with efficiency. The latter, without taking into consideration
fundamental issues such as the lack of solidarity and
equity that affects the current health system. Moreover, this posture would reflect the individualistic changes in values introduced by the messianic neoliberal
project concerning the "re-foundation" of the nation
and which came to reinforce the already deeply rooted class bias that impales, as revealed, the Chilean society until the present, leaving an indelible mark in the
health system.
29
3
The Right to Health and the Free Trade
Agreement with The United States
Gerardo Merino
Health was recognized as a basic human right in the Universal Declaration of Human Rights of 1948, whose 25th article declares: "Every person
has the right to enjoy an adequate living standard, which ensures this person,
as well as her/his family, health and well-being, and especially nourishment,
dwelling, medical care, and the necessary social services".
Before that year, legal references to the right to health were scarce and
imprecise. Health was considered to belong to the private field, not the public. It was defined merely as the "absence of illness". This definition was
broadened afterward. Thus, among other instruments, the International Pact
of Economic, Social and Cultural Rights (1966), and the Protocol of San Salvador (1988) define it as: "the enjoyment of the highest level of physical, mental and social well-being". In this explanation emerges the criterion that
health is a human right and a public good, and owing to this it is a responsibility of states to do whatever necessary to guarantee its fulfillment.
30
Inasmuch as a human right, health presents a
number of important characteristics:
●
●
The term gratuitousness (free health programs) is
relative, and may have the connotation of "state charity". In fact, the population does not receive anything gratuitously; they have already paid for it amply,
either directly through taxation, or indirectly by
means of the social debt, which the State accumulates with the poorest population that has been dispossessed from everything owing to the process of
accumulation-exploitation. Hence, it proves to be
fairer to aspire to a universal insurance system in
health.
Inalienable
Albeit not acquainted with the full significance of
the right to health, we, citizens, cannot resign it.
Neither may the State deny it, and is obliged to make its fulfillment certain without any kind of distinction.
●
Indivisible
To enjoy the right to health we must benefit from
other rights, such as work, nourishment, dwelling,
education, the opportunity to participate, and a
healthy environment.
●
●
Interculturality
It is necessary to establish an intercultural dialogue
(of different types of health knowledge), a mutually
respectful interaction among experts of official, traditional, and alternative health. This principle is particularly important in a country such as Ecuador,
where diverse cultures, peoples, nationalities, diverse ways to see the world, health and medicine coexist. It is possible to have intercultural services,
wherein traditional doctors, alternative and complementary medicine caregivers, and formal health
workers operate with mutual respect, jointly and
consistent with needs and preferences.
Individual and collective
All that affects one individual affects the family and
community. Concurrently, all the damages suffered
by environment, communities, and families affect
each one of the individuals who constitute them.
The right to health responds as well to several
fundamental principles:
●
Gratuitousness
Universality
●
Every citizen has the right to health. No one can be
denied this right. Measures as the "focalization and
intervention in groups or areas of risk" demanded by
the World Bank, seek to discharge the State from the
responsibility to tend the entire population. In Ecuador, where at least 30% of the population does not
access public or private health services these exigencies would violate even more the right to health.
Citizen participation
In order make effective the health rights, organized
participation must be implemented at all levels of
the health care and prevention process.This participation will permit the social supervision and control
of the commitments assumed in health and the quality of services offered. Nevertheless, genuine participation is essentially local, within the district and
31
community, and it is only guaranteed when organized communities have control over processes which
are health determinant. The delegation of responsibilities to leaders is not enough: participation is a
factual process of organization, education and collective action.
The right to health is not only related to doctors, hospitals, and/or medicines. It depends on complex social, economic and political processes, in
which there are different interests at stake, such as
the ones currently affected by treaties like the Free
Trade Agreement (FTA) with the United States:
which impose the logic of large scale economic accumulation by transnational corporations that operate
the pharmaceutical, tobacco, alcohol, and food companies, all of which is carried against the rights of the
people.
An Impact on Generic Medicines
and the Right to Health
●
The Laws of Intellectual Property and 20-year and
older patents: A Threat to Public Health.
Though the defenders of the concept of intellectual
property argue that it was originated in the necessity to defend the effort and creativity of inventors,
and thus foster scientific development, various laws
concerning intellectual property hinder research
and scientific development and endanger the right
to health of the majority of the population.
When a laboratory "discovers" a medicine, the laws
of intellectual property grant it a monopoly for 20
years (patent).The patents restrict other companies
from manufacturing, using, selling, or importing the
32
patented products. The essential requisite for a patent to be valid is novelty, and not having been introduced publicly before the presentation of the
original petition.
One of the most common arguments to justify the
commercial monopoly that patents provide is that
during the restricted period it allows the patent
holder an opportunity to recuperate the research
and developmental costs of medicines.
However, medicine patents turn out to be a question of life and death when the population or the
State is not able to pay the price fixed by the company, which possesses the patent or drug monopoly.
On the other hand, the final price is not primarily
determined by the investment in research and development as transnational CEOs argue, but by marketing expenses, and in particular by the enormous
profit margins of companies.
For instance, the profit made by the anti-retroviral
Convivir patented by Glaxo-Smith-Kline during its
first three years in the market paid for the 800 million dollars supposedly invested in research and development (the net profit for GSK due to this medicine amounted 265 million dollars a year). Inasmuch as the exploitation monopoly of Glaxo will go
on for a whole period of 20 years, its profit is ethically reproachable.
The most serious issue is that the Free Trade Agreement intends to extend the patent protection period for medicines. Up to now, the twenty years of
monopoly is triggered starting from the date of presentation of the patent petition, independently of
the requisites each country demands before the
product can be legally recognized.
The Free Trade Agreement plans to prolong the
term of effect of patents when "unjustifiable delays
in the granting of a patent" are produced, or "delays
in the granting of sanitary register". The Free Trade
Agreement defines neither whom nor which arguments will qualify as an "unjustifiable" delay.
Frequently, this delay is intentionally provoked by
the petitioner laboratory on not presenting the required documentation. Thus, a company may avail
of various artifices to dilate the patent granting
process for as long as five years. Subsequently, it
would allege "unjustifiable delay", and hence would
attain a twenty five-year patent. The same could
occur as regards the sanitary register. Every purportedly "unjustifiable delay" in procedure would
serve the plaintiff transnational company with the
continued benefit of extended patent periods,
which would add to the twenty original patent protection years.
● The
Risk of Generics and Low Cost Medicines Disappearing
When medicines can be produced freely, their price
is determined by various factors: demand, differential prices, Agreement on Intellectual Property
Rights (ADPIC) protection (which permits countries to manufacture or import medicines in terms
of their development objectives), generics competition, and local production.
If the measures contained in the Free Trade Agreement between Ecuador and the United States are
applied, which are basically a copy of the treaties already signed with Central American countries, the
only factors involved in the fixing of prices will be
the small scale local demand, and the monopoly leverage of transnational corporations. Organizations
such as "Doctors Without Frontiers" have alerted
our countries that the first effect of this kind of
"free trade" agreement would be the immediate increase of the price of medicines.
Despite membership to the World Trade Organization (WTO) and the obligation of member countries to abide by the rules of WTO, different international instruments1 recognize the right of countries to produce generic medicines in emergent circumstances. This is known as obligatory licenses.
The Doha Conference and the Common Regime of
Intellectual Property of the Andean Community establish that with a prior declaration of reasons of interests, emergency or national security, at any moment the patent may be subjected to an obligatory
license. Inclusively, the Agreement on Intellectual
Property Rights (ADPIC) instituted in 1995 in the
framework of the WTO, leaves a door open in order that countries may avail of measures to omit or
not grant patents under certain suppositions, in
terms of their necessities and development objectives. However, the Free Agreement critically limits
the circumstances under which a government may
issue an obligatory license.
The importance of obligatory licenses became extremely clear to George W. Bush, the United States´
president. After September 11th of 2001 and under
fears of biologic attacks, the United States government called for pharmaceutical companies who hold
patents for the anthrax vaccine to lower prices or
1. Among them, the departmental meeting of the WTO held in Qatar in November of 2001, and the Common Regime of Intellectual Property of the Andean
Community.
33
face the possibility of obligatory licensing. This event
highlights the need for patent exceptions.
Medicine parallel imports are an additional public
health emergency protection mechanism that could
also be obstructed by the Free Trade Agreement.
This mechanism allows for a government to purchase directly from the producer who offers the best
price in the international market, being either generic or brand medicines.
The Free Trade Agreement broadens the circumstances under which a medicine may be patented.
The most worrisome is the possibility of patenting a
medicine again, when the legal monopoly is on the
verge of expiring, through the ascription of a further
use distinct from the original (second use). For instance, if a medicine was patented as an anti-flu drug
and later its anti-inflammatory properties are "discovered", the laboratory may claim a second 20-year
patent in view of this new use.
The Free Trade Agreement makes possible for a medicine already patented to be presented once more,
by means of the "always new" technique, which resides in that companies patent "new presentations" of
medicine already in circulation within the market,
whose patents are about to expire. As mentioned
several times, "pharmaceutical transnational corporations do not patent inventions anymore, they invent patents".
Thus, it is a question of eliminating or delaying the
appearance of new competitors; the lesser the competitors, the greater the prices. The difference in
costs among generics and brand medicines is bet-
ween 100 and 1,000 percent. In Guatemala, country
that signed a Free Trade Agreement with the United
States, there are brand medicines 8,000 percent more expensive than generics.
The Free Trade Agreement that has been proposed
to Ecuador by the United States just increases the
power of transnational corporations by allowing
them to be the only ones to produce medicines, and
to fix prices, to benefit their economic interests. In
a world ruled by a number of pharmaceutical corporations, there is no freedom of commerce, just monopoly.
The manager of Pfizer in Ecuador (North-American
corporation), nation which he qualified as "one of
the countries with more advanced laws regarding
patents", declared to be satisfied with the subscription of the Free Trade Agreement for the reason
that "it will compel the (Ecuadorian) government to
comply with the patent laws".
Various people have questioned themselves about
why the United States was so severe in its impositions on intellectual property and patents upon negotiating the Free Trade Agreement with Central
America, considering the entire region represents
less than 1% of the medicines world market.The object can not be anything other than creating models
of international agreements for their benefit"2.
Thus, the dominant trend is to eagerly claim that the
Free Trade Agreement, as supported by the United
States, is something "inevitable" since "many countries have signed it in this manner", and for this reason "we can not remain isolated from the international concert".
2. "Iniciativa de acceso a medicamentos esenciales de Nicaragua", en Revista Envío 269, Managua, 2004
34
The attainment of human rights proposed by the
Ecuadorian Constitution would be lost if the Free
Trade Agreement is accepted.The Free Trade Agreement would develop into a supreme supranational
and supra constitutional law, at the disposal of economic greed and big business interests.
35
Institutionalization
of Violence
and the Hazards
of Hemispherical
Security
4
Military Occupation, Militarism
and Health*
Adolfo Maldonado
"America" is Still Written with Blood
The history of America has been written with the blood of killing, epidemic
illnesses, and famine. In North America, 15 million people have been assassinated since colonial days, and about 14 million in South America; some authors estimate as much as 80 million in total. However, independently of the numbers,
the American Continent is affected by an endemic and well- orchestrated process of extermination.
The policy of terror and the practice of extermination have been, and still
are, inherent to the continuation of capitalist rule in America. Neo-liberal policies have been imposed by violently crushing any form of resistance. For that reason, two decades ago the concept of "social missing" had to be developed to take into account all forms of exclusion: the unemployed, the forcefully displaced,
and the migrants resulting from economic exclusion.
The history of America has witnessed a constant struggle and resistance
against commercial, political, and cultural occupation, and against the armies that
support it. This chapter intends to analyze the relationship between violence
(military occupation, militarism) and health.
* Editor´s note: the author does not state bibliographical sources for some valuable quantitative information in this
paper, which is important; the reader must contact the author if those sources are required.
37
The Geopolitics of Military Occupation
The struggle for independence from Spanish rule evolved into an increasing dependency on the rule
of the United States and its geopolitical project of forceful occupation of Latin America. By 1829, Simón Bolívar declared: "The United States appear to be destined by the Providence to infest America with misery
in the name of liberty". President Jackson confirmed
this in 1837: "Providence has chosen North-American
people as the guardians of liberty, for them to preserve it in benefit of humankind". Yesterday the excuse
was Providence’s will; today the U.S.A. speak of "bringing democracy, liberty and justice to oppressed peoples" to justify domination and war.
The usurpation discourse by the United States
ruling groups is evident. Although the Monroe Doctrine (XIX century) had already raised the issue of annexation of all South America to the U.S.A. –"America for
the Americans (people from the US)"-, the geopolitical
documents coming from the North are increasingly demonstrative of the greedy nature of that imperial conduct. The real interest resides in the strategic resources of our territory; that interest is not focused on our
people’s wellbeing; to the contrary they think we are
ungovernable and too many. "We have to protect our
resources (those of the U.S.A.), the fact that they reside in other countries is only an accident, alleged George Kennan, diplomat of the U.S.A. in the 50’s, stating
clearly the real interests that are expressed in the United States international policies and plans, independent
of which political party is in power: "The crude oil of
the Persian Gulf is of vital interest to the U.S.A., and
has to be defended by any necessary means, including
military force," said James Carter, Democratic President of the U.S.A. in 1980 [Klare, 2004]. Following the
same line, the former secretary of Energy, Hazle
O’Leary, stated: "One should not exhibit contentment
with regard to the security of oil supply proceeding
38
from Latin America;" and the Republican VicePresident
Cheney (2001-2004) announced straightforwardly:
"The African and Latin-American crude oil is of national strategic interest to us."[Cheney, 2001]
In this sense, the words of Democrat James Schlesinger, former secretary of Energy under the Carter
administration, clearly made the point after the Gulf
War in 1991: "American people have understood that
it is much easier and amusing to go to the Gulf War
and remove the oil from the Middle East by kicking the
hell out of those people, than going about the sacrifices of limited imported oil consumption for the Americans." [Martinez, 2003] This attitude results from a
political discourse and scenario where there is no place for repentance, ethics, or respect for human rights.
Violent arrogance is the norm, as indicated by George
Bush (senior), Republican President of the U.S.A.: "I
will never apologize in the name of the U.S.A. I don’t
care what happened".[La Jiribilla, 2005]
The interests of the U.S.A. and its corporations
in Latin America are evident:
●
Oil. The main strategy of multilateral banks is to
seek privatization of national petroleum companies.
In 1998, General Wilhelm declared that the new oil
explorations of that country increased the strategic
relevance of Colombia to the U.S.A. and of the widely known as "Plan Colombia". The U.S.A. government has insistently manifested that they find 338
points of strategic interest in that country. Something similar happens with all countries in possession
of significant oil reserves.
●
Biodiversity. In 1974, Kissinger proposed the appropriation of territories rich in natural resources
and biodiversity. This is presently being accomplished by pharmaceutical companies, which contract
and finance botanical gardens or researchers, and by
privatization of protected areas through delegation
of their administration and management to private
NGO’s such as The Nature Conservancy; International Conservation; The Smithsonian Institute; the
World Wildlife Fund (WWF), and their national associates. Also the patent control of wild varieties
and knowledge related to them favors multinationals. Moreover, one should not overlook alarming
signs of the dispossession strategy we have been
describing, such as the declarations of well- known
institutions like the Rockefeller Center for LatinAmerican Studies, which during the last two years
has advocated the convenience of territorial fragmentation of countries like Chile, Argentina and
Brazil, and the creation of new smaller countries,
such as Belize, in order to assure the economical occupation of that territory to the timber dealers operating in Guatemala.
●
●
1.
Genetics. Genetic data are of fundamental interest
to pharmaceutical companies , which seek homogeneity of isolated population groups (for geographical, cultural and political reasons) that makes it easier to identify genetic characteristics of economic
importance, such as those related to specific illnesses, transmitted within a family or community. Currently, the genes of the Huaorani people in Ecuador
are for sale on the Internet, and we find some of the
largest pharmaceutical transnational corporations
behind several "public" research projects in Mexico,
where various indigenous groups have been selected as "groups of interest."
Water.Water resources are privatized by means of
aggressive policies coming from multilateral banks,
which place conditions on the acceptance of loans
requested by countries. Such conditions are intended to boost privatization policies. When the Vice-
president of the World Bank during the late 90’s affirmed that wars in the 21st Century would be over
water, he was not merely pretending to be a visionary; he was underscoring the main concerns of the
bank and the policies they expected to promote. In
2003, the income of the water industry reached
46.000 million US dollars, nearly 40% of the oil sector’s income and a third higher than that of the
pharmaceutical sector. 100 thousand million liters of
water were bottled –requiring 1.5 million tons of
plastic bottles. The price of bottled water is 1,100
times greater than that of running water. Companies such as Coca Cola, Nestlé, Pepsi Cola and Danone, among other multinationals, are in pursuit of
privatizations. Another aspect of enormous interest
to the U.S.A. is the so called "triple frontier" between Brazil,Argentina and Paraguay, where the main
sweet water reserves (subterranean aquifers) of Latin America and the World are located2.
To obtain these resources, the financial control
and subordination of Southern economies are imperative. In the last decades this has been accomplished by
exerting pressure by means of the external debt. Likewise, the territorial military occupation conducted
by the Southern Command of the USA Armed Forces,
the commercial occupation by means of the Free Trade Agreements system, and the political subordination
of the Latin American states, are also crucial.
The occupation of all of Latin America began during President Bush’s administration. He inaugurated
the Free Trade Agreement for the Americas (FTAA)
strategy.The inner nature of globalization for the creators of FTAA could be described by saying: "Globalization is, in fact, another name for the dominant role of
the United States." [Isch, 2004] As said by Henry Kissinger and confirmed by Colin Powell, both former U.S.
Editor´s comment: no information sources were cited
39
Secretaries of State, former: "Our objective through
the Free Trade Agreement for the Americas is to guarantee North-American companies the control of a territory that goes from the Arctic Pole to the Antarctic,
and the free access, without any obstacle or difficulty,
to our products, services, technology and capital in the
entire hemisphere". [Acción Ecológica, 2002]
The Occupation Strategy
The main figures and cadres of the U.S. government during the period of 2001-2004 responded distinctly to the commercial interests of large transnational companies: oil companies—such as Harken Energy,
Halliburton Chevron Texaco, British Petroleum; pharmaceuticals—such as Pharmacia and Merck; automobile industries—such as General Motors, Ford and
Daimler-Chrysler; and armament industries such as
Gulfstream Aerospace.The occupation policies of those corporations were applied.
The strategy to support this occupation and to
subsidize the neo-empire is based on three central aspects: 1) financial policies of the multilateral institutions (IMF, WB) and the economical agencies of the
U.S.A. (Treasury,Trade, EXIM bank, …), which force national economies to yield to their interests; 2) concealed operations of espionage that subdue the population and the directing political class; and 3) wars and
military interventions when both previous strategies
fail or become insufficient.
1.-Multilateral Banks. Since the mid 1970’s, multilateral banks approved a U.S. policy wherein the debt
of countries was the first step of the intended financial setback of Latin America. The CIA and banking
system were in charge of the countries becoming indebted via forged reports of economical bonanza
40
and vast future petroleum income; the strategy included also the recovery of companies that had been
nationalized.The debt of Latin America and the Caribbean, at present, is 22 times greater than in 1970.
The total external debt was increased by a factor of
4 between 1975 and 1980 (during the period of military dictatorships in the region), reaching 261.000
million US dollars, and it again tripled between 1980
and 2002, reaching 725.000 million US dollars. Total
interest in 2002 amounted to 55.260 millions, which
is on the record as the subvention by countries of
the south to countries of the north. Although the
debt has been paid three times already, it continues
to increase relentlessly. In 2002, the debt of each
country in millions of US dollars was as follows: Brazil, 229.000; Mexico, 141.000; Argentina, 133.000;
Chile, 39.000; Colombia, 38.000; Venezuela, 33.000;
Peru, 28.500; Ecuador, 16.000; Cuba, 12.000; Uruguay,
7.000; Nicaragua, 6.000; Panama, 6.000; Bolivia, Costa Rica, El Salvador, Guatemala, Honduras, Jamaica,
Dominican Republic, 4.000; Paraguay, 2.000; and Trinidad and Tobago, Haiti and Guyana, 1.000. The countries with higher debts are the petroleum countries.
However, the necessity of capital accumulation is
not fulfilled with the external debt and pillage measures are orchestrated, as manifested by the privatization of Pension Funds, the "bankruptcy" of banks,
the narco-dollars, and the pillage of local elites. According to the U.S. Federal Reserve Bank., between
1974 and 1982, during a period of dictatorship,
84.000 million US dollars were transferred to the
U.S.A. from Mexico, Chile,Venezuela, Argentina and
Brazil.This system is so necessary to the maintenance of the dollar and the North-American commercial deficit that it continues to be employed even after the dictatorships. Mexico transferred more than
100.000 million US dollars stolen from state loans
by private firms in the 90’s. In the same period,
Ecuador was swindled out of 40.000 million US dollars, while in Argentina the bank fraud amounted to
60.000 million US dollars, impoverishing millions of
middle class Argentineans, Ecuadorians and Mexicans, and benefiting the bankers who transferred
their finances to the U.S.A.
2.-Concealed Operations.The CIA, created in 1947
by president Truman following the signature of the
National Security Law, was chiefly responsible for
gathering and analyzing information about the external enemies of the United States to permit the
President, the Pentagon and Congress to respond
to existing and potential menaces. Nevertheless, it
soon turned into the dirty arm of its government,
transmitting the message that "the interests of
North-American companies in Latin America are
not to be touched," even if those companies were
involved in plundering, massacre, or extortion.
Among more than 6,000 concealed operations, we
will mention those that stand out: the overthrow
the elected president Arbenz in Guatemala (1954),
support of the United Fruit Company; the murder
attempts against Fidel Castro (from 1959 to 2005);
the propaganda campaign against elected Dominican
president Bosch, which ended in a coup (1965); the
millionaire propaganda campaign against elected president João Goulart, who nationalized a subsidiary of
the ITT in Brazil (1964); the murder of Ernesto Ché
Guevara in Bolivia (1967); the three years of destabilization of the Chilean government of elected president Allende and the coup which put an end to his
life (1973) by order of Kissinger-Nixon and the ITT
company; the organization of the Cóndor operation
from the Kissinger-Nixon axis with the collaboration
of the Latin-American military dictatorships and the
purpose of eliminating all left-wing politics of South
America (1970); the murder of the first Ecuadorian
president elected after the military dictatorship, Jaime Roldós, in an aerial attempt on the 24th of May,
just nine weeks before the murder of Omar Torrijos;
with his death, the Texaco company obtains one of
the most important contracts of its history in the
country, one which had been denied by Roldós; the
murder of Panamanian president Omar Torrijos, who
was assassinated under Nixon, as he could not be
bought with the million US dollars Nixon "offered.
Prior to this, with the intention of discrediting Torrijos, they tried to make him appear as a drug dealer.
Torrijos neutralized this maneuver and frustrated three more murder attempts against him. Nevertheless, on the 31st of July of 1981, his plane crashed as
a result of sabotage.
The United States does not believe in elections, unless these favor puppets who accept the policies of
their corporations.
3.-Wars and Military Interventions. The dictatorships of the 70’s, sponsored by the U.S.A., annihilated the anti-imperialists, nationalists and independents, and left in their place military and socio-economical institutions which permitted the US banks
and multinationals to conquer Latin-American economies. Through policies of state terror, the autonomous labor unions were eliminated, hundreds of
thousands of expert technicians, professionals and
researchers were exiled, and simultaneously any residual resistance to these policies was avoided.
The objective was to paralyze several coming generations through terror, thus: 1954-Guatemala, the
U.S.A. organized a coup against Arbenz, which produced four decades of dictatorship with more than
200,000 peasant and indigenous deaths and 40,000
41
missing people. 1961-Cuba, the U.S.A. contracted
more than 1,500 mercenaries to devastate the
triumphant revolution in Playa Girón. 1965-Dominican Republic, the U.S.A. assassinated 3,000 people
and overthrew the government that intended to
emerge after the 30-year dictatorship of Trujillo, the
bloodiest of the Caribbean. 1973-Chile, the U.S.A.
carried out a coup against president Allende, resulting in the death of 17,000. 1976-Argentina, the
U.S.A. established terror with more than 30,000
murders, a terror which had "Operación Cóndor",
an international system for coordinating the repression of all Latin-America. 1983-Granada, 5,000 US
marines invaded the island and subdued the population using bayonets. 1980/90-Nicaragua, the government of the U.S.A. was responsible for the
deaths of more than 60,000 residents, creating the
internal war with the aid of the contras. 1980/90-El
Salvador, the U.S.A. supported the war with more
than 80,000 brutal deaths; the massacres terrorized
the entire region. 1989-Panama, the U.S.A. invaded
the country on Christmas and slaughtered more
than 8,000 people to capture president Noriega,
who had been a member of the CIA and had collaborated with the drug dealers under the orders of
the U.S.A and was now accused of being a drug dealer himself. 1991-Haiti, the U.S.A. supported the
coup against elected president Aristide and killed
more than 4,000 Haitians. 2001-Venezuela, the
U.S.A. organized the coup against elected president
Chávez. 2003-Haiti, the U.S.A. invaded the country
and deported elected president Aristide to Africa.
Militarism, the Base of Imperialism
Beyond being an instrument and guarantee of
occupation, militarism is a strategy of political control.
It is a form of consolidating the empire. Madeleine Al42
bright, Secretary of State of the U.S.A., in Clinton’s administration, affirmed: "McDonald’s cannot expand
without McDonnell Douglas (military airplanes constructor). The invisible fist that guarantees the World
Security of the technologies of Silicon Valley is called
the Army of the United States of America".
The military budget of all Latin America increased in 2000 to 25.000 millions of US dollars, which, as
large as it is, represents only 7% of the entire military
budget of the U.S.A. More than 450.000 million US
dollars were spent in 2004, the same as the rest of the
world’s combined military expenditures. At present,
the U.S.A. has 71 military bases throughout the world,
and 800 aerial, naval and infantry bases; there are also
espionage groups, communication posts, and arms deposits distributed among 130 countries. Since World
War II, the U.S.A. has bombed at least 21 countries:
China (1945/46 and 1950/53); Korea (1950/53); Guatemala (1954, 1960 and 1967/69); Indonesia (1958); Cuba (1959/1960); Congo (1964); Peru (1965); Laos
(1964/73); Vietnam (1961/73); Cambodia (1969/70);
Granada (1983); Libya (1986); El Salvador (throughout
the 1980s); Nicaragua (throughout the 1980s); Panama
(1989); Iraq (1991/2001 and 2002 to 2005); Sudan
(1998);Afghanistan (1998 and 2001);Yugoslavia (1999).
The Peace World Council denounced North-American rulers for using their armed forces 215 times between 1946 and 1975 to attain their political goals in
other parts of the world.They currently have an army
of 2.2 million soldiers.
The military policy of the U.S.A. concerning Latin America is channeled through the South Command
of the U.S.A., an army that controls all Central America, South America, the Caribbean and the waters that
surround them, and which was born after the creation
of the Central Command, located in the Persian Gulf
and established by Reagan. Its aim was and is to insure access to the petroleum of the Middle East. The
South Command seeks the same objectives in Latin
America and focuses on those places where their interests reside.
In Colombia, with the pretext of combating the
drug trade, the U.S.A. has invested more than 3.000
million US dollars already in the Colombia Plan, and it
plans to invest 700 million more by 2005 in the Patriot
Plan; public opinion has criticized the credibility of
such justification. The U.S.A. organized the heroin
market in Vietnam (1960), and made use of it in Laos
(60) with heroin, in Nicaragua (70) with coke, in Afghanistan (80) with heroin, and in Kosovo (90) with heroin. Such support of the drug trade would indicate
that the intention is not to extinguish it in Colombia
but rather to once again use it as the vehicle to finance other objectives. If there were a true will to stop
drug trade, the US would confront major banks, including Citibank, the Bank of America and the main banks
of Miami and other cities, where they launder drug
money—The U.S. Senate acknowledges between
250.000 and 500.000 million US dollars a year—with
absolute impunity, in Central America and the South
Cone, the pretext is international terrorism, which
simply is used to veil the U.S.’s economical and strategic interests.
The military strategy for Latin America designed
by the South Command implies three aspects:
a) Establishing a presence in the territory with military bases, sending more than 50,000 soldiers each
year to Latin America and the Caribbean. Although
the U.S.A. already owns 14 bases and there are 6
more underway, smaller installations are numerous
as well as those in combination with national states.
All of them are deployed in the zones of interest,
due to the resources found in those areas.
b) The subordination of the Latin-American armed
forces to the U.S.A., by means of joint armies (Cabañas, Águila, Unitas, Cielos Centrales, Nuevos Ho-
rizontes, Fluvial, etc.), which endangered the land,
marine and aerial armies; and the programs of education, considered the chief mechanism with which
to create a dependence of Latin-American armed
forces on the U.S.A. From 2000 to 2003, the U.S.A.
trained 65,941 soldiers from 27 Latin-American and
Caribbean countries, of which 43% (28,200) are
Colombian, and if one adds those coming from other Andean countries (Bolivia, Ecuador, Perú and Venezuela), they total 64%. From Central America,
9,886 soldiers were trained (15%); from the South
Cone, 9.7%; and from the Caribbean, 7.2%. This in
several ways uncovers the interests the U.S.A. has
in the different regions.
The ‘School of the Americas,’ also called the ‘school
of dictators,’ is sadly celebrated at the moment in
Fort Benning, for having increased the power and
implementation of torture as a war weapon: the publication of training manuals on torture is proof of
that. The New York Times has mentioned the existence of "eleven secret manuals" in the School of
the Americas, through which "interrogatory techniques, forms of torture, blackmailing, and imprisonment of relatives were developed". Since 1961 to
the present, more than 60,000 Latin-American soldiers have been trained in that school, of which
nearly 500 are accused of war crimes.
The visible outcome is that the presidents of Honduras and El Salvador have already requested the
creation of a regional army, under the command of
the U.S.A. George W. Bush has proposed the creation of a multinational operative marine force of the
Americas identified as "Lasting Friendship," obviously under the command of the U.S.A.
c) The development of mercenary armies, which can
do what international legality impedes. They are
43
staffed by ‘retired’ soldiers of the U.S.A., slaughterers from Latin-American armies, and death squads.
The South Command assembles trains and indoctrinates national armies to serve the interests of
the U.S.A. under that country’s direction. Doing this
avoids the use of North-American troops and reduces political opposition by U.S. citizens to such confrontations.
Health as a Tool to Weaken Peoples
With impoverished governments and without
resources for education, the statistics of literacy instruction fall much lower than the anticipated objectives and health is shattered by the loss of control over
more than 30 infectious diseases, whose incidence increases in each country. In Latin-America and the Caribbean, there are 1.6 million infected with the AIDS
virus. Of these, only 8% receive treatment, due to the
high costs of pharmaceuticals. 2.3 million children suffer respiratory distress syndrome each year as a result
of urban air pollution, and 35,000 people die prematurely in Mexico for the same reason. Tobacco, promoted by northern companies that see their markets affected in those countries, destroys 550,000 people
each year in Latin America. Contaminated water causes the deaths of more than 36,000 people annually.
At the moment, 78 million people in Latin America do
not have sufficient water, while 117 million lack adequate hygienic installations and 59 million suffer from
chronic hunger and famine.
The strategy of occupation and militarization has
begot consequences such as an increase in unemployment, a rise in migratory fluxes of cheap manual labor
to the countries of the north, while peasants are urbanized (77% of the population is urban), escaping from
a land with no supports. Violence is becoming a resource: each year 140,000 Latin-Americans are assas44
sinated, and one in three families in the region is a victim of some type of criminal aggression. The murder
rates of women in Mexico and Guatemala reach outrageous numbers, and more than 17 million schoolage children work in very poor conditions in the mines of South America, are enslaved as "domestic workers," or are sexually exploited. Simultaneously, 40 million street children, victims of violence, drift throughout the cities, and more than 30 million of them inhale superglue in an attempt to run away from poverty
and abandonment.
The strategy of occupation, accompanied by the
policy of debt and pillage, has been, on one side, the
source of impoverishment of Latin-American countries, leading them to abandon their industries (just raw
materials are exported), and to the proliferation of the
volume of exportations, making products cheaper.The
national industries purchased by multinationals went
from the local manufacturer system to models of pure
assembly. Research diminished, the situation fostered
brain drain, and exportation economy was prioritized
rather than production for the internal market.
The destruction of health is an adjunct to the unlimited destruction of environment. This presupposes
the reality of pushing the population to a struggle for
survival, where it becomes totally alienated from the
fight for freedom, justice and human rights. Environmentally speaking, Latin America retains the highest deforestation rate in the world, having lost more than
46.7 million of forest hectares in 10 years. The transgenic crops are an important element of this deforestation and the heavy irresponsible use of pesticides
destroys both legal and illegal crops in Colombia, through fumigation.
Mechanisms for social domination are also implemented in the health field. The "business of illness"
opens doors to large pharmaceutical emporiums that
have systematically rejected any natural treatment that
is not patented. It is the case of vitamins, micronu-
trients and drugs used to treat AIDS or prevent cardiac illnesses that were patented and now are inaccessible because of income shortage, and this inevitably
results in millions of deaths. Likewise, the Rockefeller
Foundation, together with Harvard University, prevented the success of the World Health Organization’s
plan (1978, Alma Ata) to regain control of healthcare
and place it in the hands of the population.The World
Health Organization renounced to Primary Health
Care and only countries like Cuba, which have incorporated it, have been successful.
Health is Dignity and Dignity is Resistance
Health, dignity and sovereignty are all connected.
The seed of resistance is within the person who does
not resign him or herself, but struggles for his/her
rights, not just against a model, but in favor of an alternative system that conserves forests, keeps land in the
hands of peasants, and protects cultures, dignity, and life. We are tied to a model of production and consumption that is economically and ecologically unsustainable, and if we do not change it, we will certainly
drown along with it.
After 500 years, there has been a resurgence of
indigenous peoples, and at this point in time they lead
some of the most relevant struggles. In Mexico, the
EZLN unites the indigenous peoples of the entire nation by cultivating collective memory. They assert:
"Gods bestowed the peoples of corn a mirror named
dignity. In it, they see themselves equal, and become
rebellious if they do not." In Bolivia, Peru, Ecuador,
Guatemala, and Mexico, the indigenous movements
have arrived at an impressive level; those ethnic groups
of America recognize the need to overcome 500 years
of violence, discrimination and exclusion.
The peoples who resist irresponsible oil production, not just guarantee their health and their territory,
but their dignity. Such is the case for the Kichwa and
Sarayacu groups in Ecuador; the peasants and indigenous groups of Oaxactum, Guatemala; those who uphold the ‘trail of the century’ in Ecuador against Texaco; the fishermen/women of Limón in Costa Rica, who
successfully declared their country "Petroleum Free;"
the indigenous group of Moskitia in Nicaragua, who asserted their autonomy; the assured and exemplary cultural resistance of the U’wa people in Colombia, all
these exemplifying actions led the world to think beyond simplistic environmental technical and economical issues.
Results are evident. The interruption, delay, or
deviation of large oil pipelines, as in Santa Cruz (Bolivia) and in Urucú, Brazil, have been managed. One of
the strategies has been to cease financing, as in the case of the Import Export Bank in Camisea, Peru, or the
declining of projects of colonization, such as the one
against the re-colonization of the lands of Neuquén by
the Spanish company Repsol.
Women have become renowned as "Zapatista"
commanders; the ‘Mothers of the May Plaza;’ the Argentinean "piqueteras" and workers, who recover factories abandoned by their bosses; the Bolivian female
workers, street vendors and housewives of the grand
city of El Alto, who organize their district committees
of defense and fight, block by block; the thousands of
hungry Nicaraguan women, who inaugurated their
protest march towards Managua in April of 2004; or
the Colombian women, who have created the Women’s Pacific Route to convey hope to communities
devastated by violence; and the women who have
pressured the closing of the military base of Vieques in
Puerto Rico.
In front of the dominant ecological policy of
"protected empty lands with no people on them", the
Movement of the Landless (Movimento dos Sem Terra) puts forward the re-occupation of lands in Brazil,
with success. In Ecuador, the struggle for territories
45
allows for the recovering of legal rights over those territories, while at the Latin-American level, the indigenous peoples propose the launching of an agenda for
territorial autonomy.
The struggles of Guatemalan and Colombian
workers strengthen the boycott against companies
such as Coca Cola, which assassinates labor union
members in these countries while in Mexico it confronts the rejection of the indigenous communities of
Chiapas, where it intends to seize the water sources.
Other struggles receive each time more support in
the assembly plants ("maquiladoras") of Mexico and
Central America, and against privatization in Mexico
and El Salvador. In Uruguay, a coalition of workers and
associations has inhibited the privatization of water by
way of a national referendum.
A resistance in its full extent, with all colors,
with all sexes, and with all ages has taken place. From
the pension holders, who would rather die in the stri-
46
kes of Quito, fighting, than be neglected in their misery by the government, to the students’ marches in
Argentina. Youth is the most constant presence in the
streets, in the student strikes and in the movements
against the impunity of officials of past and present
dirty wars.
Still, we have words, we have dreams, we have
hope, we have land, we have laughter, we have singing,
we have our hands, we have health, all of which would
be useless, unless we empower ourselves and protect
our resources from corporate greed. We need to recuperate our capacity to think for ourselves, our willingness to participate jointly in the construction of
our future. Also allowing for moments of leisure and
rest, in order to recreate ourselves. We must also take time for dancing and enjoying life, to produce art,
and cultivate our identity with pride. However, we
must also maintain a firm awareness of the fact that we
still lack rightful and genuine independence.
REFERENCES
● ACCIÓN
ECOLÓGICA (2002). Nuestro Mundo no está en venta. Alerta Verde nº 117, mayo. Quito.
●
CHENEY, DICK (2001). National Energy Policy, Mayo. www.soberania.info
●
CHOMSKY, NOAM (2003).Video "Plan Colombia". willfree.
●
ISCH, EDGAR (2004). La mayor amenaza contra la vida y la democracia en el Ecuador. El tratado de Libre Comercio con EEUU.
Memoria del taller. Coca
●
KLARE, MICHAEL T (2004). La nueva misión crucial del Pentágono I y II. La Jornada, México. 18-10-2004. www.jornada.unam.mx
●
LA JIRIBILLA (2005). La verdad al desnudo. www.lajiribilla.cu
●
MARTÍNEZ, ESPERANZA (2003). Conflictos bélicos y Petróleo.
Oilwatch. Conferencia en Chiapas, México en encuentro internacional contra militarización de A.L.
●
NAVARRO, GUILLERMO (2004). Geopolítica Imperialista. De la
"Doctrina de los dos Hemisferios" a la "Doctrina Imperial" de
George Bush. Edit. Zitra. Quito)
●
OILWATCH (2001). La manera occidental de extraer petróleo. La
Oxy en Colombia, Ecuador y Perú. Edit. Oilwatch. Quito.
47
5
Social and Political Violence in Colombia:
A Social-Medical Approach
Saúl Franco A.
Introduction
Violence is not only a political, sociological and military problem; it is
also a public health issue. In Colombia, violence is in fact the main threat to
public health.The high rates of homicide and kidnapping, the significant reduction in the quality of life of the country’s citizens and the systematic violation
of international humanitarian law and the medical mission are evidence of the
enormous impact of violence on health in Colombia. Different theoretical
approaches have been proposed to study the violence. They have emerged
mainly from the social sciences.Within the health sector, epidemiology, with
its different trends and different approaches, has been the discipline most
actively involved in the study of the problem. This article presents the conceptual bases, the main findings, and the conclusions of the author’s research
on this topic over the past 15 years from a social medicine perspective.
Conceptual and methodological bases
Acknowledgements:This article
was translated from Spanish by Drs.
Luis Franco and Paola Pinto.
48
The concept of violence. There is no accurate and universally accepted
definition of violence. Each of the many proposed definitions highlights specific aspects, usually related to the author’s area of expertise. The World
Health Organization, for instance, defines violence as "The intentional use of
physical force or power, threatened or actual, against
oneself, another person, or against a group or community, that either results in or has a high likelihood of
resulting in injury, death, psychological harm, maldevelopment, or deprivation" [World Health Organization,
2002]. Of course this definition includes the most
essential elements of the concept. In my opinion, however, it excludes important aspects and includes particularities that are not necessary in a definition. I
define violence, more concisely, as a specific form of
human interaction in which, in order to achieve a given
purpose, force is used to cause harm or injury to others. Given its implications, it is necessary to discuss the
contents of this definition: the human character of violence implies that it is an intelligent activity.Violence as
a form of human interaction is a learned behavior.
Although violent acts may initially appear to be irrational, they have an intrinsic logic and a context. The
most specific characteristic of violence is that it is a
relationship based on the use of force. Force can be
physical or psychological. Violence always produces
harm or injury.Without damage, there is no violence.
Damage can be physical or psychological and it may
also occur in different levels of intensity. Purpose is the
most controversial characteristic of violence and it
refers to the intention of achieving a particular goal.
Violence is not a random event. Power is one of violence’s most common purposes and the two are closely related [Arendt, 1970]. However, they are very different concepts: while power is a goal, violence is an
instrument. Analysts of violence often refer to power
as the instrumental nature of violence [Arendt, 1970;
Benjamin, 1995; Cortina, 1998]. As a consequence of
the above, it is clear that violence is a process and that
it has a historical context. Violence is not a single
action: it involves different steps, activities and consequences for both the victim and the agent, and it
affects not only individuals but also their surroundings.
Violence changes: its intensity and modalities vary
among different countries and among different times.
This implies that violence can be reduced and modified; thereby, some types of violence are preventable.
Homicide as an indicator of violence. Homicide has
long been recognized as one of the most important
indicators of violence because of its serious consequences and greater reporting reliability. In the case
of Colombia’s current cycle of violence, homicide is
undoubtedly the indicator that most clearly portrays
the magnitude and severity of the situation.With certain limitations, especially in those regions of the
country that are under the control by illegally armed
groups, homicide is the most documented form of
violence in Colombia. Research on Colombian violence involves the analysis and comparison of diverse
and often variable sources of information.
Structural conditions and transitional situations.
Methodologically, in the study of Colombian violence
within the framework of social medicine its useful to
differentiate between structural conditions and transitional situations. Structural conditions are processes
of longer duration that are related to the fundamental
components of the phenomenon under study.
Transitional situations, on the other hand, are processes of shorter duration that exert an important but
complementary influence over the fundamental components. In the case of violence, this differentiation is
useful when attempting to explain the phenomenon
and when seeking possible solutions. The study of
Colombian violence has involved a long debate
between "structuralist" and "transitionalist" views.This
conflict of views has had a clear impact on the country’s policies and strategies towards violence. The
social-medical approach attempts to study the ways in
which structural and transitional elements interact.
This discipline avoids exclusions that initially appear to
simplify the task and emphasizes the need for a strategic solution that integrates both doctrines for long
term effectiveness.
49
El estudio de la violencia colombiana ha implicado una confrontación permanente entre los "estructuralistas" y los "coyunturalistas". Esta confrontación ha
tenido un impacto significativo en las políticas y las estrategias del país frente a la violencia. El abordaje sociomédico procura estudiar las formas en las cuales interactúan los elementos estructurales con los coyunturales y enfatiza la necesidad de una estrategia de solución que integre ambas dimensiones, evitando las exclusiones que aunque inicialmente parecen simplificar
el trabajo, generalmente son ineficaces a largo plazo.
The theory-fact-discourse approach. As another
methodological contribution to the study of
Colombian political and institutional violence from the
social-medical perspective, I have implemented an
approach that integrates three elements: the theoretical insight of different schools of thought, the factual
data that arises from different sources, and the verbal
or written testimony of the individuals and victims
involved. Although often attempted, approaches that
isolate each of these three elements are insufficient
for a useful analysis of complex problems.An integrated approach is far more demanding but offers a more
thorough view of a situation. It overcomes, at least in
part, the problems associated with an overly theoretical or an overly subjective and emotional view and the
limitated descriptions offered by mass media.
Main findings from the study of Colombia’s
current homicide violence
Three aspects of Colombia’s current situation of
violence are particularly outstanding: its generalization,
its growing complexity and its progressive degradation. The generalization of Colombian violence refers
to its expansion in time and space, as well as in the
number and type of social settings it permeates.While
the problem expands, its complexity increases contin50
uously; the agents of violence are increasingly diverse,
often switch from one group to the other and the
manifestations and implications of their acts of violence are highly variable and rapidly evolve. The progressive degradation of political violence in Colombia
refers to the disregard of any ethical or humanitarian
principles, including those internationally accepted
under situations of war. This degradation also covers
the methods and mechanisms of action, which include
massacres – understood as collective murders of
unarmed individuals, kidnappings – sometimes also
collective and indiscriminate, and the destruction of
entire towns.
A number of facts and figures help illustrate the
situation. Figure 1 presents the corresponding homicide rates in Colombia between 1975 and 2001. A
slow increase is evident between the late 1970’s and
the mid-1980’s. From then on, an accelerated rate of
increase is seen, with the highest levels recorded in the
early 1990’s.A slight decrease is then seen, with a second reactivation starting in 1998.As shown, in the past
few years the annual homicide rate in Colombia has
oscillated around 60 per 100,000 inhabitants. In 2000,
the world’s average homicide rate was 8.8 per 100,000
inhabitants, about seven times less than Colombia’s
rate. Presently, the country’s rate is the highest of any
country in the world.
By far, the greatest impact of homicide violence
in Colombia is on the male population. In 2001, males
accounted for 92.5% of homicide victims. However,
two worrisome facts should be noted. First, the percentage of women victims of homicide has been rising
over the past 20 years. Second, despite a 1:12 ratio
when compared with males, the actual number of
women victims of homicide is extremely high. In 2001,
the National Institute of Legal Medicine and Forensic
Sciences (INMLCF) registered 1972 homicides in
females, so during that year an average of five females
were murdered in Colombia every day.
According to the available data, the distribution
of homicides in males shows a significantly higher
impact on young adult populations. Clearly, the highest
rates affect males between the ages of 15 and 44 years
old. The murder rates for adolescents and for young
adults ages 25 to 34 are alarming. During the year
1999, for example, the homicide rate for males ages 20
to 34 was three times the national average.The situation is even more dramatic when analyzed in terms of
age and gender distribution by geographic location; in
2001 the homicide rate for males ages 18 to 24 in the
Department of Antioquia was 728 per 100,000, an
overwhelming the fact that portrays the extreme
severity of the problem (see figure 1).
The distribution of homicides among different
regions of the country – administratively divided into
Departments – shows striking contrasts that can be
helpful in defining the origin and dynamics of the problem. Antioquia, a Department whose capital city is
Medellín, has persistently led the country in homicide
rates and it even tripled the national average on the
year 1991.Antioquia has been a very important setting
in the armed conflict as well as in the problem of illegal drug traffic. Interestingly, its homicide curve
decreased immediately after the time when the infamous Medellín Cartel was most severely hit by the law
enforcement authorities. In the Department of Valle,
homicide rates began to increase as the rates in
Antioquia began to decrease. Valle has also been an
important scenario for both the armed conflict and
illegal drug traffic; an increase in drug-related activities
was seen in Valle immediately after the Medellín Cartel
HOMICIDES PER 100,000
INHABITANTS
FIGURE 1 ANNUAL HOMICIDE RATES COLOMBIA, 1975-2001
YEARS
Data sources: Revista Criminalidad, Policía Nacional (Publication of the Colombian National Police) INMLCF (National Institute of Legal Medicine and Forensic
Science)
51
was dismantled.The Colombian capital city, Bogotá, has
maintained rates below the national average, and from
1993 on, has shown a steady decrease that coincides
with the implementation by the local authorities of a
number of programs for violence prevention and
peaceful social interaction. This regional distribution
of homicide violence shows recent changes. In 2001
Antioquia was replaced as having the leading rate of
homicides by three other Departments – Arauca,
Guaviare and Putumayo – where a significant increase
in both the armed conflict and illegal drug production
and commercialization has been evident during the
past few years.
The explanatory contexts of
Colombian violence.
What is an explanatory context? In an effort to go
beyond the descriptive level in the study of
Colombian violence and attempting at the same time
to overcome the theoretical difficulties posed by the
concept of cause, I have proposed the use of explanatory contexts as a useful theoretical tool in the study
of violence that can be extended to other areas of
social research. An explanatory context is the specific combination of cultural, economic, social-political
and legal conditions that make a phenomenon historically possible and rationally understandable. In this
way, the idea of explanatory contexts accounts for a
description of the origin and explanation of a phenomenon, but avoids the ideas of blame and determinism that are so often involved when using the
concept of cause.
When studying a specific phenomenon it is necessary to identify the different components of the
explanatory context or, even better, the different
explanatory contexts involved. It is also important to
understand that while the phenomena being studied
52
are ongoing, explanatory contexts can and should be
seen as provisional. Definitive explanatory contexts
can be established only when dealing with events of
the past.
Based on the current state of research, on an
extensive field study and on a continuous observation
of the situation, I have proposed four explanatory
contexts of Colombian violence: the political, the
economic, the cultural and the legal [Franco, 1999].
●
Political explanatory context. The interviewed population in the field study assigns this context the greatest importance. It includes four main aspects: the
characterization and the role of the government, the
persistence of the political-military conflict, intolerance, and the role of society as a whole. The first
aspect is related to corruption. A progressive decay
in the legitimacy and reliability of the government
and its relative absence from different regions and
different aspects of national life, fostered by the
imposition of an economic model that weakens its
role [Pecault, 1995].The political-military conflict has
a long and complicated history. Its roots can be
traced to the period of exacerbated violence of the
mid-20th century [Guzmán, Fals-Borda, Umaña,
1980; Oquist, 1978] and its activation occurred
between the mid-1960´s and the early 1970’s
[Sánchez, Peñaranda, editors, 1995]. The conflict
began as a military confrontation between extreme
left-wing guerrilla groups and the government. In the
early 1980’s a new actor appeared: the paramilitary
organizations [Medina, 1990]. The paramilitary
groups began as self-defense groups led by drug
lords and landlords determined to take the war
against the guerrilla groups in their own hands were
often supported by certain sectors of the country’s
military. Illegal drug traffic has significantly permeated the conflict and the armed groups involved have
sustained variable and ambiguous links to the organ-
izations that control drug traffic.The strong multinational economic interests involved in gun trade have
also been a permanent stimulus for Colombia’s
armed conflict [Tokatlián, Ramírez, editors, 1995].
Over the past two decades the conflict has worsened and the illegal armed organizations have
increased their military power and their geographic
control. During the same period, several attempts to
reach a negotiated solution have failed, including the
development of a new Constitution in 1991
[Valencia, 1998]. The participation of the international community in these attempts to find a solution has been minimal.
●
Economic explanatory context. The fundamental economic explanatory context for violence in Colombia
is the structural inequality of Colombian society.
Colombia is a good example of the fact that there is
no direct relationship between poverty and violence. It is also a good example of the fact that
inequality and violence are strongly related.This relationship has been demonstrated at an international
level by the World Bank, in a study conducted
between 1970 and 1994 in different regions of the
world [Fajnzylber, Lederman, Loayza, 1997].
Inequality in the distribution of resources and
opportunities has progressively increased in
Colombia [Fresneda, Sarmiento, Muñoz, 1991]. Some
data may be helpful in understanding the situation:
60% of Colombia’s population lives under poverty
and 23% under extreme poverty; 3.3 million
Colombians are unemployed and informal labor
accounts for 61% of those employed; 37% of those
who work earn less than the minimal salary and
48.6% of the population is not covered by any type
of social security [Colombia. Contraloría General de
la Nación, 2002]. The traffic of illegal drugs towards
the large amounts of consumers in first-world
nations, which was commonly perceived in the mid1970’s as a path towards a more even distribution of
wealth in Colombia, has worsened the concentration of rural property and other resources, increasing the levels of inequality and thereby the levels of
violence [Deas, Gaitán, 1995; Uprimny, 1995].
●
Cultural explanatory context. This is possibly the least
studied of the explanatory contexts in both
Colombian and international studies of violence.
Violence is human, historical and social, and therefore it is clearly immersed in the realm of culture.
In the case of Colombia, this context has three main
aspects. The first refers to ethics, which are still in
Political intolerance, understood as the inability to
solve ideological and political differences in a nonviolent manner, has been a continuous trend in
Colombian affairs.The armed conflict expresses and
continuously feeds a high level of intolerance that
has led to the extinction of several unarmed political organizations and to a reduction of politics to
either biased elections or military confrontation. As
much as 20% of all homicidal action can be attributed to political and social intolerance [Franco,
1999]. And although political intolerance manifests
itself most clearly in the armed conflict, it becomes
a pattern that is easily reproducible in other areas of
social interaction.
Two important components of the political explanatory context are social apathy towards violence and
the precarious levels of organization and participation to confront the problem. Despite its intensity,
persistence and generalization, Colombian society
has shown little in the way of a clear and consistent
position towards violence. The responsibilities and
possibilities of the international community are also
increasingly recognized [Franco, 2000].
53
the core of all matters related with violence.There
is a gap between social values and current problems, especially violence. Even the primacy of life as
a value is commonly underestimated or ignored
[De Currea-Lugo, 1999]. The second aspect refers
to education. It includes both the extent of coverage and the contents of the country’s public education system. 83% of the Colombian population has
access to primary education, 63% to secondary
education and only 15% to higher (professional)
education.There is a clear discrimination against the
poorer populations [Colombia. Contraloría
General de la Nación, 2002].The third aspect refers
to the psychological components of the origin and
dynamics of violence. It involves the chronic accumulation of feelings of hatred and revenge between
individuals and groups. It also includes the individual
and collective psychopathologies behind certain
forms of cruelty and the behavior of some paid
murderers.
●
Legal context. It is closely linked to the political and
cultural contexts of violence and involves two main
aspects: the inadequacy of the country’s legal structure with respect to the type and magnitude of
present violence and the inefficacy of the judicial
system. Its clearest indicator is the lack of legal
action taken against criminals, which has worsened
over the past four decades. According to official
estimates, "while the probability of charges for a
crime in the mid-1960’s was 20%, this number was
down to 5% in 1971 and has decreased continuously since to the current 0.5%" [Comisión de
Racionalización del Gasto y las Finanzas Públicas,
1997]. According to the NILMFS, 75% of homicides
in 1999 [Colombia. Instituto Nacional de Medicina
Legal y Ciencias Forenses, 2000] and 89% in 2001
were unsolved. Figure 2 portrays the inverse relationship between the number of homicides com-
54
mitted per year versus Colombian penal capabilities. As homicide rates increase, the capture and
conviction of murderers decreases.This also exposes the negative effect impunity can have on violence
in Colombia..
In summary, there are three structural conditions and
three transitional situations that affect the origin and
dynamics of the current cycle of violence in
Colombia. Inequality, intolerance, and impunity are
the three structural conditions, while the internal
armed conflict, drug trafficking and the progressive
weakening and neoliberalization of the government
are the three transitional situations that contribute
to violence.
Conclusions
Many conclusions can be drawn from this socialmedical approach to violence in Colombia, but there
are three that are particularly important.
●
First, homicidal violence in Colombia is a severe and
complex process. Colombia is a country of slightly
over 40 million inhabitants, where homicide rates
remain above 60 per 100,000 and over half a million
humans have been murdered in the past 27 years
alone.The structural conditions and transitional situations that generate violence in Colombia interlink; new actors appear and combine, and conflicts of
interest involved are increasingly strong. The case
appears to deserve a greater degree of attention
from Colombian society, its Government and the
international community.
●
Secondly, the social-medical approach to Colombian
violence has possibilities and limitations.With such a
complex problem any single discipline, theory or
FIGURE 2 HOMICIDES AND INDIVIDUALS CAPTURED FOR HOMICIDES
COLOMBIA, 1975 – 1995
Fuente: Franco, S. El Quinto: No Matar. IEPRI-Tercer Mundo. 1999, p:111.
methodological approach can be expected to be
insufficient. The social-medical approach offers the
combination of careful permanent observation, the
introduction of new analytical categories, methodological resources, and the generation of integrative
and consistent data. The limitations of the socialmedical approach in this setting include the difficulty – and sometimes risk - of accessing valuable information on violence in Colombia, the lack of specific
indicators for certain facts and processes, the fledgling nature of some of the concepts and methods
being implemented, the number – still small – of
researchers using the approach and the irregularity
of communication among them. Overcoming these
limitations can be an important step towards understanding and solving the problem.
●
Finally, the intensity and complexity of Colombian
violence requires a greater degree of social participation and mobilization and a faster transition from
theoretical discussion to plans for action. There
appears to be agreement on the idea that intellec55
tuals and academicians should participate in the
descriptive and analytical study of the problems, the
formulation of feasible proposals for action and the
effective support of the transitional phase between
theory and social action. Social medicine may – and
should - make a growing contribution to this effort.
56
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la Cruz Roja. Plaza y Janés Editores, Bogotá.
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DEAS M, GAITÁN F (1995). Dos ensayos especulativos sobre la
violencia en Colombia. Santafé de Bogotá:Tercer Mundo Editores.
●
FAJNZYLBER P, LEDERMAN D, LOAYZA N (1997).What causes
crime and violence? Washington,The World Bank.
●
FRANCO S (1999). El Quinto: No Matar. Contextos Explicativos
de la Violencia en Colombia. Bogotá: IEPRI - Tercer Mundo Editores.
●
FRANCO S (2000). International dimensions of Colombian violence. Int J Health Serv. 30(1):163-185.
● TOKATLIÁN
JG, RAMÍREZ JL, editores (1995). La violencia de las
armas en Colombia. Santafé de Bogotá, Tercer Mundo Editores.
●
UPRIMNY R (1995). Narcotráfico, régimen político, violencias y
derechos humanos en Colombia. En:Vargas R, editor. Drogas, poder y región en Colombia. Segunda edición, Santafé de Bogotá, Cinep, 59-146.
● VALENCIA
GA (1998).Violencia en Colombia y reforma constitucional, años ochenta. Santiago de Cali, Editorial Universidad del
Valle.
●
WORLD HEALTH ORGANIZATION (2002). World report on
violence and health. Geneva:WHO.
57
Economic
Fundamentalism,
Legal Regression,
Work Degradation
and the
Ecosystem
6
The Impact of Neoliberalism on the Health
of Latin-American Workers
Mariano Noriega,
Cecilia Cruz,
María de los Ángeles Garduño
1.
The application of the neoliberal model in Latin-American countries disrupts the social fabric of the working population. One of the expressions of this
problem is the deterioration of working conditions and, consequently, that of
health.
Large transnational companies propose the neoliberal model to LatinAmerican governments as a valid alternative for development in the next century when, in fact, the model leads to great sacrifices for the majority of the population.
In effect, this "modernizing" project has generated disadvantageous conditions especially for the working population.These disadvantages are visible in notable inequalities; the political defeat of its organizations; the permanent and progressive decline of their income levels and of the reduction of the labor market.
In Latin America, in general, the intervention of the State, two or three decades ago, guaranteed a minimal regulation of capital –labor relations. In opposition, one of the consequences of today’s neoliberal policies and subsequent social crises modernization and market globalization is the dismantling of State intervention to protect and regulate the worker´s social reproduction. In effect,
neoliberal policies marked the end of the welfare State.
At present, many strategic public companies have been privatized, the markets have been deregulated (including the labor market) and commerce has been
59
liberalized, but above all, foreign investment is promoted at any human and social cost. The outcomes of
such movement in different Latin-American countries
vary, but there are common effects: unemployment
(owing to the shutdown of companies that are not in
the capacity to compete with high tech transnational
corporations); loss of labor rights; and imposition of
hazardous working processes. [Benería, 1999]
The base of this so called productive "modernization" in Latin America has not been technological
change, but the intensification of labor, the constant
dismissal of workers and the systematic exclusion of
rural and urban workers. A report presented by the
World Labor Association explains that, in 2003, 185,9
million people throughout the world were unemployed, and that the largest part of the employed were in
a situation of poverty [OIT, 2004a]. Specifically in Latin America, the rate of employment amounted to
8,9%, which represented a significant upsurge in relation to the past decade (7,3%) [CEPAL, 2003].
Strictly in terms of labor, an analysis of modernity in Latin America is a complex task because it implies understanding the connection between the new
characteristics of the working process and legal deregulation, with the old structures and models.Thus, although labor flexibility is dominating the productive
processes, it tends to blend and even expand previous
organizational structures of labor, such as "taylorist"
labor division, benefiting at the same time from the renewed resources of automation, data processing, microelectronics, and complementary elements, such as
quality control and total quality planning.
2.
The combination of elevated unemployment and
underemployment rates and the instability of the labor market, with its wage depression, create a critical
situation for workers, yet this is not all. The above
60
mentioned modernization process has additionally
lead to important modifications in other aspects of labor relations. For example, working centers have
been implemented with the intention of incrementing
productivity. For instance, flexibility, understood as
multiple task or polyvalence activities, is used as a
strategy to augment the adaptive capacity of operators. Accordingly, these kind of measures increase hazards and labor exigencies which deeply affect workers’ health.
In this sense, the neoliberal model has not only
sacrificed strife for profit increase by means of productive recomposition, -innovative and revolutionary
technologies (dynamic flexibility)-, but is has relied on
static flexibility or, the "diminution of the wage cost:
wage restriction, work intensification, enlargement of
the workday and reduction of social benefits." [Lóyzaga, 2002]
In Latin America, flexibility has been imposed,
mainly through the violation of labor and social laws.
Hence, legal control has been avoided by various strategies such as temporal contracting by the hour wages
payment, and worker subcontracting that dissolves the
companies´ labor responsibilities. In addition, companies receive fiscal benefits and promote instability in
the jobs and posts, divisibility of wages (salaries, bonus,
incentives, grants), variable workdays, fewer breaks, collective contracts with lesser rights and benefits and, of
course, restrictions in the right to go on strike.
Labor organization is one of the aspects that suffered the greatest change. It has portended to foment
in people a sense of possession and compromise, making this out as of common interest, but, in reality, the
characteristics for the majority of workers are an accentuated social and technical division, standardization
of tasks, limited assignation of jobs per person, scientific selection of personnel, individualization, drilling for
the job, objective measurement of individual performance, remuneration in function of productivity, strict
supervision, and lastly, reduction of the margin of autonomy [Noriega, 1995].
The new polyvalent or multi-task working system, simultaneously, takes advantage of the gender
characteristics of the workers. Several studies have
revealed that, in men for instance, there is a predominantly "vertical" polyvalence –multi-competence stages that need special training-, while amongst women
there is a predominant non-qualified multi-competence, of horizontal nature, which permits the realization
of different tasks [Acevedo, 2002].
In Latin America, we find a combination of structured jobs with extensive work journeys and intensive
rhythms, as well as those non-structured occupations
that invade daily life, converting it into an undifferentiated workday [Cruz, Garduño, Noriega, 2003].
Nevertheless, at present, the relation between
workers’ jobs and health should not be explained only
from the scope of remunerated work, but from that of
domestic activities, which entail no less than half the
workday. Work organization, starting from new technologies and new types of processes has allowed, especially in women, to double and even triple labor
hours, provoking remarkable health deteriorations.
Along these lines, to elucidate the damage caused to health, one should not separate the working
and the consumption spaces to simplified scenarios,
for example the interior from the exterior, or the manufacturing space from the domestic space, as this
would dissociate the unity of workers life. We must
overcome those predominant scientific approaches,
which intend to divide everything: the factory from
the house, emotions from energy, and production
from politics and culture.
Furthermore, this flexibility imposes diverse labor dynamics in men and women, and it additionally
promotes non-rigid working times and spaces, bringing
about the possibility of combining domestic with remunerated work. What actually ensues is that flexibi-
lity leads to deregulation and the ability of company
owners to autonomously establish working conditions
[Garduño, 2001].
These changes of the traditional working model
of industrial society also implies a reduction in the
number of employed workers in manufacturing companies. This situation affects principally the young and
increases the number of migrant workers to developed countries as the sole economic solution. Then
again, the proportion of temporary employment and
part-time work is on the raise. All told, it is a phenomenon of labor impoverishment and of long-term
structural unemployment [Tezanos, 2001; Feo, 2002].
The phenomenon of "impoverishment of the labor market" is, certainly, the most unsettling characteristic of the contemporary situation. In a different way
than in previous periods, precarious employment circumstances are not any longer a transitory or fortuitous state of affairs, but they tend to develop into
structural features of Latin-American societies. The
predominance of the informal sector in the labor market has accompanied the "tertiary industry employment", which is the growing involvement of labor force in the services sector. A further extremely important issue to be underscored is the prominent increase in infantile work, unsalaried employment, family
workshops and small industries in the occupational industrial structure.
Numbers are overwhelming and illustrate well
the situation. As indicated by the World Labor Association, at the moment, the informal sector concentrates 75% of occupied workers in Latin America. In the
period of 1990 to 2003, on average, 6 of each 10 engaged workers were part of the informal economy.
The expansion of this sector affects every worker, more so for women though, as 85% of their employment
is affected by this characteristic [OIT, 2004]. During
the past twenty years, millions of job posts have been
lost in Latin America. In the region, 19,5 million wor61
kers have become unemployed, equivalent to 10,4% of
the labor force [OIT, 2004].
3.
A dramatic instance of this massive aggravation
of working conditions has taken place in Mexico as a
result of the North American Free Trade Agreement
(NAFTA), which has produced permanent negative
consequences in the country. It has been more than
10 years since this Treaty took effect under the purposed objectives of trimming down poverty in Mexico,
multiplying employments and accomplishing macroeconomical stability. Yet, none of these benefits have
been attained. In the field of employment, specifically,
the NAFTA proposed the "improvement of the working conditions and the living standards in the territory of each one of the participant countries" [Samaniego, 2000].That is to say, the protection of the workers, but governmental and employers’ actions have
gone in the opposite direction. In 1991, three years
before NAFTA, there were 10 million workers in the
informal economy and, already in 2002, this number
has climbed to 17 million" [Castañeda, 2004].
What NAFTA has accomplished, in effect, is a
quick subordination of the Mexican economy to that
of the United States, but without economical growth
and with no achievements in terms of welfare for the
Mexican one, and, in particular, for workers and their
families [Ornelas, 2003].
Numerous transnational companies have invested in the country, taking advantage of new national
market openings. These companies were hungry for
cheap labor and for legal facilities. Nevertheless, many
full-time jobs were lost in Mexico, precarious employment increased (mainly contracts by the hour with
low wages) and unemployment has been boosted. As
a consequence of this situation, more and more Mexicans have abandoned their country. One piece of in62
direct evidence of this phenomenon is the rapid increase of remittances sent by workers in the United
States to their relatives. In 1995, one year after the
NAFTA, these remittances amounted to 3,673 million
dollars, but now in 2003, they have almost quadrupled
to a high of 13,266 millions. [Arroyo, 2004]
During these NAFTA years, just 58% of the necessary employment has been created on average annually. Amid these, 59,5% lack the benefits determined
by the law. In the manufacturing sector -which is the
greatest exporter within Mexico’s economy (87% of
the total, and half of the foreign investment)- contrary
to all declarations and expectations, jobs decreased by
12.8% since the start of NAFTA. In addition, the integral cost of labor has declined 37.7%, despite a 58.6%
increase in productivity [Arroyo, 2004]. With the minimum wage of 1976, nearly two basic consumer baskets
could be purchased, whereas at present, only 18% of a
basket can be purchased. Added to this, the absence of
codes of conduct for transnational companies signifies
that the Mexican government, in its urge to install direct foreign investment in the country, has allowed violations of various labor rights such as the right of organization and freedom for the unions, the right of social
security; and the rights to an adequate wage and satisfactory working conditions [Castañeda, 2004].
4.
This regressive reorganization of production implies profound changes which will alter the typical labor characteristics of the twentieth century, as much
from the viewpoint of people as from the perspective
of the social system. Its instrumentation has had and
will have both direct and indirect consequences and
changes, in such areas as the modalities by which the
productive tasks are executed, the occupational structure, the available employment supply, and the social
structure [Tezanos, 2001].
The corollary of this panorama is expressed in
four distinct levels: a) the reduction or vanishing of various basic components of the development of human
work; b) the emergence of new labor exigencies or
the intensification of the old ones characterized by
their synergy and activity; c) stress (severe and chronic) and fatigue, as mediating elements of the pathology associated with the new forms of labor organization; and d) the proliferation of illness associated with
these changes, among them, mental and psychosomatic disturbances, diverse but with common origins
[Noriega, Laurell, Martínez, Méndez,Villegas, 2000].
The neoliberal phenomena demand a renewed
research framework concerning labor illnesses. Innumerable new processes and diseases have acquired the
dimension of public health problems. Thus, there is a
diverse set of disturbances that are resultant of the
exposure to stress, such as psychosis, major depression, pathologic fatigue, burnout, gastrointestinal disturbances (ulcerous peptic illness, gastric and duodenal ulcer, non-ulcerous dyspepsia, irritable bowel syndrome), cardiovascular illnesses (coronary cardiopathy; hypertensive illness, cerebral-vascular illness),
post-traumatic stress disorder, disturbances related to
anxiety (anguish crisis, generalized anxiety, obsessivecompulsive disturbance, phobia), and lastly, Karoshi (incapacitation or sudden death by excess of work).
Among the many health problems derived from
ergonomic exigencies are: musculoskeletal syndromes
and illnesses (accumulated traumatisms in shoulder
and neck, in hand and wrist, in arm and elbow, for repetitive compressions and tensions, neuropathies for
pressure), visual fatigue, physical or muscular fatigue, as
well as mental and psychological pathologies.
One should also be aware of the damages produced by toxic agents and widen the spectrum of cancers, to liver, biliary tract, larynx, esophagus, stomach,
colon, and other parts of the digestive tube, cerebrum,
prostate, kidney and mamma. There are also illnesses
of the nervous system generated by chemical products, capable of inducing a constant pattern of neural
dysfunction or changes in the biochemistry or structure of the nervous system [Noriega, 2004].
Finally, it is necessary to take into consideration
some very recent labor health problems involving the
new computer technologies and automation in the
processes of work; the new chemical substances and
physical energies; the hazards to heath associated with
new biotechnologies; the transferal of hazardous technologies; the aging of the working populations; the special problems of vulnerable and unproductive groups
(chronic illnesses and invalidities), including migrants
and the unemployed; those that have to do with the intensification in mobility of the working population;
and, the advent of new labor illnesses of different origins [OMS,1995]. The situation in this field appears
desperate or, at least, with scarce possibilities of being
overcome in the coming years.
5.
Upon modifying the economical and social variables, market globalization has many negative repercussions on health due to the fact that it severely affects living conditions. At work and in consumption,
illness that had been apparently resolved has reemerged, others have been aggravated and still new ones
have arrived on the scene. The whole of this has been
compounded by the weakening of health services and
the cutback of health budgets [Franco, 2002].
A summary of the main trends found in the field
of occupational health, include:
a) A wider range of worker demands, as a result of the
deterioration of the quality and content of work.
b) The accidents and illnesses legally concerning labor
will become more difficult to recognize since mobi63
lity and polyvalence of workers will surely provide
the arguments necessary to deny labor causality.
c) Labor morbidity will increase notably in those illnesses not yet recognized as work related pathology.
d) It is reasonable to forecast a disproportionate increase in morbidity in highly vulnerable groups of
workers and their families, directly linked to these
new working and living conditions. Obviously, at
present, we can clearly foresee a rise in pathological manifestations derived from violence.
e) Deregulation or reduction of labor and social security norms are boosting hazardous labor and will
surely trim down, even further, the many collective
defenses of workers.
f) The fight against organized worker participation will
lead to less possibilities for transforming and improving hazardous working conditions and health.
6.
In the opening of the twenty-first century, despite the advancement of microelectronics, we cannot
count on information concerning the health conditions
of Latin-American workers, information that is indispensable to evaluate working conditions adequately.
The lack of an integral occupational health system and specific programs concerning labor and health
64
conditions persists in several of our countries. Legislation on this subject is realistically un-observed. Further, our institutional actions are very limited, dispersed, inclusive, contradictory, and they tend to the limit
any evaluation. And the behavior of companies is
oriented more toward the reduction of insurance payments than to the improvement of labor conditions
and the surveillance of workers’ health; and lastly, legal
provisions of a preventive nature are not monitored as
part of the inspection actions of institutions such as
Departments of Labor.
The neoliberal model is in effect a clearly inefficient health care and health security model. Gradually,
health care activities are being privatized (and consequently becoming increasingly inaccessible to the mass
of the working population), which in turn leads to a
very limited capacity for medical care and treatment,
and a decrease or suppression of benefits (indirect wage and social wage). This becomes evident, for example, in the policy of not recognizing work related incapacities (temporal and permanent), invalidities and
pensions for unemployment, and oldness or death. In
sum, we are denouncing an institutionalized policy of
toleration for a diminished social response to adverse
and hazardous working conditions, and their consequent diverse and long-lasting negative health outcomes.
The modification of the policies of public institutions and companies is indispensable in order for
health problems of the working population to be recognized. Alternatives can and should be furnished to
improve the working conditions that provoke them.
REFERENCES
●
LÓYZAGA, O (2002). Neoliberalismo y flexibilización de los derechos laborales. UAM/Porrúa, México.
●
NORIEGA, M (1995). "Realidad Latinoamericana. Paradigmas de
Investigación en Salud Ocupacional". Salud de los Trabajadores.
3(1): 13-20, Maracay,Venezuela.
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NORIEGA, M (2004). "Aportes de la medicina social a la salud en
el trabajo". Salud Problema (en prensa), México.
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NORIEGA, M; LAURELL, C; MARTÍNEZ, S; MÉNDEZ I;VILLEGAS,
J (2000). "Interacción de las exigencias e trabajo en la generación
de sufrimiento mental". Cadernos de Saúde Pública 16(4): 10111019, Río de Janeiro, Brasil.
●
NOVICK, M (2000). "La transformación de la organización del trabajo".Tratado Latinoamericano de Sociología del Trabajo (Enrique
de la Garza, Coord.). Colmex, México; pp. 123-147.
●
OIT (Organización Internacional del Trabajo) (2004a). Comunicado de prensa de la OIT, 7 de diciembre de 2004 (OIT/04/54)
●
OIT (Organización Internacional del Trabajo) (2004b). "Panorama
Laboral 2004 América Latina y el Caribe". Lima/OIT Oficina Regional para América Latina y el Caribe.
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OMS (Organización Mundial de la Salud) (1995). "Global Strategy
on Occupational Health for All (The Way to Health at Work)".
Recommendations of the Second Meeting of the WHO Collaborating Centers in Occupational Health, 11-14 de octubre de
1994, Beijing, China. Ginebra.
●
ORNELAS, J (2003). "El Tratado de Libre Comercio de América
del Norte y la crisis del campo mexicano". Revista de la Facultad
de Economía, Universidad Autónoma de Puebla. VIII (23):25-48,
Puebla, México.
●
SAMANIEGO, N (2000). "El caso del Tratado de Libre Comercio
de América del Norte (TLCAN)". [Disponible]
www.ilo.org/public/spanish/region/ampro/cinterfor/publ/erm_bar/pdf/saman.pdf
● ACEVEDO, D
(2002). "El trabajo y la salud laboral de las mujeres
de Venezuela. Una visión de género". Universidad de Carabobo,
Venezuela.
● ARROYO,A
(2004). "El México de Fox y el TLCAN. La dura realidad del pueblo mexicano contrasta con el optimismo de su Presidente". [Disponible]
www.rmalc.org.mx/documentos/fox-tlcan.htm
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BENERÍA, L (1999). "Mercados globales, género y el hombre de
Davos". Revista Ventana 10. Universidad de Guadalajara. México.
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CASTAÑEDA, N (2004). "Desmitificar el Tratado de Libre Comercio de América del Norte como instrumento de desarrollo social
y económico". [Disponible]
www.actualidadeconomica-peru.com/pdf/datos/dat_jun_04.pdf
●
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CEPAL (Comisión Económica para América Latina y el Caribe)
(2003). Pobreza y distribución del ingreso en: Panorama Social de
América Latina, 2002-2003. Publicación de las Naciones Unidas
LC/G.2209-P.
CRUZ, C; GARDUÑO, M Y NORIEGA, M (2003). "Trabajo Remunerado,Trabajo Doméstico y Salud. Las Diferencias Cualitativas y
Cuantitativas entre Mujeres y Varones". Cadernos de Saúde Pública 19(4): 1129-1138, Río de Janeiro, Brasil.
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DELCLÓS, J; BETANCOURT, O; MARQUÉS F Y TOVALÍN H
(2003). "Globalización y salud laboral".Archivos de Prevención de
riesgos Laborales 6(1): 4-9, Barcelona, España.
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FEO, O (2002). "Globalización y salud de los trabajadores". Salud
de los Trabajadores 10(1-2): 5-15, Maracay,Venezuela.
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FRANCO, A (2002). "La globalización de la salud: entre el reduccionismo económico y la solidaridad ciudadana (segunda parte)".
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GARDUÑO, M (2001). "Para estudiar la relación entre el trabajo
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9(1): 35-43, Maracay,Venezuela.
● TEZANOS, J
(2001). El trabajo perdido ¿hacia una civilización postlaboral?. Biblioteca Nueva. Madrid.
65
7
Floriculture and the Health Divide*:
A Struggle for Fair and Ecological Flowers
Jaime Breilh, Arturo Campaña, Francisco Hidalgo, Doris Sánchez,
Ma. Lourdes Larrea, Orlando Felicita, Edith Valle, Juliette Mac Aleese,
Jansi Lopez, Alexis Handal, Alex Zapatta, Paola Maldonado, Jorgelina Ferrero
and Stella Morel**
Floriculture and the Contradictions of "New Rurality"
The outburst of economic fundamentalism since the 80s has accelerated capital accumulation and social regression in Latin America. Policies were
changed to benefit big corporations. Social protection norms were dismantled and labor rights were abolished.The so-called "Keynesian" or protector
State was dismantled and inequity flourished in most countries.
The impact on rural societies was profound. A "new rurality" appeared
[Giaracca, 2001]: ancestral and classical plantation ("hacienda") agriculture
and indigenous community cultural forms evolved into a scenario of aggressive agribusiness productivity, based on "green revolution" technical systems.
The logic of competitiveness and mono-cultural agriculture exportation penetrated the fields of Latin America, displacing community agrarian relations
and agro-ecological cultures.
Great pressure has been imposed on small peasant economies, which
have affected rural relations and socio-cultural patterns. Indigenous organizations and rural communities that attempt to stop the concentration of land,
water, financial resources, and above all, the subordination of people to foreign and non-solidarity modes of life have counteracted this imposition.
Cut flower production in countries like Colombia, Costa Rica, Ecuador
and Mexico, illustrates neoliberal mechanisms that have been imposed in ru* Preliminary paper based on first stage research analysis; CEAS EcoHealth Program supported by IDRC/
Canada
** Research team of CEAS´ EcoHealth Program; [email protected]
66
ral development and is an interesting subject of debate that can be approached from opposing perspectives
about social and human development. Some would argue in favor of agribusiness as the panacea of modernization and progress (higher productivity; employment source; complementary business activation and
modernization of rural life).To many others, entrepreneurial monopoly floriculture is a false solution that
conceals, under apparent affluence and highly rentable
private business, serious social and ecological problems. Job supply and slight income raises do not imply
a real redistribution process that can encounter the
accelerated income concentration rate, the ever widening social gap, and above all, the loss of human rights
and cultural identity.
The impact of floriculture surpasses the economic terrain and affects communities, social organizations and the fundamentals of life in small cities of the
region. High tech floriculture farms do not solve socioeconomic problems, but rather take advantage of
cheap community labor and low income due to the
ineffectiveness of the agrarian reform process and the
eagerness of traditional "haciendas" to become prosperous modern cut-flower farms and holdings.
CEAS´ EcoHealth Program operates in the Granobles River Basin (North Andean Region of Ecuador),
characteristically a modern floricultural area, where
high productivity in relatively small areas has put pressure on the land market, forcing many impoverished
peasants to sell their properties. This has favored a
process of land concentration, attracting labor from
nearby communities –and even other regions- and
created and an ever-growing dependency of young
workers. Nevertheless the transformation of peasants
to workers operates through drastic mechanisms of
cultural changes that annul the values of solidarity, of
care of the "mother land" and of ancestors that make
up their original identity.
The absence of agrarian development policies
and social support especially drives younger peasants
towards floricultural work and impedes the building of
sustainable community economical activities that
could prosper in the area. Land ownership concentration, and corresponding access to irrigation water and
to financial support close all other local alternatives
and stimulate either emigration or the search for agribusiness employment.
There are two kinds of cut-flower farms (mainly
export cut rose production): those that comply with
the international code of conduct and FLP Program
(fair and ecological labor, social security, health and
ecological protection norms); and the majority of
farms (around 80%) that unfortunately operate without any control and increase their capital accumulation and profit by avoiding responsibilities to their
working force and environment.
Floriculture has grown dynamically in the last 15
years (refer to Figure 1). It is globalized not only since it depends on the ups and downs of the world market, or as it arises from the logic of external investment, but primarily since essential decisions are made
beyond the region. This decision-making process is
vastly subject to global technologies: computer science, for real time electronic interchange of data, chemical research and genetic research. It is neither in Cayambe nor Tabacundo where issues, such as the following are decided: what will be produced; with whom
to become associated; with whom to sell; or from
whom to purchase resources.
Floriculture production circuit1 has a previous
stage in the patentees or "obtentores" (Holland, United States); afterwards flowers are produced in Ecua-
1. According to Santos (2001), analysis centered on work territorial division proffers only a relatively static view. An approach that takes into consideration spatial
production circuits defined by the circulation of goods and products, offers a dynamic perspective of the manner by which fluxes go across territory.
67
ECUADOR. EXPORT CUT FLOWER PRODUCTION AREA
HECTARES
Fuente: Expoflores. Elab.: M. Lourdes Larrea (CEAS)
dorian inter-Andean valleys, mainly on the basis of external resources, however, employing a national workforce; subsequently postproduction and packing are
performed within the same farm, and finally flowers
are sent to international markets by airfreight, especially the United States, followed by Europe. Technologies and logics of multinational agrochemicals, as
well as those of variety producers determine the
rhythm and characteristics of productive processes
and finances of companies. Flower prototypes are
produced by companies specialized in genetic research to launch a greater number of and more sophisticated varieties in the highly competitive and capricious international market2.Though floriculture receiver zones, such as the Granobles River Basin,
achieve urban and agricultural modernization, they lose control of local production [Larrea & Maldonado,
2005].
Floriculture does not stem from the development of traditional agriculture, as would milk products, intensive agriculture, or fruit industrialization,
since, in its implantation; characteristics of pre-existent production are not so significant. The determinants of its installation correspond to factors, such as
quantity of light per day and during the year; access to
land with relatively easy credit; availability of abundant
and inexpensive workforce; presence of plentiful water in the land; access to communication services
(electric power, telephone, internet, cable, etc.), and
to a large extent, the proximity to markets by high-
2.The operational resources almost totally imported correspond to 50% of the required. In addition, payment of royalties for the acquisition of bulbs and cuttings,
and maintenance of plants reaches, consistent with several experts, 85% of culture costs (Alvarado 2002).
68
ways and airports. This indicates that floriculture is
extremely dependent on public networks of modern
infrastructure.
The installed production capacity is distributed
in various managerial groups, from family groups to international holdings, and multinational branches, which
tend toward vertical integration. A sign of capitalist
development is the high profitability of a majority of
farms (300 farms of 10-15 has on average), with important investment, use of resources and workforce.
Medium or large companies have their own topology
spread within the territory: farms in diverse regions;
administrative offices, and commercializing agencies in
Quito or Cuenca; their own truck fleets, and even
cold-storage installations at the airport. It has not accomplished the resolution -neither individually nor as
a union– of the critical knot of airfreight transportation to destination markets.The latter constitutes one
of the higher expenditure items in the net price3 [Alvarado, 2002].Additionally, it has not succeeded in productive research and intellectual property policies to
confront elevated payment to patentees. The high cost
of money that resulted from the "dollarization" of local currency is also evident [Alvear, 2000].
Moreover, the floriculture spatial circuit in its
marked dynamism requires numerous and varied resources and related services (packing, industrial protection equipment, textile and shoemaking industry,
graphic and paper industry, nourishing services, computer production and knowledge (hardware and software), personnel specialized in constructing and repairing greenhouses and diverse machinery). The location of farms decisively influences demographic
growth.
The axis of location of farms within the national
territory, and thus the main axis of fluxes, follows the
route of major roads (Panamerican Highway and other first-rate ones) concentrated in the inter-Andean
valleys, from 2600 to 2900 meters above sea level, in
8 provinces, as illustrated in the map.
It is confirmed that floriculture presents itself as
an archipelago of areas with strong technological density –typical of globalization-, against a background of
low technological density, agricultural and traditional
peasant zones [Larrea & Maldonado, 2005].
Workers are predominantly young, with vitality
and the capacity to adapt to overtime demands, performance, high productivity, severe rhythm; with basic
educational levels that permit their training in the
farm; and a minor degree of involvement in peasant-indigenous and/or union organization. To assume working living modes, they must modify their cultural patterns. Albeit, their leaving the peasant community circle, or even the one of indigenous culture, implies a
certain level of personal freedom and relative autonomy of a wage or income, conversely it supposes
subjection to a new bond of a very strenuous proletarian working pattern. In the case of working young
women, it entails a particular rupture with respect to
patriarchal relations of the traditional community to
fall into submission to intense demands of productivity
of companies.
Water And Soils: Perfect Flowers And Threatened Life
Consumers of the so called "First World" demand "perfect flowers" –without spots on petals or foliage. However, this symbolic value is attained by means
of plague and illness control, which could be accomplished by integral management systems, without or
3. According to Alvarado (2002), transportation corresponds to 19% to 37% of the final price of the product. The cost of management and sales (brokers, wholesalers, customers and retailers) in destination represents roughly 32%.
69
70
with a substantial reduction of chemical use. Unfortunately, the majority of companies (which do not participate in the FLP program) resort to irresponsible use
of pesticides and other dangerous agro-toxics, due to
their profit logic. Also, the advertising of agrochemical
companies promotes the massive use of chemical products and subjects them to the culture of the green revolution. Thus, the majority of flower companies,
which do not work properly, contribute to contamination in valleys. Small highland farmers, forced by their
economic and technical needs, also have recourse to
chemical control of their agriculture, especially potatoes and pastures. In numerous occasions the situation
is aggravated due to low-priced and highly dangerous
chemicals –red and yellow label- (refer to Table N°1).
CEAS designed a sampling system4 to differentiate these impacts, obtaining results whose prelimi-
nary analysis show perturbing conclusions [Sánchez &
Mac Aleese, 2005].
Impact on Hydric Systems
Systems connected to La Chimba and Pesillo zones (potatoes and cattle producers) and San Pablito
de Agualongo and Cananvalle (floriculture effluents
collection zone) were studied. Water of the corresponding hydric systems and sediments of the matching river basins are contaminated with chemical residuals in a proportion relative to their proximity to
contaminating sources: lesser in higher sectors of
fountains, moderate in potato, pasture and barley production zones, and greater in the floriculture agro-industrial valley (refer to Table N°2).
TABLE Nº 1 CHEMICALS USED IN FLORICULTURE AND OTHER CROPS
PRODUCT
CHEMICAL GROUP
USE
TOXICITY LABEL
Fosetil aluminio
Hidrocloruro de propamocarb
Mancozeb
Methiocarb
Metomil
Carbofuran
Diazimon
Demeton – S – metil
Malathion
Metamidefos
Tiociclamhidrogenoxalato
Bromuro de metilo
Phosphate
Carbamate
Acetamide
Carbamate
Carbamate
Carbamate
Organophosphates
Organophosphates
Organofosforado
Organophosphates
Nerehistoxina
Methyl bromid
Flowers-potatoes
Flowers *
Flowers-potatoes
Flowers *
Flowers *
Flowers-potatoes
Flowers *
Potatoes *
Potatoes & other *
Flowers-potatoes
Flowers *
Flowers *
Blue
Green
Yellow
Yellow
Red
Red
Yellow
Red
Blue
Red
Yellow
Red
4. Sampling points to study residuals in water through liquid and gas chromatography; they are explained in Table N02.
71
Research on highly persistent agrochemical hydro-soluble residuals in the basin reveals important
results. Contamination by persistent hydro-soluble
residuals reappears mostly in periods of lesser flow
or dilution (July-August) and of greater production
and agricultural use of chemicals (November-December). Observing Table N°2, we verify a high concentration of residuals in the effluents of the flower farm
(T1), or in the branches of the hydric system of the
valley (P2 and P3) during December – the month in
which there is an intense production for Saint Valentine’s Day-. Dissemination of contaminants is thus
produced by farms lacking controls (which are not a
part of the FLP program), as a consequence of their
high productivity logic. There is no doubt that small
potato and pasture producers pollute as well, by allowing non-filtered superficial residuals to seep into the
soil (CH1 and CH2) (Table N°2). In addition to the
presence of detectable residuals in water, there is the
incidence of heavy metals (chrome, manganese, and
zinc) that are residual components in levels correlative to the use of pesticides. Furthermore, the general
deterioration of water quality results from the presence of nitrogen, sulfur, and phosphorus derived
from fertilizers and pesticides in high grades detached
from agrochemicals. In other words, water from floriculture basin hydric systems denotes a critical effect
in its physicochemical and biological properties. Also,
we begin to confirm the consequences that the presence of toxic elements and residuals have on human
health.
With the aim of strengthening the community’s
capacity of early detection of water chemical contamination and its impact on living organisms, CEAS undertook an experimental program to perfect bioassays
originally conceived of by an international team under
the auspices of the CIID (Canada)5. The first results
show the expected gradient in growth inhibition of
onion roots (Allium cepa L.) within high zones (potatoes and pastures with only 16% to 21% of inhibition)
and the flower zones samples (with 46% to 72% of inhibition) [Felicita, 2005].
Evidence of contamination by lipo-soluble chemicals in bovine milk (bio-accumulation) were also
found; hence, the troubling corroboration of highly
dangerous chlorinated chemical residuals, such as
ppDDT in distinct sampling points during December
are an alarming and deserves continuous study by the
CEAS.
Albeit, floriculture is not the only source of contamination, collected evidence demonstrates it is of
major importance. Moreover, contamination by dangerous residuals in water is not the only mode of impact on the ecosystem, since our study establishes
that the productive system employed in flowers contaminates soils. The accumulation of residuals in sediments is effectively superior to that of water in the
majority of cases (Table N°2). In farm soils, the accumulation of residuals in soils (studied by phase extraction –"solid phase extraction" SPE- and analyzed by
gas chromatography) is greater as the time of productive use of soils passes (refer to Figure N°3) [Aguirre,
2004].
The mentioned process triggers soil degradation, causing loss of biodiversity, with grave alteration
of its composition, diminution of metabolic rate, destabilization and sterilization; a prolonged effect not
counterbalanced by the artificial elevation of the organic composition, a conventional indicator [Aguirre,
2004].
5.The Research Center for Development (CIID) of Canada sponsored an international study to implement easy-operation bioessays to measure the impact of water
chemical contamination on the four biotic systems (i.e. onion/lettuce, water fleas, and algae). They are systematized in Dutka, BJ (1996) Bioessays: A Historical
Summary of Those Used and Developed in our Laboratories at NWRI. National Water Research Institute, Environment Canada, Burlington.
72
TABLE Nº 2 STUDY ZONES : DIFFERENTIAL CONTAMINATION IN THE FLOWER
PRODUCTION REGION
ZONE
COD
NAME
LOCATION
CHARACTERIZATION
CH1
Chahuancorral
Alto
High altitude, near
water fountains
Water:ORG. PHOS/CHLOR : Betaendosulfan & Endosulfan sulphate (trace)
PHYS/CHEM/BIOL: pH low; sulphur; nitrite; high bacter & high DBO5.
Sediment: CARB:3 Hidroxicarbofurán ( trace, August); ORG.PHOSP/CHLOR:
Betaendosulfán (trace , August)
CH2
Chahuancorral
Bajo
After potato crops,
pasture and other
Water: ORG. PHOSPH/CHLOR : Endosulfan Sulphate (trace, Feb)
PHYS/CHEM/BIOL: pH low; sulphur, nitrites, nitratos; c. bacter & highDBO5
Sediment: CARB:3 Hidroxicarbofurán ( trace, August); ORG.PHOS/CHLOR: Betaendosulfán
(trace, Feb)
AY1
Ayora
Puluví
After community and Water: ORG. PHOS/CHLOR :Betaendosulfán (trazas Feb)
before flowers
FIS/QUIM/BIOL: nitrite, nitrito, con bact & high DBO5 , hardness
(Low North)
Sediment: ORG.PHOS/CHLOR:Betaendosulfán (trace, Augst); ppDDT (trace, Diciembre)
AY2
Ayora
Granobles
After community and Water: CARB: Carbofurán (high Dec. 0.08 y Feb 7.1); Metomil (high Dec 1.53 y 18.2 Feb)
before flowers
ORG. FOSF/CLOR: Cadusafos (August 7.59 y Feb 0.66); Dimetoato (trace, Feb);
(Low North)
Clorpirifos (trace, Feb); Betaendosulfan (0.28 Dec y Tiabendazole (trace, August)
PHYS/CHEM/BIOL: sulphate, nitrito, nitrate, hardness, very high bacter y& DBO5
Sediment: CARB:3 Hidroxicarbofurán (trace, August); ORG.PHOS/CHLOR: Cadusafos
(trace, Feb) & ppDDT (trace, Dic)
P1
Pisque
Pool area
Center, after river con- Water: PHYS/CHEM/BIOL: nitritos, nitrate, hardness, high bacter & DBO5
fluence Guachalá River Sediment: ORG.PHOSP/CHLOR: ppDDT (trace, Dec)
& Granobles River;
oxygenated river tract
P2
Pisque
"Gorge"
Gorge, farm water dis- Water: ORG. PHOSP/CHLOR :Betaendosulfan & Endosulfan sulphate (trace, Dec)
charge point (7 km
PHYS/CHEM/BIOL: nitritos, nitrate, hardness, high bacter & DBO5
from P1, South
Sediment:ORG.PHOSP/CHLOR: Betaendosulfán (trace, August)
Cayambe)
P3
Pisque
"Bridge"
Basin exit point
Water: CARB:Carbofurán (1.5 August); ORG. FOSF/CLOR : Betaendosulfan (trace, en Dec)
PHYS/CHEM/BIOL: sulphate, nitritos, nitrate, hardness, very high bacter & DBO5
Sediment: ORG.PHOS/CHLOR: Betaendosulfan (trace, en August)
T1
Flower
Farm T
Farm effluent
(Cananvalle)
Water: CARB: Carbofurán (23.1 in Dec);Metomil (3.8 Dec & 1.2 Feb). Oxamil (4 in Feb):
ORG. PHOS/CHLOR : Diazinon (trace, Feb); Clorotalonil 0.99 in Dec); Alfaendosulfán
(0.09 in Dec); Betaendosulfan (0.35 in Dec); & Endosulfan Sulphate (trace, Dec).
PHYS/CHEM/BIOL:very high DQO; low sol O , sulfphate, sulphur, high nitritos &
nitrate , chloride, hardness, high bact & DBO5
Sediment: ORG.PHOS/CHLOR: Dimetoato (trace, Feb); Alfaendosulkfán (0.09 in Dec);
Betaendosulfán (78.76 in Dec); & Endosulfán sulphate ( trace, Feb)
CHEMICAL CONTAMINANTS
& IMPACTS (*) (**)
(*) CARB= Carbamates; ORG.PHOS/CHLOR:= Organophosphates & organ chlorinated; PHYS/CHEM= physical chemical parameters
(**) Types and names of observed chemical residuals are stated, Either traces or bigger concentrations, either in water or sediment: water (1g/L) or sediment 1g/kg.)
Source: EcoHealth (CEAS), 2004; Ecuadorian Atomic Energy Commission Laboratory
73
FIGURE Nº 3 SOIL CHEMICAL CONTAMINANTS BY FARM TYPES
CONCENTRATIONS - µG KG -1
Source: Aguirre (2004)
A further serious consequence in the ecosystem
is the problem of water demand. To have an idea of
the magnitude of this, we just have to contrast water
consumption by small farmers of the zone (only 1.000
liters / month / ha in peasant production), or that of
traditional "haciendas" (17.000 to 20.000 liters/ month
/ ha in agriculture and livestock production), with the
enormous water demand by flower farms (900.000 to
1.000.000 liters / month / ha in monthly flower production) [Sánchez & Mac Aleese, 2005].
In sum, our study offers evidence of severe impact of the current floriculture system, and requires reflection upon whether this type of productive system is
sustainable, or if it should be continued, that it do so
without gravely compromising future ecosystems.
Health Impacts on Workers ("ex-peasants"):
Selling Life at a High Cost
The logic that organizes entrepreneurial floriculture provokes serious changes in the life patterns of
communities and agricultural workers.A contradiction
exists in their modes of living because, on the one
hand, it generates employment and monthly income
slightly above the average rural wages, while on the other hand, unfortunately, imposes hazardous daily activities and exposure to dangerous chemical substances.
Our study reveals that, on average, 31% of families of the study area6 have at least one economically
important member working in floriculture. In those
communities with weaker ties to this activity, as many
6. Communities that made part of our sample were: "La Chimba", "Pesillo", "Agualongo" y "Cananvalle", totaling 388 families.
74
as 24% family heads work in flower farms and up to
52% in those villages with closer links [Handal, 2005].
In the Cananvalle Community, as many as 67% family
heads work in cut flower production. [Ferrero & Morel, 2005]. Therefore, a significant proportion of villagers live under conditions directly or indirectly defined by the floricultural system.
The flower production process obeys the logic
of capital accumulation: maximum profitability and surplus value extraction. It depends on highly demanding,
chained, routinary and stressful work, with insufficient
brake periods (especially during high flower demand
cycles like Saint Valentine’s Day or throughout the
months of November to January), as well as chronic
exposure to chemical, physical and ergonomic hazards.
Intensive pesticide use is characteristic of non-ecological flower production and in communities with a high
proportion of flower workers, 60% to 75% of pregnant
women used pesticides. In communities with fewer
ties to floricultural work, only 17% of pregnancies were exposed to pesticides; also in the first group, 40% of
children were in contact with contaminated working
clothes, contrary to a lower 18% in those communities with weaker floricultural ties [Handal, 2005].
Working conditions vary among different farm
areas based on the following: the type of labor, schedules, and type of tools and equipment used.Those working modes vary among sections and also determine
workers’ quotidian forms of practice. Overall, cut flower production rhythm is intense and permits little
control on the part of the worker during the productive process. Workdays are demanding, extenuating
and stressful, which leave little time for daily and periodic rest. Depending on the work area, tasks, involve
five types of hazardous processes7. Problems, such as
physical dynamic overload, are prominent, combined
with static overload (as in post-harvest); repetitive
movements; thermal fluctuations; exposure to noise;
respiratory irritants; dermal irritation and fungal skin
infections; and above all exposure to agrochemicals
–occasionally acute and generally chronic and low intensity- is due to the improper use of highly dangerous
substances (red and yellow label products), occasioned
by the absence of plague alternative and integral management systems, and the ineffectiveness or nonexistence of protection mechanisms (deficiency in equipment; incorrect implementation of fumigation turns
and modes). These problems are amplified in farms
that are not subject to FLP program controls8.
New rurality has brought about special overloads and problems among women, not only because
of the "feminization of poverty", but also since peasant
women have transformed into working women. Relationships based on old patriarchal dependence have
been substituted, on account of the tearing apart of
cultural communities, by relationships of submission to
industrial work [López, 2004].
CEAS has designed an epidemiological interpretative model based on a critical processes matrix,
which associates general floriculture production relations with flower workers’ typical living styles, as well
as specific impacts it has on people’s organism and
mental health [Breilh, 2004]. For the detection of main
impacts, different test modules were designed9 that
7.Their classification and explanation is developed in Breilh (2003) CDROM "SaludFlor": PDI: procesos físicos derivados de la condición de los medios; PDIIa: procesos emanados de la transformación de materia prima; PDIIb: Procesos de contaminación biológica; PDIII: procesos derivados de la exigencia física laboral; PDIV:
proceso derivados de la organización del trabajo; PDV: instalaciones y equipos peligrosos.
8.The "Flower Label Program" (FLP) is an international program based on the implementation of guiding principles of labor, social, human and ecological protection
rights, fostered by an association of European unions and NGO’s; of which an Ecuadorian interdisciplinary team of the CEAS is in charge.
9. General questionnaire (socio-cultural; working conditions and exposure patterns); stress and mental illness; computerized neurobehavioral evaluation tests –NES2;
laboratory blood tests (toxic impact in liver transaminases-; renal –serum creatinin-; blood marrow -hemoglobin, ferritine & transferrine- genetic instability – lymphocyte comet test-; erythrocyte acetylcholinesterase; control variables and nutritional condition.
75
covered nervous system toxicity problems; liver, cardiovascular, and renal impact; impact on bone marrow;
genetic stability disturbance; impact on mental health.
Preliminary test data analysis yielded very high
toxicity impact rates (see figure Nº 4) in a representative sample of workers of both an FLP farm and a nonFLP farm10. From a preliminary analysis of databases
being processed, the following concerns have been established. In the first place, a very high percentage of
workers on both farms are exposed to hazardous elements and processes. This is the case particularly on
60% of the farms, which are those that do not pertain
to the FLP program.
In the second place, quality and coverage of workers’ protection equipment is limited, mostly in the
farm that does not comply with international standards. In the third place, all types of health exams, high
percentages of impacts on health were registered.
Control and analytical variable analysis needs to be
performed prior to answering the following question:
How many of these problems are attributable to floriculture?
However, in this preliminary phase of analysis
several worrying facts begin to be revealed: workers
are affected in significant aspects of their health (arterial pressure, 52%; toxic anemia, 14%, low leukocytes,
12%; hepatic transaminase increase –inflammation-,
26%; genetic instability, 25%; neurotransmitter system
enzyme reduction –acetylcholinesterase-, 23%11; and
69% showed clinical signs of toxicity, moderate and
severe (refer to Figure N04). Furthermore, 56% were
in a state of moderate and severe stress, and 43% of
malnutrition (overweight); all which indicates that the
workforce has bad health conditions. When analysis
advances and we have community comparative data,
we shall understand more thoroughly how much of
this wide-ranging problematic is occasioned by floriculture; nevertheless, if we recall the higher proportion of contamination which exists in the floriculture
zones and in the work settings of flower farms, we
may estimate that an important part of these health
problems could be due to irresponsible floricultural
production.
Current mental suffering among workers studied reaches 38.8%, distributed between moderate
suffering (24.4%) and severe suffering (14.4%). The index happens to be high if one considers that in an average population, it should not be over 20%.The mental vulnerability of this working population becomes
evident when we analyze the results of the study on
"local infant development self-valuation" applied to
students of the Technical School of Cayambe, which
reveals that the majority of young people investigated
(70.21%) is classified as having limited infant development conditions [Campaña, 2005].
Neurological development of children who live
in communities of the floricultural region is also affected. The mentioned neuro-motor development, already influenced by the living modes of peasant children (low income, malnutrition, maternal and paternal
needs regarding their formal educational level, perspectives on nurturing, infant development and stimulation) is also stricken by exposure to pesticides
[Handal, 2005].
A Struggle for Fair and Ecological Floriculture
The EcoHealth program and the study of the
Granobles River Basin has explored, since initial design
10. A representative simple random sample made of 71% of the total workers (n=160; out of N=225 total workers) selected from all sections (proportional probability).
11. Acetylcholinesterase reduction, as conventional exposure indicator used to evaluate workers´ health, does not provide de sufficient sensibility, according to our
validation tests.
76
FIGURE No 4 DETECTED HEALTH PROBLEMS WORKERS TWO FARMS, 2003
(ECOHEALTH PROJECT CEAS/CIID)
workshops, the possibilities of an intercultural, transdisciplinary and participative construction of knowledge, rooted in an analysis of the power structure that
conditions management, work with flowers, and community life. The central idea has been to perform research, with multiple subjects of knowledge and to
triangulate the knowledge and instruments of academic and communitarian groups.
Once this first research phase is concluded, the
next phase of intervention and incidence will be undertaken. Thus far, the project has constructed valuable
tools from the perspective of communities’ interest: a
most relevant geo-codified database, with characterization and knowledge on impacts of flower production
upon workers, communities, hydric systems and soils; a
solid methodology for the sampling and discrimination
n=160
of distinct contaminating productive sources; the validation of test modules to study the impact on human
health and to demonstrate that conventional acetylcholinesterase exams are insufficient and tend to veil a
broader chronic low intensity pathology, and to evaluate the effects on school and pre-school health; advancements in the implementation of community bioessay
laboratories; CDROM software for workers’ health clinical management and monitoring in farms; a rigorous
system of verification (checking list) for the FLP program; the commencement of a campaign within the
United States to foster support of flower consumers
to put pressure for fair and ecological flowers.
All this effort, must be projected along the phase of incidence in the next years, to fortify the organization, awareness and advocacy of communities; the
77
municipal and national juridical transformation on floriculture sustainable management norms; the organization of a communitarian, municipal and general floriculture monitoring system; the construction of alternative proposals for a non-monopolistic floriculture,
centered in the wellbeing of communities and workers
and the sustainability of their ecosystem; the updating
of study programs on cut flowers ecosystem health, at
various educational levels and scenarios; and the
strengthening of an international campaign of "fair and
ecological flower".
Together with the people of Cayambe and Tabacundo we are recreating in our work the idea that
beauty of Ecuadorian flowers must not be constructed
on the basis of reproducing poverty and threatening life in our ecosystems. Research alone does not bring
about ecosystem health, but must be accompanied by
well-informed collective struggle.
78
REFERENCES
●
AGUIRRE, PATRICIA (2004) Effects of Pesticides on Soil Quality:
The Case of Ecuadorian Floricultura. Aeche: Universitat Göttingen (D7).
●
ALVARADO, SILVIA (2002). El caso del comercio exterior de la
flor ecuatoriana como una alternativa para la comercialización de
otros
del Agua en la Cuenca del Rio Granobles (Canton Cayambe Y Tabacundo). Quito: Programa EcoSalud CEAS/CIID.
●
FERRERO, JORGELINA & MOREL, STELLA (2005) Informe de Pasantía (Universidad de Córdova) en Programa EcoSalud CEAS
●
GASSELIN, PIERRE (1999). La floriculture et les dynamiques agraires de la region agropolitaine de Quito (Equateur).Tesis doctoral.
Instituto Nacional Agronómico, Paris.
●
GIARACCA, NORMA (2001) Prólogo en "¿Una Nueva Ruralidad?". Buenos Aires: CLACSO.
●
HANDAL, ALEXIS (2005) Plaguicidas y la Salud de Mujeres y sus
Hijos: Región Floricultora del Ecuador. Ann Arbor: Estudio del
Programa Doctoral en Epidemiología, Universidad de Michigan
asociado con el Centro de Estudios y Asesoría en Salud ((Programa EcoSalud CEAS/CIID).
●
LARREA, MA LOURDES & MALDONADO, PAOLA (2005). Circuito Espacial de Producción de la Floricultura de Exportación,
Caso Ecuatoriano. Quito: Programa EcoSalud CEAS/CIID.
●
LÓPEZ, JANSI (2004) Gender and Floriculture: A Study of Ecuador’s Cayambe-Tabacundo Region. San Diego: Masters of Arts
Degree,Thesis in Latin American Studies, University of Califórnia,
associated with the Center for Health Research and Advisory
(CEAS) EcoHealth Program (CEAS/IDRC).
●
SÁNCHEZ, DORIS & MAC ALEESE (2005) La Dinámica de Plaguicidas y los Sistemas Hídricos en la Cuenca del Granobles. Quito:
Programa EcoSalud CEAS/CIID.
●
SANTOS, MILTON; SILVEIRA, M. LAURA (2001). O Brasil: territorio e sociedade no inicio do século XXI. Rio de Janeiro, Record.
● ALVEAR, LUCIANA
(2000). "La Dolarización y el Sector Agropecuario Ecuatoriano", resultados del grupo taller Impactos de la
Dolarización en el Sector Agropecuario organizado por el Proyecto SICA-MAG / Banco Mundial (Quevedo).
●
●
●
●
BREILH, JAIME (2003). Conceptos Nuevos y Disensos Sobre la
Epidemiología de la Toxicidad Por Agroquímicos en la Industria
Floricultora en "SalufFlor: Sistema Clínico y Monitoreo de la Salud en Empresas Floricultoras – Programa en CDROM". Quito:
Publicación del CEAS (formato multimedia)
BREILH, JAIME (2004). Epidemiología Crítica (Ciencia Intercultural y Emancipadora). Buenos Aires: Lugar Editorial (2da reimpresión).
CAMPAÑA, ARTURO (2005). Sufrimiento Mental y Trabajo en
Floricultura en Ecuador. Quito: Programa EcoSalud CEAS/CIID.
CORDERO, FRANCISCO (2003). Caracterizaciuón de los Plaguicidas Utilizados en la Cuenca del Granobles. Quito: Tesis de Licenciatura en Ingeniería Agronómica de la Universidad Central en
asocio con el Centro de Estudios y Asesoría en Salud (Programa
EcoSalud CEAS/CIID).
●
EXPOFLORES (2004). Estadísticas
●
FELICITA, ORLANDO (2005) Montaje y Puesta en Marcha de un
Laboratorio Comunitario de Bioensayos Para Evaluar la Toxicidad
79
8
Aspects of Hazardous Infant Work in
Latin America
Walter Varillas
The Network of Hazardous Infant Work
One of the most extreme expressions of human globalization is the situation of children who work. This inhumane affect of Globalization, in conjunction with the egotistic policies of dominant classes in our countries, is
one of the the main sources of poverty. And poverty, in combination with
cultural factors and limited public policies in defense of childhood, is identified as the major cause of infant work. However, as we will see, virtually half
of these minors work in conditions, which can seriously affect their normal
development, their health, their security, and their life itself, creating a terrible vicious circle of poverty. This paper will thus briefly address this theme.
The Magnitude of Hazardous Infant Work
According to the Global Report "A future without infant work", published by the International Labor Organization (ILO) in May of 2000, by 2000
approximately 351.7 million children between 5 and 17 years of age were
performing any type of economical activity. Of that group, 170.5 millions
(48,5%) were engaged in some kind of work considered hazardous1.
1. The International Labor Organization defines hazardous infant work as the activity developed by minors,
which, due to its nature or the conditions in which it is performed, it is likely to damage health, security or
morality of children.
80
TABLE 1. CHILDREN FROM 5 TO 17 YEARS OF AGE WHO PERFORM HAZARDOUS ECONOMICAL ACTIVITIES AND WORK THROUGHOUT THE WORLD. BY AGE GROUPS.
FROM 5 TO 14 YEARS FROM 15 TO 17 YEARS
Children economically active
Children who perform hazardous work
210.800.000 (100.0 %)
111.300.000 (52.8%)
TOTAL
140.900.000 (100.0 %) 351.700.000 (100.0%)
59.200.000 (42%)
170.500.000 (48.5%)
Elaboración en base a: OIT (2002) Pág. 20.
TABLE 2. ESTIMATE OF THE DISTRIBUTION OF INFANT WORK IN UNDERDEVELOPED
COUNTRIES. BY ECONOMICAL ACTIVITY.
ECONOMICAL ACTIVITIES
Agriculture, hunting, silviculture, fishing
Manufacture
Commerce
Communitarian, social and personal services
Transportation, storing, communications
Construction
Mining and quarries
Total
MALE %
68.8
9.4
10.4
4.7
3.8
2.0
1.0
100.0
FEMALE %
75.3
7.9
5.1
8.9
1.9
0.9
100.0
TOTAL %
70.4
8.3
8.3
6.5
3.8
1.9
0.8
100.0
Elaboration based on: ILO (2002). Page 25.
The statistics of this report illustrate the magnitude of the problem of hazardous infant work, which
represents 11% of the total infantile population between the 5 and 17 years of age worldwide.Thus, two
out of every 10 children world-wide perform economical activities and one of them does so in hazardous
work.
In the case of underdeveloped countries, as they
are called, infant work is primarily in rural agricultural
activities, and secondly in the manufacture, commerce, and service sectors, particularly within the informal economy. Male children’s work is greater than female children’s, as age increases.
Paying Attention to Hazardous Infant Work
Hazardous infant work is not solely a problem
due to its magnitude, but additionally because of its seriousness and grave side effects. The mentioned Global Report refers to the necessity of long-term interventions for the reduction of poverty and the promotion of sustained economical growth. It also calls for
interventions in places where the problem originates
and where poverty creates the worst forms of infant
work.
In spite of the advancements accomplished, it is
still difficult to define hazardous infant work as a spe81
cific work category among the group of the worst
forms of infant work. With this in mind, the report of
the ILO indicates the following:
"Thus, it is not always simple to plot the limits of
hazardous work, especially when the damage being
caused to children is not perceptible in the short
term. Hazardous work has already been identified in
the Agreement N. 138 as work that requires a minimum age of 18 for admission…Its acknowledgement
as one of the worst forms of infant work puts forward
a new urgency of action directed to its elimination"
[OIT, 2002].
This document mentions that work can damage
the child as a consequence of the task in itself he/she
has to perform, the instruments used, the schedules,
or conditions of work. And further, other factors can
also potentially also affect the physical, mental, emotional, psychological, moral, or spiritual development of
the minors.
Minors are exposed to health and security hazards graver than adults. Due to their process of
growth and development they are more susceptible to
labor hazards and can be affected irreversibly [Forastieri, 1997]. "Chronic physical tensions on bones and
articulations in process of growth can impede their
development, cause medullar injuries and other definitive deformations" [OIT, 2002]. These hazards are accentuated by poor states of nutrition, continuous exhaustion, decreased maturity compared to adults, and
machines and tools not adapted to the characteristics
of minors.Additionally, many hazards are unobservable
to plain eyes because of their delayed effects. Such is
the case with the noxious effects of pesticides or heat
stroke in agriculture.
The International Labor Organization recognizes
the necessity to learn more about the short and longterm effects of the distinct types of work of male and
female children of diverse ages and health conditions.
"It is necessary to acquire that knowledge to be able
82
to decide what types of work are to be prohibited for
children of less than 18 years of age and to plan the
adequate rehabilitation of children who have been removed from hazardous works".
Despite not having complete data on the injuries
and illnesses brought about by infant work, we do have the following statistics [OIT, 2002]:
●
Within the United States the rate of injuries per
hour of work in the case of children and adolescents almost doubles that of adults. In the period of
1992-1998, the rate of mortality of young workers
reached its maximum in agriculture, silviculture and
fishing, followed by retail commerce and construction.
●
In a survey applied in Denmark, Finland, Norway and
Sweden in 1997-1998, rates of injuries between 3%
and 9% in children who work before or after school
were observed. In Denmark, greater rates of accidents of children were detected in agriculture than
in other sectors.
●
In a study of the ILO completed in 1997 in a number of underdeveloped countries, the subsequent
mean rates of illnesses and injuries among children
were noticed: 25,6% in construction, 18,1% in transportation, storing, communications, 15,9% in mining
and excavations. All these rates were greater in female children than in males with the exception of
transportation.
Some explanations concerning the higher
level of hazard in minors for occupational
accidents and illnesses
Forastieri [Forastieri, 1997] and Hiba [Hiba,
2002] have systematized the particular conditions of a
child’s susceptibility to hazards, as compared to adults:
●
Immaturity of organs and tissues
●
Discrepancies among the indicated tasks and the
completed tasks
●
Higher metabolic and oxygen consumption
●
Greater need for energy
●
Tasks, tools, equipment and machines are designed
and made for adults
●
Lower physical resistance
●
Exposure to dangerous physical and biological agents
●
Lower physical resistance to changes in temperature
●
Exposure to toxic chemical products
●
Inferior manual skill to operate tools
●
Inadequate psychic and social environment
●
Higher capacity of absorption
●
Poor hygienic conditions
●
Higher psychological vulnerability
●
Limited access to medical services
●
Premature physical wear and incapacity, corporal injuries and fatal accidents
●
Children are sensitive to hazardous attitudes, atavisms and behaviors of adults
●
Minors wish to "stand out" and thus demonstrate
that they are equal to or capable as adults; they are
not conscious of the major risks this attitude involves
Forastieri and Hiba mention that this may be aggravated by the long-term effects of malnutrition and
work and contagious illnesses acquired by children in
hazardous working activities, and that this will in turn
lead to the following consequences: chronic fatigue,
physical exhaustion and mental stress, reduction of the
physical capacity to work in adulthood, delayed
growth, damaged auditory capacity, neurological deterioration, and damages and disabilities.
These authors further include some conditions
which worsen the situation of infant work, such as:
●
The deficient information on the hazards at work
●
The labor inexperience and the underprovided labor
information
●
Minors are not acquainted with hazards, or know
less than adults, which is an important reason why
they are more exposed
●
In general, they are neither trained for the task they
are to develop, nor to take measures of protection,
being directly and overtly exposed
●
Equipment of personal protection for minors does
not exist
Piedrahita [Piedrahita, 2002] explains that the
majority of information on the health effects of working children applies to occupational accidents; nevertheless, professional illnesses can be a consequence of
exposure to different physical and chemical agents as
well.
A pediatrics maxim indicates that "children are
not small adults". Consistent with the National Research Council, U.S.A. 1993, the biological systems of
children and young people are not mature until they
are 18 years old.Various differences in anatomy, physiology and psychology distinguish children from adults,
and expose them to special hazards at work. Hence,
the greatest hazard to which working minors are exposed may be explained by the special characteristics
83
of their psychological-biological development. Thus,
the following list of risk factors becomes evident:
●
Height: Young people vary greatly in height. A lack
of adequate adjustment of machines could lead to
accidents among young workers. Costumer Products Safety Commission carried out in 1993 research on the use of lawnmower machines and discovered that the rate of accidents was greater amid
young people from 5 to 14 years old than among
older ones. Similarly, accidents were more frequent
when children were less than 60 inches high and
their weight was inferior to 125 pounds.
●
Growth: It is believed that the diminution of coordination in young people during periods of rapid
growth could increase the risk of accident at work.
●
Sleep requirements: Adolescents require nine
hours of sleep at night, however it has been found
that students, which additionally work part-time,
sleep an average of seven hours or less. The accumulative deprivation of sleep and the fatigue in children and young people can increase the risk of accident at work.
●
Psychological risk factors: Children experience
deep psychological changes while they mature. Even
so, their bodies continue to develop physically in an
accelerated manner. This can bring about situations
in which psychological immaturity is obscured by
apparent physical maturity, and therefore they are
assigned to tasks for which male and female children
are not prepared emotionally. In addition, young
workers do not have adequate experiences to judge their ability for a certain job, leading to an even
greater risk of accident at work in several occasions.
General Characteristics of the Problem
of Infant Work in Latin America
According to the IPEC-ILO2 and regardless of
the scarcity of reliable studies, it could be concluded
that 7,6 million children between 10 and 14 years old
work in Latin America. Conversely, if domestic chores,
children younger than 10, and the proper statistic underestimations were included, the total number of
working children would be between 18 and 20 million.
This implies that one out of every five children are
economically active in Latin America.
Some other significant aspects of child work in
Latin America are the greater participation of male
children (60%) than of female children (40%) and the
predominance in rural areas (55%) compared to urban ones. The majority (90%) work within the informal sector, contrasting the 10% that work in the structured sector of economy.
The proportion of salaried child workers represents between 60% and 70% in the urban areas and
roughly 50% of the totality of working children.
The workdays, in nearly all of the cases, are greater than the maximum limits established by legislation.
The mean is 45 hours per week and even those who
go to school dedicate 35 hours per week to diverse labor occupations. The income is also very low; they receive smaller wages than adults for similar work.
General Characteristics of Hazardous Infant
Work in South America
Children who work are exposed to injuries and
illnesses in such a high proportion that it is of major
concern. Thus, on establishing the hazards of infant
2. The situation of infant work throughout Latin America can be view amply in the site of the IPEC-ILO: http://www.oit,org.pe (Infant work). We based this part on
the information provided by this site.
84
work, it is indispensable to broaden the concept of "labor hazard", as it is applied to adults, so it embraces infantile development as well. If working children are generally vulnerable to hazards related to work, very
small children –male and female- are even more so.
Moreover, workdays, in the majority of the cases, are
far greater than the laws of national legislation mandate.
It has been verified in different countries that
there is a high level of infant occupation in brick factories, mines, stone quarries, markets, rocketries, domestic service, and the agriculture sector among others.
The hazards and physical damages for these minors
are obvious: toxic inhalations, burns, partial loss of
sight, mutilations, bronchopulmonary illnesses, allergic
reactions, dermatologic problems, and infectious contagious diseases.
The Response of Countries and the ILO
The International Labor Organization, as a tripartite organization, offers countries two tools to
confront the problem.The Agreement 138 establishes
a minimum age of admission to employment, and the
Agreement 182 deals with the prohibition of the
worst forms of infant work and the immediate action
for their elimination.
This latter agreement states that, "The term
child designates every person younger than 18 years
SECTORS OF HIGH LEVEL OF HAZARD IDENTIFIED BY THE IPEC. BY COUNTRY.
Argentina
Bolivia
Brasil
Chile
Colombia
Costa Rica
Ecuador
El Salvador
Guatemala
Honduras
México
Nicaragua
Panamá
Paraguay
Perú
R.Dominicana
Brick factories, Markets, Leather industry, Agriculture, Ice cream manufacture.
Mining, Sugar making, Construction, Street work, Agriculture.
Coal furnaces, Stone quarries, Preparation of the sisal, Rubbish dumps.
Mining, Agriculture, Street work.
Mining, Agriculture.
Domestic service, Construction, Prostitution, Banana, Assembly plants, Seafood processing
Floriculture, Street work, Construction
Curiles, Assembly plants, Pyrotechnics, Construction, Coffee plantations, Prostitution, Street work, Rubbish
Lime sector, Coffee plantations, Mining; Pyrotechnics, Domestic service, Assembly plants, Construction,
Transportation; Rubbish
Leather industry, Bakery, Assembly plants, Woods; Metallurgy, Construction, Army, Pharmaceutical industry,
Chemical industry, Industry in general
Cafés and Bars; Mechanical workshops, Brick factories, Agriculture
Coffee plantations, Banana, Rice,Tobacco, Cotton, Cattle raising, Street work
Street work, Domestic service, Sugar making, Load
Street work, Domestic services
Gold placers, Brick factories, Stonecutters, Slaughterhouses, Construction, Metallurgy, Processing of coke leaf,
Pyrotechnics, Rubbish, Mining.
Agriculture, Domestic service, Rubbish, Prostitution.
85
EXAMPLES OF SOME EFFECTS OF THE EXTREME FORMS OF INFANT WORK
IN MINORS’ SECURITY AND HEALTH
SECTOR
Work in brick factories
Work in mines
HAZARDS TO HEALTH AND SECURITY
Accidents and lung illnesses
Respiratory illnesses, musculoskeletal diseases, working accidents
Work in quarries
Lung illnesses, accidents
Rocketry
Intoxications, accidents
Agricultural work
Acute and chronic intoxications, accidents
Work in markets
Musculoskeletal injuries, accidents
old" (article 2). It indicates in article 3 that, "the expression the worst forms of infant work covers:
a) tall forms of slavery or analogous forms of practice, such
as children selling and dealing, servitude for debts and
the condition of servant, and forced and obligatory work,
including the forced and obligatory recruitment of children to use them in armed conflicts;
b) the utilization, recruitment or supply of children for prostitution, production of pornography, or pornographic acting;
c) the utilization, recruitment or supply of children for illegal activities, in particular the production and dealing of
narcotics, as defined by the pertinent international treaties; and
d) work that, due to its nature or the conditions in which it
is performed, is likely to damage health, security or morality of children."
86
Hazardous Infant Work
It is precisely the group designated in the last
clause that we have named hazardous infant work.
This clarification is important, differentiating it from
the field of infant work in general, and from the set of
worst forms of infant work. The other three forms
(clauses a, b, c) are named within the mentioned global
report of the ILO as "worst forms of infant work, unquestionably".
The general definition developed in the Agreement 182 is broadened in the Recommendation 190
(1999). This recommendation establishes activities that
owing to their nature or conditions in which they are
performed imply major hazards to infantile population:
"a) the forms of work in which the child is exposed to physical, psychological or sexual abuses;
b) the forms of work under the earth, under the water, in
dangerous heights, or in closed spaces;
c) the forms of work with dangerous machinery, equipment
and tools, or which incorporate the manipulation or manual transportation of heavy loads;
d) the forms of work performed in an insalubrious environment wherein children are exposed, for instance, to dangerous substances, agents or processes, or to temperatures or noise and vibration levels hazardous to health, and
e) the forms of work that entail especially difficult conditions, such as prolonged or nocturnal shifts, or forms of
work that retain children unjustifiably in the premises of
the employer."
What are Countries which Ratify Agreement
182 Committed to With Respect to Hazardous Infant Work?
Article 4 of the Agreement reveals the commitment assumed by countries with respect to hazardous
infant work:
"1.The types of work to which article 3 refers, d) must be
determined by the national legislation or by a legally
qualified authority, with the prior consultation with the
interested organizations of employers and workers, and
taking into account the international norms on the sub-
ject, principally paragraphs 3 and 4 of the Recommendation on the worst forms of infant work, 1999.
2. The legally qualified authority, with prior consultation
with the interested organizations of employers and workers, must localize where the determined types of work
are practiced in accordance with paragraph 1 of this article.
3. The periodic examination and, if necessary, the revision
of the list of determined types of work in accordance
with paragraph 1 of this article is required. This process
is to be consulted with the interested organizations of
employers and workers."
Conclusion
Many of us, either due to economical necessity,
cultural motives, or family tradition, have had to work
as minors. Unfortunately, not every one of us has had
the good fortune of working as minor without affecting our physical, mental and moral integrity. It is the
duty of all of us to help create a situation where the
children of the world do not have to work, but instead
can study and play.We should all contribute to the surmounting of this situation of extreme injustice of minors who work despite the hazards to their health,
their security and their life.
87
El niño yuntero
Miguel Hernández
(Spanish poet and child pastor)
Carne de yugo ha nacido
más humillado que bello
con el cuello perseguido
por el yugo para el cuello.
Empieza a vivir y empieza
a morir de punta a punta
levantando la corteza
de su madre con la yunta.
Contar sus años no sabe
y ya sabe que el sudor
es una corona grave
de sal para el labrador.
Me duele este niño hambriento
como una grandiosa espina
y su vivir ceniciento
revuelve mi alma de encina.
Contar sus años no sabe
y ya sabe que el sudor
es una corona grave
de sal para el labrador.
Quién salvará a este chiquillo
menor que un grano de avena,
de dónde saldrá el martillo
verdugo de esta cadena.
Que salga del corazón
de los hombres jornaleros
que antes de ser hombres son
y han sido niños yunteros.
88
REFERENCES
● ALARCÓN W
(2001).Trabajar y estudiar en los Andes.Aproximación al trabajo infantil en las comunidades rurales de Cuzco y Cajamarca. UNICEF. Lima.
● ALCOCER
M, FORASTIERI V (2003). Informe de actividades de la
Red TIP en Centroamérica. OIT. San José.
●
FORASTIERI V (1997). Children at work: Health and safety risks.
OIT. Ginebra.
●
HIBA (2002). La seguridad y salud en el trabajo infantil peligroso.
Ponencia presentada en la Reunión Preparatoria de la Red TIP.
OIT. Lima.
●
INSTITUTO NACIONAL DEL NIÑO Y LA FAMILIA-INFA
(2001). Entre el barro y el juego. Proyecto de Erradicación del
Trabajo Infantil en las ladrilleras del sur de Quito. Programa de
protección y educación a niños y niñas que trabajan. IPEC-OIT
Quito.
●
IPEC-OIT (2001). Niños que trabajan en la minería artesanal de
oro en el Perú. Estudio Nacional sobre el trabajo infantil en la minería artesanal. Lima, OIT.
●
IPEC-OIT (2002). Criterios para la definición del Trabajo Infantil
Peligroso. Documento de Trabajo. Informe del Taller Técnico de
Quito, 7-9 de agosto (documento en preparación para su edición)
●
OIT (1973). Convenio 138. Convenio sobre la edad mínima de admisión al empleo.
●
OIT (1999). Convenios 182. Convenio sobre la prohibición de las
peores formas de trabajo infantil y la acción inmediata para su eliminación.
●
OIT (1999). Recomendación 190. Recomendación sobre la prohibición de las peores formas de trabajo infantil y la acción inmediata para su eliminación.
●
OIT (2002). Informe Global "Un futuro sin trabajo infantil". Informe del Director General de la OIT. Conferencia Internacional del
Trabajo 90ª. Reunión 2002.
●
PIEDRAHITA H (2002). Algunas explicaciones sobre el mayor
riesgo de los menores a accidentes y enfermedades ocupacionales. Monografía.
89
Life and Health
as Commodities
9
Latin America:
Neoliberalism and Survival
Laura Juárez
In the 80’s and 90’s Latin America entered the restructuring logic of the
global market.The 80s and 90s were mired with a decline in social development
and an alarming rate of poverty. As countries of the region are further subjected to neoliberal restructuring and market fundamentalism the first years of the
new century continues to show a deepening of these trends.
Generalized increase of poverty in the Latin-American population is expressed by various indicators of social deterioration: a rising unemployment;
profound deterioration of workers’ wages; forced migration from the rural to
urban areas; the intensification of the informal economy; the return of diseases
that had previously been eradicated, like cholera; curable maladies mortality such
as itch or gastrointestinal problems (typhoid fever and gastroenteritis), respiratory tract diseases (tonsillitis, pneumonias and bronco pneumonias) among others.These illnesses a direct product increased poverty, linked to deterioration
of basic health, education, and housing standards, massive malnutrition and the
reproduction of socio-economic barriers to public services. A majority of rural
and urban families are crammed in densely populated neighborhoods, suffering
lack of water and sewers, and forced to share community baths and to live under cardboard roofs.The social uprisings that have taken place in Venezuela, Brazil, Peru, and Argentina demonstrate the social discontent of the region.
These indicators of extreme impoverishment pose a crucial question: how
did Latin America reach this critical situation? The answer lays in its economical,
91
social and political history. In order pinpoint the causes that have led to the long term crisis that the region currently faces.We will analyze the recent the capitalist accumulation system and the economic history
of Latin America.
From the imports substitution model to
the secondary exportation model
The imports substitution model arose in the period between World Wars I and II. It placed industrial
development as the axis of capital accumulation, but
soon certain structural limits of the economical model became evident in the 60’s: an increasing payments deficit, resulting from weak industrial national
integration; the elevated external debt; the increase
of inflation; and the low productivity of the production infrastructure. Even so, structural economic problems were masked for almost two decades, by an aggressive credit system and from rising prices of raw
material produced by the countries. Nonetheless,
two external events have ignited the abrupt reappearance of the socio-economical crisis of the 80’s, not
allowing economies to sustain their growth. High interest rates have led to the reduction of internal credit, and secondly, the increase of the external debt of
the zone and the collapse of the cost of raw material
for export, such as coffee, sugar and petroleum. Economies came to a standstill: external credit was suspended, and capital received by means of raw material and primary products exportation decreased
considerably.This undermined the capacity for importing the intermediate and capital goods that the economic apparatus demanded. The financial effects didn’t take long to become evident including the flight of
financial resources, devaluation, interest rates increase, decreased credit, and deficit in the balance of capital.
92
The insertion of Latin America into
the global market
In view of the manifest crisis of the imports substitution model, Latin-American governments gave way
to a new pattern of capital accumulation, based on the
impulse of the secondary exports sector, which corresponded to the new trends of international capital.
Actually, this implied a direct tie of the region to global
economy and to the new profit strategies of national
enterprises and large transnational corporations.
This is how neoliberal economical policies were
imposed in Latin America.These policies were maintained or ratified even in countries where there had
been political transitions from military to civil governments, as in Brazil, Argentina, Chile and Uruguay. Not
to mention authoritarian governments, like in the Mexico, which had already signed the first letter of intent
with the International Monetary Fund in 1977. In it, the
Mexican state made the commitment to adopt austere economical policies.These policies were postponed
until 1982, due to the momentary economic relief
from the "oil boom".
The neoliberal economic policies and the global
capital market strategies have aimed at making the
economical structures of countries suitable to the necessities of large capital investment. It is since the crisis of Latin-American external debt, during the early
80’s, that generalized measures have been imposed on
the countries of the region: opening of internal markets to external competition; the privatization of public companies; the liberalization of investment policies, not only the direct foreign investment (IED), but
also the portfolio or speculative investments; the liberalization of financial systems; the diminished State’s
role in the economy; and the imposition of labor flexibilization on companies.
In sight of the financial crisis of the 80’s, the Latin-American governments applied shock plans to sta-
bilize the economy. In response pressures from international creditors, the private debt was nationalized.
This in effect passed the bill to the working class. Later, they prepared themselves to deepen the reorientation of economical growth centered in the secondary sector of exportation and the national and foreign financial capital. This reorientation has benefited
powerful entrepreneurial groups, while excluding the
great majority of the working class.
Latin-American economy meets structural problems as a consequence of this new form of integration to the international market. On one hand, the
concentration of economical growth a few financial,
commercial and industrial groups belonging to transnational corporations, therefore dependent on the external market; on the other hand, those sectors that
depend on the internal market, with limited employment and low wages, face unfair competition and stagger behind in all economic rates. The dependence on
external factors and the weakening of the internal
market is due to the external growth model, which
does not confer the workers any real importance as
consumers. The purchasing power and potential employment and subsequent demand as consumers, does
not have any significance to the new model and its investment strategies. This means that the people are
not considered determinant factors of economical
growth. In times of global restructuring, labor force is
considered solely as a production cost, thus something
to be diminished in order to promote competitiveness
in companies and the economy. On account of this,
low wage policies and restrictive labor rights have
been imposed through policies of labor flexibilization.
Internal companies investment and consumer
demand tend to be substituted by increasing imports,
in detriment of internal production. National industries in the region, which activate the internal market
and provide the worker population sustenance is neglected.The new globalization tendencies do not con-
sider this an essential aspect. According to neoliberal
ideology, if national productivity of goods and services
is lower than the international market standards, then
it has to be substituted by imported goods. According
to this concept, only the most competitive and productive companies should be backed and financed. In
others words, the principle of "comparative advantages" is drastically applied.The role conferred to LatinAmerican economies is that of productive enclaves linked to international enterprises. This is a mechanism
of combining high technology with cheap and greatly
discredited labor.
Then again, the deliberate policy of attracting external financing, starting from the liberalization of the
financial systems of Latin-American countries and the
management of internal interest rates that have superseded the international financial costs, has signaled the
restriction of internal financing due to the rise of interest rates. In addition, the overvaluation of Latin American currency is geared at making imported goods
cheaper.
Impact on rural and urban workers,
and on their survival
Neoliberal policies have failed in every facet.
They haven’t been able to achieve a sustained economical growth or to eradicate the recurrent financial,
much less to ensure the well-being of the population.
This is evident in the bank crises the financial systems
of the region have experienced, such as Venezuela’s; in
1994, Argentina’s, Mexico’s and Paraguay’s in 1995;
Ecuador’s in 1999; more recently, Argentina’s, in 20012002.
In relation to the evolution of wage trends, the
International Labor Organization (ILO) states that the
majority of Latin-American countries have followed
wage cutback policies, and explains that the purchasing
93
power of minimum wages in the subcontinent are now
under the levels of the 70’s and 80’s. If we compare minimum wages in the region, taking 1980 as a reference
year, we find that among eighteen countries, Mexico
has experienced the worst minimum wage reduction 68.6% reductions. For this reason, Mexican manpower
has become one of the cheapest in the region. El Salvador follows with -68.1%; then Peru with -67.5%;
Haiti with -66.3%; and, Ecuador with -58.9%.The countries that follow are: Uruguay -58.4%; Venezuela 53.9%; Bolivia 51.6%; Argentina 20.6%; Honduras
19.1%; Brazil 12.3%; and Guatemala -7.5 %.
Only a few nations have experienced a contrary
trend of wage recovery: Costa Rica, with 43%; Panama
30.3%; Chile 26.9%; Colombia 12.8%; Paraguay 3.9%;
and Dominican Republic 2.5%.
The containment of minimum wages constitutes
a referential point for the labor market, and for the reduction of the rest of the workers’ salaries is forced;
deterioration of the mini-wages reflects the loss of absolute income of the rest.
The real industrial wages, for instance, experience a tendency similar to the behavior of the minimum
wages of the region, since they diminished for nearly all
countries. Mexico is once again one of the most affected, obtaining the third place with a loss of -31.9% in
2001 (taking 1980 reference). The country with the
highest reduction of industrial wages was Peru with 56.6% followed by Venezuela -56.6%.The countries that
follow are:Argentina-22.3% and Ecuador -0.2%.The nations where increase in real terms was registered included: Chile 58%; Costa Rica 50.5%; Panama 36.4%;
Colombia, 36.7%; Uruguay 16.3%; and Paraguay 1.7%.
In respect to general working conditions, the International Labor Organization (ILO) points out that,
in the Latin-American region, the impoverishment of
labor is accentuated. This is demonstrated in the fact
that just six out of ten new employees have access to
social security, and only two out of ten workers of the
94
informal sector obtain social protection.The organization recounts that the deceleration of economies and
the strong recession provoked by the model (particularly in Argentina, Venezuela, Uruguay and Paraguay)
was clearly expressed in the decline of social and labor
indicators. In other words, the recuperation of the
companies in this region has been based more in the
intensive use of the working factor, the reduction of labor rights, low wages, than in the increase of social
productivity of work. This occurs mainly in times of
economical crisis.
The International Labor Organization (ILO) acknowledged in 2002, that the deficit of decent work, relative to an insufficient supply of working posts, inadequate social protection, and systematic violation of social rights of workers, affected 93 million urban employees.This figure increased by 30 since 1990.[OIT, 2002]
As we have said before, economic neoliberalism
in Latin America confers the work force factor, the
responsibility of bringing down the costs of production and increasing productivity, by imposing low wages and restricting labor rights. By this means, it offsets
the general inefficiency of the economy.
Regarding the employment levels in Latin America, the minimal product growth reproduces high levels
of unemployment in the region.
According to the Economic Commission for Latin America (CEPAL), the Latin-American Gross National Product (GNP) hardly accumulated a growth
mean rate of 3.2% during the 90’s.This was below the
rates registered in 1950 and 1980, of 5.5%.
Likewise, the International Labor Organization
(ILO) indicated that in 2001 and 2002, the deceleration of economies was accentuated, due to the slow
growth of the world economy (particularly of the
USA); the diminished capital flow into the region
(where the input of Direct Foreign Investment is affected the most).The was also accentuated by the political, economical and financial instability with Argentina
as the most noteworthy case, as four presidential
changes were provoked in a month by the social outbursts produced by that instability. The organization
reveals that this instability and the adjustment generated a situation of recession and inflation with several
consequences: a strong collapse of the Gross National
Product (10.6 for 2001); a considerable increase on
the open unemployment rate 17.4%, (as a proportion
of the economically active population, reaching its highest level history; an increase in the inflation rate; an
unusual upsurge of interest rates; and a depreciation of
the national currency ("peso").The International Labor
Organization (ILO) indicates that the strong contraction of the country affected the economies of its main
commercial partners of the Mercosur, particularly Brazil and Uruguay.
Moreover, the Economic Commission for Latin
America (CEPAL) admits that the mean growth rate of
the Gross National Product in 2001, of 1.7% [CEPAL,
2002-2003] for Latin America, proved to be unsatisfactory in terms of generating employment and wages1.
The International Labor Organization (ILO) explained
that the moderate increase of the estimated product
in the subcontinent, 5% in 2004 and 3.5% in 2005, was
also unsatisfactory in front of a larger labor supply. For
the same reason, this institution projects an unemployment rate of 10.1% for the region in 2005, and ascertains that this rate could reach, 12.8% in Argentina,
11.1% in Brazil, 8.2% in Chile, 14.7% in Colombia,
10.8% in Ecuador, 9.2% in Peru, 12.8% in Uruguay,
15.3% in Venezuela and 3.6% in Mexico.[OIT, 2004]
Even if Mexico is situated as the nation with the
lowest open unemployment rate, it is important to
point out that ILO declared, in the International Labor
Conference (2002), there are 25.5 million Mexicans,
employed in the informal economy. Among them, the
number of men is 17 million (67%), and the number of
women is 8.5 million (33%). [OIT, 2002] Seemingly, official Mexican statistics, register these people as employed In addition, Mexico is one of the foremost manpower exporters.
Finally, it is substantial to consider that ILO reports that, between 1990 and 2003, in the urban areas
of the region, six out of each new ten employed people worked in the informal economy. [OIT, 2002]
In relation to agricultural workers of the region,
neoliberal policies drive them to a severe crisis. The
cause is the subordinated integration to the global
agro-nutritional market. Our countries have become
simple importers of food (especially from the United
States, with its enormous alimentary surplus and their
multimillionaire subsidies), and exporters of crops
(fruit, vegetables, flowers, etc.).[Trápaga, 1996] The
abrupt commercial opening of agricultural sectors and
the progressive withdrawal of agricultural promotion
programs, leads to a decrease of food and industrial
goods production.The consequences include a loss of
nutritional sufficiency of nations along with the migration of thousands of producers in the region, forced to
abandon their land for economical reasons. [Juárez
Sánchez, 2003-2004]
The neoliberal structural adjustment has various
aspects that impact workers directly. The policies are
impoverishing and affecting them economically and
morally. Examples include wage contention; the opening of national productive sectors to international
competitiveness, with the resulting disintegration of
national productive chains and the systematic bankruptcy of micro, small and medium companies; the
cut in social expenditure. All of these affect the foundations of workers´ social reproduction (housing, education, health, subsidy to nourishing consumption,
etc.); the forceful integration of national production
units to external chains, that employ the Latin Ameri-
1. CEPAL, Una década de luces y sombras: América Latina y El Caribe en los años noventa
95
can population, paying them misery wages; the limited
employment generation, in most cases precarious, as a
result of the imposition of labor flexibility, to adjust for
lesser labor demand (personnel adjustment); and the
decrease in salaries, not proportional to workers’ productivity.
The region has experienced the bitter experience of two decades of neoliberal policies, and the only
clear results are an ever increasing poverty that alarmingly rose from 1980 to 2002, poverty increased
65.6% in the region, passing from 135.9 to 220 million
people.This means that 89.1 million new poor people
have been aggregated.This number includes 37.6 indigents and 51.5, not indigent, but poor. For the year
2002, the number of poor people rose to 220 millions;
this amount includes 95 million indigents and 125 million poor.
In 2003, according to the statistical projections
of the ILO, poverty in Latin America reached 225 million people, of which 100 million were indigent (meaning there was an increase of 5 millions in just a year),
and 125 million that were poor, not indigent.
The CEPAL has pointed Argentina as a country
that showed evident deterioration of living conditions.
Its poverty rate in the urban area duplicated between
1999 and 2002, rising from 23.7% to 45.4%.This the indigence rate increased by three times from 6.7% to
20.9%.This alarming increase was mainly related to the
crisis of 2001.As well, it sets forth that a significant raise in poverty was registered in Uruguay, which went
from 9.4% to 15.4%, although indigence affected only
2.5% of the population.
Additionally, the United Nations demonstrated
that the major reason for migrations in the World is
economic. In 1992, 125 million people moved, from
which 86% (107 millions) were labor migratory purposes, while 13.4% (18 millions) were for political or re-
96
ligious motives, or natural disasters.[ La Jornada, 1996]
It also revealed that 150 million migrants existed in the
year 2002. One out of every ten migrant was born in
Latin American or a Caribbean country. [ONU-CEPAL, 2002]
The movement of Mexican, Central and South
American workers to the United States is becoming
one of the most important and dynamic human migrations in the world.The remittances or savings that are
sent by the Latin American workers to their countries
of origin are fundamental to their families’ survival and
to the regional economic sustainability.[Waller Meyers, 2000]
It is in this context that workers from Latin
America have been forced to search for a variety of
survival mechanisms. Among these mechanisms: their
engagement in the informal economy; the migration to
other regions and countries in the world; their employment in sweat shops and assembly plants ("maquiladoras").The sweat shops offer employees low wages
and hazardous working conditions.The employees are
expected to work long hour. They have had to reduce their consumption habits, and increasing, at the same time, the enrollment of family members in the formal or informal labor markets.
The subordination of Latin-American to a global
market controlled by transnational capital results in increased underdevelopment and dependence. It also
augments the loss of national sovereignty of our countries and the depredation of our natural strategic resources. All of this is at an extremely high social cost.
The new century starts under social unrest and
profound economical, political and social crisis.The collapse of the neoliberal program in most countries,
illustrates the evident failure of a historical project based on greed and the subordination to the interests of
large transnational companies.
REFERENCES
●
CEPAL. Estudio económico 2002-2003. América Latina y El Caribe. Situación y Perspectivas.
●
CEPAL. Una década de luces y sombras:América Latina y el Caribe en los años noventa.
●
JUÁREZ SÁNCHEZ, LAURA (2003-2004). Los exiliados económicos de América Latina. En Revista Trabajadores No 39 noviembre-diciembre 2003 y 40 enero-febrero 2004. México.
●
LA JORNADA (1996). 10 de marzo, p. 15.
●
OIT (2002). Conferencia Internacional del Trabajo, XC Reunión,
2002, Informe VI, "Trabajo Decente y Economía Informal", Ginebra, Suiza, p. 144.
●
OIT (2002). Panorama laboral 2002. América Latina y El Caribe,
Lima.
●
OIT (2004). Panorama laboral 2004. América Latina y El Caribe,
Lima. p, 41.
●
ONU-CEPAL (2002). Globalización y desarrollo, Brasilia, Brasil.
●
TRÁPAGA, YOLANDA (1996). Panorama regional de la producción de alimentos en el mundo en El reordenamiento agrícola en
los países pobres, Ed. IIEC-UNAM. México.
● WALLER
MEYERS, DEBORAH (2000), Remesas de América Latina: revisión de la literatura, en Revista Comercio Exterior, v. 50,
n. 4, México, abril.
97
10
Regression of Health in
Neoliberal Colombia*
Miguel Eduardo Cárdenas, Luz Helena Sánchez, Martha Bernal
The introduction of the neo-liberal model at the end of the 80’s and beginning of the 90’s in Latin America, unleashed a process of legal regression
and deregulation that paved the way for profound change in social policy conception. According to neo-liberal reformers, an efficient use of resources
would be promoted, and economical growth would be accelerated. But these reforms were oriented towards endowing the market as a main distributor of resources and as a barrier to the State´s intervention. With this purpose, norms that limited the unrestricted functioning of markets were eliminated. In sum, it was a question of making goods, capitals and work markets
more flexible.
In the framework of this new model characterized by the hegemony of
financial capital, and with the argument that States hinder the access to social services of the poorest population (the reason being it was an inefficient
and corrupt State), the social policy adopted the following guidelines: to reduce the role of the State (in the stipulation of social rights), to allot greater
prominence to the private sector; to cut public expenditure in order to preserve fiscal balance; to leave in the hands of the market the assignation and
regulation of these social rights; to focus expenditure, through subsidies to
demand, and to decentralize competence and resources of these services to
territorial entities.
* Document prepared in the context of activities of the Working Round Table ‘The social reforms Colombia
requires’, with the support group of Luz Helena Sánchez of Colombian Association for Health –ASSALUD, Martha Bernal of the Center for School Studies for Development –CESDE-, and Miguel Eduardo Cárdenas
of the Friedrich Ebert Stiftung in Colombia –FESCOL.
98
Social Rights in the Framework
of Structural Reforms
Under the auspices of neo-liberalism, the meaning of social policy has shifted from being considered
a policy of universal and redistributive nature, to becoming a focalized, transitory and merely complementary policy. Severe social problems such as poverty are
now common issues; no longer considered important.
They are treated as "mitigation programs" against poverty, marginal issues, which no longer require integral
policies from the State.
Public discussion on the importance of the improvement of living and working conditions for low income groups has been abandoned and substituted
with approaches related to macro-economic balance.
Other issues, like inflation reduction, have become of
greater concern than public health to technocrats and
entrepreneurs.
Thus, within the current economical model, social policy ends up being subordinated to financial capital in two ways: (1), financial intermediation becomes
pivotal in the network of the resources flux for the
provision of social services, (2) from the fiscal perspective, the payments to the financial sector prevail over
social expenditures; and (3) the financial predominance, debilitates the productive apparatus, which brings
about negative social effects, such as unemployment
and poverty.
Neoliberal Reform to Health
Within this context, health reforms for Latin
America are sponsored by international agencies. The
World Bank acquires great influence in the formulation,
conception, planning and financing of health systems.
The State has reduced the task of implementing
basic or limited public health programs and invested
instead in only elemental clinical services. In the language of reformers, the State has intervened exclusively in the "pure public services"; namely the ones that
can only be furnished by actions of the State.
In Colombia, this health reform was instigated
with the argument that more than 70% of the population was excluded from access to health services.
The National Health System fostered the existence
of inequalities at that time due to the manner of subsidies distribution, and the low quality and inefficiency
in the use of resources. The reform was consolidated
through the counter reforms established by the so
called "Law 100" (1993), which established the National System of Social Security (integrated by the General System of Pensions and the System of Social Security in Health, Occupational Risks and Complementary Social Services). These are fancy denominations
that hide the real regressive nature of the reforms.
The new law bases its principles on the prescriptions
of the World Bank: self-financing; decentralization; financial separation; provision and focalization functions.
The new System of Social Security in Health has
sought advances in universality, solidarity and efficiency in the utilization of resources and health services provision, hence, consistent with the Law 100,
every person theoretically has the "right" to acquire a
health services package and may choose the insurer
affiliate. People with purchasing power become affiliated with the "contributory regime", by means of
health promoter companies called "EPS"- and the
poor population becomes affiliated with the "subsidized regime", through administrator agencies called
"ARS".These intermediary organizations contract the
provision of services from service provision institutions called the "IPS". Depending on the regime with
which anyone affiliates, one can have access to a package of services included in the obligatory health plan
called the "POS". Moreover, to select the poorest
99
people, a beneficiaries system was created called SISBEN. This instrument identifies and selects the "poorest" populations.
In terms of coverage, it was expected that all the
population would have become affiliated with any of
the regimes by the year 2001. Despite the fact that
one of the major efforts of Law 100 was oriented to
the affiliation of the poor population, defined by the
poverty line (LP), the results (Table 1) illustrate that by
the year 2000 only 37.3% of the poor had become affiliated with the subsidized regime. By the year 2003,
only 62% of the population had become affiliated, and
the remaining 38% were on the outside of the system.
At the same time, roughly 40% to 50% of the population in each of the three quintiles with lesser resources had not become affiliated with any regime (Table
2).
A disturbing issue in terms of coverage, is that a
significant sector of the population not qualifying as
beneficiary of subsidies, wouldn’t qualify for contributory regime on account of its socioeconomic conditions and the precariousness of their work.
The Law 100: A Balance
After more than a decade of its application, the
Law 100 (1993) has not furnished satisfactory health
results. Controversial effects have triggered the demand for debate. During 2004, a reform was discussed, which made evident a contradictory finding: resources for health increased meaningfully.(In 2003 resources were directed amounting to 15 billion Colombian pesos (more than 10% of gross national product), however there was no real, positive effect on
the improvement of the health conditions. Subsequently, some of the problems evidenced came to the
surface.
TABLE 1
COVERAGE PERCENTAGE IN
THE SUBSIDIZED REGIME
BY POVERTY
YEAR
COVERAGE NBI
COVERAGE PL
1996
40.0
29.4
1997
47.0
35.5
1998
55.5
41.9
1999
59.7
41.2
2000
59.8
37.3
100
TABLE 2
AFFILIATION WITH THE SGSSS BY REGIME,
BY INCOME QUINTILES 2003
RÉGIME
QUINTILES
CONTRIBUTORY
%
1
2
3
4
5
TOTAL
6.1
16.2
36.1
57.4
78.9
38.9
SUBSIDIZED NOT AFFILIA%
TED %
40.5
36.3
22.1
11.9
3.8
22.9
53.5
47.5
41.8
38.7
17.3
38.2
Another fundamental problem of the system refers to financing. In the case of the subsidized regime,
there is dispersion in the management of resources,
which contributes to the deviation of their original
destination. Thus, resources directed to the ARS’s are
not directed to the care of "clients"; they remain in the
financial intermediation sphere, provoking prejudicial
effects on the IPS’s, especially in the public hospitals.
Furthermore, resources from the solidarity account
that contributions to the financing of the subsidized
regime have stagnated due to the economic crisis,
unemployment, and the high levels of poverty, in conjunction with the non fulfillment of the government on
disbursing the corresponding resources.
In regards to the contributory regime, one of the
main problems is related to evasion and elusion. Similarly, the number of contributors has been reduced,
owing to the increase of unemployment and the growing composition of informal work in the labor market.
One of the central arguments to justify the neoliberal reform is connected with the so called free
choice. The original promise stated that free election
would improve the quality of services (through the
competitiveness of insurers and providers), and consequently would respond to user’s interests. Recent studies of the Research Center for Development (CID)
of the National University of Colombia demonstrate
that free election is not possible in small municipalities
where there is only one IPS.
These are just some of the problems that appear
when one analyses the current social security in health
systems of Colombia. But there are other relevant
problems concerning public health including epidemiological consequences, like the reemergence of diseases
that hade already been controlled, the extreme weakness of the health information system. ( the careless
extrapolation of a client-centered administration within the system creates barriers to the access of the affiliated population; among others).
Upon observing the outcome of the reform, it
may be concluded that guaranteeing the right to
health has encountered serious difficulties; that health
policy and its results are intimately associated with
the economical, political and social process of Colombia (chiefly when this system is based on the criterion
of purchasing power of people). In addition to the upsurge in health resources resulting from Law 100, the
logic with which these reforms were inscribed is corroborated by the logic of "financialization" of economy.
Evaluation of the Health System from
the Equity Viewpoint
During the last decade, the living conditions of
the Colombian population have deteriorated. From
1997 to 2000, the line of poverty has passed from
50.3% to 59.8%.This signifies that more than half of the
population is poor. The line of indigence, also passed
from 18.1% to 23.4% for the same period (Table 3).
As well as the economical conditions influencing
extensively the deterioration of the population’s wellbeing, war has been another contributing factor. An
expression of this is the forced displacement that had
its major manifestation between 1995 and 2000, when
1.123.000 people were displaced.
The deterioration of working conditions which
are a product of labor flexibilization, originated from a
substantial proliferation of the working population in
the informal sector (Table 4), (primarily in the segments of population with lesser incomes).
Coverage however, within the System of Social
Security in Health from 1993-1997 augmented and
festered from 1997-2003, as a consequence of the
economical and sociopolitical crisis of the country.
Problems facing equity persisted as well, which reveals
an orientation of social policy that was pro-cyclic to
101
TABLE 3
POPULATION UNDER THE LINE OF
INDIGENCE AND POVERTY (%)
NATIONAL AND BOGOTÁ 1997 – 2000
LINE OF
POVERTY
LINE OF
INDIGENCE
1997 1999 2000
1997 1999 2000
NATIONAL 50.3 56.3 59.8
18.1 19.6 23.4
BOGOTÁ
32.4 46.3 49.6
6.1
13.2 14.9
the behavior of the economy, and did not produce redistributive impacts.
The coverage of the contributory regime, in the
same period, passed from 39.5% to 35.4%, and of the
subsidized regime, from 17.7% to 16.9%. Nevertheless, in the subsidized regime, equity problems were
evident at the time of assignation of subsidies; hence,
while the percentage of subsidized poor population
decreases from 27% to 20,3%, the percentage of subsidized non-poor population augmented from 9.2% to
13.4% (Table 5).
In the face of services provision for the period
of 1993-2000, the percentage of people who felt sick
TABLE 4
CREATION AND DESTRUCTION OF EMPLOYMENT IN THE FORMAL AND INFORMAL
SECTORS SEVEN CITIES 1992–2000 AND THIRTEEN CITIES 2001–2003
(THOUSANDS OF PEOPLE)
PERÍOD
FORMAL
INFORMAL
% FORMAL
% INFORMAL
1992 – 1994
146
39
185
76.05
20.95
1994 – 1996
67
57
124
54.27
45.73
1996 – 1998
14
298
312
4.37
95.63
1998 – 2000
- 254
368
113
-224.67
324.67
2001 – 2002
57
237
294
19.35
80.65
2002 – 2003
142
94
236
60.12
39.88
and were taken care of diminished in all the quintiles
(in this manner general care was reduced from 67% to
51%). The inequalities between the richest and poorest quintiles are also evidenced; while the poor population, more vulnerable to illnesses, receives minor ca102
TOTAL
re, the quintiles with higher incomes concentrate major care.
In 1993, within the first quintile 48% of the people who felt sick were taken care of, while in the last
quintile, 80% were taken care of. By the year 2003, the
TABLE 6
AFFILIATION BY REGIME,
WITH COMPLEMENTARY PLANS OR HEALTH
INSURANCE 2003
TABLE 5
HEALTH INSURANCE
1993, 1997, 2003
AFFILIATED
QUINTIL
1993
1993
1993
1
2
3
4
5
TOTAL
528.283
1.349.623
2.026.569
2.407.533
2.460.038
8.772.046
4.052.475
4.296.587
4.781.450
4.634.566
4.936.741
22.701.819
4.069.971
4.589.412
5.092.794
6.052.662
7.226.875
27.031.714
RÉGIME
ESPECIAL
%
% WITH COMPLEAFFILIATION MENTARY PLANS OR
INSURANCE
5.86
9.12
CONTRIBUTORY
57.07
11.16
SUBSIDIZED
37.07
1.61
100
7.50
TOTAL
TABLE 7
INCOME DISTRIBUTION, HEALTH COVERAGE AND UTILIZATION OF SERVICES.
BY POPULATION QUINTILES
QUINTILES
BY HOME
1
2
3
4
5
TOTAL
INCOME
TO
HEALTH
2.20
5.92
10.44
18.05
63.38
100
AFFILIATED
15.56
16.11
19.03
22.22
27.08
100
CONTRIBUTORY SUBSIDIZED
REGIME
REGIME
3.17
7.86
17.93
29.68
41.35
100
situation improved for the people who showed illness,
so that 60% of the first quintile and 77% of the last one
received care (Table 9).
One of the main barriers to the access, for people who do not seek professional care even if they are
sick, is the lack of money. In the period 1994-2000, the
percentage of sick, who were not taken care of on account of a lack of funds, increased from 43% to 62%. By
36.59
30.11
20.91
9.55
2.85
100
NON-AFFILIATED
AND WITHOUT
INSURANCE
27.81
26.58
21.43
16.15
8.03
100
UTILIZATION
OF HEALTH
SERVICES
15.13
16.85
21.80
23.80
22.41
100
the year 2003 it decreased to 39%, despite the fact that
this continues to be the reason why people do not receive care (Table 8). It is demonstrated that the current
system of social security in health does not contribute
to the reduction of socioeconomic inequity; on the
contrary, the system maintains it.
A further factor that expresses inequity throughout the health system is pocket expenditure . Accor103
TABLE 9
PROBABILITY OF GETTING SICK, RECEIVING CARE AND ACCESSING AN INSTITUTION
1993/1997/2003
1993
Quintil Get sick
%
1
2
3
4
5
Total
15.2
15.3
15.9
16.1
17.2
15.8
Receive
care %
15.2
15.3
15.9
16.1
17.2
15.8
1997
Access an Get sick
%
institution %
15.2
15.3
15.9
16.1
17.2
15.8
15.2
15.3
15.9
16.1
17.2
15.8
Receive
care %
15.2
15.3
15.9
16.1
17.2
15.8
2003
Access an Get sick
institution %
%
15.2
15.3
15.9
16.1
17.2
15.8
Receive
care %
Access an
institution %
15.2
15.3
15.9
16.1
17.2
15.8
15.2
15.3
15.9
16.1
17.2
15.8
15.2
15.3
15.9
16.1
17.2
15.8
TABLE 8
PEOPLE WHO FELT SICK IN THE LAST 30 DAYS AND DID NOT REQUEST
OR RECEIVE MEDICAL CARE 2003
REASON
Falta de dinero
Caso leve
No tuvo tiempo
Centro de atención queda lejos
Mal servicio
Muchos tramites
No confías en médicos
Consultó y no resolvieron problemas
No lo atendieron
Total
SICK PEOPLE WITHOUT CARE, NON-AFFILISICK PEOPLE
ATED AND WITHOUT INSURANCE %
WITHOUT CARE %
39.03
37.1
5.1
4.1
3.7
3.5
2.9
2.5
1.8
100
ding to calculations obtained in Ramón Abel Castaño’s
study on equity for the period 1993-1997, within the
quintile of lower incomes the pocket expenditure had
an increment of 6.700 pesos, while that of the quintile
104
76.32
38.64
26.12
43.70
15.33
27.75
64.03
41.86
33.20
52.48
with higher incomes had a decline of 20.000 pesos approximately. By the year 2003, 55% of the sources
used to cover care costs were their own or family resources (Graph 1).
GRAPH 1
SOURCES USED TO COVER HEALTH CARE COSTS ECV 2003
Proposals
The construction of a new System of Social Security in Health must start by guaranteeing every person who lives within the national territory the right to
health, as a fundamental, individual and collective human right. Consequently, this system will be universal
and will be organized as a Public System of Health, autonomous and democratic, unified, with decentralized
management by regions.
Subsequently, some guidelines of this new system
are presented:
●
The set of services, provisions or benefits, individual
or collective, which the health system grants will be
equal for every person, independent of their purchasing capacity and any other economical, geographical or social condition.
●
The Health System will be reorganized in order to
stop exclusivity in a system of illnesses care and be
transformed into a Public System of Health: which
prioritizes prevention, promotion, education, and
the fostering of health at every one of its levels, and
guarantees Public Health as a primordial good of so-
1. El gasto de bolsillo son los pagos directos que hacen las familias a los proveedores de servicios de salud cuando demandan atención.
105
ciety, (as well as the access of all the population to
integral health services).
●
●
●
●
●
Every citizen will be required to contribute to the
extent that his/her economical possibilities for
health financing permit. (The mechanisms of control
of contribution will be completely separated from
the access to services.)
The public system of health will be directed by a collegiate organization, for a fixed period, (autonomous, formed democratically), in an attempt to guarantee the representation of regions, sectors by
means of their social organizations and workers.
Neither the public system of health, nor its regulating or directing organizations will depend hierarchically on the government. This will not designate
them, or give tutelary control over their decisions
of the autonomous institution. Moreover, administrative, budgetary and financial autonomy will be
guaranteed.
In regards the provision of services, territorial units
distinct from the existing will be organized, with the
intention that they consult the population of the different regions in relation to their cultural, economical and communicative reality. Concerning the organization and planning of services, the affiliation
with the system will be performed by the place of
residence of the family. A municipality may decide
democratically which region to appoint.
The financing of the system will be based on state
public funds having as their source the profits of the
nation, the contributions of employers and workers,
the current quotation for occupational risks, the income favoring the private sector, and the rest of local or departmental tributes, as well as the profits of
bondholder monopolies.
106
●
All the resources of the health system, including the
quotations of salaried people and people with purchasing power, will be collected and administered
through a National Unified Public Fund.
●
The health resources may not be oriented to any other destination, and may not be used to finance the
national government, or to nurture and strengthen
the private financial sector.
●
The System of ‘Subsidies to Demand’ will be suppressed. Public hospitals and the rest of institutions of
the health services public network will be financed
directly by the State, by way of the National Public
Fund. (Demanding from the public network the selling of services, or criterions of economical profitability, or financial self-sustaining is prohibited, as a
condition to gain access to the necessary resources
for the functioning of services.)
●
Integral and satisfactory maintenance of the public
network is a priority of the system.
●
Humanization of services, which emphasizes human
beings’ dignity over any other consideration, will be
the ruling criterion (that all the people, officials or
workers, will observe within their activity as members of the public system of health).
●
The quality of the system and its services will be guaranteed through previous internal mechanisms, and
organized forms of effective social control of services.
●
Within the health system, the poor treatment of
clients (or any other that fails to recognize the principle of humanization, or that intends to impair the
public nature of the system with the purpose of
adopting business or commerce policies or criterions) is forbidden.
●
People and communities have the right to the totality of supplies, medicines, means of diagnosis, and
professional care, in proportion to the major grade
of technology or the advance of science available in
the country.
●
A provision will only be excluded from the set of
services if it is clearly proven to be superfluous, noxious or unnecessary.
●
Public policies must provide the necessary mechanisms to attain the production and generation of
knowledge, research, science and technology in the
country.
●
Ethnic and cultural diversity of the nation will be respected, and the autonomies acknowledged within
the Political Constitution.
●
Alternative therapeutics will be incorporated into
the set of forms of practice implemented by the
health system. These will be subjected to quality
controls, analogous or similar to the ones demanded from traditional therapeutics.
●
The education and training of human resources in
social security will be activated in line with the prin-
ciples and requirements of the system. Rigorous
mechanisms of control regarding the training of professional personnel will be applied to guarantee quality and capacity of health workers.
●
Health plans for each region will be adapted to their
specific needs and the epidemiological profile of the
population.
●
The services network will have to be organized in
order to guarantee the geographical accessibility to
the distinct levels of care.
●
The set of rights and duties of health personnel and
patients will be regulated thoroughly.
●
The health workers will be selected in accordance
with an objective system, and their employment stability will be assured to prevent and combat clientcentered structures.
●
Personnel parallel nominations and contracts will be
implemented to execute labor that has permanent
features within the public institutions.
●
A Public System of Information in Health will be organized, as an indispensable instrument for the management and control of health policies.
107
11
Destruction of Urban Space: "Concealed
Genocide" in The Ituzaingó District
María Godoy, Norma Herrera, Sofía Gatica, Corina Barbosa,
Eulália Ayllon, Marcela Ferreira, Fabiana Gómez,
Cristina Fuentes, Isabel Lindon
The Annexed Ituzaingó district is located in the south west of Cordoba,Argentina in the urban periphery.This impoverished area has nearly 5,000
people living in 1,200 residencies.
Serious environmental violations are being carried out by various agricultural industries that threaten the health of the residents of this area. Research and data has been collected by a concerned group of citizens known
as The Group of Mothers.This organization, a collection of female residents,
has helped uncover some of the environmental atrocities that have occurred
and still occur in this region.The Group of Mothers has helped determine a
possible link between water, soil and air pollution by these industries and incidences of leukemia, birth defects, and other forms of cancer in both new
born babies and current residents of this region.
History
The struggle began at the end of 2001 when Sofia Gatica, one of the
mothers of The Group of Mothers, noticed that several women used handkerchiefs to cover their baldness and several children covered their mouth
and nose with surgical masks to breathe. Ms. Gatica surveyed various households in the neighborhood for approximately four months. She collected
data that included: the name of the resident, age, address, ailment, diagnosis
108
and the hospital where the resident received medical
treatment.
With the help of two neighbors, Ms. Gatica presented her data to the Department of Health. They
used the information to create a map of the location
of the sick residents and the location of electric transformers and possible sources of soil, air and water
contamination.
Water samples were taken in the neighborhood
and agrochemicals such as Agrosulfan were found.The
residents of these areas have documented cases of
leukemia and other cancers where the water and other forms of pollution has occurred.
Roberto Chuit, the Secretary of Health, helped
improve the water quality in the area. However, to accomplish this goal, the residents of the area were forced to sign a waiver stating that legal action would not
be sought against the various groups responsible for
the pollution.
On the same day that Mr. Chuit met with the residents, the Electrical Provincial Company of Cordoba,
EPEC, removed the transformers. Tests were not conducted on the transformers to determine the presence of PCB, dioxins and furans in the transformers.
Measurements of the harmful magnetic fields produced by the transformers were also not tested prior to
removal.
A few days after the initial meeting, Mr. Chuit
sent a team consisting of doctors, social workers, psychologist and some less skilled members, such as a kitchen assistant, to conduct a survey.This document was
inadequately completed.
The Group of Mothers conducted its own survey and determined the environmental and health situation to be extremely grave. An appeal to the Justice was made by The Group of Mothers
As a result of the research by The Group of
Mothers, the advocate of the agricultural industries,
the local farmers and the agronomic engineer were
unaware of the harmful effects of the chemical on the
human body that were found in the fumigation sprays.
Gliphosate and endosulfan are harmful chemicals in
the sprays that have the ability to enter the human
body upon exposure. According to Raul Montenegro,
specialist in environmental management at the National University of San Luis, these substances are endocrinal disruptors and may alter the hormonal mechanisms in humans.
The Group of Mothers demanded that the soil
was tested for pollutants, the sediment of tanks were
tested for pollutants, the transformers were tested for
PCB and other cancer causing agents, the air was tested for air born toxins and the surrounding region
monitored for harmful magnetic fields. By the end
2002 the following results were obtained:
●
In the domiciliary tanks, agrochemicals (endosulfan,
heptachlor), and heavy metals (lead, chrome, and arsenic) were found.
●
In soils::
Sample 1: Malathion, Chlorpyrifos,Alpha-endosulfan,
Cis-chlordane, DDT isomer
Sample 2: Malathion, Chlorpyrifos,Alpha-endosulfan,
Beta-endosulfan
Sample 3: Alpha-endosulfan, DDT isomers
Sample 4: HCB (Hexachlorobenzene), DDT isomer
Sample 5: DDT isomer, Beta-endosulfan
●
In the air:PVC with a high level of Phthalates (plasticizers)
●
In transformers: PCB 281 ppm.The Group of Mothers obtained a transformer that had PCB.This one
was different from the one tested by the EPEC.
●
Magnetic fields: 1 micro la. This result was obtained
by CEPROCOR , an organization sub-contracted by
109
the Government. The Group of Mothers did not
conduct a sampling of the magnetic field by a third
party as a result of the lack of funds. The group
questions the validity of the results of the research
conducted by CEPROCOR.
The number of incidents of cancer and other
health issues increased in the neighborhood. The
Group of Mothers decided to travel to Buenos Aires
to present their case of environmental violations to
the following organizations: Human Rights of the Nation, Defender of People of the Nation, Environment,
and Department of Health of Nation. The Group of
Mothers were under constant surveillance by police
and threatened by authorities with firearms to not
present the data in Buenos Aires.
The effort by The Group of Mothers in front of
Congress produced the Project of Law which prohibited fumigations of harmful chemicals near residencies.
Protests were used to help ensure delivery of
cancer fighting medicines and the continuation of data
collection on environmental pollutants in the region.
In 2004, a doctor verified 150 cases of cancer
and other diseases in the neighborhood to the Municipal and Provincial Authorities.
People continue to live in these polluted areas.
More than 200 cases of cancer have been registered.
These do not include the incidences of Lupus, Proteobacteria, Hemolytic Anemia, Lymphatic Hodgkin’s Disease,Tumors and Leukemia.There have also been documented incidences of brain tumors with individuals
having over 30 tumors. Some of the most numerous
cases of leukemia have been reported in the neighborhood that lies between two transformers and the soy
crop in the district.
This is a portrait of thirteen of the cases in the
region that helps illustrate the atrocities suffered as a
result of the environmental pollution:
110
Girl, 5 years old (alive). Leukemia, Lymphocytic,
Acute
● Girl, 7 years old (alive). Leukemia, Lymphocytic,
Acute
● Girl, 13 years old (alive). Mixed Leukemia
● Adolescent, 15 years old (alive). Leukemia,
Lymphocytic, Acute
● Adolescent, 17 years old (alive). Leukemia,
Lymphocytic, Acute
● Adult, 30 years old (alive)
● Adult, 50 years old (alive). Leukemia, Lymphocytic,
Acute
● Adult, 57 years old (dead). Leukemia, Lymphocytic,
Acute
Acute
Acute
● Married couple, 56/60 years old (dead). Leukemia,
Lymphocytic, Acute
● Adult, 58 years old (alive)
●
The normal range of Leukemia is 2-3 cases/
100,000 people.
Other cases of malformation have also been documented.These include:
Fryn Syndrome (born with multiple malformations,
died at birth)
● Spina Bifida (still alive)
● Boy with 6 fingers (alive)
● Kidney Malformation (alive)
● Osteogenesis (alive)
● Girl with multiple malformations (dead)
● Woman 7 months pregnant, baby with malformation
(still not born)
●
The Group of Mothers first presented the "querellantes" or complaints on 10 June, 2002. A Federal
Judge sent the case to the District Attorney’s office IV,
Turn 2.This case was appealed and later presented to
the Supreme Court Justice of the Nation.
A technical report was completed by the Department of Health of the Province. The Group of
Mothers questioned the validity of the data and sent
an appeal to a Corpus Data.
The Group of Mothers plans to present civil demands to the district for damages.
The Group of Mothers want the following actions to be carried out by the Government: the distribution of adequate medicines, the acknowledgement
by the government as the main contaminator, the creation of a healthy environment, the immediate end to
fumigations over people and the exposure of PCB and
Heavy Metals into the water and soils.
The following has been accomplished as a result
of the demanding efforts by The Group of Mothers:
●
Elimination of the PCB (throughout the province of
Córdoba)
●
2.500m away (it was never observed)
●
Municipal Ordinance, which prohibits fumigation in
the area of the Capital of Córdoba
●
Change of water for the entire district
●
Inauguration of two health centers
●
Law of agrochemicals (it has neither been regulated,
nor published within the official bulletin)
The following has yet to be realized:
●
The State to take responsibility for the situation.
●
A formal study to determine the causes of the illnesses of the residents
●
The construction of the public transportation line to
reach the contaminated area. Currently, other citizens fear that they could become infected with even
though cancer is not contagious
●
The installation of the medium tension line (13,5
kw), which would reduce magnetic fields
●
The ceasing of fumigations within the district
●
The Secretary of Health, Roberto Chuit, to admit his
mistake publicly
The Different Environmental
Problems Detected
●
Endosulfan, a prohibited pesticide, and high levels of
sulfate and carbonates were found in the water supplied by the water company, SABIA SRL. The company distributes the contaminated water underground and the residents of this area continue to
pay for the use of this polluted water.
●
The Group of Mothers determined through their research that pesticide chemicals such as Beta-endosulfan, DDT, DDT isomers, Malthion, Cis-chlordane,
Alfa-endosulfan, Beta-endosulfan, BHC and Chlorpyrifos are harmful to human health. Ariel and terrestrial applications of these pesticides and agrochemicals were being conducted on two private cultivation properties of soy and other grain in fields adjacent to the Annexed Ituzaingo district.
Studies conducted by the CEPROCOR revealed
that there was neither chrome, nor arsenic. However
in other studies of the same area, it was found that 25
parts per million (ppm) of arsenic were found in homes.The limit established by the law is 30 ppm. Arsenic may also be derived from agrochemicals.
111
Edgardo Schider, founder and president of the
Argentinean Society of Environmental Medicine, explained that health issues caused by exposure to environmental toxin usually have two elements: predisposing and unleashing causes. In this case, the exposure
to pesticides was the unleashing element. The predisposing element was the fact that the district was constructed in an insalubrious place, where there had been
no urban planning and where people had drunk intoxicant water for 40 years. This produced an accumulative effect. He also added: "here we are witnessing
something that already appeared in some developed
countries, what has been named the zone of ecological or environmental catastrophe".
Those Affected
The Group of Mothers of the Annexed Ituzaingo
District, consisting of approximately 5.000 people, have documented the different incidences of illness. Studies were conducted by group member that went home by home and listed all the know cases of illness.At
first it was a list of 28 sick people in a radius of 400 m.
However, more documented cases of individuals with
cancer appear as more time passes.
forced the ordinance that prohibits fumigation within 2.500m of residential areas.
2.The Province of Córdoba, especially the Agriculture,
Livestock and Natural Resources Undersecretary’s
Office, did not enact limits over fumigations in accordance with the provincial Law N.6629 and its regulation decree N.3786/94. This governing body is
responsible for monitoring and enforcing the laws
concerning fumigations in the Province. An advisor
needed to be present when fumigations occurred
near residential areas as outlined in Article 13 of the
law of agrochemicals.
3.The Department of Health of the Province, including
Health Secretary Roberto Chuit), did not closely
monitor the health of the residents. Mr. Chuit continually hid evidence of health issues of the residents
caused by the environmental pollution. Mr. Chuit
created confusion within this serious situation and
concerned himself more with the devaluation of homes than to human life.
4. The DIPAS (Provincial Office of Water and Sanitation) is in charge of the provision of potable water
among the inhabitants of the province. DIPAS outsourced the water provision to SABIA that did not
monitor the water quality correctly.
Those Responsible
The following groups have been identified by The
Group of Mothers as wholly or partially responsible
for the environmental catastrophe in the Annexed Ituzaingo District that has left so many people seriously
ill with cancer or other life threatening ailments.
1.The Municipality of Córdoba, which allowed the urban settlement to exist in an area where there is extensive cultivation. The Municipality should have en112
5. Metallurgical factories owned by such companies as
Fiat, Materfer, Iveco,TuboTranseléctrica, and Machiarola polluted the water, air and soil with know chemicals harmful to the health of humans.
6.The agriculture and livestock company that operates
in the zone supported the laboratories by purchasing herbicides that are potentially harmful to human health. This company used these herbicides in
order to increase the yields of the harvests with lit-
tle attention paid to the harmful effects of these
herbicides on human health.
7. The EPEC (Electric Power Provincial Company of
Córdoba) denied that the transformers, owned by
their company contained PCB. The EPEC claimed
that there were only 36 transformers distributed in
open areas. However, further research by The
Group of Mothers confirmed that all of the transformers in the area contained PCB.
Conclusion
The Annexed Ituzaingo District is home to residents of low socio-economic standing. Besides these
hardships, the residents must endure environmental
contamination which dramatically decreases the already low standard of living of this region. Many residential areas adjacent to soy crops experience these
same unnecessary hardships. Environmental degradation has an effect on many aspects of peoples’ lives and
the Ituzaingo District faces this reality.
Argentina experienced rapid expansion of agricultural markets as the country produced more and
more transgenic crops during the 1990’s.The results if
this immense growth from world demand is easily noticeable. Hundreds of indigenous peoples were forced
to move from their territories and over 400.000 small
agricultural producers went under. Some small farmers
accumulated large debts as a result of the need to purchase new machinery that was required by this industrial method of farming. Farmers needed to purchase
transgenic seeds and herbicides manufactured by
Monsanto to produce the high yields required by global markets.
The agriculture industry spent large amounts of
energy and resources to conceal these environmental
atrocities that resulted in the degradation of human
health.The Group of Mothers focused on exposing the
harmful effects the actions of these companies and governmental organizations have had on the people of
the Ituzaingo District.
The impact on the health and quality of life of
the people of the Annexed Ituzaingo District could be
generalized to include nearly all Argentinean cities
where soy monocultures have made a clean sweep of
"tambos" (dairy farms) and old farms.
Fumigations with gliphosate, endosulfan, 2, 4 d,
paraquat and other poisons have created a constant
threat to numerous Argentineans.
Many questions remain unanswered.What is the
responsibility of the State to protect its citizens? Who
controls the demands required by farmers to adopt
high-impact farming practices? Who controls the use
of biotechnology?
There may be a need to adopt these high impact
farming practices, but the negative impact as a result
of the use of this agro-exporter model that heavily focuses on the use of transgenic crops cannot be ignored.
Currently, soy crops cover nearly 14 million hectares of some of the best agricultural land in Argentina. As a result of converting this land to soy crops, native forests have been destroyed, food cultures have
been displaced, water cycles have been ruined, the biodiversity has been destroyed and thousands of poor
peasants have suffered
The Group of Mothers within the Annexed Ituzaingo District of Córdoba, has helped to uncover some of the environmental impacts on human health as
a result of negligence by the State and the adoption of
high-impact farming techniques. There have been negative impacts on both the people and the environment as a result of ignoring health risks for the sake of
progress. Many victims have been impacted as a result
of large corporations and government personnel seeking a record harvest.
113
The existence of PCB in the soil, air and drinking
water had been confirmed by Adrian Calvo, spokesman for the EPEC. Mr. Calvo said that PCB was used
because it was cheap. As a result, the use of PCB has
contaminated the area and left many people in the
District with cancer. PCB accumulates in the fatty tissues of the body. Even if transformers are chemically
stable, fire and high temperatures may produce molecular rearrangements as many transformers exploded
daily, thus possibly freeing highly carcinogenic dioxins
and furans.
The Department of Health performed only two
analysis of maternal milk and one of bone marrow
among 5.000 inhabitants. The Department of Health
showed little interest in conducting further research
even though several children had mental illness and other adolescents had learning disabilities, lupus, proteobacteria, testicular ascent and respiratory problems.
The reality of the situation is that cancer causing
agents are entering the environment.The residents of
the Ituzaingo District are dying of cancer and other illnesses as a result.These incidents of cancer and other
severe illnesses have been thoroughly documented.
There is an apparent connection between the use of
pesticides and herbicides by the large agricultural corporations and the use of PCB in the transformers by
the EPEC on the health of the residents.The Group of
Mothers would like compensation, medical attention
for the residents, an open apology by the Secretary of
Health and the exposure of these harmful chemicals
to end. There is no denying that the quality of life of
the residents of the Ituzaingo District has been impacted.The goal of this campaign is to make sure that the
children do not suffer the same horrible fate as their
parents and grandparents.
114
12
Neoliberalism, Pesticide Use and
the Food Sovereignty Crisis in Brazil
Ary Carvalho de Miranda, Josino Costa Moreira,
René Louis de Cavalho y Frederico Peres
Since the nineties, Brazilian economic policies have gradually moved towards neoliberalism. As everyone knows, neoliberals assume that market regulation is the most efficient way of controlling economic activity. Microeconomic management, allocation of resources in space and in time – including
the balance between investments and consumption – and the setting of prices were the main economic functions transferred to the market by the Brazilian government during that period.
The process has also led to the privatization of assets, extensive economic deregulation, and liberalization of exchange rate movements, foreign
trade and the capital account of the balance of payments [Mollo & Saad-Filho, 2003]. Trade liberalization brings on the threat of competing imports,
which constrains prices charged by domestic companies (as well as workers’
wages). Moreover, capital account liberalization limits the capacity of the State to monetize its deficits. The combination of policies can indeed eliminate
high inflation efficiently, but at a high cost.
The neoliberal consensus was that these measures would create a favorable environment for foreign capital to enter the country and for investments to increase. However, the opposite has happened in Brazil:The investment rate declined in tandem, from an average of 22.2 percent of the GDP
in the eighties to 19.5 percent in the nineties and 18.8 percent in 2000-03.
115
Under neoliberal policies, Brazil received large foreign
resource inflows (debt, FDI, bonds and equity capital).
However, the outflows (debt service, interest payments, profit remittances, divestment and capital flight)
were also substantial.The net inflows were insufficient
to compensate for the contraction of public and private investments.Therefore, the investment rate fell and
growth petered out. Between 1994 and 2003, Brazil
had an average 2.4 percent annual economic growth
rate; in contrast, between 1933 and 1980, the economy expanded an average 6.3 percent per year [Mollo & Saad-Filho, 2003].
Low economic growth rates over an extended
period necessarily affect the level of employment.The
unemployment rate has increased substantially, especially in the six largest metropolitan areas. In São Paulo, open unemployment went from six percent in the
late eighties to thirteen percent in recent years.Taking
precarious employment, hidden unemployment and
discouraged workers into account, unemployment rates reached 20 percent of the labor force. The destabilization of the Brazilian labor market can also be
seen through the rapid increase of irregular employment since the late nineties.
The declining income level and its inequitable
distribution are other important factors contributing
to the increase of poverty and marginalization. Average incomes have recently steadily declined, largely because of the economic slowdown. Brazilian per capita
income fell from 21.6 percent of the average income
in developed countries in 1980 to 16.5 percent in
1995, and 15.5 percent in 2001. Furthermore, Brazil is
still one of the most unequal countries in the world
and neoliberalism has worsened inequality [Mollo &
Saad-Filho, 2003].
Thus, the economic changes that marked the
90’s are still affecting the country. Brazil has inherited
major structural weaknesses that continue to constrain the economic development and decrease the
116
possibility of developing more independent policies,
that is, an increased external frailty and the accelerated growth of its domestic debt. External debt service
and the increasing deficits on capital and service accounts underline Brazilian dependence on external capital.The scope of financial actions carried out by the
government is, thus, violently diminished by the expanded primary surplus necessary for paying domestic
debts.Therefore, the indispensable sustained growth in
national economic development presumes the generation of increased external commercial surpluses and a
change in plans as to the internal debt.
The external scenario favors trade (the growth
of international trade and a relative improvement in
the terms of trade) and has helped the country’s positive external economic results, particularly in 2004.
Agricultural exports were the major causes of this
progress. Agribusiness external sales totaled 39 billion
dollars in 2004, 27 percent more than the previous
year. These exports represent 40 percent of Brazil’s
total exports, which greatly contributed to the surplus
of the country’s balance of trade.
Thus, Brazil has been claiming its position as an
important exporter of agricultural commodities. However, the recent and favorable evolution in prices and
quantity of products exported shouldn’t let us overlook the important structural weaknesses of the Brazilian agricultural sector, since the scenario may change at any time. Some aspects of this situation are of
particular concern. Brazilian agricultural and cattle exports still concentrate on a restricted number of primary products, which are found in a slow growing phase of their life cycle (soy beans, coffee, sugar, beef
meat, chicken meat and wood pulp).The country’s exports in the sectors of agroindustrial products, quality
products and products with more aggregate value have been growing slowly. The possibility of increasing
exports rapidly remains attached to a favorable evolution of prices in the international market.
Together with Brazil’s integration in the international agribusiness trading scene came a regressive
specialization. The country entered the 70’s as an exporter of primary items and left it exporting agroindustrial products. With globalization, however, Brazil’s
exports – particularly soy-related products – are
changing into less industrialized products.
To produce the necessary machinery, equipment
and input products internally was a premise for the
modernization of Brazilian agriculture. From the 90’s
on, however, Brazil is becoming increasingly dependent
on importing inputs. Besides that, the balance of trade
as related to input products and agricultural equipment has been showing a deficit.
The major asset for Brazil’s agriculture competitiveness in the world market is the large availability of
land, which allows the country to expand its production rapidly and at low costs. This competitive advantage, however, is not sustainable and strongly pressures the environment.The fact that new lands are being
used for agriculture, especially for harvesting soy (the
soy areas grew 30 percent in the South and Southeastern regions and 66 percent in the Center-Western
region in the last three years), contributes to deforestation (almost seven thousand square miles of forests
were lost in 2002 and 2003). The new soy areas occupy land previously dedicated to cattle raising, pushing the cattle into areas with native vegetation. Several studies have dealt with the impact of the expansion
of soy harvesting lands in Brazil (Indicadores de Desenvolvimento Sustentável [Index of Sustainable Development] [IBGE, 2004]; Agriculture and Environment
[WWF, 2002].
According to the Research Program entitled
Agriculture and Environment, funded by the WWF,
"the production of soy involves around 32 billion dollars per year, employs around 5.4 million people and
is an important generator of foreign exchange. However, this success in trading has also brought along so-
cial, economic and, in a particular way, environmental
problems and unbalances. The increase in soy harvesting resulted in the use of virgin soil for production as
well as the substitution of other products by soy. Besides that, inadequate intensive harvesting practices
have caused serious environmental degradation, such
as erosion and loss of fertile soils, shallowing and pollution of important rivers, the disappearance of water
springs and decrease in biodiversity." [WWF, 2002]
The price increase in the international market and the
expectation of producing more at lower prices, caused
by the introduction of the genetically modified soy, were responsible for the increase in production. Since the
Brazilian government decided to stimulate the production of soy as a commodity, Brazil is now one of the
largest soy producers in the world. In Brazil, soy is basically destined for export, since it is not part of the
Brazilian’s culinary habits.
The harvesting of genetically modified soy first
began illegally in Brazil in 1997 and was later legalized
in 2003 by the Medida Provisória [Presidential Decree] 223/04.According to data obtained by the International Service for Acquisition of Agri-biotech Applications (ISAAA), the area planted with genetically modified soy in Brazil increased 66 percent in 2004, reaching 31 thousand square miles – consequentially followed by an increase in the use of herbicides.The area
includes approximately 22 percent of all soy plantations in the country. Between 2003 and 2004, the increase in the use of genetically modified soy was larger in developing countries (35 percent) than in developed countries. ISAAA estimated that 90 percent of
farmers planting genetically modified soy are from developing countries and that most of these are family
producers [Folha de São Paulo, 01/13/2005].
This is of particular concern (without taking into account all the potential hazards of the dissemination in nature of genetically modified plants) since the
most widely available seed of genetically modified soy
117
in the market (Soja RR®), which is resistant to the
herbicide glyphosate, and both the seed and herbicide
are produced and marketed by Monsanto Co.
Besides the ethical aspects involved in cultivating/marketing genetically modified plants, the possible
threats these plants may pose for human health and
for the environment have been neglected.The deterioration of biodiversity, the decrease in the variety of
and nutrients in food crops and the fact that farmers
may become dependant on the biotechnology and
chemical compounds produced by certain companies
(by the commerce of sterile seeds and/or chemical
products which must be acquired yearly) is disregarded. Doubts on the impact of genetically modified
plants on human health are also ignored.These doubts
include: allergenic potential, gene transfer – especially
the transfer of genes related to antibiotic resistance
from GMOs to bacteria and cells of the intestinal tract
or the exchange of genes between genetically modified and non-modified plants, which poses indirect threats to food safety [Lancet, 2002]. The "Precaution
Principle" is, therefore, being ignored and economic
and/or foreign trade aspects are being used as excuses.Thus, the interests of capital overrule the health of
the populations and environmental preservation.
In Brazil, the increase in agricultural exportation
is not incompatible with the increase in the amount of
food produced for domestic consumption. Most of the
time, the increase in exportation – caused by favorable international prices – elevates domestic prices, but
allows the production system to improve. Decreased
domestic demand is not a necessary condition for exportation. On the contrary: the low increase in the domestic demand, as occurs today, increases the differences between potential production capacity and actual
production and results in domestic agriculture being
growingly dependent on external demands.
However, despite the present production capacity of the Brazilian agricultural sector, relevant seg118
ments of the population have difficulties in having a regular and secure access to the food they need. This
contradiction shows that, as to Brazil, the access to
food is no longer a matter of supply, but fundamentally
of demand, that is, of income distribution, in order to
grant everyone access to essential foods.
Another aspect to be considered about the Brazilian agrarian situation is the "development of a surplus of workers without any known destination, since
the collapse of the traditional policulture, which allowed stable occupation of land, was not accompanied
by a change in the structure of property.The collapse
was not replaced by a modern agriculture based on
small farms, which would also be able to assure stable
occupation of land.As a consequence, employment opportunities decreased because of the increasing mechanization and the process of urbanization was accelerated by the expelling of workers from the rural
areas" [Benjamin et al, 1998]. Having that been presented, we face the battle field in which this reality is confronted by another one, built in the last 21 years and
stemming from the organization of workers expelled
from the land by the capital. These workers were organized by the Landless Workers’ Movement (MST),
which mobilizes thousands of workers with a high degree of organization and political consciousness.Their
program assumes the following general objectives:
1.To build a society without exploitation where labor
overrules capital.
2.To assure that land is everyone’s and serves the society as a whole.
3.To assure that everyone is employed, with a fair distribution of land, income and wealth.
4. To permanently seek social justice and equality of
economic, political, social and cultural rights.
5. To propagate humanist and socialist values in social
relations.
6.To fight all forms of social discrimination and to seek
an equal participation of women.
A political alternative for dealing with these problems was the creation of a rural credit line ("linha de
Ação PRONAF Crédito Rural") by the Brazilian government in 1995.As a part of the so called "Programa
Nacional de Fortalecimento da Agricultura Familiar" –
PRONAF – (National Program to Strengthen Family
Farming), it intends to provide better financial support
for agrarian activities developed with the direct labor
of the farmer and his/her family. Family farming in Brazil employs 75 percent of the work force in rural areas,
is responsible for 31 percent of all rice produced, 67
percent of beans and 52 percent of milk. Family farmers
were also responsible for 1/3 of the 50 million tons of
soybeans produced last harvest. Until the year 2000,
the program produced around four million credit contracts and cost around ten billion reais (approximately
4 billion dollars). The government announced around
seven billion reais (2.8 billion dollars) to support family
farming in 2004 and 2005.
In order to collect data to analyze the impact of
this project, questionnaires were handed to families
with a family income of 220 dollars or less. These families owned small farms and had or not received financing for the 2000/2001 crop. The survey involved
2,299 small farms in 21 different municipal districts in
eight different states (Alagoas, Bahia, Ceará, Maranhão,
Espírito Santo, Minas Gerais, Santa Catarina and Rio
Grande do Sul) and showed a connection between
PRONAF and both the increase of erosion and the use
of pesticides. No positive associations were observed
between PRONAF and actions to recover environmentally deteriorated areas.The study recommended,
among other things, that PRONAF should be mindful
of the possible human and environmental damages
connected to productivist and technological actions
that stem from the intensive use of pesticides. Therefore, the study recommended that PRONAF not only
finance production but also stimulate changes in the
production system and diminish the dependence on
foreign input products. Moreover, the study also observed no significant association between the program
and the decrease of poverty in the households analyzed [Kageyama, 2003].
The connection between the action carried out
by PRONAF and the increase in erosion and use of
pesticides shows the lack of specialized technical guidance given to these farmers. This has also been observed in countless other studies [Moreira et al, 2002,
Rozemberg & Peres, 2003] and poses elevated risks
to human health and the environment. We shall later
see that this happens because the farmer is being
transferred the responsibility over the correct use of
this input.The use of the input usually requires special
attention that has not been given and has, thus, contributed to human exposure beyond acceptable levels.
The model of chemical dependence adopted in
Brazilian agricultural policies was first introduced in
the 60’s and boosted in the 70’s through the "Plano
Nacional de Defensívos Agrícolas" (National Plan for
Agrochemicals), which supported the modernization
of the rural economy [Augusto, 2003].The world’s expenditures on pesticides between the years of 1983
and 1997 jumped from 20 to 34 billion dollars per year
[Yuldeman et al., 1998].These pesticides contaminate,
according to the World Health Organization, between
three and five million people per year. The picture is
even more concerning in developing countries such as
Brazil, where the use of technologies based on the intensive use of chemicals occurs without clearly defined policies as to marketing, transportation, storage,
use, safety measures and knowledge of the risks asso119
ciated to its use. Therefore, these countries consume
20 percent of all pesticides used in the world and house 70 percent of all patients contaminated with these
products.
Latin America is the fastest growing region in the
planet in terms of pesticide use (approximately 120
percent), mostly due to Brazil, which is responsible for
half of the region’s use. Between 1964 and 1991, the
use of pesticides by the country jumped 276.2 percent. In the same period, the planted area grew only 76
percent (MMA, 2000). Between 1991 and 2000, the
consumption of these products increased 400 percent
and the planted area was increased in 7.5 percent
[FAOSTAT, 2005].
The country spent 28.4 million dollars importing
pesticides in 1989 only, which is approximately five times more what was spent in 1964 (5.12 million dollars), when these products began appearing in the domestic market. Expenses with pesticide imports increased 638 percent between 1990 and 2000, jumping
from 41.6 million dollars to 256.8 million dollars,
which is half of Latin America’s expenses [FAOSTAT,
2005].
Since farmers are unaware of the risks associated with the use of pesticides and consequently neglect basic safety precautions, the widespread use of
the products results in severe levels of human poisoning and environmental pollution observed in Brazil.
This situation is worsened by a lack of constraints on
sales, by heavy pressures from distributors and producers and by the social problems existing in underdeveloped rural areas. These problems are aggravated by
the absence of technical assistance and/or supervision.
Farm workers are firmly blamed for the problem, worsening the scenario of one of the most serious public
health problems in rural areas, particularly in developing nations [Pimentel, 1996].
In addition to the severity of many cases of poisoning in rural areas, nearby residents and possibly
120
even urban dwellers are also being affected, due to environmental pollution and residues in food.
The impact caused by the use of these products
in rural workers in Brazil is reflected in data issued by
the Ministry of Health: In 2001, there were 7,900 cases of pesticide poisoning, of which 5,384 (68.1 percent) occurred in rural areas [SINITOX, 2001]. However, these data fail to reflect the real dimension of this
problem, as they are issued by Poison Control Centers
located in urban hubs; these centers are not found in
many of the major agricultural areas, and are, therefore, of difficult access to rural communities.
Some studies assessing occupational contamination levels by pesticides in Brazil, focusing on certain
specific aspects [Almeida & Garcia, 1991; Faria et al,
2000; Gonzaga & Santos, 1992], showed human contamination levels varying from 3 to 23 percent.Taking the
number of rural workers involved in ranching and farming activities in Brazil into account – estimated at
around 18 million (data from 1996) – and applying the
lowest pesticide poisoning percentage reported in these papers (3 percent), the number of individuals contaminated by pesticides in Brazil should hover around
540,000, with approximately 4,000 deaths each year.
Besides that, it is necessary to take into account
the chances of long term exposure and effects such as
endocrine disruption, effects on the nervous system,
etc. which were not mentioned above.
It is important to stress that, other than major
exporters, farming activities near large urban hubs
tend to be carried through in small-scale family farms,
where children and adults work the land together.This
places children and young people at significant environmental and occupational risk for pesticide poisoning. This situation causes even more concern, since
little is known of the prolonged effects of these compounds on the developing human body or even on the
human body under special circumstances (pregnancy,
etc.).
In family farming, it is men, with significant involvement of children and young people, who do labor.As
to child labor, the participation of young women is also significant. Surveys conducted in an agricultural area
of the state of Rio de Janeiro, in the southeast of Brazil (Table 1), presented some of the social, economic
and cultural characteristics of rural workers in this region. The patterns are also observed in other regions
of Brazil.
According to specific Brazilian Law (NR 7), when
cholinesterase enzyme activity test results are lower
than 75 percent of the reference value, tests should be
repeated; if this figure is confirmed in the second test,
the individual is considered possibly poisoned. Using
this criterion to indicate poisoning, some 12 percent
of adults and 17 percent of the children of the studied
group showed low levels of cholinesterase activity,
which could represent exposure. The possibility of
poisoning is not excluded.
The improvement in the level of education is
being noticed, as is the increase in use of certain basic
precautions for individual protection. However, it is
clear that there is a large lack of training and guidance
for handling these substances.
The fact that farm workers are properly trained
and guided associated with intensive marketing activities, places the responsibility for correct pesticide use
and disposal solely on rural workers, which is leading
to human poisoning and environmental pollution. The
rural workers’ low levels of education result in a serious lack of awareness of the correct way of applying
these products. Consequentially, they are almost completely unable to comprehend instructions and thus
implement safety precautions. The industry exempts
itself of the responsibility over its aggressive selling
strategies, casting the blame for an accident on the ‘unsafe procedure’ of the worker.
Final Comments
Adopting the neoliberal model of development
has worsened large national problems, particularly the
huge social and economic disparity. Complying with international agreements, especially when related to the
demands of the financial capital, is prioritized over fighting the major structural problems of our society.The
fact that huge tracts of land remain in the hands of
few, together with the constant inflow of technology,
expels thousands of farm workers to the urban centers.This contributes to a chaotic and accelerated urbanization and a significant increase in unemployment
and underemployment. This, in turn, associated with
the lack of investments for maintenance or improvement of basic social infrastructure (such as housing, sewage systems, access to healthy food, road conservation, etc.) or its deterioration has contributed to worsening the country socially and economically.
As stated in the book "A Opção Brasileira" (The
Brazilian Option): "what we need, most of all, is a cultural change. With low self-esteem and an identity in
crisis, we won’t be capable of building an environment
in which great ideas can blossom and options are made possible. To ponder upon an alternative way is, in
the first place, to question once again which ends our
institutions and economy should serve. Specifying the
five principles we should be committed to should help
solving the problem: commitment to sovereignty, representing our will, in face of ourselves and the world,
to advance in the process of building the nation, seeking to attain enough autonomy in the process of decision-making; commitment to fraternity, in order to
build a nation of citizens, eradicating all social exclusions and the shocking inequalities in wealth, income,
power and culture distribution; commitment to development, expressing the decision to put an end to the
121
TABLE 1
SOME CHARACTERISTICS OF THE RURAL WORKERS IN THE STATE OF RIO DE JANEIRO, IN
THE SOUTHEAST OF BRAZIL [MOREIRA ET AL, 2002]
CHARACTERISTIC
ADULTS
CHILDREN
Age (average)
34.9 year (s.d =10.26)
13.6 year (s.d = 2.37)
Gender (%)
85.2 (masc.); 14.8 (fem.)
69.7(masc.); 30.3(fem.)
Level of education (%)
< 4 years – 32.1
4-8 years – 64.9
> 8 years – 3
< 4 years – 19.8
4-8 years – 76.1
> 8 years – 3.1
Use of individual protection equipment: (%)
Masks
Clothes (gloves, etc)
37.7 (yes); 62.3 (no)
8 (f); 3(a); 89 (n)
5 (f); 2(a); 93 (n)
61.4 (yes); 38.6 (no)
13 (f); 5 (a); 82 (n)
8 (f); 3 (a); 89 (n)
Activities (% involved)
Preparation
Application
Harvest
Transportation
82.3
88.9
96.5
62.3
33.3
75.8
75.5
22.4
Reported contact of pesticide with skin (%)
98.6
78.0
Received any kind of training in handling
pesticides (%)
47.8
52.0
Reported symptoms after application (%
47.8
34.0
f = frequently; s = sometimes and n = never
tyranny of the financial capital and to cease being a peripheral economic force; commitment to sustainability,
referring to the need of searching a new form of development, not based on any of the previous socially
unfair and environmentally unfeasible models, in order
122
to form a link to future generations and; commitment
with extended democracy, pointing at resettling the
Brazilian political system, laying it in new broadly participative and plural foundations, with the goal of reestablishing the value of political functions on all levels.
REFERENCES
●
ALMEIDA, WF & GARCIA, EG (1991). Exposição dos trabalhadores rurais aos agrotóxicos
no Brasil. Rev. Bras. Saude Ocup., 19, 7 – 11.
● AUGUSTO. L.G.S
(2003). Uso dos Agrotóxicos no Semi-árido Brasileiro. In: PERES, F. & MOREIRA, JC. (Org.) É veneno ou é remédio? Agrotóxicos, saúde e ambiente. Rio de Janeiro:
Ed. Fiocruz.
●
BENJAMIN, C., ALBERI, J.A., SADER, E., STÉDILE, P.J., ALBINO, J. CAMINI, L., BASSEGIO, L.,
GREENHALGH. L.E., SAMPAIO, P. A., GONÇALVES, R., and ARAÚJO, T.B. (1998). A Opção
Brasileira [The Brazilian Option], Contraponto Editora Ltd, Rio de Janeiro.
●
FAOSTAT (2005). Agricultural Database. Geneva. Available: http://apps.fao.org/faostat/collections?version=ext&hasbulk=0&subset=agriculture
●
FOLHA DE SÃO PAULO 01/13/2005. Available: http://www.folha.uol.com.br
●
IBGE (2004). Indicadores de Desenvolvimento Sustentável – Brasil 2004 [Sustainable Development Indexes – Brazil 2004]. Rio de Janeiro: IBGE. Available: http://www.ibge.gov.br/home/geociencias/recursosnaturais/ids/default.shtm
●
KAGEYAMA, A (2003). Produtividade e Renda na Agricultura Familiar: Efeitos do PRONAFCrédito, Agric. São Paulo, 50(2), 1-13.
●
LANCET (2002). Editorial, 360 (9342), October.
●
MMA (2000). Informativo MMA [Bulletin from the Ministry of the Environment], Número
15. Available: http://www.mma.gov.br/port/ascom/imprensa/marco2000/informma15.html
●
MOLLO, M. L. R. and SAAD-FILHO, A (2004). The Neoliberal Decade: Reviewing the Brazilian Economic Transition. Available: http://netx.uparis10.fr/actuelmarx/m4mollo.htm
●
MOREIRA, J.C.; JACOB, S. C., PERES, F., LIMA, J. S (2002).Avaliação integrada do impacto do
uso de agrotóxicos sobre a saúde humana em uma comunidade agrícola de Nova Friburgo,
RJ, Ciência e Saúde Coletiva, 7 (2), 299-312.
●
PIMENTEL, D (1996). Green revolution agriculture and chemical hazards. The Science of the
Total Environment, 188(1):586-598.
●
SINITOX (2001). Sistema Nacional de Informações Tóxico-Farmacológicas. Base de Dados –
Tabulação Nacional. Available: http://www.cict.fiocruz.br/intoxicacoeshumanas/index.htm
●
WWF (2002). Programa Agricultura e Meio Ambiente [Agriculture and Environment program]. Brasília: WWF-Brasil. Available: http://www.wwf.org.br/projetos/default.asp?module=tema/programa_agricultura.htm
● YUDELMAN, M., RATTA,A. &
NYGAARD, D (1998). Pest management and food production
looking to the future. Food,Agriculture and Environment Discussion Paper 25.Washington:
IFPRI. Available: http://www.ifpri.org/2020/dp/dp25.pdf
123
13
The Water Policies in Latin America:
Between Water Bussines and Peoples´
Resistance
Alex Zapatta
Water policies and in general public management of water are determined by two kinds of processes:
a) Structural conditions of the economic and social formation of Latin-American countries ; and
b) Economic accumulation model of our societies, which is currently expressed in neoliberal structural adjustment policies.
Owing to the limits of the present work, the analysis will be centered
in the problems caused by the adjustment policies regarding water management in Latin America.
In the framework of the adjustment and stabilization policies fostered
by multilateral credit institutions (World Bank, Inter-American Development
Bank and International Monetary Fund), a new legal basis has been established, forcing deregulation through the so called "water adjustment" policies.
This reform started in the middle 80’s, and was expanded in the 90’s throughout Latin-America –including the firm and dignified exception of CubaTo this purpose, the adjustment experts have recognized three types of
constitutional and legal issues:
a) The dominion over hydric resources. All through Latin-American legislation, water from the juridical point of view is characterized as "national
good of public use".
124
b) The right to the use and availability of water. Within Latin-America, there are a variety of modes,
which range from the granting of rights strongly regulated by the State, to those whose concession is
regulated by the logics of the market –the Chilean
case being the most representative.
c) The provision of public services derived from the
availability of water, such as those for irrigation, consumption, sanitation, hydroelectricity, etc. –wherein
Latin-American legislation combines the possibility
of establishing services of direct provision (State)
with the possibility of establishing services of indirect provision (private enterprise).
Subsequently, a synthetic revision of each one of these
three levels is given.
The Dominion over Water Resources
"According to the majority of legislations consulted in
Latin America, water water resources are acknowledged as
goods of public dominion, national goods, namely goods
whose dominion and use belong to the entire nation". [Cubillos, 1994]
"Moreover, the qualification of inalienable and not
prescriptive is included in referring to water resources, signifying they neither can be sold, nor lose their juridic nature of national goods, even if there is a sustained use by private individuals through time." [Cubillos, 1994]
The above mentioned declaration is normally in
the constitutional texts, Leaving the implementation
to the laws that regulate water use.
In this respect, it is suitable to underscore the
constitutional reform approved in Uruguay by way of a
referendum. With the intention of preventing the pri-
vatization of water and sanitation of public services,
and affirming national sovereignty over water resources, important reforms to the constitutional text have
been incorporated. Its core component indicates: superficial water, as well as subterranean (with the exception of pluvial) integrated to the hydrologic cycle, constitute a unitary resource, subordinated to the general
interest which is a part of state public dominion.
The right to the use and availability of water
The yielding of the right to the use and availability of water to individuals is executed by the State, by
means of administrative actions (assignations, adjudications, concessions, authorizations, permits, licenses,
etc.).
These are conferred in terms of distinct criterions: priorities of use (human consumption, animal
watering, productive uses, etc.), water consumption
(consuming, non-consuming), intensity of use (permanent or contingent), etc.
These rights are defined by volume (liters per
second, generally) and by time (occasional, of determined or undetermined length).
Every granting of rights to the use and availability
establishes the object of that granting (for the supplying of water in a certain locality, for the watering of
animals of a particular herd, for the irrigation of a specific property, for the use of one factory, etc.).
Frequently, the concession of the rights to the
use and availability of water occasions the obligation of
the properties situated between the place of harnessing of water and the place where it is availed of. The
cited obligations are natural or forced.
These rights are not absolute: they are conditioned by the fulfillment of definite regulations and criterions, whose inobservance may imply their loss (revocation is possible).
125
Thus far, these are (generally speaking) the attributes of the rights to the use and availability of water
within the different legislations of Latin America.
The leading difference between a legislation that
guarantees a strong regulation of these rights by the
State, and another whose orientation is that they be
regulated by the market resides in the conditions and
limitations of the rights to use and benefit from water.
Which are the characteristics that ensure a market of rights to the water? As maintained by Holden
and Thobani, they are the following: [Holden y Thobani, 1995]
Negotiable Elements of the Regimes
of Water Rights
●
They are secure and may be negotiated in accordance with the guidelines established by an institutional
and legal regulating framework.
●
The rights over water are separated from the rights
over land, and thus may be negotiated independently.
●
In an ideal situation, it should be viable to sell the
rights over water to anyone, with any purpose, and
at prices freely negotiated.
NEGOTIABLE ELEMENTS OF THE REGIMES OF WATER RIGHTS
●
They are secure and may be negotiated in accordance with the guidelines established by an institutional and
legal regulating framework.
●
The rights over water are separated from the rights over land, and thus may be negotiated independently.
●
In an ideal situation, it should be viable to sell the rights over water to anyone, with any purpose, and at
prices freely negotiated.
●
Every so often countries impose restrictions, such as demanding that the buyer utilize water for the general good, or that these rights be sold exclusively to a public organization at a price determined by the State.
●
The owners of the negotiable water rights must abide by the laws and regulations, such as those relative
to the quality of water, or concerning the maintenance the maintenance of a certain minimum volume with
environmental and recreational purposes, as well as the non-impairment of the water rights of third parties
by the transactions of the market.
●
The negotiable water rights may be directed volumetrically, as a proportion of the volume, or of the volume
of water in a dam, or by a transfer.
●
The application may be effected using the same means and institutions that are used to regulate the traditional water rights.
●
The rights are notarized in a public register.
126
Every so often countries impose restrictions, such as
demanding that the buyer utilize water for the general good, or that these rights be sold exclusively
to a public organization at a price determined by the
State.
●
●
The owners of the negotiable water rights must abide by the laws and regulations, such as those relative to the quality of water, or concerning the maintenance the maintenance of a certain minimum volume with environmental and recreational purposes,
as well as the non-impairment of the water rights of
third parties by the transactions of the market.
●
The negotiable water rights may be directed volumetrically, as a proportion of the volume, or of the volume of water in a dam, or by a transfer.
The mentioned elements, if incorporated into
the legal frameworks of Latin-American countries,
would imply the recognition of the rights to the use
and availability of water as real rights. Such is the laying out of Peruvian advocate Ada Alegre Chang, who
in line with the "hydric adjustment" believes that the
attributes of the rights to the use and availability of
water should be the same as those of any real right,
specifically:
●
●
●
The application may be effected using the same
means and institutions that are used to regulate the
traditional water rights.
The rights are notarized in a public register.
Rights over goods
WHAT ARE THE MAIN CHARACTERISTICS OF WATER RIGHTS?
USE
ENJOYMENT
ACCESS
DEMAND
Take possession,
manage
Take advantage,
to benefit
Sell, mortgage,
transfer
Recuperate
any lost good
RESOURCE
CHARACTERISTICS
LEGAL
CHARACTERISTICS
Elaborado por Ada Alegre Chang.
127
They ought to be respected by everyone
Different from personal rights
● They should be noted in a Public Registry
● Regarding natural resources, they are usually established through "concession" and "assignation"
● They facilitate the creation of a market of rights
●
●
In general, the civil legislation refers to real rights
as the ones that we have over something, not in respect to a certain person. Real rights are: dominion,
inheritance, usufruct, use or inhabitation, active obligations, pledging, and mortgage. From these rights, the
real actions are derived1
In this sense, Chang asks , what attributes may
the rights to the use and availability of water have?
Her answer is: rights to use, to benefit from, to dispose of, and to vindicate.[Chang, 2003]
The provision of public services derived
from the availability of water
One of the axes of the policies of structural adjustment has been to privatize public services. This
process, though with nuances has been verified in the
majority of Latin-American countries.
DISPLAY CASE EXPERIENCES OF THE IADB
ADMINISTRATION CONTRACTS
CONCESSION CONTRACTS
Cartagena de Indias (Colombia)
Lara (Venezuela)
Monagas (Venezuela)
La Paz (Bolivia), Montería (Colombia),
Buenos Aires (Argentina), Santa Fé (Argentina)
Guayaquil (Ecuador)
SELLING
Georgetown (Guyana)
Pereira (Colombia))
To orchestrate such policies, it was necessary to
reform the corresponding constitutions and laws became necessary. In the new constitutional and legal
framework it is established that the provision of public
services, as water for consumption, sanitation, irrigation, electricity, etc. are a responsibility of the State.
This responsibility may be exercised directly or indirectly, through the delegation to private enterprise. In
this case, several legal mechanisms have been provided: the transformation of public companies into mi1. Artículo 614 del Código Civil ecuatoriano.
128
SELLING OF ASSETS
Santiago de Chile
Valparaíso (Chile)
xed companies; or the concession and privatization of
public companies, etc. The modes have varied from
one sector to another and obviously from one country to another.
To demonstrate the diverse options -which
could be labeled "personalized"- of privatization of potable water and sanitation services, the Inter-American
Development Bank exhibits the menu of "successful"
experiences to be imitated: [Traverso, 2004]
The free trade treaties and water
The contingent constitution of an Area of Free
Trade of the Americas would entail a dramatic accentuation of the "hydric adjustment" within the Region.
In the matter of water, the principles of "free trade" wielded by the United States are oriented towards2:
Popular Resistance to the
"Hydric Adjustment"
●
The constitution of a continental water market that
would contain the possibility of exporting it.
●
The incorporation of commercial mechanisms tending to the loss of public control over water by the
State.
In the menu of the IADB (Inter-American Development Bank) inserted previously, there is no reference, obviously, to the rejection provoked by the privatization of the sector of water provision in El Alto (Bolivia), where recently a popular uprising was generated,
which demanded the expulsion of the company "Aguas
del Illimani", subsidiary of the multinational Suez –
Lyonnaise. Neither there is any allusion to the rejection generated by the presence of the company
"Aguas del Tunari" subsidiary of another multinational
Bechtel in Cochabamba, Bolivia. This popular rejection
was manifest through a formidable uprising that mana-
●
The favoring treatment to North-American companies, similar to the one donated to any national, public or private company, which wants to avail of water with commercial ends.
PRIVATIZATION OF THE WATER
SERVICE IN COCHABAMBA
BOLIVIA
Although the possibilities of implementation of
the Area of Free Trade of the Americas seem each time more remote –owing to popular resistance throughout the continent, as well as the rise of governments of left-wing tendency within Latin America-, the
fact that those principles are integrated in the texts of
free trade treaties –the "TLC" (Treaty of Free Trade)that the United States is subscribing with the countries of the Region should not be overlooked.
Under the same tendency of water commerce is
the General Agreement of Trade of Services of 1994
by the World Trade Organization, which estimated the
lucrative world market of services in 3,5 trillion USD
in health; 2 trillion USD in education; and 1 trillion
USD regarding water3.
●
Privatized in 1999, concession for 30 years
●
Beneficiary company: "Aguas del Tunari" with
the capital of Bechtel (USA)
●
Increase in the tariffs (200%)
●
Investments not fulfilled
●
Peasant water sources usurped
●
Contract does not respect the presence of
district local systems of harnessing and distribution of water. Bechtel is expulsed in April,
2000, as the result of a social revolt
●
Currently, a trial is discussed within the CIADI
(World Bank)
Elaboración: Juan Carlos Alurralde (2004)
2. Taken from the paper of Maude Barlow published in the Internet under the title of "El ALCA una amenaza para los programas sociales, la sostenibilidad del medio
ambiente y la Justicia Social en las Américas". Revista CONTRAPUNTO. Red SAPRIN. Número 9. Quito, 2001.
3. Campaña "Agua para todos". Public Citizen: www.wateractivist.org
129
ged the expulsion of the "concessionary" company.
Consult the index card in page131.
Moreover, the menu of the IADB does not mention the process the Argentina underwent during the
90’s. This process of privatization of public services
deserved the ensuing commentary of an Argentinean
erudite:
The most exhaustive process of privatization of the
region has been enforced in Argentina, and now we are witnessing the consequences: companies that did not fulfill investments; increase in tariffs; and millionaire demands before the CIADI by virtue of the existence of the BITs.
[Fairstein, 2004]
The CIADI is an instance of extrajudicial resolution of conflicts between transnational companies and
the states, receptors of the investments of those companies. The CIADI pertains to the sphere of the World
Bank. The resolutions of the CIADI, as obviously could
be expected, by and large are favorable to transnational companies.
If we should revise the cases submitted to the
CIADI regarding conflicts derived from the State and
the companies which benefited by the privatization
processes during the "menemato" (Menem’s presidency), it may be appreciated that 19% of the cases are
related to water services and sanitation. Refer to the
following chart in the next column [Alurralde, 2004]
The government of Néstor Kirchner began a
process of re-nationalization of water services which
were transferredin concession by the government of
Menem. Evidently, the process of re-nationalization is
not as simple as one should desire.
...within those places where service shifted from private to public hands, as in Tucumán (very similar to what
occurred in Cochabamba in terms of the provision of the
service), due to the lack of financing, companies once more plunge into the logic of the IADB and the World Bank,
which condition the granting of loans to a series of terms
in the line of privatization. [Fairstein, 2004]
130
CASES SUBMITTED TO THE CIADI,WHICH
IMPLICATE THE ARGENTINEAN STATE
SERVICES
Petroleum and gas
Electricity
Ports
Water and sanitation
Data processing services
Others not privatized
Total
PERCENTAGE
37%
22%
3%
19%
6%
13%
100%
Source: Juan Carlos Alurralde (2004)
Then again, it is to be assumed that the IADB
and the World Bank would rather keep absolute silence in front of the astounding success of the Uruguayan
people, who won the popular consultation to reform
the Political Constitution of the eastern country, whereby an important overturning of the national policies
concerning the water and sanitation sector is guaranteed. On October 31st of 2004 more than 60% of the
citizenry voted in favor of the project of Constitutional Reform promoted by the National Commission in
Defense of Water and Life. On account of the relevance of this popular achievement, subsequently is the
transcription of the text of the Reform included in the
Uruguayan Constitution:
Article 47.To be included:
Water is a natural resource essential to life.The access to potable water and the access to sanitation constitute fundamental human rights.
1) The national policy of Water and Sanitation will be based on:
a) the organization of territory, conservation and protection of the Environment and the restoration of nature.
b) the sustainable management, jointly responsible for future generations, of the hydric resources, and the preservation of the hydric cycle, which represent issues of
general interest.The users and civil society will participate in all the instances of planning, management and
control of hydric resources, establishing the hydrographic waterheds as the basic units.
c) the institution of priorities for the use of water by regions, waterheds, or parts of them; being the supplying
of populations with potable water the first priority.
d) the principle by which the provision of potable water
and sanitation services is to be executed must be that
of putting before the reasons of social nature to the
ones of economical nature. Every authorization, concession, or permit that violates these principles in any
manner is to be considered without effect.
2) Superficial water, as much as subterranean, with the exception of pluvial, integrated to the hydric cycle, constitute a unitary resource subordinated to the general interest, which is part of the state public dominion, as hydric
public dominion.
3) The sanitation public service and the water supply public service for human consumption will be provisioned
exclusively and directly by state legal entities.
4) The law, through the three fifths of votes of the total
components of each chamber will be able to authorize
the provision of water to another country, when this is
left without supplies, or for solidarity reasons.
Article 188.- To be included:
The dispositions of this article (as regards the associations of mixed economy) will not be applicable to the essential services of potable water and sanitation.
Transitory and Special Dispositions.- To be included:
Z’’) The reparation corresponding to the enforcement of this
reform will not generate indemnification for ceasing profit, being reimbursed only non-amortized investments.
In the style of the menu of the IADB, a "menu"
of the multiple forms of popular resistance to the "hydric adjustment" in Latin America could be made, from
the experiences on communitarian management of
water systems and conservation of hydric resources
by populations throughout Our America, the Ecuadorian experience of the Forum of Hydric Resources, the
experience of great mobilizations of activists within
Mexico, Central America, Brazil,Argentina, and the experiences of insurrectional trait in Bolivia, to the Uruguayan experience of constitutional reform.
A Latin-American Platform to Confront
"Water Adjustment"
In August 2003, in San Salvador (El Salvador), organizations and social movements throughout Latin
America, Canada, and the United States left a record
of their rejection of the processes of privatization of
water resources and water services, putting forward
at the same time these proposals:
1.The management of water resources must be based
on fundamental principles, such as social justice, sustainability, and universality.
2.Water is a public good and an essential and inalienable human right, which must be promoted and protected for everyone.
3. Water is not merchandise, and no person or entity
has the right to get rich at its expense, consequently
water must not be privatized.
131
4.Water must be protected from all contaminating human activities, particularly mining and industrial and
agroindustrial processes. The protection of ecological systems and the integral managing of the resource is imperative.
5. Water must be totally excluded from the negotiations of the World Trade Organization, the Area of
Free Trade of the Americas, and the Treaties of Free
Trade, and must not be considered as a matter of
‘goods’, ‘services’, or ‘investments’ within any international, regional, or bilateral agreement.
6. Projects of water development in a large scale are
being implemented, as the mega-dams, which are
neither ecologically nor socially sustainable; thus, alternatives must be sought that respect the rights of
people and communities, ensuring a full social participation.
7. On acknowledging the existent inequity between
men and women with regard to the access to, the
managing of, and the rights over hydric resources and
potable water, policies and forms of practice that eliminate the mentioned inequities must be developed.
8. A future with assured availability of water depends
on recognition, respect, and protection of the rights
of indigenous, peasant, and fishing populations, and
of their traditional knowledge.
9. It is demanded that public water systems be protected, revitalized, and reinforced, in order to ameliorate their quality level and efficiency. The participation
of workers of both sexes and the community must
be guaranteed within all of them, so as to democratize decision making, and to make certain the transparency and giving of accounts.
10. In the case of communitarian systems of water, urban and rural, political policies that support the eco132
nomic, social, and environmental development and
sustainability of these projects must be formulated
and instigated, respecting the autonomy and rights
of communities.
11. Rejection to the conditioning imposed by international financing organizations to grant loans directed
to the management of water, violating the sovereignty of our peoples.
Thus is the platform to confront the "hydric adjustment", from the viewpoint of popular organizations, social movements and progressive sectors of all
of Our America.
AGUAS
Dicen que el agua será imprescindible
mucho más necesaria que el petróleo
los imperios de siempre por lo tanto
nos robarán el agua a borbotones
los regalos de boda serán grifos
agua darán los lauros de poesía
el novel brindará una catarata
y en la bolsa cotizarán las lluvias
los jubilados cobrarán goteras
los millonarios dueños del diluvio
venderán lágrimas al por mayor
un capital se medirá por litros
cada empresa tendrá su remolino
su laguna prohibida a los foráneos
su museo de lodos prestigiosos
sus postales de nieve y de rocíos
y nosotros los pálidos sedientos
con la lengua reseca brindaremos
con el agua on the rocks
Mario Benedetti
REFERENCES
● ALURRALDE, JUAN
CARLOS (2004). Ponencia presentada en el
Tercer Encuentro Nacional del Foro de los Recursos Hídricos.
Quito, Noviembre.
● ARTÍCULO
614 DEL CÓDIGO CIVIL ECUATORIANO
●
CHANG, ADA ALEGRE (2003). Ponencia presentada en el Foro
de las Américas. La Paz, Diciembre.
●
CUBILLOS, GONZALO (1994): "Bases para la formulación de leyes referidas a recursos hídricos". CEPAL. Santiago de Chile.
●
DECLARACIÓN DE SAN SALVADOR "POR LA DEFENSA Y EL
DERECHO AL AGUA" (2003). Agosto 22.
●
FAIRSTEIN, CAROLINA (2004). correo electrónico.
●
HOLDEN Y THOBANI (1995). Citado en un documento del BID
elaborado por GARCÍA, Luis E.: Manejo integrado de los recursos hídricos en América Latina y el Caribe. Informe Técnico Washington DC., 1998.
● TRAVERSO,VÍCTOR
(2004). Ponencia presentada en nombre del
BID, Quito.
133
Cultural Agresi n
Uniculturality and Health
14
The "Zapatista" Struggle and Health:
Cultural Aggression, Discrimination and
Resistance as Triggers of Indigenous
Potentialities
Catalina Eibenschutz y Marcos Arana
Antecedents
The uprising of the "Zapatista" Army of National Liberation ("Ejército Zapatista de Liberación Nacional,"or EZLN) in January 1994 surprised the world
for multiple reasons: for being primarily indigenous; for its impressive originality;
for using weapons in a different manner; and for making the most of modern
communications technology. Moreover, it challenged the government and requested the resignation of President Carlos Salinas, declared War on the Mexican Army, it revealed itself against the taking over of political power??, and addressed civil society as its foremost interlocutor.
A lot was rumored throughout the country about its origin, however these rumors disappeared gradually while it’s the EZLN struggle advanced and dialogue was accepted. Armed war was substituted by a low intensity combat strategy. Eleven years after, the "Chiapaneco" indigenous people and several others
in other countries continue to struggle for their acknowledgement as people
with proper identity. The "Zapatista" Army of National Liberation remains the
reference for numerous social and indigenous movements all over the world,
mainly in Latin America.
Various researchers and analysts mention as the causes of the uprising: discrimination, poverty, marginalization, exploitation, and the attempt to force their
incorporation to the mestizo (mixed parentage) culture [González Esponda and
Pólito, 1995; González Casanova, 1995; Harvey, 2000; Barabas, 2000]. Among the
135
demands of the "Zapatista" Army of National Liberation one must highlight the need for recognition of
their own identity and culture, the acknowledgement
of their autonomy (without separation) and free determination, [Blanco, 1996] the right to housing, health
and territory, etc. Their struggle had a impact worldwide against neoliberalism, and their phrases became
famous: "Enough! A world wherein all worlds fit! To
rule obeying! Everything for everyone!"
So, two rationalities were openly confronted the neoliberal logic of exclusion and the indigenous logic of inclusion-.The neoliberal, based on markets, generated illnesses, and the indigenous struggle, based on
dignity struggled for health.
What has happened today to the "Zapatista"
Army of National Liberation? Subcommander Marco’s
communiqués are not as frequent as they were in
years past; there are no more headlines that occupy
first pages in papers. What is wrong with the EZLN?
Do they still exist?
The clear cut answer is that they do exist, struggle, take care of health, develop their culture, and enhance organization around their autonomy and the
Boards of Good Government (JBG).
Our Purpose
In the course of this work, we purport to describe and analyze the unexpected tensions, contradictions and results of the social and sanitary struggle of
the "Zapatistas" and of non-indigenous citizens, as ourselves, who accompanied closely the struggle for
health of the "Zapatista" Army of National Liberation
and the "Zapatista" Movement in Chiapas. Note: Why
is Zapatistas always in quotes? It minimizes its importance.
In particular, we set out to delineate a broad account of the main facts of the struggle for health that
started with the "Zapatista" uprising. The concerns,
which guided our experience and our reflection, are as
follows:
●
What happens to health when people decide to take
charge of their own history1?
●
What tensions arise, how are they solved, and how
are they surmounted?
●
What did the resistance policy signify concerning the
restatement of public policies?
●
How have the actions of some agents influenced the
"Zapatista" struggle for health?
It is essential to appreciate that the struggle for
health has been constant within the indigenous population of Mexico for many years. Indigenous people
have been the victims of discrimination, were excluded
from the "Mestizo" (mixed parentage) National Project proposed by the Mexican Revolution in 1910, and
(with few exceptions) have been excluded from the
national public health system as well.
In the state of Chiapas--more concretely in the
zone of the "Lacandona" Jungle-- "health promoters",
trained by all types of institutions: universities, the
Health Department, civil organizations, the church,
etc. were in charge of medical care. The indigenous
communities constructed their own clinics and health
centers several years before the "Zapatista" uprising.
Furthermore, the vindications presented in the First
Declaration of the Lacandona Jungle [EZLN, 1994] regarding health were a product of the participation of
these communities themselves, which had already
been investing and working on their health care.
1.We understand taking charge of their own history as having a sense and a project of future, put forward starting from their own history.
136
There are a small number of published studies
on the health situation of the "Zapatista" indigenous
communities. However, due to the condition of poverty and marginalization in which they live and the absence of health services, these data were rather unreliable. One of the first specific studies published after
the uprising [Blanco, Rivera & López, 1996] qualifies
their situation as of permanent emergency.
Possibly the best health diagnosis was profiled by
Subcommander Marcos on January 18th of 1994, only
16 days after the uprising, in its communiqué named:
"For what are they going to pardon us?"
"Who must ask for forgiveness and who ought to
grant it? Is it the ones who during years and years sat before a full table and satiated, while we sat before death; so
quotidian, so proper that we ended up not fearing it…The
dead ones, our dead ones, so mortally died of "natural"
cause, explicitly measles, whooping cough, dengue fever,
cholera, typhoid fever, mononucleosis, tetanus, pneumonia,
malaria and other gastrointestinal and pulmonary beauties? Our dead ones, so massively dead, so democratically
died of sadness since nobody did anything…….with no
one pronouncing at last: ENOUGH!…….? Who must ask
for forgiveness and who ought to grant it? Subcommander
Marcos, 1994.
After The Uprising
It is necessary to remember that the armed confrontations lasted only twelve days (from January 1st
to January 12th of 1994), owing to the fact that during
this period there were important manifestations of civil society2 in which President Carlos Salinas was ur-
ged to suspend the war and sit at the dialogue table.
The "Zapatista" Army of National Liberation accepted
the suspension of armed actions to maintain dialogue,
at the same time that it initiated a process of interlocution with civil society.
In March of 1994, the "Zapatista" Army of National Liberation and the government established a series
of peace dialogues in the Cathedral of San Cristóbal
de las Casas. It seemed at the outset a promising, unquestionably constituted, and valuable forum for people from all over the country to participate and let the
entire world know the indigenous nature of the movement and the validity of its demands. Nevertheless,
the murder of the candidate of the Institutional Revolutionary Party, who was running for President of the
Republic, precipitated the "Zapatista’s" distrust and the
failure of dialogue. As a response to this new situation,
the "Zapatistas" launched a new offensive. Though in
this occasion it was about an appeal directed to its base (sympathizers of civil disobedience), which has
constituted, the most recent fighting strategy of the
"Zapatista" Army of National Liberation:
"We will accept nothing that comes from the
rotten heart of the bad government, not even a coin,
medicine, a grain of food, or the scraps of charity it offers in exchange for our worthy going. We will receive nothing from the supreme government. Even if our
pain and distress increase; even if death still accompanies us at our tables, our beds and the earth; even if
sorrow cries in the rocks. We will accept nothing. We
will resist…".3 [EZLN, 1994]
As an almost immediate result, health personnel
of official institutions were expelled from the "Zapatista" localities, and many health centers closed. The "Zapatistas" summoned national and international civil so-
2. One of these manifestations was the first expression of civil resistance during the conflict, when on January 9th of 1994 nearly a thousand demonstrators against
the confrontations marched from San Cristóbal de las Casas, dressed in white to place themselves in the middle of both armies and force a seize of fire in locations severely attacked by the Army.
3. "Zapatista" Army of National Liberation, Second Declaration of the Lacandona Jungle, June of 1994.
137
ciety organizations to support the establishment of a
health care system without governmental participation.
The strength of the civil resistance embodied a
formidable force of great propagandistic efficacy; impossible to confront by arms. It is not disproportionate to affirm that currently the capacity of pressure and
negotiation of the "Zapatista" Army of National Liberation resides quite exclusively in its resistance, which
has placed its military capacity as a secondary position.
[Arana, 1999]
The efficacy of this strategy consists primarily of
the incapacity of governments to confront or restrain
it. This form of pacific struggle constitutes the essence of what some have called biopolitics (geopolitics??),
which progressively has been adopted by numerous
groups of activists worldwide to face the extensive hegemonic (neoliberal??)political and economical powers. To a great extent, the resistance of the "Zapatista" Army of National Liberation has inspired environmentalist and those who oppose market monopoly
globalization. Their struggle at the same time feeds into and reinforces the "Zapatista" discourse of resistance, and proffers a platform of international support.
The force applied by the Federal Army had a
counterproductive effect, since civil resistance kept
gaining strength and legitimacy, while controls, patrolling and military posts augmented.
Nevertheless, on February 9th of 1995, Ernesto
Zedillo, president at the time, ordered a military operation of great importance, which generated a strong
presence of the Army within indigenous communities.
Subsequently, the Zpatistas lost territorial control
over several regions of Chiapas.The government justi-
fied the installation of innumerable military posts and
control stations, adducing the necessity to protect the
population-- which had moved out of the region in the
beginning of 1994 due to fear of confrontation. This
population returned in March of 1995 accompanied by
a strong military operation4. Once the Army, positioned firmly in the conflict regions, laid siege to the "Zapatista" localities, a strategy of counterinsurgency
commenced.This was based on the usurpation of functions of health, education, public institutions, and the
control of social expenditure in the region. With this
strategy of a low intensity war, the actions concerning
health, nutrition and education were usurped. In the
face of the "Zapatista’s" rejection, which had declared
resistance, public funds were directed to the population willing to accept them, and this occasioned serious tensions among the inhabitants of the region
[Arana, 1988]. This excluding development plan was
the core strategy of the federal and state governments
to confront "Zapatismo" until the year 2000, and its
consequences were more devastating for the population than the sum of all the military actions.
Another effect of this policy was that a large
number of localities suffered internal ruptures, manifested as violent actions, expulsions and divisions. The
military presence and its discriminatory behavior promoted violent responses against the resisting population, including the formation of paramilitary groups.
Until the year 2000, the regions in conflict were
the scenarios of constant violations of the principle of
medical neutrality, and the discriminatory execution of
social programs, which violated the International Pact
on Economical, Social and Cultural Rights, and other
instruments signed and ratified by the Mexican State.
4.When the armed conflict initiated, the Army itself and some municipal authorities promoted the departure of the population from their communities. Just about
1500 families remained displaced until February of 1995 and were assisted by public institutions coordinated by the Army. The "Coordinator of Civil Organizations
for Peace" denounced repetitively the deliberated disinformation of the ones displaced on the course of the conflict and the use of health and nourishing actions
to encourage a favourable and dependent attitude of them towards the actions of the Army. (CONPAZ, Informe de la Comisión de Derechos Humanos sobre las
condiciones de los desplazados por el conflicto, Noviembre, 1994).
138
In spite of this, the "Zapatista" Army of National
Liberation continued to count on the resolute support
of national and international civil organizations which,
regardless of the blockade attempt maintained by the
government, persisted in the health care attention of
the "Zapatista" indigenous populations of the zone.
In the year 2000, during the first transparent
elections of Mexico (won by the right wing party of Vicente Fox), the "transition to democracy" allowed the
"Zapatista" Army of National Liberation a respite and
new hope. Effectively, President Fox conveyed the
project law on Indigenous Culture and Rights to be
discussed in Congress. However, the resulting law did
not correspond to the principles of acknowledgement
of indigenous peoples, among numerous issues, and
was not accepted by the "Zapatista" Army of National
Liberation nor the "Zapatista" movement.
As a reply to this "new treason" of the State, the
"Zapatistas" decided to retreat to their territories, and
continue their struggle from there. With a double
identity as Mexicans and as indigenous peoples, they
dedicated themselves to constructing their autonomy
in practice. The same year, the first elected Governor
since the military uprising took possession (without
the participation of the "Zapatistas") of Chiapas. Although this fact did not lead to the resolution of the
conflict, it has contributed to create an atmosphere of
less violent confrontation.
Resistance and Public Policies
The decision to refuse the governmental resources and programs, particularly those related to health
and education, as part of the resistance policy, was of
great concern for various members of the academy
and civil organizations. This was condensed in two
problems: on one side, the negative impact that the interruption of health actions could yield--chiefly vaccination and care for women and children. On the other side, the fact that the voluntary rejection of public
resources would not contribute to promoting the necessary demand of their economic and social rights in
face of the State, namely a mode of kidnapping of their
civil rights.
Nonetheless, even if the intention of the "Zapatistas" never was to influence health policies by means
of resistance, their impact over them has been very
important, given that after the year 2000 some programs of the government of Chiapas have incorporated the concept of rights and the explicit commitment
not to discriminate or cliental use of patients. The inclusion of this focus has played a part in reducing the
tensions generated throughout several years between
the "Zapatista" and "non-Zapatista" population.
One of the factors that added to this change was
the Alternative Report of Economical, Social and Cultural Rights, which the Committee of the United Nations and national civil organizations elaborated in
1999. This report included a special chapter on Chiapas, in which military interference in the health programs and the negative effects of the counterinsurgent
use of public resources was described. As a result of
this alternative report5, the Committee of Economical, Social and Cultural Rights of the United Nations
made several recommendations to the Mexican government. Standing out was the recommendation to
"impede the interference of the army in social programs…"6. These recommendations provided the vigilance of public policies with a valuable instrument.
Presenly, the interference of the army in health actions
has practically disappeared.
5. Espacio Civil de los Derechos Económicos, Sociales y Culturales, Informe Alternativo sobre la situación de los DESC en México, México 1999.
6. Comité DESC de la Organización de las Naciones Unidas, Recomendaciones del Comité DESC al Gobierno de México, Ginebra, Noviembre, 1999.
139
Knowing how the evolution of health conditions
has been since the uprising of 1994 is not simple, not
only due to the bias in presenting and interpreting the
epidemiological information available, but for the reason that during the first years after the uprising, the information of broad regions of Chiapas, ones of major
poverty, were not included within official statistics.This
created a false appearance of general improvement.
The consequences regarding health throughout
the first years of the conflict were extremely negative,
albeit quantitative evidence is basically nonexistent.
Conversely, national and international civil organizations present in the region could verify the deterioration of the nutritional state of those displaced following the Massacre of Acteal in 1997, and the increment increases in numerous transmissible illnesses.
The major part of that information nonetheless refers
to the displaced or circumscriptive populations. On
account of this apprehension, between 1999 and 2002
a wide-ranging study was undertaken in which health
conditions of the population in resistance were contrasted. It received official public services in three regions of Chiapas: Los Altos, the North Region and the
Jungle Region. The study was developed at the domiciliary level in 46 localities selected randomly as a sample of the communities in resistance.. [Sánchez,Arana,
Ford, Brentliger, en prensa]
On contrasting the health conditions of the population in resistance and the general population, it
was revealed that the worst health conditions were
not from those who had rejected public health services, but of those who live in divided communities. This
finding was consistent throughout the study. For
example: in the case of chronic undernourishment rates (small height in proportion to age), the rate among
minors of communities in resistance was 48.6%; the
rate of groups without resistance was 52.2% and that
of the divided groups was 58.6%; significantly higher in
the latter.
140
In the same study, eight maternal deaths were
identified, six of which corresponded to localities without resistance. The other two were in divided communities, and none were in localities in resistance. The
rate of maternal deaths was calculated starting from
the 1319 life born studied?. Additionally, a mortality
rate of 60.7 per 10,000 live born was obtained; this is
markedly superior than the one indicated by official
statistics in the country and in Chiapas. [Brentlinger,
Sánchez-Pérez, y otros, en prensa]
Malnutrition and maternal death rates coincide
with other studies and observations, in that the health
situation of indigenous populations in these regions
continues to present serious lags. This situation is not
worse anymore within localities with resistance, where people have compensated for the lack of services
through organization. The contrary happens in communities that have two or more distinct authorities as
a consequence of internal divisions. Throughout these, the health situation has deteriorated because of
the rupture of social texture and the disappearing of
mechanisms of reciprocal support, both features of indigenous peasant societies of the region.
One of the aspects not sufficiently evaluated that
could be cause for difference among communities in
resistance and the ones not in resistance, is the prohibition of the selling and consumption of alcohol and
drugs in the Zapatista communities. The decrease of
domestic violence and the nutritional improvement
within families are also two important indicators that
are certainly demonstrative of the positive changes in
the health of communities in resistance.
The organization around autonomous municipalities has intensified communitary actions, stimulating a
gradual improvement of life and health conditions in
these localities.
Creating an atmosphere of ease, tolerance and
social inclusion is considered indispensable for solving
the crisis of divided communities.The more civil, paci-
fic, propositional, and inclusive nature attained by autonomous municipalities, undeniably will be a significant contribution for communities suffering internal
tensions to solve their conflicts.
Within communities in resistance where health
structures have gained a strengthened position attributable to organizational capacity, people avail themselves of the official hospital structure and take advantage of other resources, such as vaccines, controlling
their application by themselves.
Presently, "Zapatistas" are constructing their Autonomy as the finest manifestation of the principle
they have fought for: "taking charge of their own destiny".
"Zapatista" Autonomy
As any other indigenous autonomous process,
the "Zapatista’s" acquires two dimensions: as a model
that aspires to become a law and as a form of practice of a new collective subject [Rico, 2004]. This form
of practice is the one, which has led to the construction of these autonomies and the regaining of control
of their lives and health in the "Zapatista" territory.
According to Héctor Díaz Polanco (1997: 15),
the Indigenous Movement of Latin America prioritized
amidst its objectives and aspirations the struggle for
autonomy, and it is precisely this the key to multiethnic States, which guarantee the acknowledgement of
diversity without separation from the State.
The "Zapatista" struggle for the acknowledgement of Indigenous Autonomy within National Legislation failed in the Congress of 2001 with the final approval of the so called Indigenous Law, which did not
include autonomy or recognition of the Indigenous
Peoples; thus, the "Zapatistas" decided to construct it
by means of concrete resistance and facts.
The Rebellious Autonomous Municipalities manage their territories in line with their organizational
forms and communitarian assemblies, and they regulate their process by revolutionary laws and their own
form of government. In August of 2003, the Municipalities had already begun constructing conforming regions, building of the so called "Snails" as their physical
space and the Boards of Good Government as their
social space.
Snails are programmed regions, becoming the
political frame of regional development and territorial
organization. The "Zapatista" Snails are doors to enter the communities and for communities to exit.
Openings to see inside and from which to project integration, so that communities are not isolated from
the global world. The "Zapatista" Snails are a further
step in Autonomy, in cohesion and in the coordination
of the movement by regions, where autonomous principles may share their experiences and work.
The Boards of Good Government have as their
objective to promote equitable development of all the
municipalities. They are composed of one or two delegates from each Autonomous Council of the zone,
and their headquarters are the ‘Snails’. These aid in the
coordination of work in all regions, though the MAREZ ("Zapatista" Autonomous Municipalities) continue to have their own dynamics in the implementation
of: justice, health care, autonomous education, housing,
land, commerce, information, culture and local transit.
The Boards of Good Government ensure that
the resources reaching the national and international
civil society are used in the equitable development of
all the municipalities, and solves and mediates the conflicts within communities in the regions as well. The
Snails are an organizational effort of communities not
only to face the problems of autonomy, but to build a
more direct bridge between them and the world. [Rico, 2000:22]
141
Final Reflections
Once the Indigenous Law approved by the Congress left out the propositions that the "Zapatista"
army of National Liberation had compelled, or the
acknowledgement of autonomy, the "Zapatista" indigenous civil bases decided, still without official recognition, to proceed in the construction of the Autonomous Municipalities, or the Boards of Good Government.
The organization and effort this task has demanded has reinforced the nets of mutual support, which
themselves promote equity and have a positive impact
on health. For example, the training of midwives and
health promoters adds force to the successful experiences of several indigenous communities anterior to
the uprising, and makes them available to the development of a project of more ample reach.
The construction of health clinics sponsored by
national and international solidarity are more than
8. Municipios Autónomos Zapatistas
142
structures of general care and educational centers of
human resources; they are structures that strengthen
the organizational capacity and fortify the population’s
appreciation for what they have.
However, what is unquestionably more important is the process of self-assurance in their capacities
("empowerment") to direct their future destiny, which
eventually produces the amelioration of health conditions, in spite of the adversity that surrounds them.
"We have intelligence and capacity to direct our
own destiny."
Board of the Good Government of
an autonomous municipality
(H. Bellinghausen)
In his article of La Jornada January 2nd, where he
develops a report of the celebration of the 11th Anniversary of the "Zapatista" uprising and the declarations of the Board of the Good Government.
REFERENCES
● ARANA, M
(1998). "La labor social del ejército" La Jornada, Febrero 20.
● ARANA, M
(1999). "Atención para la salud y conflicto en Chiapas" Parte Aguas,
Comisión Mexicana de defensa y Promoción de los Derechos Humanos, No 1,
Junio - Agosto. pp. 15-22.
●
BARABAS,A (2000). "La constitución del indio como bárbaro: de la etnografía al
indigenismo". Rev. Alteridades. Año 10. num. 19, enero-junio. UAM-I. México, pp.
9-20.
●
BLANCO F.,V (1996). "La cuestión indígena y la reforma constitucional en México". Revista Internacional de Filosofía Política. pp 121-140. México.
●
BLANCO GIL, J., RIVERA, J.A.Y LÓPEZ ARELLANO O (1996). "Chiapas. La emergencia Sanitaria Permanente" Rev. Chiapas Nº 2. Ed. ERA.. México, pp 95- 115.
●
BRENTLINGER P, SÁNCHEZ-PÉREZ HJ, ARANA CEDEÑO M, VARGAS MG,
HERNÁN, MA, MICEK M, FORD D (En prensa, 2004). Pregnancy outcomes, site
of delivery, and community schisms in regions affected by the armed conflict in
Chiapas, Mexico. A community-based survey. Social Science and Medicine.
●
EZLN (1994). "Declaración de la Selva Lacandona" en: EZLN. Documentos y Comunicados .Vol.1. Del 1º de enero al 8 de agosto 1994. Ediciones ERA, México,
pp. 33-35.
●
FOUCAULT, M (1994). La politique de la santé au XVIII siècle. Gallimard, Paris, p.
729.
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GONZÁLEZ CASANOVA, P (1995). "Causas de la Rebelión en Chiapas" La Jornada Semanal, 5 septiembre 1995. México. D.F.
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GONZÁLEZ ESPONDA, J. y PÓLITO, E (1995). "Notas para comprender el origen de la rebelión zapatista". Revista Chiapas, no 1, pp 101-123. ERA, México.
●
HARVEY, N (2000). La Rebelión de Chiapas. La lucha por la tierra y la democracia. Ed. ERA. México.
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RICO MONTOYA, N.A (2004). "Naciones Indias Estado Nación Autonomía Zapatista" Ensayo del tercer trimestre Maestría en Desarrollo Rural UAM-X. México.
●
SÁNCHEZ, H.J,ARANA, M, FORD, D. BRENTLIGER P, y otros, Salud y conflicto
en Chiapas: un análisis de las condiciones de salud y el uso de servicios desde
una perspectiva de los derechos humanos. Informe elaborado por Physicians for
Human Rights, Ecosur y la Defensoría del Derecho a la Salud, en prensa.
●
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de los armados de verdad y fuego Editorial Fuente Ovejuna. México, pp. 107-108.
143
15
Communication Hegemony and
Emancipatory Health:
An Underestimated Contradiction (The
Case of Dengue)
Charles L. Briggs, Clara Mantini Briggs
Health constitutes a crucial link between neoliberal political-economic
changes and their deleterious effects on the lives of most of the people on
the planet.The rise in infectious and chronic diseases associated with the growing conversion of health from human right to commodity and the withdrawal of the state from one of its classic functions—safeguarding the health of
its citizens—is a key means by which global structural changes become bodily experiences. Mainstream medicine and public health in the United States
have just begun to face the issue of "health disparities" directly, particularly after the publication of the influential report, Unequal Treatment [Smedley,
Stith, and Nelson, 2002], and the establishment within the National Institutes
of Health of a National Center on Minority Health and Health Disparities.
In Latin America, the social medicine and critical epidemiology movements have drawn attention to the dialectical relationship between health-disease and reproduction of unequal control over capital and power for more
than three decades, and they have scrutinized the effects of neoliberal policies and their structural adjustment programs on health and related sectors
[Armada, Muntaner, and Navarro, 2002; Laurel, 2000].These scholars have demonstrated how social class, gender, and race/ethnicity are not simply factors
that influence individual health outcomes but structural inequalities that sha144
pe our ability to imagine and achieve health [Breilh,
2002; Menéndez, 1981; Navarro, 1998]. Challenging the
power of "hegemonic epidemiology" to produce seemingly objective pictures of people and health, they
developed innovative quantitative and qualitative methodologies that reveal the suffering obscured by
mainstream approaches and analyze its multiple causes
[Breilh, 1994;Almeida Filho, 1989]. Finally, critical practitioners have challenged the prevailing reductionism
by examining medicine and public health as ideological
systems that transform global social inequalities into
bad individual choices [Breilh, 2002; Menéndez, 1981].
Attention to dominant ideologies seems particularly crucial. The problem here is that proponents of
social medicine and critical epidemiology in Latin America join their colleagues in North America and elsewhere in uncritically upholding ideologies that play a key
role in creating inequalities and making them seem natural—ideologies of communication. Along with critical medical anthropologists [Baer, Singer, and Susser,
1997; Farmer, 2003; Singer and Baer, 1995], progressive Latin America health scholars have shown that
health systems produce more than modes of diagnosis
and treatment—they define diseases, limit acceptable
accounts of what causes them, tell professionals and
patients alike how they should respond to disease, and
designates the knowledge possessed by some people
as scientific and authoritative and other knowledge as
superstition, ignorance, or misinformation. My goal in
this essay is to demonstrate that ideologies of communication similarly reproduce inequalities of capital and
power.
The dominant ideology of communication in
health1 pictures a linear process in which information
is generated by professionals who control the sites
where authoritative knowledge about health is produ-
ced. The productive sectors are defined in terms of
specialized training, technologies, and institutional authority as embodied in medical researchers, epidemiologists, policy makers and administrators, clinicians, and
others. These sites are not unified and homogeneous;
the "flow" of information is rather mapped according
to epistemological and institutional hierarchies. A second projected phase focuses on the translation of
this information into less technical languages and its insertion in different communicative networks. Here reporters stand in for "the public" in determining which
press releases and other sources are "newsworthy." A
parallel but distinct channel in the translation/dissemination track is pursued by health promotion departments in transforming technical information into manuals, pamphlets, materials for public presentation.This
ideology of communication then imagines a third phase that takes place as health-related information is
"transmitted" or "disseminated" to mass audiences through newspapers, magazines, radio and television
programs and advertising, and the Internet. Finally, "the
public" is assigned the role of assimilating this information cognitively, restructuring their understanding of
health in its terms, and behaviorally, turning cognition
into everyday conduct. Persons who are deemed to
fulfill this role are construed as sanitary or biomedical
citizens with [Hammonds 1999; Ong 1995; Shah 2001],
while those who are judged to fail—often no matter
what they say or do—become unsanitary subject
[Briggs with Mantini-Briggs, 2003]. Failing to adequately receive and assimilate health information can lead
to broader violations of human rights, health and otherwise [Farmer, 2003].
The standard story suggests that this process
helps overcome health disparities by making the distribution of knowledge about health more democratic,
1. I am not referring here to the field of "health communication" but to the sum total of information in society that relates to the socially constructed categories of
"health," "disease," "medicine," and "public health."
145
providing information needed to attain healthy states
even people with limited or little access to healthcare.
I argue that this linear model of communication in
health is both empirically wrongheaded and politically
misguided. Martín-Barbero (1987) suggests that we do
not live simply in societies with media but in mediated
societies, where our identities and even our concept
of society is shaped by the media. Information about
health is thus shaped by mediated concepts from the
beginning, not just when it is reinterpreted by reporters. Science studies scholars demonstrate that scientific knowledge does not exist independently from social and political life [Latour, 1993]; popular social
constructions of race, gender, class, and sexuality inform epidemiological categories and notions of causation [Haraway, 1997; Harding 1993]. My ongoing research on health and media in the United Status and
Venezuela suggests that public health institutions and
social movement organizations are increasingly guided
by media logic [Altheide, 1995], such that media specialists are part of the development of programs from
the onset, and many officials work closely with media
professionals to develop sound bites and "stay on message." Clinical visits are shaped by the images of doctors, nurses, and patients that each party brings to the
encounter, which are shaped by media images, whether
they appear in the news or soap operas. "The public"
that receives media messages actually consists of really multiple, competing publics [Calhoun, 1992], and public discourse about health actually helps create publics [Warner 2002].The CDC’s 1983 declaration that
homosexuals, hemophiliacs, heroin-users, and Haitians
were at high risk for AIDS, for example, helped separate the U.S. population into five publics—these four
and the remaining population, which was presumably
not at high risk [Epstein, 1996, Farmer, 1992].The dominant ideology also fails to take into account how individuals respond to messages and place themselves in
relationship to them—as true believers, skeptics, cri146
tics, satirists, etc.—thereby shaping the social impact
of health information.
At the same time, this ideology reproduces the
power relations that progressive public health scholars
and practitioners are attempting to challenge. Foucault
(1973) insisted that power is knowledge, and this has
perhaps never been as true as in "the information age,"
in which, some argue, information is the most valuable
commodity [Castells, 1996]. To suggest that knowledge about health is only produced in sites dominated by
health professionals (even progressive ones) bolsters
the role of science and medicine in reproducing social
inequality. It also blunts critical understandings of
health by making it more difficult to see how scientific
facts are shaped by and shape social and political-economic relations.This dominant ideology reinforces the
notion that laypersons can only assimilate knowledge
about health produced by others; when persons without specialized training attempt to position themselves as producers of knowledge about health, they are
branded as resistant, non-compliant, ignorant, or even
dangerous purveyors of misinformation. The linear
equation allocates agency to dominant institutions and
their professional employees, that is, the capacity to
create ideas, devise courses of action, carry them out,
and thereby affect the world. It is, in short, a magical
formula for disempowering communities. Moreover,
no one can adequately undertake the role assigned to
the public—reordering their cognitive universes on
the basis of exposure to a few texts, broadcasts, or public presentations and then turning this information—
point by point—into behavior.The real losers in this linear equation, of course, are the people with least access to healthcare, education, and other services; even
when they assimilate a great deal of biomedical information, they are judged to have failed [Briggs with
Mantini-Briggs, 2003; Farmer, 1992].
Finally, the news and in some countries advertisements contain more and more health content. This
saturation forms part of the privatization of health, its
transfer from a right guaranteed by the state to a commodity that it bought and sold by individuals. By accepting the ideological premise that the role of the public
is to assimilate health information, critical public health
scholars and practitioners further the health regime of
governability, that is, how people are governed by requiring them to inform themselves about health and
then make rational choices among available alternatives. The dominant ideology of communication is thus
particularly amenable to neoliberal ideologies and institutional arrangements.
to fill them. Biomedical regimes of communicability generate communicative health inequities that are linked
to but not coterminous with health disparities.
In short, the dominant ideology of communication is an obstacle to developing genuinely emancipating perspectives, practices, and policies for health.
Progressive perspectives on health are incompatible
with:
●
Ideologies that view health communication as produced by experts for consumption by "the public"
●
The notion that the state and its institutions are the
legitimate producers of truth and knowledge about
health, and that of citizens should be grateful recipients of state informational largess
●
Depoliticizing communication just as biological reductionism depoliticizes health and disease
●
The massive consolidation of media ownership by
large corporations.
●
The notion that translators (reporters, health promoters, etc.) should be subordinated to biomedical
epistemologies and professionals; such subordination curtails the potential for critically evaluating dominant biomedical perspectives and presenting alternatives
●
The idea that laypersons—and particularly members
of the communities who are most affected by health
disparities—have no role in the production of legitimate knowledge about health
Achieving Equity and Justice in Health and
Communication
Different versions of these dominant ideologies
of communication are widely shared among medical
and public health professionals, journalists, and laypersons. Communicability operates in a roughly parallel
fashion to medicalization, ideologically constructing a
separate realm of communication consisting techniques and technologies used in creating texts, broadcasts, and the like, inserting them in modes of transmissions (newspapers, television and radio stations,
the Internet), and perceiving and understanding them.
Just as biomedical frameworks deal with health, disease, the body, society, and power in oversimplified ways
in constructing health and disease as a scientific realm
that exists apart from political, cultural, and social relations, these ideologies imagine communication as a
separate domain. In spite of their lack of correspondence to how information about health travels, these
ideologies do provide the basis for what I refer to as
regimes of communicability, ideological constructions
of different positions in relationship to the health
communication, hierarchical arrangements of these
roles, and recruitment of individuals and communities
Effectively challenging hegemonic epistemologies, policies, and practices in health and confronting
health disparities thus requires combating biomedical
regimes of communicability.
My goal in this essay is to make progressive
health scholars and practitioners aware of how they
147
fall victim to these dominant ideologies of communication and to outline some alternatives. Here are some principles that may stimulate the search for ways
to counter communicative inequities in health:
●
Stimulate research that documents how information
about health is produced, circulates, and is received;
the social impact of this process; and the impact of
new social and political-economic relations and
communicative technologies
●
Treat communication as a key element in the production of knowledge in medicine and public health, not
just its dissemination
●
Explore perspectives on communication that view it
as multidirectional, with multiple sites of production
of production, circulation, and reception
●
View communication in health as an ideologically-informed political debate, one that is structured by
unequal relationships to capital and technologies, as
a struggle between competing voices and interests;
in short, as a part of any social struggle
●
Foster debates about health in sites in which power
is less centralized, such as community radio and television, alternative and "ethnic" newspapers, and
the Internet
●
Do not seek to subordinate voices within and outside medical and public health institutions to biomedical authority
●
●
Debates about health should be forums in which
multiple languages come together, avoiding the hegemony of "global languages" (particularly English),
national languages, and languages of specialists (medicine, public health)
Accord members of the populations that experience
the negative effects of health disparities the status of
148
full partners in the production, circulation, and reception of health-related information
●
Rather than becoming spokespersons for marginalized groups, join them in challenging the barriers that
exclude them from participating in public debates
about health
The last thing that I would want to do would be
to tell people around the world how they should conceive of communicative processes; particularly given
my status as a North American researcher, such a move would simply trade one kind of hegemony for another. Nor can alternatives be devised by the health and
communication professionals who have heretofore enforced regimes of communicability.What are needed, I
think, are debates taking place in a wide range of forums and settings in which barriers are exposed and
alternatives explored.To relegate these discussions to
a "communication" or "communicative equities" table
at a working conference or—even worse—to hold a
separate meeting to discussion "communication"
would simply reproduce the ideological separation of
these issues from the broader debates concerning social justice and human rights. I hope that at the very
least I have convinced you that they are one in the same.
Preventive Education in Health or
Communication Reductionism
to Maintain Inequality
In favor of obtaining a more critical and explicit
perspective of the complex nature by which the communication of graphical preventive messages are conveyed to populations, the theory exposed by Charles
Briggs throughout the paper that precedes this will be
employed. In it, the author describes how the domi-
nant ideology of communication in health is expressed
as a linear process.
Here, we will analyze how images and discourses
captured in printed graphic materials of communicative strategies of prevention of as much chronic as acute illnesses are destined to failure, on account of being
framed in the perspective of ignorant individuals,
which represent the population or public "under risk"
and project the ingenuous conscience that continues
to support the paradigm that people will never be actors of their own destiny, much less will they understand themselves as real participants in the prevention
of illnesses. This was the object of the struggle put forward by Freire (1970). Individuals are thus exposed to
biological agents, the sole causers of illnesses, due to
their behaviors filled with habits deprived of "hygiene
and moral". The illness will then take possession of
their bodies making use of the threat to pay with their
lives the irreverence of not having complied with the
instructions given by the medical authority for prevention. Hence, there is a legitimating process of scientific knowledge over what is humane, as evidenced in
Focault (1977). Medical knowledge therefore illustrates, educates, trains and saves the individual alerting
him/her on the mode of transmission of illnesses, the
way to prevent it, and finally that preventive graphical
message will indicate the redeeming medical action,
which produces the magical change in the conduct
that each one individually must implement to recover
health or remain free of illnesses, and supposedly continue with his/her life "happily" for the threat of illness
will disappear.
An entire process of medicalization, which Barros (2002) in his critical analysis considers the cause
and effect of the imposition of the hegemony of the
biomedical model of the state. It could be aggregated
here that it is the cause of the assimilation of incompetence of individuals in the preventive tasks of illnesses.
As an instance of what was rendered, we will
avail ourselves of a pamphlet enclosing messages that
tend to educate the population "in risk" on avoiding
the contagion of dengue fever by means of curative
and preventive measures. We will reveal through this
pamphlet, "How Pedrito terminated the mosquitoes",
the representation of a classic example of this alienating and linear form of communication in health: "Pedrito" characterizes all the people/public of a country
(in this case we refer to the Venezuelan people/public),
who were supposedly in risk of dengue fever contagion in 1989-90. Within this pamphlet infantilizing,
ahistorical and contradictory symbolic structures can
be observed, in its characters and narratives. Not only
the simplistic and slangy language used but also Pedrito’s garments -with a newspaper hat on his head, a
shield that is the lid of a garbage can and a sword,
which he will use to combat the gigantic mosquito that
threatens him with its enormous beak or proboscis
and its aggressive look from a rubber- communicate
the same reductionist message. Moreover, tales the
ironical behavior images of its characters in the fact
that they displace an old rubber tire from the garbage
to a middle class home setting, explicitly that the norm
of this population/public, object of the message, is the
contact with dirt at the expense of contaminating with
all kinds of germs, such as the ones that bring about
dermatological and digestive illnesses among others.
The character represents the years 36 or 40 in a rural
Venezuela, with no access to television, which not even
identifies with the figure of children at the end of the
80’s, when the outbreak of the dengue epidemic in Venezuela, and nor does it take account of the point that
the first Venezuelan official victim was from Maracay,
the capital of the Aragua State. Consequently, in view
of its scientific lexicon and formal syntax, we discerned
it implicitly embodies the hegemonic discourse of the
state, delineating its origin in the biomedical sector,
setting the standard of the medical preventive advice,
149
150
as a case in point: "an old piece of rubber at home represents a hazard to the entire family’s health" or
"When the mosquito bites you, the consequences may
be deplorable. Dengue and yellow fever can be transmitted to you…" This biomedical discourse turns explicit when it illustrates the reproductive cycle of the
mosquitoes, transmitters of filariasis, malaria, which
are illnesses that the public is supposed to be acquainted with and know how to prevent, and of course,
dengue and yellow fever, there are no other mentioned. The classic model of graphical educational strategy for prevention of illnesses is presented; it reflects
a systematized employment of biomedical reductionism of communication in health.
Thus, the dissemination of communication produced in the framework of manufactured ideologies by
the scientific supra-sphere of the ones who get to the
bottom of what is relative to the biological cause of illnesses, form of contagion, guides of treatment, life styles, and social conditions that induce the dissemination
of pathologies -by no means exempt of social stereotypes-, is transmitted directly to the public in the
centers that offer health services or dispensed personally in the communities, as a proof of the discursive
educational or preventive action of the state. Conforming to this, the workers of the health sector translate to a puerile extreme these messages exhibiting
them as the quintessence of simplification and dissemination of scientific knowledge, which turns out to be
accessible to the comprehension of the public in general, indicating the correctives the insalubrious citizen,
as described by Briggs and Martini-Briggs (2003), must
apply to reach the ideal status of a salubrious citizen.
This ideology of communication creates the inequable roles of producers, diffusers and receivers of
medical information, which places the public within an
imaginary space that neither corresponds plainly to the
wealthy social class, nor to any other sector of society.
On one side, the image of Pedrito and his mother are
not identified with the poor and rural population, due
to their denigrating and retardant features (no child or
person of the rural means would kill a mosquito with
a shield and sword), and on the other side, no mother
of middle class, without exposing herself to being classified of at least negligent, would permit her children to
play with objects collected from the garbage, which impedes the identification of the public with the characters and, even worse, it promotes the rejection of or
inattention to the message.
Continuing our analysis, we found the characters
of this story of prevention leave aside their ignorance
on assimilating passively their responsibility over the
occurrence of the illness. Without any critic, protest,
or interpretation, they just incorporate the hegemonic
word within their behavior, which then is integrated
harmonically to the effort of the state to protect the
citizen’s health in fulfillment of its function, as expressed by Charles Rosenberg (1962). This is represented
in the pamphlet through the image of an apparently regular service of garbage collection. In this manner, citizens are placed in the position of having to repay the
effort of the state with the tacit obligation to participate in the preventive strategy, as facilitators of the
medical action, according to Briceño-Leon (1998), accepting the medical authority that, in the name of the
state, determines the new forms of conduct and the living together of individuals, and has the power to decide on the organization of housing and, furthermore,
the physical situation of their bodies at a certain point
in time. This brings up Menéndez´s (1998) work in
which he questions this type of participation as another means of hegemony/ subalternation.
Finally, Pedrito and his mother are portrayed as
individuals isolated from any context, depoliticized,
who do not suffer the lack of basic services, nor do
they suffer, as documented by Armada, Montaner, and
Navarro (2002), Briggs and Farmer (1999), the effects
of neoliberal policies, the privatization of public servi151
ces. These policies are imposed by international organizations and national elites, which promote the internal budgetary cuts of countries, that sustain basic public services, enforcing an order in which the risks of
citizens are not measured, despite their living in a inequitable society saturated with psycho-social problems; a society, which responds to an inequitable distribution of the phenomena of health-illness.
152
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153
16
Despair in the Americas:
Evidences for a Psychosocial Autopsy of
Suicide during Neoliberal Dispossession
Arturo Campaña
The postmortem inquiry of the personal, family and social characteristics of suicide cases tends to be named psychological autopsy. Likewise physical autopsy, this is a cruel, painful and unpleasant resource; however it certainly helps to discover and orient around the reasons of a tragic destructive determination. The foundation is to systematize the knowledge accomplished through attentive observation, the collection of testimonies, the following of leads, completing a typology of motivations and differentiating risks
by groups, et cetera, and orchestrating measures for the reduction and control of that death cause. A similar procedure is by some means applied to the
inquiry of the reasons that took someone to be converted into the object of
homicide or other causes of violent death. Through these inquiries, referred
to individual cases, hypothesis and explanations emerge, which illustrate the
enormous complexity of suicidal behavior and the remainder violent behaviors. Interpretations cover a gamut, which range from the suspicions placed
within genetic predisposition and biochemical proclivity of the subject, pass
through considering the psychological and affective deficiencies and defects
in the individual, family and social scope of personality structuring, and arrive
at the contemplation of more direct inhuman sufferings, such as unemployment, hunger and marginalization.
154
In this context, talking about "a constellation of
factors leading to despair and loneliness" is growing to
be a current formula. We deem such a concept to be
of value within the psychosocial field, as it concerns the
idea of an assembly of one’s own determinations of different dimensions and dynamic of human life, and by
some means directs us to avoid adhesion to causal explanations supposedly integrating, but unilateral, primarily the ones which tend to reduce the social into the
monetary, and whose purpose is to base their explanations on simple numerical and statistical correlations,
among causes of violent deaths and loose socioeconomic indicators. Nevertheless, the concept of factorial
constellation conveys an analogous danger: to lighten
the weight of social determination and dim it –even
making it disappear- on privileging a multiplicity of important mediations and determinations in the analysis,
but torn apart or isolated from their relation and unity
with the general and historic development of life. The
study of human behavior and collective mental health
compels us not to lose sight of the role of old anthropological, cultural, emotional, and intellective referents
proper to peoples, at the same time that it compels us
to track attentively the modifications, displacements,
adjustments, and maladjustments of the social matrix
wherein their spiritual life develops presently.
For instance, if in Yucatán, México, a particular
"suicide culture" prevails, associated with the spiritual
importance conceded especially by women to Ixtab,
the "Mayan goddess of hanging", that cultural aspect
must be considered when interpreting the problem of
suicide and the preference of hanging among Yucatecas. However, it is insufficient to explain why within Yucatán, in such a short time, the double of the national
average rate has been reached, and why, in the same
way as Campeche, it shows a preoccupying increase of
feminine suicide between 1990 and 2001.
In addition, the famous legend of the massive suicide of the Chiapanecas in the "Sumidero" Canon, as a
collective decision to deprive themselves of life rather
than accepting the domination of Spanish conquerors,
is to be remembered and appreciated now, at the moment of interpreting why Chiapas presents the lowest
suicide rate in Mexico in 2001, and why from 1990 to
2001 it has reduced its population from 1,98 to 1,03
per hundred thousand inhabitants. Perhaps it is not
illogic to think the collectivist spirit of the masculine
and feminine Chiapanecas -who played a leading role
in one of the most salient anti-neoliberal rebellions
known in the beginning of 1990 and continuing to the
present- found motives to believe it is not the moment of the dignifying sacrifice of death against the disgrace of slavery anymore, but of collective resistance,
of the exploit of liberation, life, and hope.
The epidemiological panorama of suicide in the
period of implantation of the neoliberal model within
our countries, which we will see illustrated through a
few examples afterward, invites us to consider the
possibility that beyond the numbers that support the
rates of "human development" controlled by the agencies of the international capitalist system, and which
boast of the diminution of infant and maternal mortality, of the access to primary school, to vaccination, and
minor coverage of basic services, the model is undoubtedly aggravating the gap between proprietors
and non-proprietors, imposing unfair and prejudicial
labor conditions in health.This consequently generates
each time major unemployment and marginality, destroying communitarian solidarity networks, family liaisons, principles of education, and human values and
the social senses of orientation and identification. In
brief, this neoliberal model generates spaces of uncertainty and lack of perspectives for human groups ever
larger, if one takes into account the proportion of people who swell the band of poverty.
As indicated by a Chilean author [Camus, 1999],
these "social costs" of neoliberal progress not only
would be reflected in the increase of behaviors such as
155
delinquency, the abuse of drugs, alcoholism, corruption, but also in the elevation of others, which are less
visible and less quantifiable, such as sadness and despair, but concretized in syndromes of clear depression,
or masked by various forms of somatization. In the
word of James Petras: "what has not received serious
attention is the psychological damage inflicted on salaried and contingent workers, which is in many aspects
as grave as material loss. The interviews, testimonies,
and visits to communities reveal the mental pathologies due to unemployment, insecurity at work, and the
degradation of it. These pathologies are illustrated in
the rates of chronic depression, family ruptures, suicide, domestic violence, infant maltreatment, and increased antisocial behavior, particularly if the unemployed
are isolated or incapable of externalizing their hostility
and anger, by means of collective social action.The individual’s social and political impotence produces personal impotence, and is expressed under the form of
loss of confidence, sexual disturbances, and the inversion of anger towards the interior, which causes selfdestructive behavior.
In my opinion," Petras states, "organization and
collective action, under the form of unemployed movements, communitarian social organizations, which
demand collectively, have a positive effect not only on
the creation of new working opportunities, but from
the therapeutic viewpoint as well. Collective struggles
enhance self-esteem and personal efficacy, form solidarity, and offer a social perspective, everything which reduces anomy." [Petras, 2002]
As Petras states, "Mental health, more than a hereditary disturbance or anchored in infantile experiences, is socially determined by the relations of power,
which suggests that those who suffer mental illnesses
or depression induced by unemployment, labor insecurity, or worsening of living standard, may access cure
through adult socializing (class conscience), either by
collective organization, or social action." [Petras, 2002]
156
With the example of three American countries
of which there are reliable studies and current statistics on violent deaths in comparison to previous data,
we will examine, in the subsequent paragraphs, the variations of the epidemiological profile of mortality by
causes associated with depression and/or anguish.We
will additionally begin documenting their possible connection with conditions typical of neoliberal macroeconomic and macropolitical exercise. And finally, we
will begin to experiment our hypothesis that says that
the dynamics of present capitalism entail a psychopathogenic capacity with no precedents in history. (Refer
to Table 1).
As it is acknowledged, the rates of suicide within
American countries in the past century evidence important contrasts. However, a tendency was noticeable
of maintaining certain stability. At present, leaving aside
the case of Cuba (as this country exhibits an important
decrease in the rates of suicide, while others display an
increase, but that deserves a contextualized analysis in
the scenery generated by the rigors of the criminal imperial blockade, as well as in the transition from capitalism to socialism, inevitably painful particularly for the
proprietor classes), the majority of American countries,
subjected one way or another to the pressures exercised by the neoliberal model, have begun to show for approximately twenty-five years an unusual proliferation
of suicide. In some cases the rates are so high they incite health professionals to use the term epidemic. Let
us take notice, in Table 1, of the increments of suicide
within countries such as Uruguay, Chile, Brazil, Mexico,
Ecuador,Argentina and Costa Rica.
In the beginning of 1980, Mexico had one of the
lowest rates of suicide in the world, with 1,9 per
100.000 inhabitants.Currently, according to a recent
study [Puentes, López and Martínez, 2001], it reaches
3,72. For instance, in Chiapas a rate of only 1,03 is registered –we have already suggested that Chiapas probably illustrates the case of the protective effect of
TABLE 1
ESTIMATED SUICIDE RATES (PER 100.00 INHABITANTS) ADJUSTED BY AGE IN SELECTED
COUNTRIES, REGION OF THE AMERICAS, BEGINNING OF THE 80’S, END OF THE 90’S, AND
BEGINNING OF 2000.
COUNTRY
BEGINNING
OF
THE 80’S
END
OF THE
90’S
BEGINNING OF
FIRST DECADE
OF 2000
Argentina
Brasil
Canadá
Colombia
Costa Rica
Cuba
Chile
Ecuador
El Salvador
7.0
1.7
12.1
3.8
5.1
17.2
5.2
3.6
14.9
5.9
5.0
11.7
3.5
6.2
17.6
6.1
5.3
10.8
8.2
11.8
6.7
13.6
10.9
5.9
COUNTRY
Estados Unidos
México
Nicaragua
Panamá
Paraguay
Perú
Puerto Rico
Rep.Dominicana
Uruguay
Venezuela
BEGINNING
END BEGINNING OF
OF OF THE FIRST DECADE
THE 80’S
90’S
OF 2000
10.6
1.9
0.8 *
2.8
2.9
0.5
9.4
3.0
6.1
10.6
9.7
3.5
12.2
5.3
3.7
2.3
7.3
2.1
13.9
5.5
10.4
4.1
6.3
7.8
15.0
Source: La salud en las Américas, OPS. Edición de 2002. Las condiciones de salud en las Américas, OPS. Edición de 1990. CoreData Tabulator, PAHO. Elaboración:
Arturo Campaña. *!974
their organized struggle, with a consequent elevation of
self-esteem and reduction of anomy1 - and that in
Campeche (9,68) and Tabasco (8,47), the national mean
is practically tripled. Correspondingly, in line with data
from the INEGI, the suicide percentage compared to
the total violent deaths in the Mexican United States
during the first years of 2000, remains roughly between
7 and 8 per hundred, while in Campeche, in Yucatán,
and in Tabasco it approaches 20, 16, and 15 respectively,
which would illustrate these as depressive States.
Moreover, it is impossible not to associate the
high suicide rates of Campeche and Tabasco with the
deepening of their marginalization, after the Structural
Adjustment imposed on Mexico by the World Bank
and the International Monetary Fund, in combination
with the application of the Free Trade Treaty with
North America started in 1994. Along with Bulletin N.
244 of "Chiapas al día" (Chiapas up to date) [CIEPAC,
2001], eight out of ten of the states with greater degree of marginalization within Mexico in 2001 belong
to the South Southeast region.These states are, in descending order, Chiapas, Guerrero, Oaxaca, Veracruz,
Puebla and Yucatán, Campeche and Tabasco.
The same source affirms that the largest part of
the South Southeast inhabitants are among the 50 millions of poor people of the country; and that 83,9%
1. Anomy: lack of moral standards in a society
157
(714) of 851 municipalities (10,6 million inhabitants),
considered of high and very high marginalization, are
concentrated in the South Southeast (8 million inhabitants). Let us stress another complementary fact: although it is true in Mexico that the cause of suicide is
generally unidentified (58%), according to the National
Institute of Statistics, Geography and Computing, being
certain there must be a sub-register of suicides by
economical difficulty, in 1991 and 2002 what was attributed to this cause does not exceed the 3,8 per 100
suicides. Nevertheless, there has been a national peak
of 5,2 per 100 in 1995, and within federative organizations, known for the expansion of poverty and marginality, there have been moments of uncommon suicidal behavior –in the manner of microepidemics- for
economic reasons. In 2002, in the States of Guerrero
and Puebla, for example, a proportion of 14,8 and 7,9
per 100 suicides respectively was reached.
In Zacatecas, it was an extremely important
question, as their rates peaked at 23,5. A further relevant clue is that in 1991 the national percentage of suicides by family annoyance was 6,7, and in 2002 the
numbers rose to 10,5, with Zacatecas at the head
(35,3%), followed by Yucatán (19,5%). We believe that
this would probably express an intensification of belligerence at home, usually involving economic difficulty.
Yet, what alarms Mexican researchers the most is that
the age group with the greatest increments of suicide
between 1990 and 2001 is the one from 11 to 19
years old, in which the rate has varied from 0,8 to 2,27
girls per 100.000, and from 2,6 to 4,5 boys per
100.000, in only a decade. To examine the percentage
of deaths by suicide, in relation to the total amount of
violent deaths by 5 year age groups between 1990 and
2003, reported by the INEGI, is also extremely revealing (see table 2).
As we can see, suicide in Mexico doubled in only
twelve years with regard to the total number of violent deaths, though primarily at the expense of youn158
ger ages. Something that specifically draws our attention is the near quadruplication of this indicator within the group from 10 to 14 years old (2,4 to 9,1 per
100), and the aggravation of the problem in adolescent
and young adult girls, in whom the upsurge is more
evident: from 1,8 to 10,8 –more than five times-, and
from 8,8 to 19,4 respectively. This apparently exposes
the level of lack of motivation in life among those who
are just at the dawn of it, and the abandonment and
lack of perspective and social organization of a substantial segment of Mexican youth.
In the last few years, the case of Uruguay is perhaps the one that best allows us to analyze the demoralizing effect of the great socioeconomic crisis. Uruguay’s economy has undergone several transformations since the 1970’s, when its experience of financial
and commercial liberalization started. Like all Latin
American countries, it endures the economic crisis –as
regards the demand of payment of external debt- since 1982. Uruguay recovered and consolidated in the
beginning of the 90’s, with the integration to the MERCOSUR, and in 1995, it achieved the full devastation of
the neoliberal crisis, related to the "tequila effect" in
the region, which intensified later with the Brazilian
and Argentinean crisis, economies more directly connected to the Uruguayan.
Opposite other countries of the region, Uruguay
has been characterized in the past century by having
comparatively high rates of suicide, almost always approaching 9 or 10 per 100.000 inhabitants. In the second and third decade of the twentieth century
–which were decades of great depression worldwide,
not only economically- the rate of suicide in Uruguay
surmounted 12 cases per 100.000 inhabitants, stabilizing again at about 10, and lowering to 8,8 in 1988.
Subsequently, it experienced a sustained escalation after 1992 until the present, when numbers reached as
high as 16 per 100.000 in 1998, 15 per 100.000 in 2001
[Dajas, 2002], and a dramatic 21,7 in 2002 [Montalbán,
TABLE 2
PERCENTAGE OF DEATHS BY SUICIDE,WITH RESPECT TO THE TOTAL NUMBER
OF VIOLENT DEATHS, BY GENDER AND 5 YEAR AGE GROUPS, MEXICO,
1999-2003
1990
2003
Total
10 a 14 años
15 a 19 años
20 a 24 años
3.9
2.4
5.6
5.0
7.8
9.1
12.9
12.7
Boys
10 a 14 años
15 a 19 años
20 a 24 años
4.1
2.7
5.0
4.9
8.2
8.4
11.3
12.4
Girls
10 a 14 años
15 a 19 años
20 a 24 años
3.1
1.8
8.8
5.7
6.4
10.8
19.4
13.9
SEX
AGE GROUPS
Source: INEGI. Elaboración: Arturo Campaña
2004]. In essence, Uruguay is facing the triplication of
its rate, already excessively high, in only a decade.
The observation of Dajas is equally important, in
the sense that between 1975 and 1996 the initially low
proportion of Montevideans (2,5 per 100.000 versus
15,0 per 100.000) in the determination of the total rates of suicide had increased so critically, that the difference with rural people tends practically to disappear
(in 1996 the rate within Montevideans increases to
11,3, and the one of rural people is about 14,0 per
100.000). How to explain this marked increment of
suicidal behavior of people from Montevideo, traditio-
nally less affected by self-destruction, in only two decades? As indicated by the experts in Uruguayan economy, poverty is more intense in the country, but there are recent regional changes that may not be ignored;
and they point out that albeit being in Montevideo in
1991 implied a decrease in probability of being deprived; conversely, in 1997 it implied an increase in the
probability of being in the stratum of privation.They remark that since 1991 wage inequality and the access to
goods and services of education, health, and inclusively
basic infrastructure worsened and peaked at their most
critical level in the last year of this study. The following
159
TABLE 3
INCIDENCE OF POVERTY IN URUGUAY AND MONTEVIDEO
TOTAL AND IN YOUNG AGES, 1999 AND 2003
YEAR
GROUP
1999
2003
URUGUAY (%)
MONTEVIDEO (%)
Total
15,3
15,0
Younger than 6 years old
32,5
30,9
From 6 to 12 years old
28,3
26,7
22,7
20,6
Total
30,9
31,8
Younger than 6 years old
56,5
58,2
50,2
49,4
42,7
41,3
Fuente: INE, Uruguay. Estimaciones de pobreza por el método de ingreso1999 a 2003. Resumen de la tabla, Arturo Campaña.
table illustrates, additionally, the striking fall of Uruguayans into the pit of poverty from 1999 (15 of each 100
people) to 2003 (31 of each 100), (see table 3).
With reference to the exclusion of urban settlements and the agony of the open and integrationist
multi-class district, which was common in urban spaces, such as Montevideo and Maldonado (whose
growth rates, compared to the national mean of 6,4
per 1.000 between 1985 and 1996, had shot up over
25 per 1.000 annually), it is noticeable that in the existing settlements disintegrated families predominate.
These families tend to be marginalized from culture,
160
and have a prevailing composition of children and adolescents who refuse formal education even if it is gratuitous.
It is literally said that, "Montevidean society is
highly hierarchical. The extremes of richness and poverty have been transformed into impervious ghettos.
Distances among those who find their way within the
formal system and those who have fallen from it, or
never reached it, are very extensive and still on the rise. The risks of violence (delinquency is simply a
symptom) augment each day. Marginalization, scarce
ascendant mobility in the social and economic realm,
TABLE 4
DISTRIBUTION OF THE RATE OF SUICIDES PER 100.000 INHABITANTS,
BY SELECTED AGE GROUPS, URUGUAY 1985 AND 1996
GROUPYEAR
15-19 Y
20-24 Y
25-29 Y
30-34 Y
35-39 Y
40-44 Y
45-49 Y
50-54 Y
1985
2,3
7,0
8,5
9,0
11,0
15,5
11,0
13,0
1996
10,0
13,0
14,0
15,0
9,0
21,0
8,5
24,0
Source: Dajas, F. Alta tasa de suicidio en Uruguay. Rev. Med. Uruguay; 17:28. Figura 5. Elaboración A. Campaña.
and the sense of non-belonging in the system are in
due course the principal enemies of democracy and
pacific living together" .
Dajas’ acute observation permits him to underline other crucial modifications in the current suicide
profile of Uruguayans. For example, the proliferation of
suicides as much in women as in men, though with
masculine preeminence, and for the most part among
young ages and people over 70. And even if Daja is
tempted to explain this phenomenon as a World
trend of suicide, we think that in the case of Uruguay
it specifically corresponds to the accelerated changes
in the social profile of the Uruguayan people, due to
the direct impact of what has been called the "crisis of
the South Cone countries", were economy became in
the last years directly dependent of inequitable World
market relations, and on the economic fluctuations of
Brazil and Argentina; neighbors also fully immersed in
the neoliberal experiment. Unfortunately, we can not
look at the picture of critical recent years, due to the
lack of updated data.(see table 4 ).
Note the changes in the 15 to 19 group of age
(it almost quintupled in a decade), and in the three following groups (the tendency to double their rates).
Excepting the groups from 35 to 39 years old, and the
one from 45 to 49, in which the statistics were lower
in 1996, all groups have perceptible increases, in particular the last, whose rate has virtually doubled. Let
us observe in the following table the absolute number
of suicides, by age and gender (see table 5).
Looking at this table, we can verify the significant
increase of suicides in males within the four younger
groups, and the increase of suicides in females, which
is additionally worrisomethough it is consistently surpassed by men, in all the age groups, with the exception of the group from 35 to 39 years, in which the
number diminished. Dajas is right when he questions
himself about the increment within mature men between 40 and 50, and its association with the anguish of
unemployment. If we observe the evolution of the rate of Uruguayan unemployment, we notice a minimum
unemployment rate of 7% in 1981, which rapidly rises
to 15,4% in 1983, and gradually decreases until it arrives at 9% from 1987 to 1994.Then, in view of the impossibility to include in the services sector the unemployed of industry and the generation of unemployment within the services sector itself, as a consequence of the low internal and Argentinean demand -asso161
TABLE 5
DISTRIBUTION OF THE NUMBER OF SUICIDES, BY SELECTED AGE GROUPS, IN WOMEN
AND MEN, URUGUAY 1990 AND 199
GROUP YEAR
1990
1998
15-19 Y
20-24 Y
25-29 Y
30-34 Y
35-39 Y
40-44 Y
45-49 Y
50-54 Y
M
16
23
19
16
20
20
19
21
F
2
6
5
4
7
8
5
5
M
25
24
39
31
17
35
35
29
F
3
11
9
6
4
14
11
6
Source: Dajas, F. Alta tasa de suicidio en Uruguay. Rev. Med. Uruguay; 17:27. Figura 4. Elaboración A. Campaña.
ciated to the Mexican crisis- it recommences its ascension, approaching 11,5% in 1995 [Spremolla, 2001].
Recently, with the South Cone crisis it has climbed to
13,6% in 2000, and a dramatic 18,6% in 2003.
Considering that the rate of suicide in the age
group of 15 to 19 years has increased from 2,6 in 1985
to 9,9 per 100.000 in 1996, as indicated by a digital
supplement of Diario El País in May of 2004 [Szalmian,
2004], we support [Dajas, 2002] and other authors are
correct to advocate the need for family affectionate
support as an ultimate originator of the psychological
and suicidal behavior within adolescents and young
people. In addition, this quantitative evidences must
be related to process of fast impoverishment and social privation, that Uruguayan families experienced during the last decades, all which evolved into a diminishing capacity to provide for the necessary social and
emotional stability that children and adolescents require for their mental development. Returning to Table 3, we can see the affects that poverty has from
1999 to 2003, within the three youngest groups, as it
moved from values of roughly 30 per 100 to 57 in the
group of younger than six years old; to 50, in the group
162
from six to twelve; and to 43, in the group from thirteen to seventeen.
It is not in vain to point out that according to data from the National Institute of Statistics, the number
of divorces registered increased from 4.611 in 1987, a
year before the beginning of a long economic recession, to 9.800 in 1991. This number had an important
decrease, though not under 5.700 until 1997, a year in
which poverty involved already 23,9% of the Uruguayans and statistics radically increased to 8.347 divorces, and in 2001 and 2002, the number of divorces was
7.409 and 6.761 respectively [INEC, 1987-2002].
Overlooking the most appalling years, this signifies that
divorces increased by 46,6% in Uruguay between 1987
and 2002 despite the fact that there were departments, such as Maldonado, where a number of divorces increased by 158% in 2002, compared to 1987. Let
us remember that Maldonado’s population shifted
from 13,1% poor people in 2000 to 27% poor people
in 2002, as a result of the Argentinean debacle and the
reduction of tourists.
Let us now look at the Ecuadorian situation. This
country rich in petroleum and resources, such as sh-
rimp, banana and flowers, in the last years of the 1990’s
fell into the deepest part of its economic crisis, corresponding to the period of structural adjustment policies initiated in 1982.
In addition to the accumulation of problems produced by the payment of the external debt (by 1999,
nearly 16.000 million dollars), we must add the expenditures due to the armed conflict of 1995 with Peru,
the damages caused by the El Niño Phenomenon in
1998 within its provinces of the Pacific Coast, the massive corruption of state resource use by successive administrations, and the devastating effect of the international financial crisis, which lead to the freezing of deposits, incontrollable inflation, monetary depreciation,
capital flight, bankruptcy in banks, productive stagnation, and to the imposition of the dollarized system. In
such circumstances, the deterioration of wages, unemployment, poverty, marginalization, and social inequities severely increased to astonishing levels. Unemployment, which had remained for a long time at
roughly 8% of the labor force, increased to 17% in
1999.After finally rising and dropping, it established itself at approximately 12%. Nevertheless, experts recommend us not to overlook the fact that since 1998,
not less than a million Ecuadorians of working age migrated. Thus, the reductions in the rate of unemployment are certainly not a product of the reactivation of
the economic apparatus [Acosta, López Olivares & Villamar, 2004]. In reference to the most conservative
calculations, the average national poverty has increased from 56% in 1995 to nearly 65% in 2002. However, there are rural areas where poverty afflicts more
than 90% of the population. In brief, the country
struggles in the middle of the uncertainties created by
a strategy of economic stabilization and recovery,
which is seemingly sustained by a few precarious factors, for instance the international high cost of petroleum and the volume, still elevated, of the migrants’ remittances.
Table 6 reveals that Ecuador’s national rate of
suicide increased from 2,8 to 4,6 per 100.000 between
1980 and 2002. Actually, between 1980 and 1996, with
the exception of the Amazonic Province of Napo, in
which the rate had a minimum diminution, all the other provinces display weighty upsurges. The dramatic
increase in Carchi, the frontier province with Colombia, draws our attention. After being the one with
nearly non-existent suicide (0,7 per 100.000) in 1980,
it underwent an increase of almost twenty-one times
and consequently reached the highest value of the
country (14,5 per 100.000) in 1996. And further, it
continued (10,1 per 100.000) within the group of provinces to reach even higher suicide rates in 2002.
Though on a lower scale, another province that
presents a notable increment in the suicide rate is Bolivar. It reached 6,8 per 100.000, eleven times greater
in 1996 than in 1980, maintaining a definitely high rate
of 6,2 in 2002. The comparison of 1996 and 2002 rates presents ten provinces tending towards reduction,
and eight tending to an increase of suicides.Among the
ones with increasing tendency, the case of Cañar and
Zamora Chinchipe are impressive. The first is a province with a high degree of migration, redoubled even
more by the 2000 crisis. It has passed from 5,8 suicides per 100.000 to 10,2 in 2002; the second is an Amazonic province, which has elevated its rate from 4,4 to
11,1 in only six years. Taken from 2002 data, three
groups clearly differentiated by provinces are taking
shape. The one with rate lower than 4 per 100.000:
Galápagos, El Oro, Guayas, Los Ríos and Pichincha. The
group with an intermediate rate, from 4 to 8 per
100.000: Manabí, Imbabura, Loja, Sucumbios, Chimborazo, Bolívar, Pastaza, Cotopaxi, Azuay,Tungurahua and
Napo. And the group with the most elevated rate, 8
per 100.000: Esmeraldas, Morona Santiago, Orellana,
Carchi, Cañar and Zamora Chinchipe (table 6).
Thus, all the arguments and information we have
established along these pages subtitled Evidence for a
163
psychosocial autopsy of suicide during neoliberal dispossession, were aimed at highlighting the need for
scientific work which systematizes and clarifies the accumulating evidences of varied impacts of our social
system over our collective mental health and over the
psychological condition of "disinherited" peoples and
individuals. Also we wanted to emphasize the need to
activate a participative construction of awareness, and
a form of political organization and action that really
opposes this societal model, based on inequity and exclusion, which permanently reproduce mental pathology.
TABLE 6
SUICIDE RATES IN ECUADOR, BY PROVINCES. YEARS 1980, 1996 AND 2002
TOTAL COUNTRY
CARCHI
IMBABURA
PICHINCHA
COTOPAXI
TUNGURAHUA
BOLIVAR
CHIMBORAZO
CAÑAR
AZUAY
LOJA
ESMERALDAS
MANABI
LOS RIOS
GUAYAS
EL ORO
SUCUMBIOS
ORELLANA
NAPO
PASTAZA
MORONA SAN
ZAMORA CH
GALÁPAGOS
R/100.000
1980
R/100.000
1996
2,8
0,7
1,9
3,5
2,5
3,6
0,6
3,7
2,8
2,5
1,5
2,2
1,9
3,7
3,4
2,2
14,5
7,4
4,9
7,0
6,2
6,8
6,9
5,8
6,1
3,6
5,0
5,3
7,3
3,7
2,9
6,5
0,0
2,8
0,0
0,0
6,3
5,4
4,4
R/100.000
2002
4,6
10,1
4,5
3,7
6,4
6,8
6,2
6,0
10,2
6,4
5,5
9,5
4,4
3,1
2,9
2,7
5,9
9,9
7,2
6,2
9,8
11,1
0,0
Fuente: INEC, Ecuador. Anuarios de estadísticas vitales 1980, 1996 y 2002. Elaboración: Arturo Campaña.
164
Increment times
80/96
Increment times
96/02
20,7
3,9
1,4
2,8
1,7
11,3
1,9
2,1
2,4
2,4
2,3
2,8
2,0
1,1
1,3
0.7
0,6
0,6
0,9
1,1
0,9
0,9
1,8
1,05
1,5
1,9
0,8
0,4
0,8
0,9
0,97
5,4
1,14
1,15
4,4
2,5
REFERENCES
●
ACOSTA ALBERTO, LÓPEZ OLIVARES SUSANA Y VILLAMAR
DAVID (2004). Oportunidades y amenazas económicas de la
emigración (IV). La Insignia, 27 Agosto.
● ANDREA
SZALMIAN (2004). La tragedia escondida. El País Digital., Internet Año 9 – Nº 2826, Montevideo Uruguay. Sábado 1 de
mayo.
●
CAMUS ALBORNOZ GUILLERMO (1999). El suicidio como una
forma de violencia societal. Ponencia presentada al XXII Congreso ALAS. Octubre.
●
DAJAS, FEDERICO (2001).Alta tasa de suicidio en Uruguay, IV: La
situación epidemiológica actual. Rev. Méd. Uruguay; 17:24-32
●
DAJAS, FEDERICO (2002). Suicidio en Uruguay: el último incremento y la continua insensibilidad de las autoridades de salud.
Carta al Consejo Editorial . Revista de Psiquiatría del Uruguay.
Vol. 66 Nº2, Diciembre, página 164.
●
INEC: Divorcios por año de registro, según departamento donde
se dictó la sentencia, años 1987-2002.
●
MONTALBÁN, ARIEL (2004). El suicidio: la urgencia de un grave
problema. Rev. Méd. Uruguay; 20:91
●
Opiniones. Una sociedad fracturada. Comentarios al libro Desigualdades sociales en Uruguay, de Danilo Veiga y Ana Laura Rivoir
publicado por el Departamento de Sociología de la Facultad de
Ciencias Sociales de la Universidad de la República. http://www.uc.org.uy/opi0504.htm
●
PETRAS, JAMES (2002). Neoliberalismo, resistencia popular y salud mental. Los perversos efectos psicológicos del capitalismo
salvaje. Rebelión, La página de Petras, 20 de diciembre.
●
PUENTES-ROSAS ESTEBAN; LÓPEZ NIETO LEOPOLDO; MARTÍNEZ MONROY TANIA (2004). La mortalidad por suicidios:
México 1990-2001. Rev Panamericana Salud Pública vol.16 n° 2
Washington Aug.
●
ROSSI, MÁXIMO Y ROSSI,TATIANA. Privación y pobreza en Uruguay (1989-97)
●
SPREMOLLA,ALESSANDRA (2001). Persistencia en el desempleo
de Uruguay. Cuad. econ., abr. 2001, vol.38, no.113, p.73-89. ISSN
0717-6821.
165
Biodiversity:
Destruction
and Monopoly
17
Control over Nourishment:
The Case of Transgenic Food
Elizabeth Bravo
Introduction
Large transnational corporations assisted by their governments aspire to
gain each time there is a greater control over the agricultural productive system
and the production of foods in the world, starting from the control over seeds,
and arriving ultimately at the table of the final consumer. In this scenario, transgenic cultures play a major role.
Throughout the world, transgenic seeds are promoted as a technology that
is here to stay. It is adduced that only transgenic food will aid in the alleviation
of the hunger problems "of the increasing poor population of the world".
Actually, it is worth questioning ourselves on the interests behind the promotion of transgenic seeds throughout the world; if these are in fact the necessities of the poor, or the necessity of accumulation of transnational companies.
To attempt answering this question, we will use transgenic soy as an example.
Who Profits from the Business of Transgenic Soy?
The world market of transgenic soy seeds (RR soy) is the monopoly of a
sole company, Monsanto. It commercializes seeds resistant to Roundup, a Monsanto product whose active ingredient is glyphosate.Monsanto is the second lar167
gest seed supplier in the world, the third largest seller
of agrochemicals, and the produces the most amount
of transgenic seeds in the world (it controls 90% of
this market). In 2001, it reached a total of US 5.500
million dollars, of which US 1.700 millions were on account of seeds, and US 3.760 millions for agrochemicals, being herbicide gliphosate its number one (or
top)product.
RR soy is a variety into which a "genetic cassette" has been inserted that contains the gene of resistance to the glyphosate herbicide (RR gene), originated from an organism to which it is not related genetically, and thus with which it would never be able to
interchange genes. The cassette of insertion includes
a series of DNA sequences (derived from virus, bacteria that are genetic parasites), which permit soy to accept these strange genes. The entire "insertion cassette" is patented. The RR genes are the property of
Monsanto.
These patented genes do not endow seeds with
superior productivity; they exclusively convert agriculturists to? dependents of a model of weed control that
intensively uses herbicide.
Independently of who sells the RR soy seeds,
Monsanto charges the royalties for the use of "its genes".
detergents and chemicals. They control 43% of Brazil’s
oil and 80% of the European Union; the three NorthAmerican companies control 75% of the soy market
within their country. Indistinctively of who produces
the soy, these four companies are the ones, which in
fact profit from the soy business.
ADM is the most important receivers of corporate subsidies in the recent history of the United States. At least 43% of ADM’s annual earnings refer to
products that are strongly subsidized, or protected by
the United States government. Additionally, each US$
1 collected for ADM´s operation of corn sweetener,
costs consumers US$ 10, and each US$ 1 of profit gained by the ethanol operation costs tax payers US$ 30.
Bunge constitutes the major processor of soy oil
globally. It is the leading company in the South Cone
and has important interests in North America and Europe. Moreover, they are the largest importers of
commodities related to soy within Asia, and the main
purveyors of powder throughout the Middle East.
Bunge purchases, processes, and sells human and animal nourishing products for domestic markets or exportation, as well as grains and seeds.
Cargill has its own control over the nourishing
chain, with operations in 23 countries. This company
manages 40% of all the corn exports in the United States, 33% of the soy exports, and 20% of the wheat exports.
Commercialization of Soy
88% of the soy commercialized worldwide is utilized in the production of oil. With the residuals, soy
paste is manufactured, and used as forage. 25% of comestible oil emanates from soy. Four companies dominate the world’s soy market. Three are from the
United States: ADM, Bunge and Cargill. The fourth
company is French, Louis Dreyfuss. These companies
purchase soy to sell oil and powder to producers of
animal food and fodder, and to companies that make
168
The Beef Market in Europe
The European Union, with 36.9 million tons of
soy per year, is the first worldwide importer. Its principal use is as cattle feed. It is possible to foresee that
in coming years the consumption of soy within Europe will increase. The production of soy as a food source will rise 4.6% annually during the next 15 years. According to recent industry data, by the year 2011 the
production of soy could reach the 260 million metric
tons, which represent 33% more than current production.
The meat slaughter and processing sector is suffering an accelerated process of concentration within
the European Union. In several countries, the number
of abattoirs decreases year by year. Instead of small
local abattoirs, large processing plants exist, which frequently establish direct agreements with producers.
For instance, in the United Kingdom, the number of
abattoirs reduced from 1.671 in 1971 to 436 in 1994.
The number of processing plants presently happens to
be much smaller. This is, to some extent, due to the
fact that large processors are able to comply with European standards in this field. This confirms a concentration within the sector, which will continue to proliferate.
The ten greatest companies in the beef business
in Europe are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Arcadie-Bigard - France
Socopa - France
Anglo-Irish Food Processors - Ireland/England
Südfleisch - Germany
Dawn Meats - Ireland/England
INALCA - Italy
Danish Crown - Denmark
Moksel - Germany
Kepak - Ireland/England
SVA - France
(Holland/England), the third worldwide, with sales of
25.670 million dollars in 2002.
The commercialization of meat throughout Europe processed or not, is in the hands of large supermarket or retailer chains. These companies attempt to
create their own brands, and increase their monopoly
in the sector, by means of establishing direct contracts
with processing plants and cattle ranchers. The largest
are:
COMPANY /
COUNTRY
SALES IN 2000
In millions of dollars
Carrefour - Francia
59,888
Ahold -Holanda
49,000
Metro - Alemania
43,371
Rewe - Alemania
34,854
Edeka - Alemania
28,894
ITM - Francia
24,894
Source: ETC Group. 2001.
Other Benefited Companies
Source: Nielsen y Jeppesen, 2001
Subsequently, large European nourishing corporations process most of the world’s meat. The most
prominent are Nestlé (Switzerland), the largest worldwide in the field of foods processing, with sales of
roughly 54.254 million dollars in 2002, and Unilevel
Other focal sectors are companies that have specialized in the investment of risk capitals. These may go
into bankruptcy, or obtain extremely large profit from
their investments. Some have penetrated the field of
biotechnology, among them the 3i Group plc, Lloyds
TSB Development Capital Ltd from England, and Midlands Venture Fund Managers Ltd from England.
169
An additional sector is dedicated to advising or
operating as "brokers" for agrochemical and biotechnical companies, among them include:
●
Credit Suisse First Boston, which has been advisor
to Aztra Zeneca and DuPont. It operated as a broker for Rhone-Poulenc and the fusion of Hoechst
with Aventis.
●
Deutsche Bank has been advisor to AksoNobel
when Hoechst, its subsidiary, to Rhone-Poulenc.
●
Morgan Stanley Dean Witter & Co is Dupont’s broker.
All these companies profit, one way or the other,
from the world commerce of transgenic soy.
Meanwhile,What Happens
Within Producer Countries?
United States is the world’s leading soy producer (it produces 35% of the soy in the world), followed by Brazil (27%), Argentina (17%), China (9%, all
for national consumption), Paraguay and India (2%),
and Bolivia (1%). As a region, the South Cone is the
most important zone for soy production
Concerning exports, Brazil is the world leader;
it occupies 31% of the world market, the United States, 29% and Argentina, 28%.
There are three models of soy production in the
South Cone:
●
With a plow and rotation of cultures (for instance,
the sorghum, corn, and soy), with or without seeds
genetically modified. When irrigation is needed, it
can be rotated with cotton. This model is practiced
in some places of Argentina.
170
●
Direct sowing, without transgenic seeds; the residuals of the culture are given to cattle. This model
is practiced in the Central West zone of Brazil. An
abundant use of herbicides is required.
●
Direct sowing, with seeds tolerant to glyphosate
(Monsanto RR soy).Two campaigns of soy are made
annually.
Since the 70’s, the Southern Cone has undergone a process of expansion in soy culture, especially in
Brazil, Argentina, Paraguay, and Bolivia, with very high
associated environmental costs. Between 1970 and
1980, the Mata Atlántica in Brazil has practically disappeared, and at the moment there is an attempt on the
Paraguayan ecosystem. The Chiquitano forests, the
Yungas, the Pantanal, the Cerrado, and the Amazonic
jungle have been affected by making way for soy plantations, in order to feed European cattle and benefit
the four companies, which control the soy world market.
Since a significant increase in the consumption
of meat within Europe is predictable, large extensions
for the expansion of this culture will be required. After the analysis of the zones where the most apt soils
exist, the more adequate legislation and sufficient infrastructure, the South Cone, has been appointed as
the ideal region for soy expansion.
Next, there is a summary of the areas that have
been occupied by soy fields in the South Cone, and
the ones that may be affected in the future (see table
in this page).
The underlying principle of the project of the Hidrovía (water highway) Paraná-Paraguay is the rapid
and economical access of commodities to the port for
their exportation, mainly soy.
The investments, in this case, are not made by
private capital, but by governments, which share this
project (Argentina, Brazil, Paraguay, Uruguay, and Boli-
COUNTRY
PRODUCER WORLDWIDE
AFFECTED AREAS
(ha)
PROGRAMMED AREAS
FOR THE EXPANSION
OF SOY (ha.)
1st exporter
2nd producer.
It produces 27% of the world production.
21 millions in "Cerrado", 70 y 100 millions, of which,
tropical forests and Mata between 30 and 40 millions
Atlántica, Pantanal, Caatinga. of ha could be of "Cerrado"
and 7 millions in tropical
forests.
ARGENTINA 3rd. It produces 17% of the world
production. The 98% of planted
soy is genetically modified.
14,3 millions in Humid 25 millions in Humid Pampa,
Pampa,Yungas and Chaco
Yungas and Chaco
PARAGUAY
4th. It produces 2% of the world
production. 80% RR soy
1.750.000 in Pantanal, Mata 3.500.000 in Pantanal, Mata
Atlántica and Chaco.
Atlántica and Chaco.
BOLIVIA
7th. It produces 1% of the world
production. Free of GMO
600.000 in tropical forest
BRAZIL
1.200.000 in tropical forest
and Chaco
Fuente WWF, 2004
via). To ameliorate the navigation conditions, governments have to start with construction sites for river
basin dredging, to change the course of rivers, and correct and stabilize navigation channels.Then they must
post signs and mark with buoys to permit the flux of
convoys with a minimum depth of 10 feet, 350 meters
of length, and 60 meters of beam, during the 24 hours,
365 days of the year.
It is calculated that 48% of the use of the waterway ("hidrovía") will be dedicated to the transport of
grains and fertilizers. Along the Paraná River soy processing plants have been settled, to a large extent; controlled by the companies mentioned earlier.
The Impact on Productive Systems
The expansion of soy in Argentina has ousted other cultures, such as rice, corn, sunflower, and wheat;
and it has driven other activities to marginal areas.
Since 1988, there has been a diminution of productive
units of 24.5%. Farms have disappeared; 103.400.
Thousands of families migrate each year from the
countryside to the urban peripheries.
The number of "tambos" (productive units dedicated to cattle raising) has also decreased, from 30.141
in 1988, there were only 15.000 left in 2003. Hence,
protein obtained from meat has been substituted
171
compulsively for products derived from soy. Direct
planting uses very little labor, which has generated major rural unemployment within soy zones.
Agronomic Problems
Throughout Argentina, the use of glyphosate has
increased since RR soy was adopted. In the campaign
1991/1992, 1 million liters of glyphosate were utilized.
In 1998/1999 roughly 60 million liters were consumed.
At present, it is estimated that 70 million liters are expended, which is an average 2 liters of glyphosate per
inhabitant.
The profuse use of a sole type of herbicide is
provoking changes in the underbrush communities,
not only numerically, but also primarily for the appearance of certain species uncommon to these systems.
Additionally, the development of several species of underbrush tolerant to glyphosate has been detected,
which forces the farmers to use stronger herbicides.
Inclusively during fallowing, the soy that sprouts is considered underbrush, and is controlled via herbicides
more powerful than gliphosate.
The practice of direct sowing of soy has caused
common invertebrates to turn into plagues. Moreover, during the campaign of 2000/2001 the rust of soy
seriously affected the soy cultures in the Northwest of
Argentina.
The varieties of soy tolerant to herbicide have an
average yield of 2.4% less than conventional varieties.
For this reason, it has been difficult for companies to convert it into merchandise, since the seed is a
living organism that may reproduce, different from other products, and this makes its monopolized control
very complicated. In view of that, two associated mechanisms have been created: technological changes in
phyto-improvement / phyto-remediation (through the
development of hybrids and the GMO’s); and the imposition of the right of intellectual property.
In the United States, vegetal varieties may be
protected either by means of the rights of breeders,
or by patents. Although, in 1985 the patents office of
the USA broadened the scope of protection of patents
to include plants and non-human animals, including
seeds, plants, parts of plants, genes, genetic characteristics, and biotechnological processes. At present, it
seeks the expansion of the scope of intellectual property in the rest of the world, through the free trade
treaties.
In the subject of patents, the United States wants
the following to be acknowledged:
●
about plants
●
animals
●
essentially biological processes
●
genetic sequences and the material contained in those sequences
Impacts Of Intellectual Property On The
Commerce Of Soy Within The South Cone
The Rights of Intellectual Property
Traditionally farmers have had at their disposal
the seeds that they use in their fields, which they purchase, interchange, or inherit them from their ancestors; afterward they store them for the next harvest.
172
Despite the extremely high profit made by Monsanto at the expense of Argentinean agriculture, this
company has put pressure on that country in order
that a system of payment for the royalties of RR soy
seeds is established.
Within that country, the right of intellectual property over seeds is exercised through the right of breeders. According to the law, farmers may store seeds
protected by the right of intellectual property to resow their lands. Albeit the interchange of those seeds
with other farmers is not allowed, in practice this cannot be controlled. And further, with soy cultivation, it
is very easy to keep the seeds to plant them again the
next year. Farmers consider this form of practice normal, since they already paid for the seed once.
Although Monsanto introduced the RR soy under this law, it believes this form of practice "deprives
the company from its legitimate profit". Statistics of
the 2003-2004 harvest demonstrate that farmers paid
US 75 million dollars for royalties (which correspond
to 18% of the 14 million ha sowed with soy RR). It is
calculated that if all the seeds sold were certified, this
value would have risen to US 400 million dollars.
At first, Monsanto, in Argentina, was not charging
for seed royalties; it resided in the selling of herbicide
Roundup. However, the patent of glyphosate already
expired and the majority of Argentinean "soyeros" import glyphosate from China, where it is much cheaper.
Is the business of Monsanto through in Argentina? By no means; at the moment Monsanto intends to
charge for a patent not registered in the country, but
certainly registered in other countries to which Argentinean soy is exported, at the time of the commercializing of grains where RR soy is patented.
Monsanto has never patented RR soy within the
country and the company is not in the position to impose this patent to Argentina if it can impede the import of RR soy throughout those countries where it
has indeed registered this patent.
The proposal of Monsanto is that producers pay
when they sell their harvest, including the products
derived from soy, such as oil. Exporters would operate as retention agents for the biotechnological company. Initially, the sum will approach 2% per each ton
exported; this quantity will possibly increase to 3%.
In spite of the plan not being definitive, as Monsanto continues to negotiate with the government and
the organizations of producers, they mean to implement at once a system of charging royalties for the
campaign 2004-2005. If the propositions exposed do
not make progress, Monsanto is determined to sell
Soy exportation licenses.
For every dollar/ton paid on account of royalties
for soy exports in Argentina the multinational will receive US 34 million dollars annually (without farmers
having purchased seeds from Monsanto).
Regardless of the fact that Monsanto used Argentina as a launching platform for the production of
transgenic soy, and this country is an excellent client
for the company, Argentinean farmers complain that
Monsanto demanded payment in dollars for the seeds
and agrochemicals sold at the end of monetary convertibility. When the importation of glyphosate from
China initiated, Monsanto pressured Argentina to
grant them a privileged treatment pertaining to tariffs.
Analogous treatments have been applied to producers in Brazil and Paraguay. Once legalized, RR soy
cultures planted clandestinely throughout Brazil with
the endorsement of Monsanto in 2003, the "soyeros"
paid the royalties, R$ 10/ton. In 2004, the royalties
doubled to R$ 20/ton. In Paraguay, illegal cultures were legalized as well. In line with an agreement signed
by soy producers, seed producers, cooperatives and
exporters, presented to the Department of Agriculture for approval, the producers initially will pay Monsanto $ 3 per each metric ton of soy. After 5 years, the
rate would increment to $ 6/ton.
On the other hand, biotechnological companies
require varieties adapted to the conditions of the
country, to insert the patented transgenes in them.
With this purpose, they have accessed the genetic material generated by public research programs, and expect to continue having free access to this material.
173
Conclusions
Far from nourishing the poor of the world, agrobiotechnology emerges as an activity designed to increment the profit of large transnational biotechnological corporations, through the processing, distribution, and selling of foods, and through other companies
involved in the nourishing chain.
The aggressive expansion of agro-biotechnology
has been facilitated due to the pressure exercised by
the Government of the United States, with the intention that countries adopt laws on intellectual property,
investments, and sign free trade treaties, which comply
with the interests of their companies. All this is performed with the aid of the impositions of the Interna-
174
tional Monetary Fund and the World Bank, which compel us to use our best lands in exportation cultures,
and to import foods from these transnational corporations.
Independently of who produces commodities,
such as transgenic soy, it is only a handful of companies
that profit from this. Producer countries are left with
their lands destroyed and contaminated, and its social
texture shattered.
The defense of nourishing sovereignty is an unavoidable responsibility to confront this aggression. To
think first in local and national production, in the satisfaction of our nourishing and cultural necessities, with
the use of a technology we may control, are some of
the indispensable elements to achieve this objective.
REFERENCES
● AGÊNCIA
CARTA MAIOR (2003). 6/11/2003
● AGROLINK
(2003). Internet, 5-5-03
●
ECONOMIC RESEARCH SERVICE (2004). Sitio web accesado
en octubre.
●
EUROPE ACADEMIES (2004). Science Advisory Council Genomics and Crop Plant Science in Europe. May.
●
GAZETA MERCANTIL (2004). Monsanto dobra valor de royalties. 02/09/2004
●
GRUPO ETC (2003). Oligopolio, S.A. Concentración del poder
corporativo. Comuniqué 82.
●
JOENSEN, L. SEMINO, S (2004). Grupo de Reflexión Rural. Estudio de caso sobre el impacto de la soja RR. Grupo de Reflexión Rural.
●
KING, J. HEISEY, P (2003). Ag Biotech Patents: Who is Doing
What? Amber Waves. The Economics of Food, Farming Natural
Resources, and Rural America. USDA.
●
NIELSEN, N.A., JEPPESEN, L.F. (2001).The beef market in the European Union.Working Paper No. 75 The Aarhus School Of Business
●
PRESTES, S (2004). September 21, GM soybean controversy: 90%
of Rio Grande do Sul harvest will be GM. Agência Brasil.
●
RIVERAS, I (2004). "Monsanto Brazil seeks royalties for illegal RR
soy " Reuters News
● WWF
(2004).The Soy Boom:Two scenarios of soy production expansion in South America. Commissioned by WWF Forest Conversion Initiative.
175
18
Oil Exploitation in the Amazonian Region
of Ecuador: Emergency in Public Health
1
Miguel San Sebastián, Anna-Karin Hurtig
Anibal Tanguila, Santiago Santi
Asociación de Promotores de Salud "Sandi Yura"
This work is dedicated to Angel Shingre, peasant and
environmentalist, who struggled his whole life for an
Amazonían Region free of contamination. He was murdered in Coca on November 4th, 2003.
Introduction
Petroleum is one of the main sources of income for Ecuador. Since 1970
it has functioned as the motor of national economy. Before the explosion in
petroleum prices in 1970, Ecuador was one of the poorest countries of Latin America. After that moment, the production of petroleum has been
chiefly responsible for the growth of the Ecuadorian economy (an annual
mean of 7%); with per capita income increasing from US 290 dollars in 1972
to US 1.200 dollars in 2000. Presently, petroleum continues to supply 40% of
the profit by exports and of the budget of national Government [Centro de
Derechos Económicos y Sociales, 1999; Instituto Latinoamericano de Investigaciones Sociales, 2005]. The majority of this petroleum comes from the
northeastern zone of the country, the Amazonian Region.
This region in Ecuador, known as the "Oriente", occupies an area of
nearly 100.000 km2 of tropical forests in the source of the Amazonian fluvial
network. The region contains one of the most diverse collections of plants
1. This chapter is based on the article: San Sebastián M, Hurtig AK. Oil exploitation in the Amazon basin of
Ecuador: a public health emergency. Revista Panamericana de Salud Pública 2004; 15(3): 205-211 (authorization)
176
and animal life in the world. The Oriente is also the
home of approximately 500.000 people, 4,5% of the
total population of the country. This half million people includes eight groups of indigenous population, as
well as peasants that immigrated to the zone, having
left the coastal and Andean regions of the country
[Fundación "José Peralta", 2001]. These populations
moved to the Oriente at the end of the 70’s and beginning of the 80’s, driven by the agrarian policies of
the national Government.
In 1967, the Texaco-Gulf consortium discovered
an abundant oil field underneath the Amazonian tropical forest that led to petroleum "boom", which since
then has modified the region. The Ecuadorian Amazon
currently holds an extended network of roads, pipes,
and fields. Despite the national Government having
retained the right of property over all the mineral resources, numerous foreign private companies have
constructed and operated the greatest part of the infrastructure.
At present, the petroleum production activities
in the Oriente employ roughly a million hectares, with
more than 300 wells of production and 29 fields. The
country has 4,6 billions of oil barrels of proven reserves, and a daily production of around 390.000 barrels.
From 1967 to 2003, different companies have participated in the process of petroleum exploitation. At this
time, there are 16 companies operating in the country:
Petroecuador, 3 national private companies, and 12 foreign companies [Petroecuador, 2005]. Figure 1 illustrates the companies that operate within the country
and the blocks where they are situated.
From the beginning of petroleum exploitation,
foreign companies in conjunction with Petroecuador
have extracted more than two billion barrels of oil in
the Amazonian Region. Nevertheless, in this process
billions of gallons of toxic, gas and petroleum waste
have been spilled on environment [Kimerling, 1991]
(see table in follow page).
This chapter examines impact on environment
and health occasioned by the process of petroleum
development in the Amazonian Region of Ecuador and
suggests different mechanisms that could aid in palliating this enormous impact.
THE ENVIRONMENTAL EXPOSURE
Source and extension of contamination
The extraction of petroleum comprises various
contaminating processes. The seriousness of these
processes depends mainly on the environmental form
of practice and technology used by petroleum companies. In Ecuador, these forms of practice have been repeatedly argued [Kimerling, 1991; Varea, Ortiz, eds,
1995].
In the interior of the earth, petroleum is mixed
with natural gas and formation water. In the Amazonian Region of Ecuador, each well that is perforated
produces a mean of 4.000m3 of waste, largely perforation mud (used as a lubricant) and formation waters
(which contain hydrocarbons, heavy metals and an elevated concentration of salts). These wastes are frequently deposited in earth pools, from where they are
either eliminated directly to environment, or spilled
onto it as a result of a fracture of the pool or the overflowing due to the rain [Kimerling, 1991]. At the moment, there are nearly 200 pools without protection in
the entire Amazonian Region [Frente de Defensa de la
Amazonía-Petroecuador, 2003]. Albeit some companies have modified this form of practice in the last 10
years, by means of the construction of protected
pools, still the forms described above are recurrent.
If commercial quantities of petroleum are detected, the phase of production begins. During this phase, petroleum is extracted mixed with formation water and gas, and they are separated in a central station.
177
In these stations, each day more than 4,3 million gallons (16,3 million liters) of toxic waste are generated,
and then deposited without any special treatment in
earth pools. Moreover, originated from this process of
separation, in the Amazon roughly 53 millions of cubic
feet of gas are burned. This gas is burned without any
type of control of emissions or temperature. An addi178
tional contamination of air is brought about by the
evaporation of hydrocarbons from the pools or the
overflowing of oil [Kimerling, 1991; Centro de Derechos Económicos y Sociales, 1994].
It has been estimated that the maintenance
works of more than 300 wells of production existent
in the Amazonian generate more than 5 million gallons
(18,9 million liters) of toxic waste, which are deposited in the environment each year. Escapes emanating
from the wells and the overflowing of tanks are also
frequent [Almeida, 2000]. According to a study completed by the Ecuadorian government in 1989, the
overflows of flux lines that connect the wells to the
stations caused the discharge of 20.000 gallons
(75.800 liters) of petroleum each two weeks [Ecuador.
Dirección General de Medio Ambiente, 1989].
The overflows of principal and secondary pipelines are numerous as well. In 1992, the Ecuadorian government registered approximately 30 large overflows
with an estimated loss of 16,8 million gallons (63,6 million liters) of petroleum [Kimerling, 1991; Centro de
Derechos Económicos y Sociales, 1994]. In 1989, at
least 294.000 gallons (1,1 million liters) of petroleum,
and in 1992, around 275.000 (1 million liters), brought
about the "blackening" of river Napo (1km wide) during a week. In 2002, it was assessed that within the
region two large overflows originated in the main oil
fields occur per week [El Comercio, 2002].
In total, until 1993 more than 30 billion gallons
(113.700 million liters) of petroleum and toxic waste
had been spilled on the earth and the rivers of the
Oriente [Kimerling, 1991; Centro de Derechos Económicos y Sociales, 1994]. In contrast, the oil tanker Exxon Valdez in 1989 spilled 10,8 million gallons (40,9
million liters) on the coast of Alaska; one of the major
petroleum overflows ever transpired in the sea.
Environmental Analysis
Several reports have indicated that contamination in the Amazonian Region in Ecuador has arisen
since the beginning of petroleum exploitation [Kimerling, 1991; Varea, Ortiz, eds, 1995], despite the inexistence of longitudinal data on the levels of exposure of
population during this period.
In 1987, a study undertaken by the Ecuadorian
government found high levels of grease and petroleum, in 36 samples taken from rivers and streams
near places of petroleum production [Corporación
Estatal Petrolero Ecuatoriana (CEPE), 1987]. Through
a further study of the Government in 1987, it was
found that petroleum coming from 187 wells was regularly spilled on the bodies of water and soils of the
region [Ecuador. Dirección General de Medio Ambiente, 1989].
In 1994, the Center of Economical and Social
Rights, a national organization of human and environmental rights, published a report documenting dangerous levels of contamination due to petroleum in the
rivers of the Ecuadorian Amazon. Throughout this
study, concentrations of polycyclic aromatic hydrocarbons were found in the water that population drank
and used to bathe or fish, 10 to 10.000 times superior
to the limits permitted by the Agency of Environmental Protection of the United States [Centro de Derechos Económicos y Sociales, 1994].
In 1998, an independent laboratory habitually
used by petroleum companies examined 46 rivers in
the Oriente region. The study discovered contamination by petroleum total hydrocarbons in the areas
with petroleum exploitation, while no contaminated
water was observed in the areas without exploitation
[Zehner,Villacreces, 1998].
In 1999, the Institute of Epidemiology and Communitarian Health "Manuel Amunárriz", a local nongovernmental organization, performed the analysis of
water for petroleum total hydrocarbons in communities near oil fields and in communities far from them.
The analysis revealed elevated concentrations of petroleum total hydrocarbons in the rivers of communities near the fields. In some rivers, the concentrations
of hydrocarbons exceeded by more than 200 times
the limit permitted by the regulation of the European
Union [San Sebastián, 2000].
179
Since 1992, according to law, petroleum companies must monitor regularly the levels of environmental contamination and send the corresponding reports
to the national Government of Ecuador. This information is not accessible to public opinion. However,
when one of these reports was presented in 1999 to
a community that had constantly complained to the
Department of Environment for the environmental
contamination by petroleum, concentrations of petroleum total hydrocarbons superior by 500 times to the
limit permitted by the regulation of the European
Union were found in the rivers of the mentioned community. The petroleum company and the representative of the Ecuadorian Government maintained that
the levels of petroleum total hydrocarbons were normal [Ecuador. Ministerio de Medio Ambiente, 1999].
Within the Amazonian Region of Ecuador the
data available on the contamination of soil and its possible impact is scarce, and not one study has been done on the impact that petroleum development has on
both fish and fishing. Nevertheless, studies of the
Amazonian Region in Peru found high concentrations
of petroleum total hydrocarbons in the stomach and
muscles of fish after an overflow of petroleum in the
river Marañón [Perú. Dirección Regional de Pesquería
de Loreto, 2000].
Effects in Health
For several years, the residents in areas of petroleum exploitation in the Amazonian Region in Ecuador
have expressed their concerns in relation to contamination coming from the exploitation. Many indigenous
and peasant communities have declared that numerous local rivers and streams, which used to be plentiful for fishing, at present lack aquatic life.They have observed, as well, how cattle die after drinking the water
of those rivers and streams. These are the same wa180
ters that population customarily utilizes to drink,
cook, and bathe. The residents of these areas have also stated that bathing in these rivers produces skin
irritation, especially after intense rain, as this accelerates the flux of waste from the pools near the rivers
[Kimerling, 1991; Kimerling, 1995].
In 1993, an association of health promoters for
the Amazon accomplished a study that described the
communities. The study found that communities in
areas of petroleum exploitation had elevated rates of
morbidity, with notably prevailing abortions, dermatitis, skin fungus, and malnutrition, as well as a major
mortality rate compared to communities where there
was no petroleum exploitation [Unión de Promotores
Populares de Salud de la Amazonía Ecuatoriana, 1993].
In 1997, the Institute of Epidemiology and Communitarian Health "Manuel Amunárriz" initiated a research process to evaluate the possible impact on
health, of the contamination by petroleum in communities near the oil fields. Through the first of these studies, women who lived in communities near oil fields
showed greater rates of diverse symptoms (skin mycoses, fatigue, irritation in the nose and/or the eyes,
sore throat, headache, earache, diarrhea, and gastritis)
than women who lived in communities without petroleum exploitation [San Sebastián,Armstrong, Stephens,
2001]. In addition, it was detected that the risk of
spontaneous abortions was 2,5 times greater in women who lived in the vicinity of the oil fields [San Sebastián, Armstrong, Stephens, 2002]. The research in
1998 of a cluster of cancers in a community situated
in an area of petroleum exploitation in the Amazonian
Region of Ecuador uncovered an excess of cancers
among the masculine population [San Sebastián,Armstrong, Cordoba, Stephens, 2001]. In 2000, another
study investigated the differences in the incidence of
cancer from 1985 to 1998 in the Amazonian Region of
Ecuador. This study revealed an incidence of cancer
significantly greater, as much in women as in men wit-
hin cantons where there had been petroleum exploitation for more than 20 years. The cancers of stomach, rectum, melanoma, subcutaneous tissue and kidney, in men, and the cancers of cervix and lymphoma,
in women, were extensively present [Hurtig, San Sebastián, 2002]. Recently, a higher risk of infant leukemia
in cantons where there is petroleum exploitation has
been noticed [Hurtig, San Sebastián, 2004].
The Response of the Government
The peasants and indigenous people of the Amazonian Region have presented their complaints to the
distinct administrations of the national Government.
The inhabitants of this region have claimed a better life standard, the availability of basic necessities such as
electricity, the supplying of water and health services,
technical assistance, and above all the remediation of
environmental contamination. By way of their organizations and the support of national and international
environmental organizations, the residents of the
Oriente have solicited companies to clean contamination and to be compensated for the damages caused
by this contamination. Until the present, the measures
adopted by companies and the different administrations of the national Government have been described
as "patches" (covering of some pools, construction of
schools, roads) without facing the root of the problem
[Varea, Ortiz, eds, 1995].
Various administrations of the national Government have declared the principal importance of petroleum for the development of Ecuador. Ecuador currently retains the record external debt per capita of
all South America, roughly US 1.100 dollars per person
[Centro de Derechos Económicos y Sociales, 1999].
The rate of unemployment (from 6% to 7,7%) and the
percentage of population in poverty (from 47% to
61,3%) have increased from 1970 to 2002 [Centro de
Derechos Económicos y Sociales, 1999; Instituto Latinoamericano de Investigaciones Sociales, 2005]. The
ratio of the income received by 5% of the poorest population and the richest 5% changed from 1:109 in
1988 to 1:206 in 1999 [Acosta, 2000b].The Amazonian
Region has the worst infrastructure and the worst socio-economical and health indicators of the entire
country [Terán, 2000].
As a response to the nearly US 16 billion dollars
of external debt that the country has, one of the key
strategies of the national Government and the International Monetary Fund has been the expansion of petroleum exploitation within the country. The proposals of the national Government include the ceding of
two million hectares of primary tropical forest in the
South of the Amazonian Region to the exploitation of
petroleum and the construction of a pipeline of heavy
crude oils in the North of the Amazon to facilitate a
major exploitation in that area [Centro de Derechos
Económicos y Sociales, 2000].
WHAT OUGHT TO BE DONE?
In order to be compatible with the sustainable
development and well-being of Amazonian populations, modern development of petroleum and gas exploitation must be based on an integral environmental
planning that considers the accumulated impact of
present and future exploitation all through the region.
To prevent serious environmental and health impact,
strict environmental controls and careful monitoring
of the extraction activities in the long term are necessary [Kimerling, 2001]. Five interrelated actions are urgently required:
●
The Government of Ecuador should perform an evaluation of the environmental situation of the Amazonian Region. It is also indispensable to develop and
supervise the execution of a plan to remediate the
181
damage already produced and limit further destruction. The more contamination that continues, the
more will the health of the population of the Oriente and other populations in similar circumstances
remain in risk. Some indigenous and environmentalist groups have called attention to the necessity of
applying the principle of precaution [Raffensperger,
Tickner, 1999]. At the same time, they have asked
the national Government a moratorium in the petroleum and gas development in new areas of the
Amazon. Alternatives of development have been
proposed, such as eco-tourism or the conservation
of the tropical forest, which ought to be seriously
considered [Centro de Derechos Económicos y Sociales, 2000; Acosta, 2000a].
●
●
The petroleum companies that operate at this time
in the Ecuadorian Amazon should change their
forms of practice to minimize the environmental impact and construct alliances with local communities
to promote local development. Companies should
make available to the communities and independent
environmental groups the standards of environmental protection and plans of environmental management. Without this information, these groups continue to be ignorant of the possible risks, and they
cannot participate significantly in the political decisions or force companies to be responsible for their
actions. Additionally, an environmental monitoring
system should be established with the participation
of all the affected communities. This system should
comprise at least a detailed chemical sampling of the
environment regularly completed, and the report of
the control of emissions and waste.
The policies of petroleum development have an impact on health and their consequences must be eva-
182
luated and taken into account. The Ecuadorian Government should acknowledge the need of incorporating evaluations of impact on health, as an essential part of its policies of development. Consultation
with and participation of the community are fundamental, as much in the evaluation of environmental
impact as in the one concerning health [British Medical Association, 1998].
●
The new Constitution of Ecuador of 1998 recognizes the right of communities to be consulted by
companies prior to initiating a phase of exploitation.
This right to be consulted should involve the possibility of refusal of communities to this type of exploitation. Communitarian organizations in conjunction with the environmentalist groups at the regional, national and international levels are crucial in
the exercising of these rights. The Ecuadorian Government has made the commitment to develop the
mechanisms, which activate the use of laws to protect the environment and health of citizens, despite
the fact that this development is complicated. All
this should be considered in the context of the need
to uphold human rights, combat corruption and
strengthen democratic institutions.
●
From an international viewpoint, the preoccupation
exists that globalization of transnational commerce
is not creating any benefit to the environment and
health of populations [United Nations Environmental Program, 1999; Stephens, Lewin, Leonardi, San Sebastián, Shaw, 2000]. Urgent changes are required in
the commercial policies, in order to direct them toward the environmental sustainability and social justice, to reach the majority in terms of the benefits
of an environmental protection, as well as those of
economical and health protection.
Conclusion
The petroleum exploitation in the Amazonian
Region of Ecuador has resulted in a public health emergency, due to its negative impacts on environment and
health. Until now, the Ecuadorian Government has not
designed an adequate strategy to prevent future impacts on environment and health. The petroleum industry usually argues that it plays a role in the development of a country; however this should not be at the
expense of contamination and health damage [British
Petroleum. Environment and Society, 2005; OXY, 2005].
At a first glance, petroleum industry and public health
are not connected. Nevertheless, we have attempted
to demonstrate that they are deeply associated. Unfortunately, Ecuador is not the only country suffering
the negative consequences of petroleum exploitation
throughout Latin America. Countries such as Colombia, Peru and Bolivia display similar situations [La Torre
López, 1998; Oilwatch, 1999]. Public health problems
already exist and these problems will potentially increase if the petroleum industry expands without regulation within Latin America, as it has until now. The prevention of an additional hazard to health and environment represents an enormous challenge, which will undeniably require the coordinated action of social movements and networks at local, national and international levels.
183
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185
Section II:
THAT OTHER HEALTH POSSIBLE
Action
From Democratic
States
19
Health Program Achievements of the
Bolivarian Venezuelan Republic
Francisco Armada
Health Equity: A Pillar of Improving Quality of Life
Health is a pillar of development, dignity, and the improvement of the quality of life of the Venezuelan population.
Our main political objectives in health have been directed toward the rearrangement of institutional structures and public health care networks. The full
enjoyment of social rights and equity should operate as a foundation of a new
social order, one based on justice and well-being.
We started improving on our inequities by reducing the care deficit and the
health access disparity among groups; recovering the social collective nature of
the public programs; empowering our citizens; and building the capacity of citizens and social organizations to participate in the development of alterative policies. These have shown to have a real impact on the social development of the
country.
A crucial aspect to highlight our health accomplishments is that during the
five years of the present government, seven million people have been incorporated as beneficiaries of health projects. Thus, tendencies indicate that coverage
will progressively expand, comprising the social strata with major needs.
The Consolidation of the National Public System of Health
The Constitution of the Bolivarian Venezuelan Republic (1999) instituted an
important landmark in the change of public health conceptions. It confirms
health as both a fundamental social right and establishes the obligation of the State to guarantee it. This is done by developing policies oriented to elevating the
189
population’s quality of life and free access to health related services.
The constitution mandated the creation of a national system of public health that is inter-sectorial, decentralized, participative, and integrated into the social
security system. This system will be regulated by the
principles of gratuitousness, universality, integrality,
equity, social integration and solidarity. It presents its
first advancements in the promulgation of the Organic
Law of the System of Social Security (2002), which established the necessity to redefine the legal instrument
of health.
Nevertheless, to undertake the consolidation of
a national public health system, it is essential to delineate a national policy that associates the governmental apparatus with all other levels of those involved. In
view of the fact that dispersion and segmentation of
the institutional service providers has contributed to
the absence of equity and the exclusion of significant
sectors of the population, these are added to the limited capacity of existing services.
It is also important to bear in mind that the absence of an integral conception of the individual as a
bio-psychosocial being results in the lack of an integral
approach to health, one that guarantees the provision
of basic services, and also contributes to the construction of social and sanitary equity.
The health crisis in Venezuela is manifested in
many different ways: by the deterioration of sanitary
conditions, the decline of sanitary installations, the deficiency of equipment in the care centers, the scarce
coverage of medical care, the limitations in the access
to health services, the commercialization of health, and
the medicalized education and training of health professionals, among others.
Segmentation and segregation, which have characterized the provision of services, have conspired
against elementary human rights, including the right to
health.The neoliberal proposals that advocate the pri190
vatization of medical care and health services accentuate the gaps and deepen the exclusion of the most
deprived and unprotected sectors of the population.
Those are the main reasons to support the changes centered in responding to social needs to attain
equity as a new order of social justice and the material source of Venezuelan society. Hence, this objective
demands the transformation of material and social
conditions of the majority of the population, historically separate and distant from the equitable access to
wealth and well-being, and the construction of a new
health paradigms based on the acknowledgement and
full exercise of rights.
The actions lead to investing greater efforts in
the elimination of structures formed to promote domination models of any nature. These models have
both directly and indirectly influenced many aspects of
society such as: the social composition of the country,
the growth of poverty, the expansion of social exclusion, and the deterioration of health services.
The above-mentioned process has distinguished
itself as an integral social policy that intends to surmount conformism, which characterized social policy
during the implementation of neoliberal programs.
These programs were rooted in the attainment of limited goals and partial palliative care of social problems, and had the purpose of simply restraining poverty. Therefore, governance and social stability were
seriously compromised, making it unsustainable for
neoliberal actions to be applied.
Foremost Achievements in Health
From the standpoint of an integral health approach, all important changes in the living conditions
of the population are considered part of the health
program, even though they are not necessarily operated by specific health institutions. Many of the success-
ful social development programs that the present Venezuelan government has implemented in order to
overcome poverty and correct health disparities are
not explained in this report, but they constitute essential components of our health program1.
Despite endemic illnesses that continue to be an
important cause of death within our country, all actions have been performed in order to detain the tendency of the infected population to increase and to incorporate preventive measures to control this type of
illness.
So coming back to specific health achievements
we can start by mentioning that since 1998, the policy
of access to anti-retroviral treatment (ARV) has been
organized universally and under a no-fee for service
basis, allowing for the introduction of generic products
to guarantee the coverage extension of the program,
and thus to break with the limitations to efficacious
and opportune access.
By the year 2004, 12.546 patients with HIV/AIDS
had received care with high-efficiency triple therapy in
Venezuela. It is noteworthy that the integration with
other governmental institutions that developed parallel programs has been accomplished, attending th-
rough the National AIDS Program assuming those patients who require ARV medicines; it also provides
them with 100% care and coverage.
Additionally, the funds to ensure the sustainability of this policy were implemented with governmental support to initiate the national production of antiretroviral medicines. And lastly, the occupational prevention program for HIV/AIDS and the mother to
child transmission control program are being currently
implemented (see Table1)
The fact that starting from the year 2000 the
Department of Health and Social Development created the National Commission for Anti-malaria Struggle
with permanent characteristics is prominent. The general strategy to combat malaria in Venezuela is composed of early diagnosis and opportune treatment, as
well as the understanding of the population dynamics
in areas with this disease.
In 2004, an Action Plan for the Control of Malaria was formulated in the Delta Amacuro, Bolivar and
Amazonas states. Equipment and boats were acquired
to face malarial dissemination in these high risk states.
The Plan incorporates active and permanent integration of the national, regional and local teams of
CUADRO 1. PACIENTES ATENDIDOS POR EL PROGRAMA NACIONAL SIDA-ITS AÑO 2004
Año Paciente en Tratamiento Embarazadas Seropositivas atendidas Accidentes Laborales Total de pacientes
2002
7428
138
203
7656
2003
11689
110
613
11667
2004
14264
146
231
14263
Fuente: Programa Nacional de Sida MSDS
1. Editor´s note:Venezuela has been one of the few countries that has managed to revert the neoliberal tendency through an ambitious and successful set of social
development programs called "misiones", implemented under community control and geared towards improving and dignifying the life of the poor.At this point we
can only briefly mention them to give the reader an idea of their magnitude and implications: eradication of illiteracy ("Robinson Mission"); massive nutritional programs; massive school and peoples universities program; community leader scholarship programs; land reform; and community productive cooperative and factory
programs.These are only examples of the resource redistribution programs that are consequences of a just allocation of profit funds coming from the oil industry.
191
epidemiologists appointed for the services programs
and the health offices of each federal institution, with
the incorporation of malaria control activities in the
regular work of epidemiological surveillance, including
the training of health personnel, community members
and volunteers, all for the diagnosis, treatment and integral control of the disease. The mentioned actions,
for example, yielded a 70% incidence reduction of Malaria in Sucre state. Thus, the therapeutic scheme for
the Venezuelan anti-malaria treatment at the regional
level has been successfully implemented.
In the struggle against dengue significant efforts
have been fulfilled, if we take into consideration that
during the decade of the 90’s several epidemic outbreaks were registered: in 1990, 1994, 1995, 1997,
1998, and more recently, during 2001 and 2002 (inci-
192
dence rate, 337 per 100.000 inhabitants, and 152,96
per 100.000 inhabitants respectively). In this sense, the
configuration of the National Commission for Antidengue Struggle of the Department of Health and Social Development is notable. This institution coordinates the control and prevention activities against dengue within the country, and falls under the responsibility of the distinct institutions implicated above.
Overall, it must be underscored that in Venezuela a high quality epidemiological surveillance exists,
with an excellent network of laboratories and experience in patients’ medical care, which has facilitated
the lethality of the illness to be maintained under one
percent.
The National Plan of Vaccination is being developed, destined for the infantile population until the first
year of age and women in fertile age. Commencing
with an annual average of 10 million doses, the effort
doubled by the end of 2004 with the application of
more than 20 million doses through the Extended
Program of Immunization, ameliorating to a great extent our national coverage rate. By the year 2005, in
the framework of the Vaccination Workdays of the
Americas, it is intended to apply 28 million doses that
protect against 12 different illnesses.
A substantial accomplishment in the prevention
of yellow fever has been the immunization of 4,5 million Venezuelans, reducing 85% of the problem by the
year 2004.
An indicator of the high priority granted to our
preventive work has been the installation of 703 immunization centers, in zones or areas of social exclusion
and poverty, with an investment of 3,6 billon bolivares.
In the agenda of women’s integral care, 2.612
women received care in the Women’s National Institute (INAMUJER) for violations such as violation of
rights, violence against women, and legal advice in relation to diverse problems.
An important aspect to highlight is the enforcing
of the Resolutions for the "Regulation and Control of
Cigarettes, of Products derived from Tobacco for Human Consumption" and the "Regulation of Cigarette
Packing", by means of which the preventive responsibility is assumed regarding the hazards that tobacco and
its derivatives represent to health. Throughout these
regulations, the obligation of producer and commercializing companies to register before the health regulator institution and to display warnings corresponding
to the hazards that the consumption of their products
represents to health through texts and pictograms has
been established.
Moreover, the ratification by Venezuela of the
Marco Agreement of the World Health Organization
for the control of tobacco realized in March of 2005 is
additionally noticeable.
Integral Care for Indigenous Peoples
The Civil Society for the Control of Endemic Illnesses and the Assistance to Indigenous Peoples (CENASAI) applied 9.729 vaccines to 5.200 indigenous
people of all ages. It completed 24.730 consultations
concerning endemic illnesses and 6.297 in connection
with dental problems (44% indigenous infantile population and 4% pregnant women).
By way of the Autonomous National Service of
Integral Care for Children and the Family (SENIFA),
3.830 indigenous children of both genders were included to the system of integral care to reach a total of
24.000 children who received integral care.
Additional Attainments to Highlight
The expansion of access to potable water has increased to 2,5 million people in only four years. Infant
mortality and malnutrition have also reduced considerably in the last years.
Furthermore, children have been the main beneficiaries of medical policies of the Bolivarian Government. The infant mortality rate declined from 21,4 in
1998 to 17,5 in 2002 and care was enhanced. Between
1999 and 2002 more than 800 cases of children with
congenital cardiac disease have been solved, and the
investment in the acquisition of vaccines increased
from 3 to 28 billon bolivares.
Through the Agreement between Cuba and Venezuela in the subject of health,Venezuelans with certain pathologies that cannot be treated within the
country are granted the opportunity to obtain free care in Cuba, and thus improve their health condition
and ameliorate their quality of life. This agreement is
not part of the commercial oil agreement between
both countries, and it establishes no charge on account of care provided to patients sent by Venezuela.
193
Among the pathologies treated by this agreement are the ones from the following specialties: cardiology, pediatrics, dermatology, infectious and parasitic diseases, tumors, blood diseases, endocrine diseases, circulatory system diseases, nervous system diseases, diseases related to the senses organs, and traumatology.
All these advancements represent the first signals of recuperation of the health sector.They are products of inter-institutional efforts of various segments
of society, and the international cooperation harmonized with the fulfillment of the right to health as a fundamental right.
On of the most important components of the
health policies executed in the current governmental
period is the Interior Urban District Mission ("Misión
Barrio Adentro") which was conceived with the objective of offering integral primary medical care to the
excluded population with non or little access to basic
health services.
The State-Society relation provided by the
Constitution of the Bolivarian Venezuelan Republic is
the basis of the Plan Towards the Interior Urban District Mission, which began on April 16th, 2003, in the
framework of the Venezuela-Cuba Agreement as a
response of the Venezuelan State to the social and
health principal needs, constituting a point of departure in the development of an integral primary care
network.
The Interior Urban District Mission is anchored
in the concept of integral health provision, which
transcends the reductive vision that limits health to
medical care exclusively. For the Interior Urban District Mission, health is seen as composed of the social
economy, culture, sports, environment, education, and
nourishing security. Thus, communitarian organizations and the presence of doctors who join communities sharing their daily life are both integral to the overall program.
194
The Mission functions in an articulate manner
within a network of missions proposed to attend the
distinct needs concerning the promotion of integral
social development in the nutritional, educational, and
labor areas, among others.
At present, the Mission comprises 19.941 professionals from diverse disciplines, among whom we
underline the existence of 15.421 doctors, of which
1.060 are Venezuelan. (see Table 2)
Since the beginning of the Interior Urban District Mission until today, 168.188.996 cases have been
taken care of; 106.028.613 consultations have been
provided; 15.074.231 families have been visited; 24.591
lives have been saved; 1.609 childbirths have been tended; and 59.660.606 educational activities have been
developed.
Similarly, 296 Community Medical Offices were
constructed and equipped (81% in the Metropolitan
District, 7% in Miranda, 8% in Carabobo and 4% in Anzoátegui), and six Popular Clinics were activated (Anzoátegui, Carabobo, Nueva Esparta and in the Liberating Municipality of the Metropolitan District).
At the moment, Interior Urban District Mission
II is being implemented, which constitutes a leap forward in the level of health care, with the purpose of
guaranteeing specialized care to the population, through the activation of Integral Diagnosis Centers furnished with equipment for medical emergencies, diagnosis and surveillance of patients with ophthalmological diseases, and the completion of fundamental diagnostic studies (of each four diagnosis centers, one will
have surgical emergency service).And High Technology
Centers, which will allow the implementation of Magnetic Resonance Spectroscopy, Computerized Axial
Tomography in 16 sections, Noninvasive Tridimentional Ultrasound, Mammography, Video endoscope, Clinical Laboratory, Floating Rx, and Electrocardiography.
The creation of 600 Integral Diagnosis Centers
is estimated at the national level, and 35 High Techno-
CUADRO 2. ESTADÍSTICAS GENERALES
RESUMEN
CUBANOS VENEZOLANOS
CUADRO 3. ESTADÍSTICAS GENERALES
INDICADORES
ACUMULADO
AÑO 2005
ACUMULADO
HISTÓRICO
Casos Vistos
34.722.142
168.188.996
Médicos
14.361
1.060
Estomatólogos
3.070
1.341
Consultas
20.760.019
106.028.613
Enfermeras
302
2.610
De ellos en Terreno
7.743.539
42.349086
Optometristas
1.441
-
Familias Visitadas
2.760.592
15.074.231
Electromédicos
161
-
Acciones de
Enfermería
4.915.775
22.614.720
Otras Categorías
606
1.014
Vidas Salvadas
2.909
24.591
Total General
19.941
6.2025
Actividades
Educativas
12.317.575
59.660.606
Fuente: MSDS Abril de 2005
logy Centers (one in each federal institution, and more than one in those of major population density),
which will permit all Venezuelans, especially the deprived, the access to opportune quality services.
We are conscious that there is still a long way to
go before we can talk about universal high quality ca-
Fuente: www.barrioadentro.gob.ve . Abril 2005
re. However, there is one thing we are sure of and it is
that we have achieved access to medical care for important segments of the population which did not have any access to care before; populations that previously thought better living conditions and health
standards were impossible.
195
20
The Federal District of Mexico’s Health
Policy: Social Rights and the Satisfaction of
Basic Human Necessities
Asa Cristina Laurell
The Context
The elections of 2000 were a historical one for Mexico. The State Party
regime was coming to its end after 71 years with the defeat of the Institutional Revolutionary Party, the national presidential election was won by a rightwing party, National Action, and that of the Capital District by a left-wing
party, the Party of Democratic Revolution. Since then, two distinct political
projects have developed simultaneously in the Federal District area. The historic dynamic which has signified Mexican history has been again reborn.This
is the dynamic between two opposing conceptions of society, two different
systems of values: the vision from above, that of the privileged and the oligarchs such as landowners, industrial and financial entrepreneurs; and the vision from below, that of the workers, in both agricultural and industrial settings, and from the socially and economically excluded.
Social policy demonstrates this situation with greater clarity than the
field of economic policy. This is especially true when you take into account
health policy, whereby the federal government has preserved and deepened
neoliberal orientations imposed on the country for the past two decades
while the Government of the Federal District (GFD) has orchestrated a policy based on guaranteeing social rights universally, ones consecrated by the
Constitution, and on the strengthening and expansion of public institutions to
achieve this goal.
196
The Federal District Government´s
Social Policy
Overall, the social policy of México City´s government is directed at decreasing the peoples impoverishment, poor people comprising two thirds of all
urban inhabitants. In itself, it is a policy of health promotion, focusing on programs of social protection for
children, women, the old, people with incapacities and
the unemployed. In addition, the policies focus on education, and housing and environmental programs,
which have a positive impact in the improvement of living conditions. These social programs are a basic
priority to the Government of the Federal District,
along with public security,.
The central characteristics of the programs
mentioned are its massive character, including tens of
thousands of families; its redistributive nature, in channeling public resources to groups in need; and its low
administrative cost. Moreover, the programs are territorialized and integrated to the Territorial Integrated
Program (TIP) to facilitate inter-institutional operations and to promote both citizen’s participation and
control. Priority is put on the more impoverished
areas, and the program design is not focused on individuals or families, but on territorial characteristics.
This method has the best results in terms of inclusionexclusion and, in addition, it generates the lowest administrative costs.
the inauguration of the city´s government and currently reaches 371.000 citizens.
This pension program instituted another social
right for the first time in the Federal District. It gained
legal status in 2003, becoming a law and, thus a brand
new social institution was born. At the outset, its universal character brought about intense debate, but
with time it has demonstrated to be an essential vehicle to achieve broad comprehension of social rights.
Its penetration is such that, currently, an initiative
exists within the senate to implant the pension nationally, despite opposition by private insurance companies and right-wing politicians.
The Financing of the Social Policy
The taxing capacity of the local government is
restricted to some taxes and local rights and by law it
cannot operate with a fiscal deficit. In spite of this, the
Government of the Federal District did not opt for increasing taxes. The social policy financial strategy is
built on two approaches. One being that high bureaucracy expenses were eliminated and salaries were reduced 15%. The other involved a frontal struggle
against corruption. It has been calculated that these
measures have lead to an annual saving of 300 million
US dollars. This amount is enough, for instance, to finance amply the universal pension.
Universal Pension
The Health Policy
The citizen’s universal pension program deserves
special attention as one of the specific programs of the
Federal District. Conducted by the Health Department, it guarantees medical services and free medicines to the city’s residents that are 70 years or older.
It was launched in October 2002, three months after
The health policy of the Federal District Government is a component of an integral social policy
which, due to its characteristics, represents an instrument to ameliorate the harsh living and working conditions of the population of the city. The specific objective of the Health Department of the F.D. is to gua197
rantee the universal fulfillment of health protection in
the city, as much in the field of collective sanitary safety as that of individuals.
c) the conformation of health services does not correspond to existing morbidity and mortality profiles, nor to the distribution of population in the territory; and lastly,
Challenges and Restrictions
d) the lack of strategic planning is notorious in all key
aspects of the local system. Nevertheless, the basic
programs of public health (epidemiological surveillance, universal vaccination, combatting acute diarrhea and respiratory disease, etc.) had been preserved in the city.
Based on a comprehensive diagnosis, the Health
Program of the Government of the Federal District
(Health Department, 2002) has proposed six substantial challenges:
1. to improve general health conditions;
2. to decrease inequality in health among social groups
and geographical zones;
3. to guarantee the sanitary safety of the city;
4. to increase access to required treatment;
5. to diminish inequality in access to sufficient high
quality health services; and,
6. to coordinate mechanisms of stable, plentiful, and
equitable financing.
In order to understand the policies and strategies adopted, one must draw attention to the problems and restrictions which condition the activity of
the health authority of the F.D:
a) the health system is segmented and the Health Department of the F.D. has direct command over only
a small part;
b) all the public health services suffered great deterioration after 1983, owing to prolonged financial crisis;
198
The Medical Care and
Free Medicines Program
The two chief policies of the Health Department
of the Federal District are the universality of the right
to health and, as a condition of the prior, the expansion,
strengthening and improvement of existing public
health institutions. The strategy to attain the universality of the right to health is the Program of Medical Care and Free Medicines, which focuses on the population
without insurance by the public social security institutes. Upon subscription to the Program, the citizen acquires the right to receive all the services made available at the health units of the government of the city and
to the medicines required from the institutional medicine chart, devoid of cost. Presently, there are 710,000
families subscribed or nearly 80% of eligible families. In
addition, for ethical and administrative efficiency reasons, initial emergency services are offered free of charge, independent of insurance and residence status.
Payment removal has caused a significant increase in the provision of services, as displayed in Table 1.
The highest increments occur in the most expensive
services: 65% in surgeries; 53% in childbirth attention;
31% in emergencies; 30% in hospitalization and 29% in
x-rays. This confirms that the economic obstacle was
a decisive element of inequality in access to health services (table 1).
At present, actions have been taken to remove
the cultural obstacle to care with the promotion of
the Medical Services and Free Medicines Program in
the most underprivileged zones of the city, where the
population tends to have less information on health
and the governmental programs. The socioeconomic
profiles of the rightful claimants of the Program demonstrate that they have lower income,income; inferior schooling and that they often live in deprived zones of the city. Taken together, these factors disprove
the myth that universal programs give preferential
treatment to the mid-social sectors.
TABLE 1. SERVICES PROVISION 2000 TO 2004
HEALTH DEPARTMENT OF THE GOVERNMENT OF THE FEDERAL DISTRICT
CONCEPT
2000
2001
2002
2003
4,818,207
3,488,256
655,263
674,688
4,956,951
3,574,767
668,692
713,492
5,211,860
3,731,014
745,051
735,795
4,997,828
3,607,253
704,500
686,069
4,802,700
3,469,114
678,271
655,315
-0.3
-0.6
3.5
-2.9
572,024
646,078
754,369
771,588
751,817
31.4
89,973
92,225
108,441
112,092
116,875
29.9
56.4
72.6
59.9
76.2
68.4
78.6
66.2
79.5
68.9
79.9
22.2
10.1
57.1
44.1
56.6
47.8
69.6
55.8
70.1
48.9
63.0
56.4
10.3
27.9
4.4
4.2
4.1
4.0
4.0
-9.1
Surgical Interventions
42,564
50,399
59,913
67,501
70,278
65.1
Births
● Vaginal births
● Cesarean
30,922
23,865
7,057
35,137
26,852
8,285
41,539
31,498
10,041
44,661
33,736
10,925
47,241
35,819
11,422
52.8
50.1
61.8
404,878
452,462
469,376
501,133
522,265
29.0
Laboratory studies
4,345,710
4,803,259
4,461,184
4,623,660
4,970,005
14.4
Legal Medical care
576,456
568,011
622,999
538,550
546,284
-5.2
Medical office consultations
● General
● Specialized (1)
● Odontological
Emergencies(2)
Patients discharged
Hospital occupation
percentage
● General hospitals
● Maternal-infantile
hospitals
● Pediatrics hospitals
Average stay period (days)
X-rays studies
2004* 2000-2004
1/ Includes specialized and mental health consultations 2/ Includes special events, toxicological centers, administrative sanctions 3/ Includes intensive phase and permanent program * Preliminary data until December 2004 (a part of the information is missing) Source: SISPA, SSA, 2003
199
Another benefit of the Program is that it permits
people to dedicate their scarce resources to the satisfaction of other basic necessities. Thus, even conservative estimates conclude that savings on account of
medical expenses by the rightful claimants of the Program amount to roughly to 170 million dollars, in
roughly two and a half years.
Strengthening and Expansion of Services
The improvement, strengthening and expansion
of the health services in the city are the material support for the universality of the right to health and the
decrease in inequalities of access. This policy is based
on a set of actions. Epidemiological surveillance and
high vaccination coverage (95%) have been maintained.
Further, a new health care model has been introduced,
derived from Health Integrated Actions by groups of
age, with emphasis in promotion, prevention, opportune detection and control of disease. An adequate supply of high quality and dignifying services are being guaranteed with ample provisioning of medicines and other resources, in addition to maintenance and preservation of the equipment and buildings, intensive personnel training, and a sustained effort of consciousness
and human rights culture building. This is all changing
the type of relations between local government and
the public, and is anchored in the rights of citizens.
It is precisely in this context where the people´s
participation and community control play an underlying role. The basic conceptis that a reciprocal relationship of rights and duties must exist between the
government and citizens. Hence, the government has
the obligation to guarantee the rights to health protection and to encourage collective participation, furnishing the information as regards to the content of
this right. Once this has been accomplished, the citizens have the obligation to contribute to the efficacy
200
in the use and control of public resources, in fact their
resources.
Furthermore, services are being organized in a
net which strengthens the mechanisms of reference
and counter reference to guarantee the continuity of
care and bring this nearer the population. The expansion and reopening of services has taken effect adhering to the prioritization of actual health necessities
and regional service inequalities. For the first time in
15 years, new health centers and a public hospital has
been built in the city. These measures have increased
the capacity of care by 25%.
These set of actions seem to have promoted a
greater confidence in services, and this fact is demonstrated by the growth in service provision (refer to Table 1). In Fact, services are being used by people from
the center of the country, despite them not being eligible for the Program of Medical Services and Free Medicines and having to pay a moderate fee for services.
Budgetary Expression of the Political Will
The political will of giving priority to the right to
health is supported by a budgetary increase of 45%
in2000, and at the moment this budget represents
9.8% of the total budget of the Government of the Federal District.The total budget of the Health Department, including the citizenry’s pension, has been increased by 126% and represents 15.8% of the total
budget of the city. It is remarkable that 75% of the resources are local and 25% federal, in contrast to other
states where the relation is opposite.
The Impact on Health
The first and last goals of the health policy are to
ameliorate negative health conditions and diminish ine-
TABLE 2 MORTALITY BY GROUPS OF AGE FEDERAL DISTRICT, 1997-2002
Year
General
Infant
Cases Rate(1) Cases Rate
1997
1998
1999
2000
2001
2002
46,884
46,773
46,601
46,029
46,627
46,984
5.9
5.4
5.3
5.2
5.3
5.3
3,848
3,699
3,323
3,127
2,894
2,858
Preschool
(2)
24.0
23.6
21.6
21.6
20.0
19.9
Cases
425
445
381
365
384
368
School
Productive
Posproductive
Rate Cases
Rate Cases
Rate
Cases
0.8
0.7
0.6
0.6
0.7
0.6
0.3
0.3
0.2
0.3
0.3
0.3
3.2
3.0
2.9
2.8
2.8
2.8
247,560
24,840
25,793
25,567
25,931
26,490
459
440
376
402
396
378
17,571
17,336
16,711
16,535
17,003
16,875
Maternal
Rate Cases Rate(3)
52.2
49.5
49.9
47.8
47.3
47.0
93
120
119
96
101
80
5.8
7.7
7.7
6.6
7.0
5.6
1/ Rate per 1,000 inhabitants. 2/ Rate per 1,000 LIFE BORN. 3/ Rate per 10 mil LIFE BORN
Note: LIFE BORN, as a denominator, the expected births estimated by CONAPO
Sources: Poblaciones, Estimaciones de la Población en México 1996-2030, CONAPO. Defunciones, INEGI/SSA 2002, último año de cifras oficiales.
quality in illness and death.The general rate of mortality has increased lightly because of the aging of the population.The rates of mortality for different age groups,
on the other hand, has dropped persistently between
1997 and 2002: the infantile mortality rate by 17 % (24
to 19.9); the pre-school rate by 25 % (0.8 to 0.6); the
productive age mortality by 12.5 % (3.2 to 2.8) and the
post-productive age rateby 10 % (52.2 to 47.9).
The proportion of deaths in the age group 65years or older continues to rise from 55.5% in 2000 to
56% in 2001, and 57% in 2002. Opposite this, a decrease in infant deaths from 9% in 1997 to 6% in 2002 has
been observed. In this context it would be necessary
to remember that in 1970, the infant mortality represented 34 % of the entire mortality; in 1980, 22 %; and
in 1990, 13 %. This spectacular change owes itself to
the halving of number of births in the F.D. and to the
decrease in the rate of infant mortality from 75 to 20
per thousand live births. This is mainly due to the lowering of mortality as a result of diarrheic, respiratory,
immuno-preventive and perinatal illnesses.
The greatest impact on health has been the
reduction of mortality as a consequence of AIDS.
From 2000 to 2002 the F.D. succeeded in lowering
AIDS related mortality by 23% thanks to the integral
program for AIDS (which includes free medical treatment resources and medicines), while the decrease in
the rest of the country was only 9%.
Finally, from 2000 to 2002, inequality was
brought down for age groups among the 16 municipal
delegations, and consequently we have that the difference between the highest and lowest delegation rates
decreased in the infantile age group, from 2.6 to 2.3 times (13%); in the productive group, from 2.16 to 1.70
times (22%); and in the post-productive group, from
1.25 to 1.17 times (6.4%).
201
21
Cuba Breaks Through the Siege of the
Imperialist Blockade
Miguel Márquez, Francisco Rojas Ochoa, Cándido López
The Context
The differences between Cuba and the United States of America have
their origins and causes from the expansionistic eagerness generated in the
nineteenth century and, subsequently in the twentieth century with the dependent Cuba, to the transformation, at the time of the Cuban Revolution in
1959, to a policy of permanent aggression and blockade. This blockade is on
the fringe of all legal consideration and against the overwhelming international majority that supports Cuba’s decade-long proposal in the General Assembly of the United Nations to put an end to it. This support was evident
in the last voting on October 28th of 2004 in which Cuba was approved by
179 votes, corresponding to 93,7% of the total members of the United Nations. [Digital Granma Internacional, 2004]
In the 45 years since its inception, the blockade policy has imposed an
economic, financial, cultural and social asphyxia to the Cuban nation, by depriving it of fundamental means of subsistence and inflicting distress to Cuban people both materially and spiritually. The aggressiveness of the blockade has multiple manifestations and is displayed in three forms, which are a
complement to each other and act simultaneously. These three forms are as
follows: the first, the direct aggressions to Cuba; the second, the use of he202
mispheric mechanisms; and the last, those constituted
as the economic, commercial and financial blockade.
[D' Stefano, 2000]
The aggressions are directed from the ideological to the political; from the economy to the military;
and from radio and television communications to migratory regulations. Added to these are the aggressions that have recourse to hemispheric mechanisms,
such as those piloted by means of the Organization of
American States (OAS) and the International Treaty of
Reciprocal Support (ITRS), which with the pretense of
anticommunism, justify Cuba’s exclusion from the OAS
after 1962 and the unilateral decision to suspend diplomatic and consular relations of its members in
1964. It also justifies the interruption of direct or indirect commercial interchange, with the exception of
food, medicine, and equipment that could be sent to
Cuba for humanitarian reasons. Only Mexico was opposed to the sanctions and maintained integral rela-
tions with thorough respect to Cuba’s autonomy and
sovereignty. Moreover, the utilization by the United
States Human Rights Commission of the United Nations should be considered. By way of menaces, repressions and retaliations to member countries, they
have attained Pyrrhic victories on condemning Cuba in
the subject of human rights, obtaining less than 40% of
support.
The economic, commercial and financial blockade is the third intervention of the government of the
United States in Cuba, which has endured, since the
beginning of 1960, the suspension of petroleum sales,
until the Law Helms-Burton in 1996 and the shameless
Report of the Commission of Aid to a Free Cuba in
May of 2004.
The following box illustrates the more outstanding aspects of the measures applied by the governments of the United States of America against Cuba.
CHRONOLOGY OF THE BLOCKADE ON CUBA BY THE GOVERNMENTS
OF THE UNITED STATES OF AMERICA
March of 1960
President Eisenhower approves the "Program of Concealed Action against the regime of Castro". Consequences: 681 terrorist actions and aggressions against the Cuban people. Loss of human lives: 3.478, and
with permanent injuries: 2.099. Loans amounting to 100 million US dollars from European and Canadian
banks are cancelled.The plans to purchase Cuban sugar are cancelled.
October
of 1960
The Eisenhower administration applies the "quarantine", prohibits exports to Cuba (except food and medicines). Blockade onset.
January of 1961
The government of the U.S.A. ceases diplomatic relations with Cuba.
April of 1961
The invasion through Playa Girón ("Bahía de Cochinos") was undertaken.
September of
1961
The Law of External Assistance takes effect. It authorizes the establishment and perpetuation of a total
"embargo" upon commerce between the U.S.A. and Cuba.
February-March
of 1962
The embargo expands with the prohibition of imports to the U.S.A. of Cuban products.The imports from
third countries were included to products containing Cuban materials.
203
February of
1962
In the Eighth Meeting of Consultation of the OAS ("Punta del Este"), the incompatibility of Cuba with the
purposes and principles of inter-Americanism is deduced, and Cuba is excluded from the OAS and other
organizations of the inter-American system.
February of
1963
The Kennedy administration broadens the projection of extraterritorial sanctions to third countries by
prohibiting boats from transporting products to the U.S.A. if they touch any Cuban port.
July of
1963
The Department of Treasury establishes the Regulations of the Control of Cuban Capital. It freezes all Cuban capital in the U.S.A. (exonerating the capital of Batista’s dictatorship).
July of
1964
In the Ninth Meeting of Consultation of the OAS, in Washington D.C., the following collective measures
are applied against Cuba, not including México: suspension of diplomatic and consular relations, elimination
of direct and indirect commercial interchange (except for medicines and food), suppression of all marine
and aerial transport.
April of 1980
The Reagan administration severely restricts trips of U.S. citizens to Cuba.
October of
1992
The U.S.A. government extends the Law for Cuban Democracy (Torricelli Law), which prescribes the commerce of subsidiaries with Cuba, imposes severe restrictions to marine and aerial transport, and concedes
to the Department of Treasury, for the first time, the authority to administer fines to United States citizens
up to 50 thousand US dollars by violations of the "embargo".
March of 1996
The Helms-Burton Law takes effect. Overall, it consists of four headings: strengthening of international
sanctions, aid to a free and independent Cuba, protection of property rights of United States citizens, and
exclusion of foreigners who deal with confiscated properties.
2000-2004
●
The Office of Control of Foreign Assets of the Department of Treasury tries to prohibit Cuban authors
in the United States from publishing scientific articles.
●
The creation of the "Commission of Aid to a Free Cuba" is announced.
●
Immediate blockade of goods by the U.S. of ten companies which specialized in the promotion of trips
to Cuba (Argentina, Bahamas, Canada, Chile, Holland and United Kingdom).
●
A fine of 100 million US dollars was imposed on the Swiss banking organization UBS, for having financial
transactions with Cuba.
●
The dispositions emanated from the Report of the Commission of Aid to a Free Cuba are approved and
take effect. The report is composed of six chapters. The first is dedicated entirely to the establishment
of guidelines on destroying the Revolution.The other five are concentrated in undertaking measures that
would take effect in Cuba as soon as the Revolution was overthrown by the U.S. government.
Sources: Granma. Cuba y su defensa de todos los Derechos Humanos para todos (Tabloide Especial) march of 2004.
Asociación Americana para la Salud Mundial. El impacto del Embargo de EE.UU. en la Salud y la Nutrición en Cuba.
Resumen Ejecutivo.Washington, march of 1997.
204
In this account, the name "free Cuba" has been
given to the country longed for by the Miami counterrevolutionary mafia and its representatives in in Cuba. The Report of the Commission of Aid to a Free
Cuba translates the hatred of the United States government for Cuba and constitutes, in a frank demonstration of interference, the masterful plan of destruction of the Cuban Revolution.
The numerous and diverse forms of aggression
that Cuba has suffered for almost 40 years -as a whole, an undeclared war, but still causing death and serious economic and social effects- have been thoroughly documented in the country and in other
countries. [D' Stefano, 2000;Asociación Americana para la Salud Mundial, 1997; Granma, 2004; Granma,
2003; Castro, 2003].
Nevertheless, Cuba, its people and government,
have identified more appropriate responses at each
moment.
The Response
The political, ethical and social principles of the
Cuban Revolution, a revolution with an ample and solid popular base, have constituted the foundation of armed, diplomatic and economic defense. These have
been applied creatively and audaciously for more than
four decades of struggle against the powerful imperialistic enemy.
In the field of public health, medicine and closely
related spheres, the subsequent results can be highlighted.
The Cuban State and government assign the uppermost priority to the health sector.
The unique National System of Health was created and financed by the State.This system has national
coverage and requires no direct payment for any service received.
The concepts of health promotion and prevention were originally derived from Cuba’s National System of Health. The following relevant achievements
can be seen:
The Health System provides one doctor for
every 165 inhabitants, with a total of 380.576 workers.
[Cuba. Ministerio de Salud Pública, s.f]
The prominent scientific accomplishments in the
field of health are: the attainment of the vaccine
against meningococcal illness, the recombining interferon and streptokinase, the tetravalent diphtheria-pertussis-tetanus-hepatitis vaccine, and the Haemophilus
influenzae type b vaccine (the first to be obtained through chemical synthesis). [Rodríguez, 2004; VerezBencomo & Cols, 2004].
Another Cuban achievement is the production
of the most important medicines against HIV-AIDS, like generics (which is provided to the patients gratuitously), and the therapeutic vaccine against lung cancer. [Rodríguez, 2004].
Amid these successes, certain ones have become
particularly renowned. The Haemophilus influenzae
vaccine originated an article in Science magazine
(U.S.A.), which appeared after the restrictive dispositions on the publishing of Cuban scientists’ documents
in that country. The therapeutic vaccine against lung
cancer has given base to an agreement between the
Center of Molecular Immunology of Cuba and the
CANCERVAC (U.S.A.) to develop and produce vaccines against cancer.As this is a totally unheard of fact it
illustrates, to a great extent, the level achieved by our
researchers and national scientific centers. [Rodríguez,
2004; Verez-Bencomo & Cols, 2004]. These are the
weapons our scientists use to break through the blockade.
The successful immunizations program, initiated
in 1962, has eliminated illnesses (poliomyelitis, diphtheria, pertussis, measles, rubella and parotitis). Immunizations against diphtheria, tetanus, pertussis, measles, tu205
berculosis, parotitis, meningococcal BC illness, hepatitis b, poliomyelitis, rubella and Haemophilus influenzae
type b are given to 95.1% of children younger than 2
years old. The program’s sustainability resides in the
national production of several vaccines, some of which
are unique in the world. It has been reported that
2004 was the first year in which not one case of tetanus has been registered. The country also arrived at
the 33rd year without any case of tetanus in newborns. [Cuba. Ministerio de Salud Pública, S.F; Rodríguez, 2004; Verez-Bencomo & Cols, 2004; De La Osa,
2005]
Other indicators that illustrate the Cuban population’s level of health are the infant mortality rate
(less than 10 for every 1.000 live births since 1993),
and the mortality rate in children younger than 5 years
(less than 10 for every 1.000 live births since 1997). Life expectancy at birth is 77 years for both sexes.
This succinct synthesis enumerates some of the
benefits of Cuban public health. These have been obtained during conditions of blockade and aggression
that include the prohibition to acquire medical equipment and export products from the U.S.A. Nevertheless, the political will expressed in the decision of the
government to sustain each accomplishment and advance onto new projects has prevailed. A manifestation of that will is displayed in the expenses statistics
of the health sector between 1990 and 2000, a period
in which the country suffered one of the deepest crises of its history that we now know as a special period
in times of peace (see table).
Not even in that critical moment were the expenses in health reduced, nor was any hospital or
health center closed. The number of beds in hospitals
did not decrease, the training of professional and technical personnel did not cease, and the prioritized pro-
HEALTH SECTOR EXPENSES COMPARED TO THE GNP AND THE STATE BUDGET.
PERIOD FROM 1990 TO 2000.
YEARS
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
EXPENSES IN HEALTH
EXPENSES IN HEALTH
(MILLONS DE PESOS) PER INHABITANT (PESOS)
1045,1
1038,5
1038,9
1175,8
1116,4
1221,9
1310,1
1382,9
1473,1
1553,0
1726,1
98,6
97,1
96,2
107,9
106,0
111,1
119,1
125,3
132,4
153,5
165,9
% OF THE
GNP
% OF THE STATE
BUDGET
5,3
6,4
7,0
7,8
6,1
5,6
5,7
6,0
6,4
6,1
6,1
6,6
6,3
6,6
7,4
7,5
8,0
9,7
10,6
10,7
11,6
11,9
Source: MINSAP. Anuario Estadístico 1998 y Centro de Investigaciones de Finanzas. Datos a precios corrientes.
206
grams of research and development were not cancelled.
The Results
It has been demonstrated that Cuba is efficacious, efficient and equitable in the attainment of the
population’s health, despite the intense blockade to
which it has been subjected for more than four decades. [De La Torre & Col., 2004]
With regards to efficacy –understood as the capacity to achieve objectives- [ILO. UNOPS, Eurada,
2000] the present discussion concentrates in the
achievement of three health objectives defined by the
World Health Organization [OMS, 2003] within the
framework of the evaluation of the Development Objectives of the Millennium. Concerning the reduction
of the infant mortality rate, Cuba reveals a marked
trend towards a decrease in rates of younger than 5
years as well as a decrease overall. The current levels
of those rates (8,0 in 2003 [Cuba. Ministerio de Salud
Pública, 2003] and 5,8 in 2004 [Granma, 2005], respectively) are among the lowest in the world. The goal of
reducing those rates between 1990 and 2015 by twothirds was accomplished 15 years before the established deadline. In relation to maternal health, mortality
was the ninth lowest among 36 American countries
during the year 2000. [OPS, 2002] With regards to the
combat against AIDS, malaria and other illnesses, Cuba
presents, according to criteria defined by the PNUD
[PNUD, 2003], the best classification, owing to very
low rates of HIV sero-positives and AIDS cases. In addition, the last autochthonous case of malaria was produced four decades ago. [Del Puerto, Ferrer, Toledo,
2002]. Regarding tuberculosis, the incidence rate is the
lowest in the Americas, equal to that of Germany and
Switzerland, and inferior to that of France, Great Britain, Austria and Australia. [WHO, 2003]
With reference to efficiency –understood as the
relation between resources and results-, [ILO.
UNOPS, Eurada, 2000] Cuba exhibits a prominent efficiency index, in both the state of health and its determinants, in relation to economic fulfillment and resources. This is demonstrated, in the American context, which includes highly developed countries such
as the United States and Canada. An example is the
fact that Cuba has accomplished maximum efficiency,
with regards to life expectancy levels at birth, infant
mortality rate and mortality in children younger than
5 years. It has also achieved maximum efficiency in
mortality by nutritional deficiency, as well as the number of doctors, hospital beds per inhabitant and calories availability, in terms of the economic resources
existing. [De La Torre, López, Márquez, Gutiérrez, Rojas, 2004]
We will look at equity in health as the minimization of inequalities in the population’s state of health
and its determinants (those inherent in different territories of a country), among groups of people living under distinct conditions. [Braveman, 1998] Cuba, compared to several American countries, including the
United States, has the lowest territorial inequality as
to life expectancy at birth, mortality in children younger than 5 years, maternal mortality, and low weight of
newborn children, [De La Torre, López, Márquez, Gutiérrez, Rojas, 2004] provided that life expectancy at
birth, as other aspects of inequality within health, reflect structural socio-economic inequalities. Moreover, the country is considered to be one with a low income gap/breach. Indeed, it has been evidenced that
the scenarios of major socio-economic disadvantages
are not just the ones of greater scarcity of resources
and generalized poverty, but those in which there is also a greater inequality in the distribution of income.
[OPS, 2003]
The extraordinary Cuban capacity to take action
to confront health problems has been evidenced in
207
multiple occasions. Noteworthy are the 90s, when the
socialist field disappeared, and the critical worsening of
the blockade by the United States caused Cuba to undergo what has been considered the most complex
moment of its history as an independent nation. [Lage,
1995] While the accumulated variation of the GNP
from 1981 to 1990 was 39.5% (24 of 32 Latin-American and Caribbean countries had a less significant performance than Cuba in the same period); from 1991 to
1995, the accumulated variation of the GNP was
–30.6%, the highest in the negative sense of Latin America and the Caribbean. In spite of this very difficult
economical circumstance, the situation of health did
not deteriorate. We should mention that while, from
1989 to 1993, the GNP decreased 34.8%, infant mortality was reduced by 15.3%, mortality in children
younger than 5 years was reduced by 10,3%, and maternal mortality reduced by 7,9%. [Oficina Nacional de
Estadísticas (ONE), 1995; Cuba. Ministerio de Salud
Pública (MINSAP), 1998]
It has been demonstrated that it is possible for a
country to be efficacious, efficient and equitable in management of health, despite its scarce economic resources. Cuba has been subjected to economic, financial and commercial blockade for more than 40 years
–with damage expenses estimated at 79.325 million
US dollars-, [Informe de Cuba al Secretario General
sobre la Resolución 58/7 de la Asamblea General de
las Naciones Unidas. http://www.granma.cubaweb.cu,
2004] but has a Health System that responds to the
208
population’s necessities. This health system does not
advocate market mechanisms by which the patient
turns into patient-client. Resulting from a group of factors motivated by the political will of the State, which
responds to the citizen’s interests, and their own will,
Cuba has successfully (efficaciously, efficiently and
equitably) managed health in the country.
The Battle
In Cuba we are summoned and immersed in a
battle of ideas. To this respect, Fidel Castro has said:
"Thus, I firmly believe that the great battle is to be waged in the field of ideas and not in that of weapons, however we will not renounce to their employment in
the case war was imposed to our country or another.
Each force, each weapon, each strategy and each tactic
has an antithesis emerged from the inexhaustible intelligence and conscience of those who struggle for a
right cause… Despite the risk of tiring you, I allow myself to repeat and reiterate: in front of sophisticated
and destructive weapons with which they intend to intimidate us and to subject us to a worldly economic
and social order unfair, irrational and unsustainable,
sow ideas!, sow ideas!, and sow ideas!; sow conscience!, sow conscience!, and sow conscience! [Informe de
Cuba al Secretario General sobre la Resolución 58/7
de la Asamblea General de las Naciones Unidas.
http://www.granma.cubaweb.cu, 2004]"
REFERENCES
●
●
ASOCIACIÓN AMERICANA PARA LA SALUD MUNDIAL
(1997). El impacto del embargo de EE.UU en la Salud y la Nutrición en Cuba. Resumen Ejecutivo.Washington, marzo.
BRAVEMAN P. (1998). Monitoring equity in health: a policy
–oriented approach in low-and_middle income countries. Geneva:WHO. (Doc.WHO/CHS/HSS/98.1).
●
GRANMA (2005), 3 de enero, p. 5.
●
ILO. UNOPS, EURADA (2000) Cooperazione italiana. Local economic development agencies. Roma; ILO, UNOPS, EURADA,
Cooperazione italiana. 150.
●
Informe de Cuba al Secretario General sobre la Resolución 58/7
de la Asamblea General de las Naciones Unidas. "Necesidad de
poner fin al bloqueo económico, comercial y financiero impuesto por los Estados Unidos de América contra Cuba". http://www.granma.cubaweb.cu (Consulta: 17 de noviembre de 2004).
●
CASTRO, F. (2003) "La gran batalla se librará en el campo de las
ideas" (Discurso). Granma, jueves 30 de enero: 4-5.
●
CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP) (1998). Salud en el tiempo. La Habana: MINSAP.
●
CUBA. MINISTERIO DE SALUD PÚBLICA (S/F).Anuario Estadístico de Salud 2003. MINSAP. La Habana.
LAGE C. (1995) "Intervención en el Foro Económico Mundial de
Davos, Suiza". Granma, 28 de enero, p. 6.
●
MARTÍNEZ, O. (2004) "Hemos denotado las maniobras enemigas
para asfixiarnos económicamente" (Discurso). Granma, lunes 27
de diciembre.
●
OFICINA NACIONAL DE ESTADÍSTICAS (ONE) (1995) La economía cubana 1994. La Habana: ONE.
●
OMS (2003). Informe sobre la salud en el mundo 2003. Francia:
OMS.32.
●
●
CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP). Anuario
estadístico de salud 2003. La Habana: MINSAP; Cuadro 21.
●
D' STEFANO, M. (2000). Dos siglos de diferendo entre Cuba y Estados Unidos. La Habana. Editorial de Ciencias Sociales.
●
DE LA OSA, JA. (2005) "Cero caso de tétanos. Por primera vez
en Cuba". Granma, martes 18 de enero:1.
●
●
DE LA TORRE E, LÓPEZ C, MÁRQUEZ M, GUTIÉRREZ JA, ROJAS F. (2004) La salud para todos si es posible. La Habana: Sociedad Cubana de Salud Pública. Cap. 4. (en imprenta).
OPS (2002). Situación de salud en las Américas; indicadores básicos 2002.Washington DC: OPS. (Doc. OPS/SHA/02.01).
●
DEL PUERTO C, FERRER H,TOLEDO G. (2002) Higiene y epidemiología; apuntes para la historia. La Habana: Editorial Palacio de
las Convenciones. 169.
OPS (2003). La transición hacia un nuevo siglo de salud en las
Américas: Informe anual de la Directora, 2003. Washington DC:
OPS. (Documento Oficial No. 312).8.
●
PNUD (2003). Informe sobre desarrollo humano 2003. Madrid:
Ediciones Mundi Prensa. 349.
●
RODRÍGUEZ, JL. (2004) "Hoy como nunca antes, se perfilan todas las posibilidades que se han creado para alcanzar una sociedad mejor" (Informe). Granma, lunes 27 de diciembre.
●
VEREZ-BENCOMO, V. Y COLS. (2004) A Synthetic Conjugate
Polysaccharide Vaccine Against Haemophilus influenzae Type b.
Science,Vol. 305, www.sciencemag.org Acceso el 23 de julio.
●
●
●
●
DIGITAL GRANMA INTERNACIONAL (2004). "Países que apoyaron nuestra resolución (179)". http//:granmai.cubaweb.com Acceso el 29 de octubre.
GRANMA (2003). Suplemento Especial. Informe de Cuba al Secretario General sobre la Revolución 57/11 de la Asamblea General de las Naciones Unidas. "Necesidad de poner fin al bloqueo
económico, comercial y financiero impuesto por los Estados Unidos de América contra Cuba". La Habana, 8 de julio.
GRANMA (2004). "Cuba y su defensa de todos los Derechos Humanos por todos". (Tabloide Especial), marzo.
● WHO
(2003). Global tuberculosis control: surveillance , planning,
financing. WHO Report 2003. Geneva: WHO. (Doc.
WHO/CDS/TB/2003.316). 146. 171
209
22
Uruguay: Community Participation in
Health and the Role of Epidemiology
Miguel Fernández, Sergio Curto
Agradecimiento:
Los autores agradecen a la
Br. Lucía Fernandez la información
y asesoramiento sobre algunos temas incluidos en este trabajo.
210
The onset of a progressive government in our country and the proposal of health system reform, implies not only institutional transformations but
also the expansion of theoretical and ethical principles for humanistic public
policies and services in the health system.At the center of this change, is people’s wellbeing.This scenario requires new and diverse approaches to health
care promotion, which focuses on citizens’ social rights.
Relevant background to this community driven effort is the different
programs implemented by recent progressive administrations of the Municipal Government of Montevideo. An example of this is the decentralization
and health participation that made up part of the Zonal Care Plan.
This Plan was founded on the ruling principle of integrating equity and
social justice to action, to give rise to co-management with the diversely
composed communities and organizations.The implementation of this municipal government plan was articulated in conjunction with the civil society, by
means of a clear agreement policy, which transferred resources to the neighboring commissions to develop services and implement programs.
The Municipal Intendance of Montevideo performs the ambulatory and
extra-hospital care of 300,000 people through its Zonal Multi-clinics.This population is comprised of a high percentage of homes with their basic needs
unmet.
The Zonal Care Plan represents a new concept
in integral health care, as expressed in its mission: "to
develop Plans of Zonal Care of health which, starting
from the Municipal Multi-clinics in coordination with
other health institutions, substantiate the basis for the
Local Health System. This presupposes a transformation or reform process of the care model and of its
management, as part of a political-administrative decentralization and social participation process, articulated by local government agencies".
tified the tactically important points at the departmental and zonal levels, determined specific priorities and defined short and medium-term objectives
and goals.
The Zonal Care Plan includes among its purposes:
"to bring about the continual diagnosis of zonal
health, as a guide to the activities of the health team
and the community, by way of a permanent process
of participative planning-action".
A component of the program is the Module of Basic Zonal Information.This is an instrument to permanently process district health information, in order to monitor and understand key aspects of the
health-illness situation and improve health management. The Module of Basic Zonal Information also
operates as the "historical memory" of the district,
and, therefore, can be used as a tool for improving
and updating the health program.
Components of the Plan of Zonal Care:
1) The changing of the health care model: "To make progress in the transformation process of the health care
model, reevaluating the concept of action integrality, with
an emphasis on promotion and prevention. To develop
care through integral programs, oriented towards highpriority groups of population and selected social priority
problems. To consolidate the interdisciplinary health
teams and strengthen their coordination with social workers of the Zonal Communal Centers" (Development
Program. Department of Hygiene and Social Care.
Municipal Intendance of Montevideo – 1990).
2) Programs of Integral Care (Promotion and Education in Health, Health Control, Preventive Activities, Preventive Diagnosis, Recuperation and Rehabilitation).
3) Technical Interdisciplinary Health Team made up of
professional and administrative members of the same Multi-clinic.
4) Zonal Health Diagnosis Systems (systems of epidemiological surveillance with geographical and population criterion). The activation of the Strategic
Planning Methodology in Montevideo (1994), iden-
5) Intra and intersectorial coordination.
6) Continual management evaluation.
7) Decentralization and neighborhood participation:
To have social impact there must be community
contribution. The work of neighborhood commissions implies a richer transdisciplinary outlook.
This outlook must incorporate the vision of those
involved, encompassing innovative perspectives
from cultural elements and knowledge not legitimized in the academy.
Via the Zonal Plan, several programmatic lines
are executed.To demonstrate this, we mention:
●
The Program of Children’s Integral Care provides integral health care to children younger than 14 years,
211
with priority given to preschool age children younger than 5 years, in the following subprograms:
- Control of newborns.
- Health monitoring of 12 infants up to 12 months
of age.
- Growth and development control program (younger than 5 years).
- Expanded program of immunizations. Control of
children of preschool age in Community Daycare
Centers
●
The Women’s Integral Care Program proposes a care model that takes into account all basic women’s
needs, the characteristics of their family and social
context, and promotes their active and responsible
participation in the social support networks. It
sponsors the training of health teams and participating neighbors to facilitate their orienting role at the
family and district level (Informed and Voluntary Maternity Hospital; Prevention and Genital-Breast Cancer Control; and Pregnancy and Post pregnancy Integral Care).
●
The Program of Dental Health Care involves preventive education and assistance aimed at children, adolescents and pregnant women. The preventive actions include local application of fluor-therapy, microbial plate control, education on the consumption
of carbohydrates and habits noxious to buccal
health. The assisting actions prioritize rehabilitating
care of permanent teeth. The zonal work, outside
these Multi-clinics, comprises of activities in public
schools and within districts.
As we have mentioned, the health plan modalities involve community participation, such as those
1. Extracted from: "Voces del Frente", semanario, Año I, Nº 14, Noviembre 2004.
212
coordinated amid the Municipal Intendance of Montevideo, the University and formal or informal social organizations. Among these, one can underline the research project "Management of Solid Remainders, a territorial approach from the perspective of social inclusion, work and production", undertaken jointly by the
Consultative Social Commission of the University of
the Republic, the Municipal Intendance of Montevideo
and the Labor Union of the Remainders Classifiers.
Finally, we must refer to the agreement between
ApexCerro-University of the Republic and the Municipal Intendance of Montevideo, which emerged from
the decision of the latter to perform the sanitation of
the districts "Casabó" and "Cerro Oeste". This Program has become an excellent opportunity to enhance health and development in the zone with university
personnel and the participation of the community.The
project includes critical zones from the sanitary viewpoint of the "Casabó" and "Cerro Oeste" districts in
Montevideo.
Among its objectives, we see the need to characterize and understand the social and population dynamics of the zones, which experience a critical sanitary
situation; zones like the "Casabó" district and the "Cerro Oeste" zone (through sanitary census of households and people). To characterize the social population dynamics, neighbors analyzed and discussed the
results of the census in workshops with technicianprofessionals.The community participation in this project implied 500 hours of work in neighborhoods located in the involved districts.
The Epidemiology of Change1
As we mentioned in the beginning of this report,
the humanistic spirit of the whole health program and
its basic assumption of the health field as a scenario of
social development towards people’s wellbeing and a
more righteous society, requires new scientific and
technical approaches.
A special chapter of such development is taking
place in the field of epidemiology and epidemiological
policies. A new paradigm must be implemented to affect deep changes in the way we conceive the role of
the State and the role of society in the struggle against
social determinants that mold the situation.
In the past, the evolution of Epidemiology, particularly in Latin America, has renovated ideas that position this special discipline in a correct relationship
with its study object -the community- and with its
main purpose -people’s wellbeing.
Epidemiology, historically evolving to the influx
of predominant political and social currents, identifies
with this new "social-medical" scientific discipline,
whose close liaison with the social derives from the
idea that "the health-illness process is made visible basically through the health problems of human groups"
[Martinez Calvo, 2003]. The correspondence between
epidemiology and society is a consequence of it being
the discipline that studies in a collective manner, the
events and processes occurring to populations.
These new epidemiological currents originated
within innovative propositions, which aimed at recovering the "correct approach to the epidemiological object", by means of the practice of a "Critical Epidemiology" [Breilh, 2003]. This practice addresses inequalities or inequities in health, as well as introduces innovative focuses, such as those of "eco-epidemiology" or
"ethno-epidemiology", some of which have been restricted to specific areas of medicalized conventional
Epidemiology until the present.
All these visions encompass a movement of renovation of Epidemiology that considers the social
matrix as the substratum of health problems and offers powerful tools for approaching the new challen-
ges that neoliberal globalization has brought about: the
accelerated increase of poverty and indigence; feminization and infantilization of poverty; increase of infant
work; massive unemployment; deregulation of working
and living conditions; migratory movements; and environmental problems.
The collective standpoint opposes and at the same time complements the classic concept of the individual clinical "case" being the study unit of health. Critical epidemiology applies a different paradigm, which
has a renewed rationale and logic in the construction
of interpretative models about health problems.At some methodological point, it needs to work with empirical data and sets of cases, but they are analyzed in a
different manner, and forms of stratification or grouping and searching for different sorts of relations with
contextual processes.
Advocates of this perspective stress the need to
expand the limited technical resources of the classic
quantitative conception (positivist paradigm) promoted by centers of scientific power, as an instrumental
resource to service political and economic interests. In
opposition to this, the new epidemiological currents
work on research approaches closer to the ethnographic model or paradigm (historical-anthropological) [Pinus, 2002], in order to rescue the potentials in
qualitative research that originate in the "social sciences".
Thus, the researcher, immersed in the social
context, collects and analyzes personal opinions, discourses, and actions to deeply understand their social
and cultural aspects, to know the community’s conducts motivations and experiences, and lastly to relate these findings to the process of health production
and deterioration. This is important because in conventional approaches, "The epidemiologists do not assume at present the complexity of the social and cultural fields in which illness and care develop" [Menéndez, 1998].
213
New epidemiology claims a greater social projection than that furnished by the analysis of illnesses
and individual risk factors, and thus conceives a conceptual framework based on social and communitarian
factors, in correspondence with the serious problems
provoked by the globalized market society.
The new progressive government needs this renewed epidemiology in order to institute spaces, both
governmental and non-governmental, and construct
the foundation for the "critical monitoring" of the
many determinants of health and illness. Also, it is necessary not to leave aside methodological advancements in statistics and mathematics, computer technology and academic advancements conventionally developed under the traditional schemes.
These new modalities of epidemiological surveillance, both non-traditional and non-conventional, intend to make possible real social participation and social "empowerment". It recognizes the need to change
the role of the collective subject in the health control
process. In other words, the Epidemiology of change
must generate the scopes and mechanisms so that the
organized society participates progressively in the
214
"evaluation and adjustment of the processes as a whole, and the scenarios of decision making" [Breilh,
2003].
The participation of the community in these processes is not just a way to exert a right acknowledged
by health international organizations [OMS/UNICEF,
1978]. Above all, it is a means to foster a different vision with respect to sanitary problems, which traditional Epidemiology does not consider, and allow us to
explain economical and cultural determinants; to understand the behaviors and interpretations of users or
beneficiaries of health services and its influence on
health indicators; and it is an instrument to study the
interactions of social groups and their implications in
collective health.
Hence, the organization of activities that respond to the objectives of social justice and wellbeing
in the health field, activities that are necessary to the
new progressive government, will be greatly enhanced
by the application of a renewed Epidemiology.This renovated approach is one that approximates the health
of the community by strengthening its own disciplinary
nature to reach the goal of people’s wellbeing.
REFERENCES
●
BREILH J (2002). "De la vigilancia convencional al monitoreo participativo" Centro de Estudios Asesoría en Salud (CEAS). Quito,
Ecuador. Trabajo basado en la ponencia a la Conferencia sobre
Salud en el Trabajo y Ambiente: Integrando las Américas – Salvador (Brasil), junio 9.
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BREILH J (2003). "Epidemiología crítica. Ciencia emancipadora e
interculturalidad" Bs. Aires, Argentina. Editorial Lugar..
●
FERNANDEZ GALEANO M (2000). "Descentralización y participación social en salud, La experiencia de Montevideo" OPS/OMS..
●
FERNÁNDEZ L. "Breve síntesis del trabajo con la basura en Montevideo: de hurgadores a clasificadores organizados, análisis político – institucional" monografía para publicar.
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MARTINEZ CALVO S (2003). "Epidemiología y sociedad" Rev Cubana Hig Epidemiol;41(2-3)
●
MENÉNDEZ, E (1998). "Estilos de vida, riesgos y construcción social. Conceptos similares y significados diferentes", Estudios Sociológicos, núm. 46, El Colegio de México, pp. 37-67.
●
OMS/UNICEF (1978). Declaración sobre Atención Primaria emitida con motivos de la "International Conference on Primary
Health Care, Alma-Ata, USSR, 6-12 September.
●
PINUS R (2002). "Paradigmas de Investigación en Salud" Córdoba, Argentina. Publicado en www.monografias.com
215
23
Real Equity in the State´s Supply of Public
Health:The Target of a Democratic
Municipal Government
Mónica Fein, Débora Ferrandini
This article is written from the perspective of those who participate in
the building of the socialist municipal administration of the city of Rosario.
This administration recognizes as its main achievements becoming the only
stronghold against the neoliberal current which has devastated the region in
the last XX years/ months.This achievement is evident through the construction of a citizen’s culture that upholds the values of equity and equality pertaining to health. Health as a basic right of all citizens is a goal built on 16
years of social struggle.
A praxis that was successful in reclaiming the notion of efficiency as a
token of the hegemonic discourse of market based neoliberalism, to reestablish it as a distinctive quality of the public sector, albeit, subordinated to equitable access.
We are not speaking of a finished model, of a finishing point, of a final
conquest. We can only discuss this as a powerful trend, and highlight how it
has had the strength to resist and move ahead in spite of the neoliberal
windstorm of 90’s. Through out this account we explain the building of this
new trend, even though we are conscious of the fact that its very difficult to
condense all the richness of a story intertwined with a diversity of socials actors, dimensions and contradictions.
The city of Rosario includes nearly one million inhabitants, and is situated in what was one of the most important industrial settings of the Argentine Republic. In the past Rosario was a city known for having extensive employ216
ment for migrant workers. During the 80’s and 90’s, the
unemployment crisis was exacerbated by an increasing
number of rural migrants, who were not necessarily in
the search of formal work anymore, but merely seeking
for survival and striving to have some access to public
assistance. In 1989, unemployment reached 7,4%, rising
to 20% in the course of the menemist decade. By 1989
Rosario was the epicenter of social outbreak and the
highest hyperinflationary.
In December 1989, the socialist party won the
local elections for the first time in history.The starting
point of the new administration, was marked by a clear
course shift, made explicit through a new form of budgetary structure:The budget assigned to the Secretary
of Health, rose from 8% to 25%; a similar increase occurred in the area of social promotion, which increased form XX% to 50% in activities directly linked to
the implementation of social policies.
Within the Secretary of Health, three new pillars
of administration were created: the Department of
Epidemiology, was assigned the objective of assessing
the population’s needs in health; the Department of
Education and Professional Development, was charged
with training the social change promoters among the
health workers; and the Primary Care Department,
was given administrative and financial self sufficiency,
and began organizing around basic public heath i n district communities called "barrios."
The district or neighborhood interdisciplinary
health teams assumed the challenge of working within
barrios on planning strategies focusing on establishing
equity, social participation, and clinical resoluteness.The
autonomy of practices in the neighborhoods and districts, the confrontation between the professional
perspective and that of diverse community actors, and
the complexity of daily life health problems, fostered
the development of an strong movement that persisted
despite its own contradictions.The team utilized theory and reality to solve daily problems and depended
heavily on the contributions of authors and academic
centers involved with Latin-American reality, such as
CESS, Mario Testa, the FIOCRUZ Foundation and the
Planning Laboratory of the University of Campinas.
Critical epidemiology and strategic planning was
combined with the social participation and, like so,
workers and communities expanded the perspective
of the possible, forming an institutive movement built
upon a micro-political transformation in the organization. This produced new values, new contracts among
workers, government and citizens, sustained in each
practice in defense of life. Universal and free health care, , constituted an target of the movement and an
obligation of the local state. Moreover, the daily experience of equitable, democratic, participative process
allowed citizenry to regain its viability, incorporating
those features to the consciousness of the right to
health, which was constructed in unison with the conditions for its practice. The philosophy of Primary
Health Care, equity, and peoples´driven conduction
was to leave behind their theoretical condition of utopian aims, to become part of real daily work.The operation of Primary Health Care, understood at the time
essentially as a strategy for the constitution of subjects
capable of fighting against the conditions that limit life,
implied primarily the possibility of dreaming and getting engaged in change. It also meant the development
of management strategies that would promote health
workers’ autonomy and a diversity of perspectives and
strategies, in order to account for the diversity of problems, interests and dreams, which coexist, not without conflict, in the reality of the city.
Learning how to value this conflict as positive
and focusing reflection, planning, and management
around it, continue to be the most arduous and fruitful task of the Department.
Revising managerial processes entails the necessity of deconstructing the bureaucratic organization,
by means of generating devices that structure the
217
forms of practice in relation to the community’s complex, dynamic and contradictory construction requirements. Bureaucracy solves conflict: it insures the only
voice that prevails is that of rules and authority. In deconstructing the bureaucracy, it was necessary to reexamine all the circuits of decisions designed around
this conception and substitute them for practices
which focused on communication and debate.
It was essential to rethink the organization of the
working process restructuring all the decision circuits,
however this process is distant from having attained its
maximum objectives.
Decentralization was essential in building of a
strong and efficient organization. It was necessary to
define guidelines that would make clear the responsibility each level of the organization. Clear roles and
responsibilities guaranteed that each decision would
be made as closely as possible to the level in which the
problem is lived. Every decision made in the enclosure
of the Secretary of Health reaffirmed the central guidelines of equity; community participation; social efficacy (prioritized over efficiency), but not excluding
prevention and health promotion.
The guidelines mentioned are summarized in the
three points:
●
Contextualized and effective forms of practice in
health care.
●
Strategies to achieve equity in the utilization of services.
●
Participative planning of actions in defense of health
and life.
Each of these three axes of work is senseless if
not intersected with the others, and is simultaneously
reformulated by that intersection. The accomplishment of equity in the utilization of services is a purpose of the local planning, which also makes propositions
218
that redefine and contextualize the clinical care strategies.
Accounts on each of these axes and the steps
towards their implementation are listed below.
Participative Planning in Defense
of Health and Life
It deals with forms of collective health practice
designed by way of local processes of participative
programming based on a dynamic epidemiological vision of the situation in each area. This local design of
programs and activities finds, at the district or neighborhood level, a context for negotiation and consensus among the different zonal perspectives, within
themselves and in their relation with the political strategies of the central level, in the bounds of the health
sector and beyond.This construction of direct democracy implied developing knowledge of socializing processes, which would encourage a permanent dialog
between technical information and popular knowledge
to produce a new way of understanding reality,. The
collective construction of the problem, that is to say,
of the situation to be transformed, involves retaining
information produced locally, with simplicity and rigorousness, attentive to quantitative and non-quantitative aspects for the description and explanation of problems, making it possible to share it with all the community sectors. The collaboration among the diverse
community actors, the technicians of the local health
team and other local state representatives (from other
sectors), not only makes possible the prioritizing and
clarification of problems, but also the explanation of
operations which confront them.
Intentionally, we speak of planning and not just
local programming, because we are dealing with the
construction of a local government that thinks strategically, and includes programming as a phase in the
process to transform reality. And one has to ask:
Which is the sense of that transformation? The one
defined by the resultant vector of the interplay of the
distinct actors that govern, along with their dreams, interests and desires.
The political decision of the municipal government to decentralize the management of the city in
six districts meant an important framework for the
development of democratizing processes. The local
planning was settled, at that point, as a essentially political activity, incorporated to an integral reform of
the municipal state. It was intended to bring the capacity of decision near that local context where the
problems are undergone. The districts are not naturally seen as distinct physical spaces, but as spaces in
continual construction, products of a social dynamic
where social subjects are stressed when set in the political arena.These districts, having been established in
the same perspectives of the municipal administration, facilitate an inter-sectorial approach. In any case,
within these districts, territories are recognized where the programming process acquires a more humane
scale, woven into the context of daily life problems. It
is around the influence area of each health center, defined as the space of interaction between the health
team and a territory’s population.The area is defined
starting from the places of origin of the people demanding services from the health center. From the
spatial analysis of the area delimited in that manner,
the co-responsibility for health between the population and the health service was defined externally, as
well as the differences that exist in its interior, all of
which implies the design of strategies, equally heterogeneous, to guarantee equity in the utilization of services as well as in the capability of participating in the
decision making process. Every territory is much more than a geophysical surface: it is an state of connections and conflicts, with diverse interests at stake,
with distinct projects and actors with distinct social
influence and power. It embodies a particular social
weave, where the economic and politic determinants
are inscribed in culture, ways of living, views surrounding sickness and dying of the population. Each local
team has autonomy to decide, to the work project including priorities, strategies to tackle problems, methods for evaluating the changes produced. One could
say that in the district, the different local realities hold
a dialogue among themselves and with the guidelines
of the central level.
The participative process made it possible to
confront the political and economical crisis, into which
the country had plunged in 2001, still with a deepening
of democracy. While twenty other Argentine intendants were compelled to resign in midst of an absolute loss of legitimacy of the politic class and the chaos
that monetary devaluation signified, the Intendant of
Rosario, Hermes Binner, kept the alternative project
alive by discussing in the district assemblies with the
neighbors, civil servants and health workers, the priorities and strategies that would support the defense of
life, in a moment in which the health budget had been
reduced to a quarter of its purchasing power.
As a direct form of management for the municipal economy, the population debates in each district
the budgetary priorities in terms of the problems it
identifies. This Participative Budget making, impelled
participation to transcend the limits of the health sector, mobilizing the inter-sectorial practice of civil servants and workers.
In sum, it is a question of structuring capacities
to recognize diverse and complex problems and to develop, along with people, peculiar resolutions to those
problems. Hence, the constant quest of a management
model, encourages the molding of health workers as
subjects who play a leading part and operate in constant revision, and promotes the removal of the institutional barriers that obstruct people’s participation in
the construction of their right to health.
219
Contextualized and Effective Forms
of Practice in Health Care
Clinical forms of practice should be linked to
clear health outcomes and not merely to rigid and abstract protocols. A way of coping with this, is to adapt
effective methods of practice to the social and cultural
context wherein the process of health illness develops,
to ensure the undertaking of each health problem with
integrality and continuity.We understand clinical health
care as the development and sustentation of an interpersonal connection, where the therapeutic team is
constantly responsible for the course of action of care,
even if it would include inter-consultations or references in other levels.This clinical practice must be reformulated permanently in reference to the epidemiological situation of the territory and be subjected to the local planning process. In this sense, we began working in
the appointment of rightful claimants to basic teams of
reference. Each team, composed by a minimum of one
doctor and one nurse, assumes the responsibility of the
health care of a number of families, and operates as
their agent in the net of services.To implement this, the
basic health team counts on the assistance of the rest
of the professionals of the local interdisciplinary team,
and the resources of the service network, so as to make certain the maximal degree of problem resolution,
and the appropriate use of technology.This network includes an emergency care system; three hospitals of
medium complexity; a maternity; a children’s hospital;
an adult’s hospital equipped for high complexity problems; second and third level rehabilitation centers; and
a Center for Ambulatory Medical Specialties.The later
has the specific institutional mission of providing with
the response, with specialized inter-consultation and
complementary studies, to the necessities submitted in
the health centers, with which patients obtain the appointment for specialized care without having to move
from one place to another, and the reference/counter220
reference of patients and cases is the object of a specific management. The Center of Ambulatory Medical
Specialties houses a central laboratory where the samples taken daily in the health centers are processed.
Progressively, the assignation of responsibilities territorially delimited to the specialists is being worked on,
with the intention that each one of them will develop
a stable association with a definite number of reference teams, and will collaborate effectively in the resolution of clinical problems by means of advising, drilling
or inter-consultation procedures, depending on the
best way, defined by the situation, to combine specific
knowledge with contextual knowledge.
Hospitalization pursues to sustain longitudinally
the therapeutic linkage, for this reason the hospital
teams include the ambulatory reference teams in the
discussion of each therapeutic project. The development of domiciliary hospitalization has allowed a rising
number of ill subjects to exercise the right to be at home receiving a more adequate, singularized, and efficient care than they would in the hospital context.
The medicines necessary for ambulatory care
and hospitalization are made available gratuitously as
through a therapeutic formulary that contains all required specifics, in different pharmaceutical modes; a
guide which was constructed with the participation of
doctors and pharmacists of the network. A significant
part of that medication is produced by the Laboratory
of Medical Specialties, a public entity that has promoted new medicine distribution policies and has confronted the risks of absolute dependence on the market. At present, it produces nearly the totality of parenteral solutions that are used in the various service
units of the Department and forty items that consist
of pills and injectable products. Processes of continuous education and auditing aim at rationalizing prescriptions, simultaneously they hinder the adherence to
chronic treatments seeking integral devices, which ensure that rationality.
Equity in the access to services entails also the
equity in the access to quality and appropriate technology and, at no rate, the state ceases assuming the responsibility of an integral response regarding care necessities, either furnishing directly or acquiring the response.The fact that this local initiative is developed in
a provincial and national context with no commitment
of the state beyond the "basic packages" of services
has pervaded this decision with growing challenges in
its concretion. Rosario has not abandoned this challenge, attributable to the political value inherent to
instituting as a universal right what other would consider nonessential for the poor. From the municipal
state, if a technology proves to be necessary, this is
worked on so that it is made available for all; if it is dispensable, this is managed so that no one has accessibility to it. A policy concerning an appropriate technology is founded in this principle, and this is translated
to the citizenry’s conscience of their right.
Prevention and rehabilitation are conceived of
integrated to the care process, in a manner that specific areas of support contribute with regard to mental
health, health of women, the AIDS problem and the addictions, tuberculosis, immunizations, the inclusion of
people with incapacities.
The process of transformation of clinical forms
of practice has permitted 22.000 women to choose
oral contraception, which they receive freely in municipal service units, and other 3.500 annually to decide
to use the DIU, IUD freely, too. Unwanted pregnancy
has reduced to a value of less than 4% of the total, the
Public Health Department having assumed the care of
60% of all the births occurred in the public sector. Immunizations coverage has reached 90% for the younger than two years old. In spite of the structural deterioration of living conditions in the country, the number of undernourished annually diagnosed in the municipal health centers remains stable and the census of
stature in first grade students made in 2003 have simi-
lar results than that of 1997. In the treatment of tuberculosis, 88% of adherence to it has been accomplished,
which contrasts tremendously with the limited 50%
that was obtained at the beginning of the changing
process. Mortality caused by AIDS has decreased significantly among the residents of the city of Rosario:
from 12 deaths of each 1.000 inhabitants in 1996, to 4
deaths of each 100.000 inhabitants in 2003.
The precedents are some of the indicators of a
process that has initiated, which is still not entirely given, which denotes a daily struggle against the inertia
of the status quo.
Strategies to achieve equity in
the utilization of services
Keeping to the conviction that inequity makes
people ill more than poverty, the management has understood that equity is brought about insofar as services are used in function of necessity, which generally
varies in a way inversely proportional to the capacity
of supply. Pursuing equity has meant knowing the population’s distribution of inequality in terms of living
conditions and its consequent distribution of illness
and death, and to develop strategies of positive discrimination that are capable of accounting for the peculiarities of each situation and ensuring the right to
health as well as people’s dignity and freedom, cultivating the capacities of listening, flexibility and dialogue
between the health services and the heterogeneous
necessities of the community. This has implied constructing, in all the contact points of citizens and the
net of services, devices of admission that interrogate
the necessity behind the demand, and analyzing continually the barriers to the access to services in the spaces of local planning.
It is more than enough to say that the changing
process encounters important obstacles within the
221
instituted bureaucracy, public management and the
educational institutions, even having to surmount their
own subjects of transformation. Hence, we speak of a
construction starting from its very contradictions.
In the subject of the education of health workers, several experiences were exploited that intended
to install a vector against the determinations mentioned. In this sense, practice periods inside district interdisciplinary teams were established as part of the educational curriculum of the basic specialties Master’s
degree. The General Medicine Residence was also
created with the objective of educating doctors for
them to be capable of integrating epidemiology and
strategic thinking to a clinical practice respectful of the
subject’s dimensions as a whole. Once graduated from
this program, they carried on feeding the establishment of the reference groups and progressively committing themselves to the management of change.
These axes are framed in an integral strategy,
which considers the construction of citizenry, the
constitution of individual and social subjects capable
of struggling against the limitations of life, as an ultimate goal of the work in health. Being this, a task assumed by the community all along history, which natu-
222
rally exceeds the potentialities of the health and public sector. The implication of workers of the health
sector as much as that of civil servants has been heterogeneous and difficult. Authoritarianism, alienation
and bureaucracy are raised as robust obstacles and
their fight is within the political, organizational and
subjective dimensions. This fight does not count on
everyone, currently, not even the greater part; it can
be assured that contradiction has installed in each
working team.
The constitution of management teams in each
health center has been a tool to imprint dynamism into an apprenticeship based on the problematic that
has promoted the creation of a critical mass of workers and communitarian referents. The management
teams were composed of every worker who would
accept deepening the discussion until the stage where
a consensus was attained, and being responsible of the
decisions produced this way.This collective of workers
and actors of the community has featured the quotidian process of widening the limits of what is possible,
seeking to overcome the contradictions, amalgamating
autonomy with responsibility. This experience constitutes, for this movement, its reserve for the future.
24
The Experience of Bogota D.C.: A Public
Policy to Guarantee the Right to Health
Mario Hernandez, Lucía Forero, Mauricio Torres
Since the beginning of 2004, Bogotá D.C. counts on a new administration headed by Luis Eduardo Garzón, who became Magistrate as a result of
the "Democratic Pole" electoral coalition which brought together progressive, democratic and left-wing sectors.
The government’s proposal has strengthened the Social State of Right
as its central axis, starting from the acknowledgement and advancement of a
set of social rights to the population. The District Department of Health of
Bogotá D.C. (SDS) had this idea at the center when constructing public policy and the main objective to advance these rights by the population of Bogotá D.C.
This document presents the essential elements of this proposition, balancing health in the city from the viewpoint of living and health standards
with population, social and institutional responses. Finally, the report defines
a strategy for guaranteeing the right to health in the midst of the complexity
of the current Colombian General System of Social Security in Health
(SGSSS) and evidences some of the results attained through the end of 2004
with the development of the public policy.
A Modern and Inequitable City
Bogotá has changed in several respects over the last 10 years. The sustained investment in infrastructure, transportation, public services and space, in
addition to advancements in tax and culture allow us to characterize Bogotá
as a modern city, or at least a city in the modernizing process. Conversely, it
223
is a city more inequitable than ten years ago. The number of people with unfulfilled basic needs ("necesidades
básicas insatisfechas"-NBI) has decreased, due to superior coverage of basic public services and sustained investments in infrastructure. Nevertheless, the number
of families that are not able to pay the growing cost of
those basic services has increased. Families often do not
succeed in accessing more complex health and education services. In the poorest parts of Bogotá, nearly 15%
of families could not afford to consume three meals a
day, as recommended by the Living Standard Survey of
June of 20031. This signifies poverty has increased; however the NBI measure does not provide a comprehensive view of the phenomenon. When we look at the
line of poverty (LP), which weighs family income against
the cost of goods and services, the problem proves to
be alarming. Between 1993 and 2003, the population
under the LP increased from 44,9% to 50%, roughly a
million more poor people. Under the line of indigence
(LI), there was an increase from 8% to 17% in the same
period [Alcaldía Mayor de Bogotá, 2004].
Families’ incomes have been affected by unemployment and labor precariousness. Within Bogotá, the
highest unemployment rate of the country persists, as
well as high underemployment and informal labor. In
2003, the city had a working age population of
5.317.000 people, a labor force of 3.558.000. A total of
593.000 were unemployed, 1.175.000 underemployed,
and 1.760.000 were inactive [DANE, 2003]. In 2004,
the labor force rose to 5.461 million, with an unemployment rate of 14,8% [DANE, 2004]. These statistics
exceed the ones registered in other cities by more
than 50%. In Bogotá, 36,6% of the labor force is concentrated in the thirteen main cities and metropolitan
areas of the country [DANE, consolidado 2000 a
2004]. If the displaced population is included in this fi-
gure, the situation becomes even more serious.
Though we face controversial data, all numbers coincide in reflecting a considerable and constant increase in
forced displacement during the last decade. According
to the Social Solidarity Network, in charge of offering
services to the displaced population the first six
months, between 1994 and February of 2005, 22.784
families representing 90.643 inhabitants arrived in Bogotá [Presidencia de la República, 2005]. Consistent
with the Advisement for Human Rights and Displacement (CODHES), between 1995 and 2002 358.188 displaced people arrived in the city [El Tiempo, 2003] this
difference demonstrates the great difficulty of the State to identify this population and respond to its needs.
Opportunities to create a secure future are not
equal.The progressive segmentation of the city has left
the poor segregated in certain localities. For this reason the Magistrate declared a social emergency within
six of the twenty localities. This inequality is most evident in the health of the Bogotanos. Although preventable mortality indicators have improved, the pace is
slow and has not brought equal benefit to everyone. In
1993, 90 maternal deaths per 100.000 live births occurred, compared to 2003, when 61,66 were registered.
During the same period, deaths of children younger
than 1 year old decreased from 26 to 15,05 per 1.000
live births. The deaths caused by preventable illnesses,
such as diarrhea and pneumonia, in children younger
than 5 years old decreased considerably. In the same
interval, deaths from diarrhea shifted from 30,9 to
5,16 per 100.000; and deaths from pneumonia dropped from 78,7 to 20,212. These could be considered
advancements if we did not have in mind the progress
made by other countries, which have accomplished
greater improvements in living standard. The United
Kingdom has a maternal mortality of 7 per 100.000 li-
1.According to calculations performed by the Research Center for Development (CID) of the National University of Colombia based on the ECV-2003 of the DANE.
2. DANE, Cifras preliminares
224
ve births, and an infant mortality of 6 per 100.000 live
births. Chile has this last indicator in 10 per 1.000; and
Sweden, in 3 per 1.000.
Despite these low rates, the majority of health
indicators reveal unfair and avoidable differences
among localities. For instance, in Ciudad Bolívar, the
rate of mortality among children younger than 5 years
old is 250,9 per 100.000 in 20023. In Teusaquillo, it reached 166,08 per 100.000. If we acknowledge the fact
that this is a question of children’s lives and not merely
numbers, then the difference between 217 and 12
seems intolerable. Sweden did not report any deaths
of children under 5 years old in 1999. In Kennedy, a
prenatal mortality rate of 809,9 per 100.000 live births
presented in 2002, while in Teusaquillo it reached
235,84. In Kennedy, the proportion of pregnancy, childbirth and post childbirth related mortality, was 83,27
per 100.000 live births, explicitly 11 women this year.
Comparatively, in Teusaquillo no deaths were reported. These inequities constitute the foremost health
problem of the population of Bogotá.
With regard to nutrition, during 2002 it was established that 11 of 100 live births had low birth weight
(less than 2.500 grams). Of these, 67% presented intrauterine malnutrition5. Among children younger than
7 years old, the Survey of Demography and Health of
Profamilia (2002) confirmed that acute malnutrition
reached 0,5%. If this analysis is applied to the populations of strata 1,2 and 3, which consult with the social
institutions of the State (ESE), the mentioned prevalence grows to 6,3%6.This is further evidence of social inequity. In Usme, the acute malnutrition rate for the total
population was 13,8% in 2002; in Usaquén, it was only
3,3%.
A Discriminatory and Inaccesible
Health System
The General System of Social Security in Health
(SGSSS), defined by Law 100 of 1993, had its major development in Bogotá. The percentage of the population affiliated with the Contributory Regime has remained nearly 55%. By December 31st of 2003, affiliated coverage through the Subsidized Regime in the
amount of 1.369.970 was obtained, corresponding to
19,95% of the total population of Bogotá (6.865.997).
Nevertheless, not all the quotas correspond to people: when the number of units per person paid in this
regime is taken, the number decreases to 1.099.164.
This implies that people, for reasons not always controllable by the insurer or the SDS, do not use all the
awarded quotas. There are still roughly a million and a
half people without insurance called "connected participants." They receive care from the public network
and by contacting the non-appointed network, with
resources from the Nation and the District administered by the District Financial Fund of Health (FFDS).
The supply of services has increased. In 2003,
the SDS registered 12.502 providers in the city7. Of
these, 2.196 correspond to health services provider
institutions (IPS), 31 to institutions of assisting transportation, and 10.275 to independent professionals.
At the end of 2003, 78% of the providers were situated in the north zone, and 11%, 6% and 5% in the southeastern zone, central eastern zone and southern zone of the city respectively. This distribution can be attributed to the dynamic of the services market, following the preferences of those making the offers more
than the population’s needs. At present, this is recog-
3. Población: Cifras del Departamento Administrativo de Planeación Distrital (DAPD)
4. Nacidos vivos. DANE, Colombia.
5. Certificados de nacidos vivos en Bogotá D.C. en 2002.
6. Secretaría Distrital de Salud de Bogotá D.C. Sistema de Vigilancia Alimentaria y Nutricional SISVAN.
7. The number was obtained as the result of the subscription realized by providers of health services to comply with the period established by the Decreed 2309
of 2002.The deadline is June 30th of 2003.
225
nized as a serious barrier for the poorest to access
services.
In line with the juridical nature, the private sector dominates: of the 2.196 IPS’s, there are 185
(8,46%) public, 1.684 (76,6%) private, 326 (14,9%) nonprofit foundations, and 1 (0,05%) mixed. The Capital
District relies on 10.223 hospital beds, of which 6.304
belong to the private sector, and 3.919 to the public
sector. This number illustrates an average of 1,52 beds
per 10.000 inhabitants, in accordance with the standards observed for the principal Latin-American countries. However, the appalling distribution contains a
series of barriers for people in the southern part of
the city to access services, which necessitates better
decisions regarding supply.
Despite the evolution of the System, serious
troubles exist in the institutional and social response
to health problems in Bogotá. The most significant is
fragmentation. Throughout various scenarios and studies, it is agreed that the health system is fragmented
in several senses: in the actions of the agents involved,
be they providers, insurers, modulators, or users; in
the distribution of services, since there are different
benefit plans in proportion to the payment capacity of
the people, such as the obligatory health plan of the
Contributory Regime (POSc), the obligatory health
plan of the Subsidized Regime (POSs), other complementary plans offered by private health insurers, the
plan of occupational accidents and professional illnesses (ATEP) of the System of Occupational Risks, and
the services of the special regimes. It is also divided
by the competition of territorial institutions and the
Nation, which impedes territorial regulation of the
system. Currently, it is not possible to know beyond
doubt which is the profile of tended morbidity of the
population of Bogotá. The SDS receives and analyzes
information about care provided by the ESE and other
IPS, however it does not obtain information about majority populations in the Contributory Regime. This si226
tuation is due to the resolution to centralize this information within the Department of Social Protection,
using numerous non-unified mechanisms, not allowing
territorial institutions to use it to make decisions.
Hence, a sufficient information system does not exist
to exercise the regulation of the system in concrete
territories, and information is reduced to supervision,
surveillance and control operations in the respects designated by the rules.
A second grave problem is the persistence of diverse barriers- geographical, economic, or administrative- to accessing services, especially for the poorest
and most vulnerable populations. For example, when
insurance contract providers that are distant from the
residence of the affiliated, or they establish administrative procedures that delay service provision and delivery of medicines, unacceptable barriers are created
that endanger people’s lives. The moderating fees, copayment and recuperation fees ignore the needs of the
poorest. Emergency care has unfair economic restrictions and administrative procedures, which diminish it
to minimal and inadequate interventions. Presently, it
is calculated that nearly 30% of the population is not
poor enough to achieve a State subsidy, and at the same time, cannot count on an adequate sustainable income to continue an affiliation with the contributory
regime. This population is increasing, largely due to
growing unemployment, underemployment, and informal of labor.
In the framework of insurance and in a mode of
care concentrated on illnesses, the emphasis has been
placed on individual curative care services, and the
preventive capacity has been undermined. The investment in preventive actions by insurers does not reach
the amounts established by the law, while the SDS public health office only received 8% of the budget in
2003. This manifests as a very limited capacity to prevent and intervene in primary problems of public
health in the city. The most important indicator is re-
lated to vaccination coverage. Between 1998 and
2003, the vaccination coverage of the Expanded Program of Immunizations (PAI) decreased between 5 and
25 percentage points. Still now, in spite of campaigns
and door-to-door vaccination programs, Bogotá is not
guaranteed to have effective coverage, even after having accomplished it in the beginning of the 90’s.
Though social participation in the health sector
has increased, it continues to be excessively institutionalized and oriented more to the needs of health institutions than those of the community. Additionally,
existing mechanisms produce a separation between
participation as a user and as a citizen, which is not
convenient. Although there is accumulated potential in
some associations of users and committee participation, their articulation is scarce, representative power
reduced, and influence in public local and district decisions is still precarious.
With this panorama, the overall appraisal of
health in Bogotá cannot be considered positive. Growing inequities and inefficiency in the social and institutional response of the System demand a reorientation. Even in the restricted framework of the current
SGSSS, the district administration has decided to take
firm steps toward supporting health as a public good,
an essential human right, a duty of the State, and a social responsibility.
A Health Public Policy to Guarantee
This Right
The Foundations
The three pivotal messages from Mayor Lucho
Garzón give an account of his vision for the city. "Mo-
dern and humane Bogotá" acknowledges modernization efforts, and asserts the priority of people. "Bogotá without hunger" puts forward a conception of poverty that recognizes the precarious situation of many
poor people and its relationship to income and employment of families. "Bogotá without indifference",
which gave a title to the District Plan of Development
approved by the Council of Bogotá D.C., expresses
the necessity of the Social State of Right to work with
society to surmount poverty and exclusion. It is a calling for collective action on the basis of solidarity, a calling for citizens to assume others’ perspectives, starting with human equality and dignity. The District Plan
of Development (PDD) is a summons to overcome
avoidable inequalities through the "construction of
conditions for the effective, progressive and sustainable exercise of integral human rights, established in the
constitutional pact and in the agreements and international instruments"8.
In this frame of reference, the District Department of Health of Bogotá D.C. undertook the challenge of advancing the right to health for the inhabitants
of the city. In line with the project defined by the Colombian Political Constitution of 1991 and the international pacts signed by the Colombian State, which are
compulsory for public management throughout the
national territory, the project aims to progressively
universalize access to integral health care. A human
rights approach was conceived to defeat inequities, as
much in the results as in the access to health services,
and ensure fulfillment of State duties, which requires
the conscious and systematic combination of the collective effort to redistribute the resources available
and the appreciation of differences among people.
This combination between redistribution and recognition is based on four principles that support the health
8. Alcaldía Mayor de Bogotá, D.C. Plan de desarrollo Bogotá 2004-2008. Proyecto de acuerdo. Bogotá sin indiferencia. Un compromiso social contra la pobreza y la
exclusión. Bogotá, abril 30 de 2004. Art. 1º.
227
policy in progress. Equity, understood under the maxim "from each one according to their capacity, and to
each one according to their necessity", constitutes the
principle guiding the priorities of intervention. Solidarity, rooted in the equality of human condition, permits
us to place ourselves in the viewpoint and circumstances of others, leaving aside our own. Autonomy as the
mainstay of liberty and self-determination of people,
allows the acknowledgement of our nature as acting
subjects, with all the capacities available. And the recognition of differences, which consents the comprehension and adjustment of public decisions to cultural,
ethnic, political, gender, and life cycle diversity.
Basic Proposals: A Mode to Improve Living Standard
and Promote Health, the APS
To move forward in guaranteeing the right to
health, it is necessary to rearrange the working mode
within the health sector of the Capital Districts. The
SDS has adopted a mode of care "to promote living
standard and health"9.This has brought about the rearrangement of all processes, both sector and transsector, institutional and communitarian, curative and
preventive, educational, protective, and rehabilitating.
The processes are as much individual as collective,
moving towards improving the living standard of the
people and the facilitating the exercise of their autonomy for the realization of their life projects.
The emphasis on illnesses care, a service of individual consumption, whose economic risk is protected with insurance in the frame of the current SGSSS,
has produced confusion between the right to health
and the contracting rights established among agents
found in the insurance and curative services market.
On this foundation, the vision and materialization of
health care has gradually proliferated, akin to the buying and selling process of merchandise. If the right to
health were assumed in the dimension the SDS has
proposed, the SDS would be required to change the
orientation of health services and undertake adequate models of provision.
This option has entailed the passing from one
mode of care based on illness –wherein the management of curative services dominates, the demands filtered and the needs of the population identified fragmentarily- to the imperative to respond to social requirements, through a mode of promotion of living
standard and health. The approach should be in line
with living standard and health needs by territories
and zones (ZCCCVS). This challenge involved the development of living standard spheres, in which social
needs derived from interdependent human rights are
expressed. Specifically, within the individual sphere the
organizing value is autonomy, emphasizing the capacity to manage for oneself, as well as the possibility to
achieve economic independence or to exercise an
emancipating political option. Within the collective
sphere, the central value is equity, the basis of redistribution. Within the institutional sphere, the values
are trans-sector operation, integrality, and democracy
to seek the maximum social efficacy possible. Within
the subjective sphere, the construction of social potential and imagination. Lastly, within the environmental sphere, the key value is sustainability.
The challenge to respond to social necessities
has required detailed identification in specific territories, differentiating these necessities from care demands, and understanding particularities along the lines of social class, gender, ethnic group or life cycle.
It has also demanded an evaluation of accumulated
9. Expression coined by doctor Armando De Negri Filho, Brazilian doctor, ex-coordinator of health planning of the Department of Health of Porto Alegre, adviser of
the SDS in the formulation of the district policy of health.
228
deficits in the institutional and social response, and
the registering of inequities or unfair and avoidable
inequalities to arrange the strategic design of new
responses.
Health Policy Objectives
The SDS has committed itself to the achievement of the following objectives:
●
To affect significantly the determining aspects of the
health/illness process, through different sectors, and
the articulation of health and social management of
territory.
●
To strengthen the exercise of citizenry in health.
●
To exercise the regulation of the General System of
Social Security in Health within the Capital District
to:
Orient health care towards an integral care system, which promotes living standard and autonomy of people.
Guarantee the access to emergency services, and
Primary Health Care (APS), with a family and
communitarian stance.
Consolidate the public hospital network and the
services networks of the entire system, in accordance with the population’s care needs.
Develop an integrated system of information in
health, which permits the observation of health,
equity and living standard goals, as guide to the
structuring of policies.
In order to accomplish these objectives, serious
transformations have transpired in the manner of thinking and organizing management and care processes,
as much in the interior of the Department as in the re-
lations with other State sectors, reinforcing the framework of the three structural axes and the objective of
efficient and humane public management of the PDD.
Currently, it has required the rearrangement of relations between the SDS, other agents of the health system, and communities. To attain this transformation,
the health sector has planned its actions in accordance with the development plan, using the central program named "Health for a proper life", and 12 sectorial investment projects.
The Family and Community Approach of the APS
The Department recognizes the relevance of the
main characteristics of the APS in the transformation
of the mode of care to meet necessities in health.
Among them: accessibility, inasmuch as the APS is the
entrance for easy, close and immediate access, recognized by the population as their permanent reference
point. Longitudinality, which presupposes a long-term
relationship between the population and the health
personnel in charge, is supported by the appointment
of families to a health team, and produces a close liaison between health professionals and people served
by them. Integrality, which organizes the set of actions
required to overcome the necessities presented by
the population. Finally, continuity, along with the health
team and the organization of APS turn become the
axis of response, either directly or by referring cases
to other care locations, guaranteeing the observation
and monitoring of care processes. These characteristics of the APS are assisted by the principles of efficacy,
effectiveness, and equity to ensure transformations in
the living conditions of peoples, and the ability to overcome existing inequalities through the optimal use of
resources available.
The point of departure consisted of locating specific territories to organize a response starting from
229
social necessities. There is a recent effort to actualize
the 20 experiences of local diagnosis, with social participation and the participation of first-level hospitals of
the public network. It served as a point of reference in
the identification of ZCCCVS within each locality. These zones display deficits of social response and inequities that allow the orientation of priorities of sectorial
and trans-sectorial intervention.
From a strategy promoting higher living standards and health, trans-sectorial government agendas
are being defined in the localities, anchored in organized social participation for the social management of
territories, with communication processes between
the health service networks and the sectorial and social networks, oriented to defeating inequities. A second organizing principle resides in defining the goal of
zero indifference about social needs, for which technical-scientific, economic, social and political means
exist, with the purpose of sustaining a social and government agenda.
Family and community health teams have been
formed and trained with this intention, with the aid of
the University of Toronto (Canada). These teams are
comprised of a doctor, a professional nurse, a nursing
auxiliary, and two or three health promoters, with some variations depending on the resources at hand and
territorial particularities. Each team is in charge of 800
families, an average of 3.500 people, according to the family composition in Bogotá. Families were assigned to
teams, and these are permanently connected with an
APS network, which includes association with the Primary Units of Care (UPAs), Basic Units of Care
(UBAs), and the Centers of Immediate Medical Care
(CAMIs), in the case of the public hospital network appointed, as illustrated in Figure 1. Simultaneously, the
development of similar complexes regarding private IPS
to progressively broaden coverage has been fostered.
The first activity of teams has been identifying individuals, families and territories. Increasingly, they have
230
created and expanded plans of family and communitarian care, in which the functions cited previously are integrated. This scheme undeniably allows participants
to overcome several barriers in accessing the health
services of the current system; hence, the denomination "Health to your home" of the central program
model (See figure 1).
Family health was organically incorporated in the
perspective of the APS, with the intention that teams
would not be isolated. As a matter of fact, their work
has facilitated the organization of care at the level of
service and support networks, articulated to sectorial
and social networks with the goal to promote higher
living standards and health. In the first place, we have
the APS network, but also one for specialized care,
another for emergencies, and an additional for hospitalization. Among the supporting networks, we have one
for pharmaceutical services,services; one for surveillance, another for rehabilitation, and one for diagnosis
assistance (refer to Figure 2). The networks will be activated consistent with the lines of care defined in the
vertical axes, conforming to needs defined by territories to increase living standard and health. By major
categories of collective problems, the goal is to make
them visible as challenges to overcome. Likewise, in
the horizontal axes, the construction of living standard
and health strategic projects is represented, considering the interrelated set of social needs within each
phase of the life cycle (childhood, adolescence, young
age, adulthood, and old age). Vertical axes correspond
to projects for the development of autonomy, by which
the causes and determinants of health throughout the
life cycle will be combated (see figure 2).
The construction of this complex structure of
networks, lines, and projects was conceived as a slow
process of adaptation to the conditions and necessities of people in specific territories. From the operational viewpoint, in the framework of the SGSSS, integration of preventive and curative services has been
achieved by articulating benefit plans according to the
financing sources (Basic Care Plan -PAB-, POSc, POSs,
non-POS activities, promotion and prevention activities of the insurance regimes). The PAB resources,
and in some cases those localities and occupational
risks have allowed the completion of projects relating
to the construction of social spaces and healthy atmospheres, such as homes, schools, work places, and
public spaces. To strengthen the exercise of citizenry,
fieldwork has begun within families’ every day spaces
to encourage less institutionalized participation.
The APS advancements
In December of 2004, 54 family and community
health teams had already been organized, operating in
zones corresponding to strata 1 and 2 (the poorest).
On March 7th 2005 the training of family and community health teams continued with 341 members of the
ESE, of the professional, technical and auxiliary level.
At the moment, 62 teams operate, which cover 41.072
families in sixteen localities, consistent with statistics
incorporated in the database through March 11th of
2005: Bosa, Candelaria, Ciudad Bolívar, Engativá, Fontibón, Kennedy, Mártires, Rafael Uribe, San Cristóbal,
Santa Fe, Suba,Tunjuelito, Usaquén, San Juan de Sumapaz, Chapinero and Usme.
The strategy constitutes the entrance to the
health system, through which demands are identified,
both the ones arising from unsatisfactory living standard and health and those that are a direct responsibility of the health sector and other sectors. Channeling demands to other sectors is performed in agreement with the obligations instituted by the Law, in harmony with the activities developed daily.
FIGURA 1 COMPLEJO DE APS
231
FIGURE 2 NETWORKS AND CARE LINES
The characterization of individuals, families and
micro-territories of the APS has been prepared through the handling of the respective characterization
form, delegated to health promoters and nursing auxiliaries of the basic team of family and community
health. The District Department of Health of Bogotá
D.C. has imparted clear guidelines among hospitals of
the appointed network, with regard to the fulfillment
of minimum requisites, which the members of health
teams ought to comply with. These must include civil
employees in the payroll, with certain seniority within
the institution, and a good level of knowledge about
potential problems within the zones in which they
conduct fieldwork. Health promoters, as well as those preceding, must be inhabitants of the micro-territory or the zone in which they work and have experience in community level work.
The existing family and community health teams
are acquainted with the local health diagnosis, updated
under the coordination of the District Department of
232
Health of Bogotá D.C., with the participation of the
community during 2003 and 2004 in each one of the
localities into which the Capital District is divided administratively. One of the criteria to select the territories where the strategy of the APS has been implemented was to belong to the most vulnerable zones
once the local diagnosis was identified, which in this
case correspond to the zones of Living Standard and
Health Conditions (ZCCVS) of type 1 and 2, and coincide with the strata of the city.
The worst problems have been evidenced in children without schooling, children and adults with acute
malnutrition, families that require relocation from high
risk zones, families that require the legalization of their
dwellings, and public services. All the population
groups identified have been channeled to the appropriate organizations: non-schooling children have been
directed to the Department of Education of the Capital District; the children and major adults with malnutrition have been connected to the program "Bogotá
without hunger"; families in high risk zones or in not
legalized zones have been routed to the Administrative Department of Emergency Prevention and Care
(DEPAE) and to the DAPD, respectively.
Environmental problems have also been identified in unpopulated areas, due to dumping residual
waste into the water, the presence of rodents and
arthropods, and zones devastated by environmental
contamination from contaminated particles in the air.
In this sense, from the Basic Care Plan (PAB) interventions have been executed to control environmental
problems for families living near unpopulated areas, in
conjunction with community education. Measures have been taken before the Administrative Department
of Environment (DAMA) to inform about the situations found regarding environmental contamination.
Further problems have been detected within the
community and are the direct responsibility of the
health sector, such as incomplete vaccination schemes,
in response to which vaccinations have been fulfilled;
growth and development problems in children, who have been linked with the growth and development programs; pregnant women without prenatal control, for
whom these controls have been initiated; and women
of fertile age, with whom the cervical cancer prevention
program has begun. At the same time, those affiliated
with the regimes of Social Security in Health have been
taught their rights and duties, along with educational actions and information clarifying the mechanisms for accessing services. The potential beneficiary population
has been identified via the Beneficiaries Identification
System (SISBEN) and conducted to the DAPD.
The institutions that have been collaborating on
strategy development of the APS are: the Colombian
Institute of Family Well-being (ICBF), the Administrative
Department of Social Well-being (DABS), the organizations participating in the Program Bogotá Without
Hunger, the Department of Education of the Capital
District (SED), the Operational Local Centers of Local
Planning (CLOPS), a number of Nongovernmental Organizations (NGO), the Administrative Department of
District Planning (DAPD), several Local Mayoralties, and
the Local Development Funds (FDL), among others.
The Public Health perspective and the APS
The the APS strategy has been implemented in
the ZCCVS 1 and 2, where the most critical conditions with respect to living standard and health prevail.
Within these zones, the highest rates of infant chronic
and acute malnutrition are concentrated (20,57% in
San Cristóbal and 13,87% in Usme), the major percentages of low weight at birth (5,74% in Ciudad Bolívar),
and the most elevated rates of maternal mortality
(Tunjuelito, 129,07%; Santa Fe, 112,87%; and Usme,
112,41%). Equally, high rates of homicide (Santa Fe,
97,69), and suicide (Mártires, 9,29) persist, very distant
from the average of the city, 25,3 and 3,8 per 100.000
inhabitants. Traditional infectious and parasitic illnesses continue, 52% of the cases of HIV/AIDS notified in
Bogotá, and 44% of deaths by AIDS. In this area we also seethe greatest rates of births from adolescents
between 10 and 19 years old (Santa Fe, 57,7 per
10.000; Usme, 51,22; Candelaria, 51,22; San Cristóbal,
48,83; and Rafael Uribe, 47,48). Women who live and
work in the sexual commerce region of the zones have limited access to appropriate living conditions of type II. Single mothers, infantile maltreatment, and
school desertion are situations directly related to sexual work. Sixty-four percent of the population of
strata I and II are located within these zones.
Derived from the particular diagnosis of these
Zones, the city’s undesirable health conditions were
identified, which prompted the formulation of "zero vision goals", as reference points for the joint efforts of
State and society institutions. The following were put
forward for childhood and adolescence: facing low
233
weight at birth; incomplete coverage of prenatal care;
childbirth and post childbirth maternal and perinatal
mortality; pregnancy in adolescents; vertical transmission of HIV and syphilis; infant mortality; avoidable
mortality by pneumonia and acute diarrheic illness in
children younger than 5 years old; acute malnutrition
in children younger than 7 years old; children with lice
infestations; scabies and parasitic intestinal diseases.Also morbidity by immuno-preventable illnesses; child
work problems; injuries by domestic accidents; home
vicinity school and public space violence; sexual abuse;
dental care and periodontal illnesses; infantile abandonment and maltreatment:Addictions in children and
adolescents; homicides in younger than 14 years old
were also frequent as well as careless child disability .
For the young population, the proposal of "zero
indifference goals" was assumed involving: homicides
and suicides, addictions, sexually transmitted diseases
(including HIV/AIDS), unwanted pregnancy, incapacity
without care, and prostitution without change alternatives. For the group of adults from 25 to 59 years old,
"zero indifference goals" were presented in: cervical
and breast cancer belatedly detected, family violence,
sexually transmitted diseases, infection by HIV, prostate cancer, unattended disabilities; absence of preventive measures for occupational accidents and occupational illnesses, maternal mortality, traffic accidents and
addictions. For adults 60 and over the "zero indifference goals" correspond to: chronic and degenerative
illnesses without care or with incomplete care, abandonment, periodontal disease without care, domestic
accidents, incapacity, and mental disturbances without
care.
Complementary to what was previously stated,
nine policy guidelines were implemented for children
and adolescents: mental health, HIV/AIDS, sexual and
reproductive health, maternal mortality, oral health,
environment, chronicles and schools promoting a higher living standard. Each of these was oriented by pu234
blic summon and the approach of promoting higher living standards and health toward overcoming serious
problems.
Thus, the first component of the rearrangement
was the management and care of identified needs and
sectorial and trans-sectorial interventions by life cycle,
from an integral care perspective. This last includes
the development of educational and protective activities, as well as those concerning health recovering and
rehabilitation. Individual and collective interventions
are executed in different contexts, such as homes,
health institutions, the non-institutionalized community, schools, work places, and public spaces. As such,
care responsibilities are identified within the APS network. Urgent care situations are made visible in the
rest of service and support networks, consistent with
requirements from the lines of care and technological
hierarchies and agents of the SGSSS. Simultaneously,
defining the context of the intervention has highlighted interactions with institutional networks of other
sectors that implement public policies along with the
social and community networks in specific territories,
in order to accomplish the territorial management of
the city. Additionally, interventions for all cycles are integrated, since the aspects related to public health management within territories in the frame of the APS,
have activities leading to the development of transsectorial programming.
Like this, the territorializing and solving of living
standard and health problems has moved ahead, by
means of a planning and local management exercise
with the participation of the community. Different local agents were summoned, and as a result twenty local diagnosis processes were actualized, which serve as
a basis for the identification of the ZCCVS, and to the
formulation of an equivalent number of integral health
projects, with which a solid articulation of resources
and interventions is expected facing the problems
identified. This perspective broadens the dialogue with
the strategy of APS and the social participation, through the proposition of social management of territory fostered by the Department, which in comparison, is being incorporated into the other organizations
forming the Social Axis of the District Development
Plan "Bogotá Without Indifference".
Thus, the Capital District advances toward the
implementation of the three objectives of public policy
put forward in the District Development Plan. At the
same time, the bureaucratic perspective of social par-
ticipation has been overcome, by strengthening the citizens organized mobilization. The power of this approach is its connection to and empowerment of the
community to demand the fulfillment of their rights,
and ensure major participation in health issues and the
management processes. The regulatory exercise of
the SGSSS has also been improved with agreement
among providers, insurers, and the remaining agents of
the territorial structure, emphasizing the needs for improved living standards and health.
REFERENCES
● ALCALDÍA
MAYOR DE BOGOTÁ (2004). Bogotá sin hambre. Un
compromiso social contra la pobreza. Bogotá D.C., enero de.
●
DANE, COLOMBIA (2003). Encuesta Nacional de Hogares, informe por departamentos.
●
DANE, COLOMBIA (2004). Encuesta Nacional de Hogares, informe por departamentos.
●
DANE, COLOMBIA (consolidado 2000 a 2004). Encuesta Nacional de Hogares, informes trimestrales trece áreas. Cidfas promedio del último trimestre de 2004.
●
EL TIEMPO (2003). Sábado 8 de marzo: 1-18.
●
PRESIDENCIA DE LA REPÚBLICA (2005). Red de Solidaridad
Social. Registro Único de Población desplazada por la Violencia.
Acumulado hogares y personas hasta el 28 de Febrero.
235
Action
From the Peoples
25
Health:
A Human Right
Frente Nacional por la Salud de los Pueblos del Ecuador
Health is a social, economic, and political issue, and primarily it is a right acquired by society. However, the implementation of neoliberal economic schemes
and their associated policies based on the dehumanized principles of the International Monetary Fund have lead to an Ecuadorian crisis, particularly within the
health and education sectors. Through mercantilist, restrictive and privatizing
policies, neoliberalism has generated labor precariousness with the freezing of
wages, a tertiary structure, and the dismissal of workers and consequences such
as major inequities and the disrespect of human rights, value crises, violence, drug
dealing, and free trade of weapons that kill popular protest. Specifically, monetary dollarization in Ecuador has created a country where efficiency and human
development are measured in terms of economic success, wherein money has
seized human conscience and dignity, and where macroeconomic indicators are
proportional to the growth of illness in children and old people death.
In this context, the Ecuadorian National Peoples Health Front was formed
by communitarian and district leaders, housewives, health workers, teachers, students, and professionals in general. It is rooted in coherent proposals on national reality and it intends to reestablish and reaffirm the universal right to health
whereby all the population would have access to health services to fulfill their
needs with equity, efficacy and efficiency. Moreover, we aim at sharing experiences among social movements, with a vision of change, whose mission is contributing to social transformation. From the viewpoint of the Front, we seek to
convert the community from an object to a subject and social agent with the capacity to deliberate and decide on health policy.
237
and unhealthy living conditions summons us to globalize our solidarity and the struggle for justice, with
the intention of jointly confronting the evils of the
present century.
WHAT ARE THE FRONT´S DEMANDS?
●
We demand the right of everyone to be heard and to
share their experiences, dreams, stories, knowledge,
and wisdom. For this reason, we think all these social
agents, people who are traditionally silent and not
listened to, have to unite in order to form a common
front.These people include shamans, healers, "hueseros", midwives, communitarian leaders, district and
communitarian organizations, health workers, students and professionals in different areas.
●
We aim to defend health as a priority and universal
right of human beings, by means of inter-institutional
coordination and community participation.
●
We aim to improve the communication among organizations committed to our ideals to help groups
socialize ideas; listen to suggestions, share working
tools, and support social change in regards health.
●
We strive for the formation of new fronts within
provinces, cantons, parishes, and distant and difficult
to access communities in order to multiply our
principles and proposals.
●
Violent and aggressive economic accumulation, indifference and even disdain for humanity, and the imposition of tariffs on account of public health services, has lead to the tragedy of the poor, who constitute 85% of Ecuador`s population.
●
In the middle of this generalized poverty, the deterioration of social and economic indicators, and the
accelerated increase in misery illnesses, such as infant malnutrition, tuberculosis, malaria, diarrhea,
dengue, low weight at birth, we oppose the collection of health services user fees. From this arises
the question: Public health to serve the poor, or the
poor to serve public health?
●
Furthermore, the imperialistic processes of globalization have disrupted people’s living styles concerning nourishment, recreation, and interpersonal relations.This process has strengthened individualism,
consumerism, and violence and insecurity in homes
and in the streets. This situates us as a country with
high rates of illness, violence, and death by preventable causes. Thus the State and society in general
should acknowledge health as a human right, a right
which must prevail and be prioritized, implementing
policies, plans and programs adequately and sufficiently financed.
●
Concurrently, this situation has created the presence of pathologies of development, such as diabetes,
cerebrovascular illnesses, traffic accidents, traumas
by violence, mental disturbances (stress and depression).This has lead to a mixed epidemiological profile, which will doubly require integral actions to be
eradicated.
DECLARATION OF PRINCIPLES
●
●
Economic changes throughout the capitalist world
have deeply affected the health of our people and
their access to sanitary care, education, employment, housing, potable water, and social well-being.
The gap between the rich and the poor, men and
women, children, young people and old people widens seriously, presenting a panorama of marginality
that infuriates and revolts us.
The contrast between the immense wealth generated by peoples and derived from nature and the millions of people suffering hunger, illiteracy, violence
238
●
Violence effected against nature by transnational corporations, timber dealer companies, shrimp dealer
companies, African palm companies, and the excessive total number of cars, has deteriorated extensive territorial areas, undermining our ecological potential.
●
The World Trade Organization (WTO), as an instrument of imperialism and specifically at the service of
the interests of North-American large transnational
corporations, dictates policies to implement the
Area of Free Trade of the Americas (ALCA). As a
component of the agreements, the incorporation of
health provision as merchandise to be supplied and
demanded in conditions of total inequity has been
instituted. An element of this strategy is the reform
in the health sector executed with loans of the
World Bank (raising the amount of external debt),
which has not aided in satisfying our needs and aspirations. In effect it has contributed to the decline
of health and to the conversion of institutions into
rigid companies directed by managers, extracting
surplus value from workers and people’s illnesses.
●
Decentralization in the area of health has turned into a process of transference of obligations to local
organizations without the resources necessary, violating social participation and the principles of solidarity and equity, with which the State plans to take
no part in its responsibility which was established
in Article 42 of the Political Constitution: "The State guarantees the right to health, its promotion and
protection, by way of the development of nourishing
security, and the provision of potable water and basic sanitation, the fostering of healthy environments
within families, at work, and in the community, and
the possibility of permanent access to health services, consistent with the principles of equity, universality, solidarity, quality and efficiency". What current
governments have accomplished thus far is the implementation of low-cost superficial measures that
seek a cosmetic effect on the health marks of a marginalized population, and a demagogic attitude with
regard to human suffering.
●
After a decade of application of the "Reform in the
Health Sector", the sanitary crisis within the country has become serious, corruption in the management of funds through MODERSA has implicated
even Secretaries, and public hospitals do not count
upon the minimum necessary to activate care and
others are sustained by the users’ money who become indebted or sell their minor belongings. In addition, professionals, workers, and employees of the
Department of Public Health constantly cease activities, since their wages are not paid on time.
TOWARDS A NEW HEALTH CONCEPT
AND PRACTICE
●
In the struggle for health and life, it is essential to
substitute the biological individualistic curative paradigm, which overemphasizes the role of hospitals and
medicines and underestimates the importance of
preventive measures that change the working and living conditions. . According to us, HEALTH IS A HUMAN RIGHT, and thus it must prevail over economic
issues. It is the result of people’s living standards in
close relation with nature, their working forms and
consumption. Thus, actions to be performed should
be integral, as much at the socioeconomic level as
the cultural and political ones, involving diverse
agents.
●
To strengthen Health Promotion, we need to begin
with new concepts, strategies and methods, making
the most of the existing best potentialities within
239
universality; by the distribution of wealth through social, economic, cultural and health policies, by the guidance and adherence to human rights, and by preservation of and respect towards environment. We
must seek alliances, commitments, actions, projects,
and platforms, with all the peoples and social agents,
which are identified with the struggle and work for a
healthy country, wherein people enjoy life.
our peoples to fortify and develop a social movement that seeks greater health and living standard in
our diverse groups and their territories.
●
Consequently, operating jointly and gathering diverse
sectors to achieve multiple actions makes Health
Promotion the feature of specific policy, inasmuch as
it contains aspirations that imply deep transformations of environments, individuals and groups, to
change negative conditions toward their human and
appropriate development.
●
The Ottawa Letter signed in 1986 by 38 countries in
the International Conference of Canada indicates
that, "Health Promotion consists in providing people
with the required resources to improve their health
and to exercise a major control over it." This means
that people are the only ones who can transform
their reality and make decisions about it. Therefore,
health, politics, and power relations must be present
within our movement, as much to demand from the
State as to exercise our right and responsibilities in
the management of health and life.
●
It is not a question of merely obtaining a budget increase for the health sector, but a Public Health based on health determinants must be concretized.
There must be legitimate social space to assume the
challenge of change, from "an agenda centered in the
consumption of medical care services, towards the
social production of health, with democracy and participation". This denotes we must operate to promote structural transformations that modify the
physical, social, cultural, and political environments
that influence the determinants of living conditions
and health, as well as the individual environments. .
●
Accordingly, our proposal of proper health and life for
our people is supported om the principles of solidarity, equity, justice, dignity, social participation, and
240
We are the ones who are dissatisfied with the
circumstances in which we live, and especially with the
crisis of the sanitary system of the country. Thus, we,
men and women of all ages and peoples of Ecuador
under the National Front for the Health of Ecuadorian
Peoples (FNSPE), with the purpose of unifying all the
agents of the health sector and society as a whole,
must merge our forces to create a new world, and a
free Ecuador that is sovereign and progressive. We
must pursue being an example of democratic and participative practice, which convenes governments to
orient health policies away from the impositions of the
International Monetary Fund, the World Bank, and other international agencies encouraged by the interests
of large capitals and profit. This entails the devisal of
sovereign, independent, democratic policies, wherein
the axis is human beings that are active and participatory, not as objects of make-up programs that conceal
their actual nature.
STRUGGLE PLATFORM OF
THE NATIONAL FRONT FOR
THE HEALTH OF
ECUADORIAN PEOPLES
●
To guarantee the universal access to Integral Health
Care of good quality, according to the needs of the
population and not its payment capacity.
●
To develop and sustain the Promotion of Health,
strengthening communitarian organization and participation, inter-sectorial work, multidisciplinary
and interdisciplinary fields in health and their problems.
●
●
●
●
●
●
●
To struggle for economic policies that are focused on
the promotion of health, equity, gender equality, and
the protection of the environment.
To adopt measures to guarantee health and occupational security, which comprise the monitoring of
working conditions focused on workers, prioritizing
people in greater risk (for instance, those who work
in floriculture, assembly plants and the informal sector).
●
To foster the elimination of criterions of cost-effectiveness as determinants of implementing health
programs and abolishing cost-recovering projects,
since they are producers of inequities and barriers
to the access of services.
To regulate the use of technology, production, and
the sales of medicines that subordinate the needs of
the population. To develop a national industry of
medicine production.
●
To direct health research, including genetics and the
development of reproductive medicines and technologies, to people and public health, respecting universal ethical principles.
●
To defend harmony with the environment, and the
protection of ecosystems and our biodiversity.
●
To connect the National Health System with Traditional Medicine and Alternative Medicines, respecting the biodiversity and multicultural aspects of our
peoples.
●
To pay the social debt by investing in health and education, primarily through reducing military expenses
and the payment of external debt.
●
To guarantee nourishing security and the equitable
access to foods, executing agricultural policies leading to the satisfaction of the needs of the population, and not to the exigencies of the market.
To curb the process of privatization of public health
services and social security, ensuring an effective
regulation of the private medical sector, including
charitable medical services and others from
NGO’s.
To promote and uphold participatory health programs oriented towards women, the eradication of
intra-family violence, and the fulfillment of the Law
of Gratuitous Maternity and Infant Care.
To establish promotion and prevention programs of
health for young people, with emphasis on sexual
and reproductive health.
To provide health care to major adults and incapacitated people.
241
26
Self Determined Peoples´ Proposals:
On Local Knowledge
Julio Monsalvo
Neoliberal Globalization Endeavors to Homogenize Cultures
Peruvian peasant leader, Hugo Blanco, making reference to the globalization phenomenon, affirmed during the World Social Forum 2002: "They
want us all to drink Coca-Cola and all our children to have fun with Pockemon1".
Feeling and thinking are neutralized by homogenizing cultures. Original
thoughts are changed from the proper values of each culture.The sought after effect is for all of us to have the same consumption models.
Economic groups have concentrated in a small number of hands powerful means of social communication. These modes of communication impose
images of "models of beauty, of success, of prestige, and of progress" according to the conceptions of neoliberal consumerism.[ Ramonet, 2005]
Likewise, formal education is not alien to this project. We have only to
examine the educational contents and methodologies in the majority of universities to realize they are functioning in the preparation of technicians and
professionals with this logic.
1. It is not a question of teaching peasants how to manage themselves, they already know! Fujimori passed
laws strengthening individual property. Peasants struggle for an agrarian reform. They struggle against the
contamination of rivers and lands. They march and block roads. The indigenous struggle undertaken in Peru
is part of the indigenous struggle in other localities of the continent. It is not surprising that, in view of the
attempt of homogenization of neoliberalism (they want us all to drink coca cola and all our children to have
fun with Pokemon), the cultures more distant to this homogenization, the indigenous, are the ones to react
against it. We were optimistic at the time we left this Forum, thinking our work in favor of a different world
would thrive. (Hugo Blanco at the Board of Testimonies, in conjunction with Rigoberta Menchú, Monday
4/2/02 at the World Social Forum in Porto Alegre, Brazil)
242
This has been witnessed, with aggressive particularity, during the decade of the 90’s in the "end of history" and the climax of neoliberalism.
Nevertheless, through this same decade and
continuing into the twenty-first century , the resistance movements world-wide become empowered and
strengthened: the proposals that emerge from the
Chiapas uprising, in Mexico; the anti globalization manifestations in Seattle, Nice, Prague, among others; the
creation of coalitions, such as ATTAC, Jubileo 2000; the
I World Assembly of Peoples’ Health in Bangladesh,
2000; the World Women’s March; the War of Water in
Cochabamba; the World Social Forums; and the numerous local, national, regional and continental social forums.[ Monsalvo, 2002]
It is not only a question of resistance to homogenization, but of an active affirmation of cultural identity through defending cultural values. These cultures
support diverse social paradigms that teach us other
ways of looking at and situating ourselves within the
world.
With different characteristics, these resistance
movements are also developed daily in local settings.
Resistance of Local Communities
Having disposed ourselves to an attitude of intercultural dialogue, we have begun to identify processes of popular self-organization in the South Cone of
our "Abya Yala"2, especially in Creole peasant communities and of Originating Peoples.
These purport to undertake integral health care
by means of self-managerial forms of practice, starting
mainly from local knowledge.
In the viewpoint of these communities, integral
health refers to the health of land, plants, animals, and
people, as an interrelated whole.
These processes of active resistance become visible and are shared within diverse and multiple meetings. We will refer, in particular, to the annual meetings designated as "Laicrimpo Salud"3.
"Laicrimpos" Meetings for Peoples´ Health
In 1990, a group of twenty-six nuns, who were
active in the movement Religious Communities Inserted in the Popular World, became aware of the fact
that their work accomplished throughout the Northwest region of Argentina in large measure was related
to health care.
That same year, they dedicated themselves to
specifically deal with "Sanitary Reality", from the perspective of the poorest populations.
After that, these meetings have taken place each
year, customarily during the first weekend of November, under several mottos that lay emphasis on the
sense of liberty, non-dependence, and self-managerial
organization.
The first meetings were attended by representatives of groups and communities of some provinces of
northern Argentina. After only a few years, the presence of delegations from other regions was already
remarked.
In addition to the people who were there by
their own means, was the gradual increase in participation of those who were sent as representatives of
their communities with the intention of sharing what
they did with regard to health care.
2. "Abya Yala", "Earth in Full Maturity" in the Kuna language is the name accepted in 1977 by the World Council of Indigenous Peoples for our continent. The term
was suggested by the Aymara leader Takir Mamani, reflecting the feeling of the Originating Peoples, who refuse to name their land, exactly as imposed by the invader and conqueror.
3. The article "Laicrimpo Salud: Un Movimiento" presents a synthetic historical account of these Meetings. Raíces Magazine, Ns. 30 and 31, Buenos Aires,April 2004.
243
In several cases, the same communities attended
to the collecting, in a common form through the "minga" (teamwork), of ways to settle the transportation
expenses.
In light of the significant attendance of people
who did not belong to any ecclesiastic structure, and
taking into account the suggestion from a nun, this
event was named "Laicrimpo Salud" (Laicrimpo
Health) ("lai" for "laical").
After 1996, health and education workers, as
well as workers of various social promotion institutions joined these meetings.
Despite having been suggested, the designation of
"Laicrimpo" was not substituted for "Meeting of Popular Health". People from the diverse communities
would not accept it, in keeping with the idea that "el
Laicrimpo ya es nuestro" (the Laicrimpo is already
ours).
During the last years the presence of representatives of neighbor countries Uruguay and Paraguay
became constant.
In Uruguay, after 2003, a similar event is carried
out, "Healthy Fair", which originated with the foundation of the "Informal Network of Popular Health." The
Informal Network of Popular Health makes explicit its
pertinence to the World Movement for Peoples’
Health.
Representatives of other countries, such as Brazil, Ecuador, the United States, and Puerto Rico, added
their contributions to the last "Laicrimpos". From the
very first meeting, in 1990, there have been fourteen
shared "Laicrimpos". This news, indeed relevant, acquires a major dimension given the non-existence of
any type of financing, or nongovernmental organizations, foundations, or "organizational commissions"
that could have been credited with the formation of
these meetings. The Laicrimpos continue to be selfmanaged as the expression of an authentic popular
movement.
244
With the purpose of understanding the development of these events, we allow ourselves to include a
synthesis of the chronicle of the Meetings completed
in the Province of Formosa, in the north of Argentina,
from November 7th to 9th of 2003, under the slogan:
Communicating among ourselves: the voices of the
Earth summon us! ("Comunicándonos: ¡Las voces de
la Tierra nos convocan!").
"650 people coming from the Republics of Uruguay, Paraguay, Ecuador and fifteen Argentinean provinces participated in the meeting. The abundant representation of the
Originating People of Pilagá stands out, as well as the artistic contribution of the Originating People Toba Qom, both
from Formosa.
After the arrival of the first groups, on Friday morning,
the "experiences fair" was enthusiastically formed.
In the sunny galleries of the establishment, colorful posters and pictures were displayed, and other eloquent samples of what has been done locally in support of health.
The joy and hunger of sharing, narrating and listening to
the diverse experiences were the constants in each group.
Once more, the acknowledgement that "few are many"
reinforced our sense of pertaining to a real World Movement for Peoples’ Health!
In the afternoon, that Friday, we gathered in an ample
hall to share welcome songs, the voices of originating peoples expressing their feelings and sufferings and narrations
that reminded us of the history of those events.
On Saturday, in an atmosphere of enthusiastic participation, 34 workshops were developed simultaneously, in
which the subsequent subjects were worked at:
Plants, Bio-energetics Method, Bio-music, Gemoterapia,
Art of Breathing, HealthArt, Domestic Uses of Solar
Energy, Local Policies of Sustainable Development, Agroecological Orchard, Micro doses, Mental Heath, Dental
and Oropharyngeal Health, Therapeutic Gymnastics, Pilagá Culture, Pilagá Own System of Health, Digiti-puncture,
Reflexology, Massages, Holistic Kinesthesiology/Kinesio-
logy, Club ODH (Obese, Diabetics, and Hypertensioned),
Cooperative Games, Habitat and Health, Home Homeopathy, Video Debate, Child to Child Program, Urohealth,
Healthy Nutrition, Communication, Mapuche Art, Antique
Knowledge.
The sole fact of the enunciation of these themes gives
an idea of the integral conception of health, enriched by
the valuable contributions of the originating peoples and
peasant communities.
The meeting closed with the traditional "bonfire" Saturday night and the following Sunday morning, when the distinct groups presented their conclusions and the proposals
that had been elaborated during the workshops.
After the commitment to meet the next year in El Do-
rado, Misiones,Argentina, we enjoyed listening to the voices
of the Young Choir of the Qom People and the contagious
joy of the Uruguayan delegation, who offered us original
songs. We said good-bye expressing the jubilation of the
Meeting, and with the certainty of having renovated the
enthusiasm in being the artisans of this Other Possible
World that is already beginning to show."
The following table intends to provide a historical overview of these meetings.
These meetings are annual manifestations of
what happens daily within multitudes of microphysical
spaces, as much in remote rural parts as in poor districts of large cities.
ENCUENTRO
AÑO
1
1990
Realidad Sanitaria
Posadas, Misiones
2
1991
Plantas Medicinales
Avellaneda, Santa Fe
3
1992
Hierbas Medicinales
Eldorado, Misiones
4
1993
Líneas de Trabajo para un Proyecto de Salud Popular
Resistencia, Chaco
5
1995
Nutrición y Alimentación Alternativa
Posadas, Misiones
6
1996
Salud en Manos de la Comunidad
San Pedro, Misiones
7
1997
Montecarlo, Misiones
8
1998
Reconquista, Santa Fe
9
1999
Resistencia, Chaco
10
2000
Red de Redes
Eldorado, Misiones
11
2001
Reconquista, Santa Fe
12
2002
Todos Sabemos, no Dependemos
Rosario, Santa Fe
13
2003
ComunicándoNOS: ¡Las Voces de la Tierra nos Convocan!
Formosa, Formosa
14
2004
Integrándonos Hacia la Tierra sin Males.
Eldorado, Misiones
LEMA
LUGAR
245
Additionally, numerous local and zonal meetings
are carried out, frequently named "laicrimpos."
The Sense of Pertinence
Where are the energies that mobilize so many
people generated? Which force is it that leads people,
families, and very poor communities to sell pastries
and turnovers ingeniously to attain the resources to
be able to travel hundreds and even thousands of kilometers to attend this meeting? What is that guides
young health workers to decide not to be present at
"scientific" events and to be here, at this type of event?
Is it maybe the valuation of a space of liberty or the
mighty sense pertaining to it?
It seems that in order to feel this love for life in
the universal mind, protest is insufficient; proposals
must be added to it and to activism.
This is experienced on an annual basis within the
"laicrimpos": there are proposals, instances of what is
done by families and shared with their neighbors. It is
a question of minority groups working locally in small
spaces, which are at the same time large, for it is demonstrated through these spaces that it is possible to
accomplish different things.
In these meetings, it is acknowledged that "few
are many", many in various parts of the country and
the world.
A Proposal from the State
Inspired in this quotidian popular featuring, the
State of the Province of Formosa activated its Department of Human Development to develop a Program
of "Communitarian Health"4.
The Constitution of the Province of Formosa since 1991 has recognized health as a right and adopts
the Strategy of Primary Care of Comprehensive and
Integral Health. This signifies that the constitutional
text incorporates the premises of the Declaration of
Alma Ata.[OMS, UNICEF, 1978] It is the only Constitution among the 24 Jurisdictions forming the Argentinean Republic which mentions the Primary Care of Integral Health.
Throughout history, we have already experienced
time and again that it is easier to approve a text or a
declaration or a Constitution, than to implement it. In
spite of this, we allow ourselves to share this attempt
to put this strategy into operation, at least concerning
some of its aspects, by means of this Program, initiated
in the beginning of 2002.
The Program is based on the following strength
ideas:
a) Community is all of us;
b) Integral Health (Health of the Local Ecosystem);
c) Addition of knowledge and doings (for the care of
integral health).
Since its launching, the objectives proposed were
as follows:
1) Promoting healthy habits throughout the entire population (including the health of health workers and
their working modes)
2) Facilitating, at the local levels, the dialogue "system
of health-community", with the intention that the
forms of family and communitarian practice develop into a part of the first level of care
3) Encouraging within the system of health the incorporation of different types of knowledge and useful
4. Constitution of the Province of Formosa, 2003, Art. 80: "The State recognizes health as a process of bio-psychic-spiritual and social equilibrium, not only as the
absence of illness, and a fundamental human right, as much of individuals as of society, contemplating their different cultural models. It will assume the strategy of
primary care of health, comprehensive and integral, as the fundamental nucleus of the health system, in keeping to the spirit of social justice".
246
procedures originated in traditional and natural
medicine for the care of integral health, and integrating popular knowledge of proven efficacy.
As a methodology, the Program is developed in
four scopes:
1)
2)
3)
4)
Field work;
Scientific activities;
Educational activities;
Communication.
In this manner, self-managerial knowledge and
doings have been systematized, and absorbed by the
families of communities:
1) Academic: alarm signs that indicate acute respiratory problems; homemade preparation of salts for
oral rehydration; therapeutic gymnastics; profit from
beehive products; care of plants; organic cultures;
elaboration of phyto-medicines and medicinal soaps;
use of microdose.
Two establishments have created a mini-structure of their own, which credits them the category of
"Centers of Local Production".
Scientific studies have also been completed, and
an interesting activity with nursing students of the National University of Formosa and professionals of the
General Medicine Residency.
Throughout the activities with students of the
intermediate level, we consider that one of the most
notable results has been the approximation of adolescents and older people of their family and community.
The young ones, on investigating natural health care
and nourishment, could value the older people’s wisdom. Moreover, they promoted and performed in
conjunction to the older people massage practices,
therapeutic gymnastics, and digiti-puncture.
Experiences such as the ones mentioned above
are examples of the participation, meeting, and interchanging spaces this program offers, whereby the
community gains a patent role.
2) Local popular: recognition of plants for health and
nutritional; homemade medicines; preparations with
plants; nutritious preparations with carob powder.
Reflections from the Viewpoint
of Popular Wisdom
3) Of other medicines: digiti-puncture; massages; distal reflexology.
Benefiting from popular wisdom has presented
us with a form of participation and with an attitude
of openness to dialogue all through these events of
great communitarian feeling. It has propelled us to
put forward our reflections, questions, discussions,
and to dare to effectuate proposals. Subsequently we
point out some of them:
We can share the achievements in these three
years. Within 7 hospitals and health centers of the interior of the Province and 5 health centers in the city
of Formosa, including the service providers of their programmatic areas, dispensations with diverse origins in
natural and traditional medicine and multiplying workshops have been accomplished; the latter have been undertaken by schools and neighboring groups as well.
1) A Change in the Cultural and Scientific Paradigm5: It is a question of shifting from an anthropocentric paradigm imposed by the occidental culture of
5. On paradigms we suggest the reading of Leonardo Boff (Ecología, grito de la Tierra, grito de los Pobres, Lumen, Buenos Aires, 1996) and Fritjof Capra (La Trama
de la Vida, Anagrama, Barcelona, 1996).
247
modernity to a bio-centric paradigm focused on
Health and Life.
lies and communities. Care, which is essentially a permanent and sustained accompaniment, is paramount.
This is what the discourse and form of practice of the
popular sectors described demonstrate.
Even having in mind the innate necessity that this right
to receive care conveys, it is by no means the totality
of the Right to Health.
2) The Right to Health: Neoliberalism shamelessly
incorporates the "right to health" to be the "right of
the consumer" and the "right of the individual consumer", knowing that this "client" is not able to elect to
have medical care, or medicines, or the apparatus, or
even access to the professional to attend to him/her in
the majority of cases.
The cultural perspective of integral health of peasant
communities and of Originating Peoples guides us to
restate the "Right to Health" as the Right to be and live in good health in a healthy world. It is about the
Right to Life and of any form of life, not only human
beings’ lives.
At best, the "right to health" has been reduced to the
"right to receive medical care".
3) Basic Necessities: Integral health, thus understood as the health of ecosystems, is the convening and
gathering topic of all these mobilizations.
In contrast, popular sectors "feel" health in an integral
manner, as has been well defined by peasant women of
Northern Argentina:
"If we want to talk about health, the first thing is to see
that the land is alive. If the land is alive, we will have
healthy plants and animals. And it will be possible for
us, human beings, to be healthy."
This leads us to the acknowledgement that the Right
to Health is greater than the right to receive care for
our health problems.
We would rather have this care materialize through
the dispensation of more adequate and culturally accepted procedures, starting from knowledge derived
as much from conventional as from traditional, natural,
and bioenergetics medicine.
At the same time, we aspire that care is furnished with
a commitment and a sense of humane warmth, involved in the feeling and thinking of affected people, fami248
From this emerges the vision that the Basic Necessities for human beings to live well, individually and collectively, amount to the "six A’s of Hope" ("seis A de
la Esperanza"): Air, Shelter and Lodging,Water, Foods,
Love, Art ("Aire, Abrigo y Albergue, Agua, Alimentos,
Amor, Arte"). If these six components are made available and allowed to themselves remain healthy in our
local ecosystem, we will undergo a state of health perceived as "Alegremia": joy circulating in our bloodstream. It is a question of a dynamic vision of health
and life.[Monsalvo, 2003]
For the dominant model, health is a "state of normality." Thus illness is conceived as a "deviation from normality."
Health is a process, which may be healthier every time
inasmuch as a change in the paradigm of the occidental culture is achieved. From reductionism, which understands illness as "a deviation" to this holistic and
ecosystemic vision of life, health is able to grow stronger and stronger.
4) Bio-centric policies: We support that formulating policies is a major priority, and primarily executing
them centered in life and in any form of life. And we
refer to policies regarding everything, not only health.
All policies should operate consistent with the principles of synergy towards concretizing the Right to
Health as a fundamental Human Right and an essential
component of the Right to Life and of any living form,
as already indicated. The Right to Health must be
comprehended as the right to be and live in a Healthy
Ecosystem.
We propose the formulation and execution of these
policies in the context of a participative and direct democracy, which consists in a revolutionary, quotidian
and artisan construction of that Other Possible World
already beginning to show.
We enthusiastically urge everyone to allow a life within love and happiness, in a world as portrayed by the
Declaration of Bangladesh6:
"A world whereby healthy life for everyone is a reality;
a world that respects, appreciates and celebrates
every life and every form of diversity; a world that permits the flourishing of talents and skills to enrich one
another; a world in which voices of peoples guide the
decisions that affect our lives".
5) Local Development: The interaction with peasant popular sectors and Originating Peoples demonstrates it is possible and advantageous to impel and
promote development policies of communities focused on ecosystem health, specifically taking into ac-
count the health of all its components. To facilitate
this, we suggest a Local Development with self-managerial emphasis, based on the development of solidarity spaces where knowledge and doings are shared, in
order to ensure liberty and surmount dependence.
This signifies putting into practice the idea that "We all
know we do not depend" slogan of one of the meetings of popular health in the South Cone.
"Health in the hands of the community is a concept of
liberty. Liberty is a value that makes us worthy as people, and dignity is an important component of our
health," in the words of peasant men and women during a Popular Meeting of Health in the North of Argentina in 1997.[INCUPO, 1997]
Local Development is founded on the following strategies:
●
Intercultural Dialogue and Theory and Practice of
Popular Education and Communication
●
Eco-literacy instruction7 .
●
Research with emphasis and qualitative methodology applied to Primary Care of Health of the
Ecosystems
●
Trans-disciplinary Work8.
The idea is to develop the self-managerial potentialities of families and the organized community, as much
in the personal-familiar scope as within the communitarian and institutional scope.
6. Declaración para la Salud de los Pueblos, Asamblea Mundial de Salud de los Pueblos, Bangladesh, 2000.
7. Eco-literacy instruction: concept proposed by Fritjof Capra in his writing "The Plot of Life" ("La Trama de la Vida") already quoted: "Comprehending the organizational principles of ecological communities and using them to create sustainable human communities". The coincidence with the vision of the peasant leader
Francisco "Tingo" Vera from San Pedro, Misiones is notable: "Let us read the book of the Forest, the book of Nature, which offer us so many lessons for the community of human beings. There are no problems since within the forest there is no egoism, they are always working one for the other". Boletín Red de Redes,
Nro. 9, junio 2004.
8. The trans-disciplinary is a qualitative leap in relation to the interdisciplinary: accomplishing an apprehension of the plot of life of ecosystems with holistic vision.
Max Neef, Manfred, Desarrollo a Escala Humana, Redes, Uruguay, 1993.
249
6) Primary Care of Health of Ecosystems: We
put forward the Primary Care of Health of Ecosystems as the adequate strategy to carry out these biocentric policies.
It is about an eco-systemic thinking, which allows us to
understand that people’s health and life is connected
to the health and life of every one of the components
of the ecosystem: the land, the water, the flora, the
fauna, the air, and, of course, the human species itself,
with its social, political and economical relations.
This thinking and feeling that we are all interrelated
leads us to a logic that compels the focus of policies,
strategies and plans to be concentrated in the promotion of health, each time healthier for the enjoyment
of life in happiness and love.
We believe that it is necessary and indispensable for
the continuity of life that we live in an ecosystem of
harmonious political, social, economical and environmental relations. This is possible, since it is the living
style the Originating Peoples teach us. They have always felt themselves a part of Nature, not as neoliberalism operating against it.
The multiple experiences shared in hundreds of
workshops (for instance, the World Assembly of Peoples’ Health, the International Forums in Defense of
Health, the World Social Forums, and several other
250
events to protest and propose) reveal that this dream
is possible.
These energies in defense of life, expressed by the
Originating Peoples ceaselessly, that feeling of being
part-of are the ideas that lead us to a political proposal that pervades all human activities: Primary Care of
Health of Ecosystems.
We refer to the ecosystem with the vision of the deepest ecology, namely human beings with their social,
political, and economical relations as another component of the ecosystem.
The Declaration of Bangladesh offers us a real plan of
action on formulating concrete economical, social, political, environmental, and sanitary challenges.
We propose permanent reflection on the problems of
Primary Ecosystems Health Care; a program to articulate transversally all governmental and organized community activities. Prior to each intervention, we necessarily have to ask to ourselves:
"With what does this endeavor contribute to the health of
the local ecosystem?"
[Monsalvo, 2004]
[email protected]
REFERENCES
●
ASAMBLEA MUNDIAL DE SALUD DE LOS PUEBLOS (2000).
Declaración para la Salud de los Pueblos, Bangladesh.
●
BOFF, LEONARDO (1996). Ecología, grito de la Tierra, grito de
los Pobres, Lumen, Buenos Aires
●
BOLETÍN RED DE REDES (2004) Nro. 9, junio.
●
CAPRA, FRITJOF (1996). La Trama de la Vida, Anagrama, Barcelona.
●
INCUPO (1997). Saberes Vivos y Diversos,Taller la Salud Popular,
Argentina.
●
MAX NEEF, MANFRED (1993). Desarrollo a Escala Humana, Redes, Uruguay.
●
MONSALVO JULIO (2003). Reflexiones sobre Salud Integral, El
Medico, Buenos Aires, enero.
●
MONSALVO, JULIO (2002). Protestas y Propuestas, Revista Raíces, Buenos Aires, noviembre.
●
MONSALVO, JULIO (2004). Ponencia en el Taller: Globalización y
Políticas de Salud, III Foro Internacional en Defensa de la Salud de
los Pueblos, Mumbai, India, 12-13 de enero.
●
OMS, UNICEF (1978), La Declaración de Alma Ata,.
●
RAMONET, IGNACIO (2005). Medios en Crisis, Le Monde Diplomatique, "el Dipló", Buenos Aires, enero.
●
REVISTA RAÍCES (2004). Nros. 30 y 31, Buenos Aires, abril.
251
27
Work, Health and Self-Management:
An Experience of Articulation between
Self-Managed Companies and Public
University in Argentina
Jorge Kohen, Germán Canteros, Franco Ingrassia
Emergence of Self-Managed Companies in Argentina
A birth is not a casual fact. The successful auto-managed, communitarians, jointly responsible companies recuperated by the workers are a creative collective expression in front of unemployment. Little by little they take
the shape of a new productive sector of the country.
They are born as a consequence of a multiple and complex process that
conveys the rupture of the circuit signed by illusion, anguish, depression and
isolation, through which unemployed workers transited and still transit.
The reencounter and reestablishment of the ties among "compañeros"
were produced by means of the organizations fashioned in struggle. By the
end of the 90’s, the blocking of roads, which set off in Cutral Có and Tratagal
gave origin to a new social actor in Argentina, the "piquetero" (street fighter)
movement. This new social actor generated a qualitative leap, permitted the
reestablishment of the ties of solidarity and the emergence of a new identity
and, thus, constituted a sanitary act of first magnitude.
This first step was deepened in the opening of the new century and
propelled a further qualitative leap in the struggle and in the development of
the social movements that resist and confront the neoliberal model: the recuperation of the companies abandoned by the employers and the launching
of the cooperative production. The worker who manages production and
his/her work force by him/herself arrives on the scene.
252
This is still an open process, subjected to diverse
technical, productive, political, financial and organizational difficulties. It is starting from the possibility of collective approach to these obstacles that self-managed
companies have developed a set of connections with
distinct institutions and national and regional organizations. In this instance, the participation of the public
university reencounters some of its foundational definitions in the role of the space of production of knowledge at the service of society and its movements. Human resources and university forms of knowledge are
reoriented and reformulated here, as of the practical
connection with specific problems that stem from the
experience of productive self-management.
The Context in Which
These Experiences Emerge
The process of globalization of its economy and
particularly the processes of Regional Integration
(MERCOSUR, NAFTA), in addition to the role of the
International organizations as the new regulating and
determining devices of the policies to be applied and
the importance given to the massive means of communication and information have played a central role in
the new social, cultural and ideological configuration of
Argentina.
Neoliberalism materializes by way of a contradictory process of gestation of hegemony combined
with coercion. This has had the effect of an increase
in the levels of social conflict, which have constituted
the determinants of the workers’ profiles of health/illness.
One of the most dramatic emergent circumstances has been the phenomenon of unemployment throughout all of Latin America. During the first semes-
ter of 2004, the Latin-American average unemployment reached a 10%, while in an equal period in 2003
the number rose to 11.4%, arriving at the highest level
in the last 30 years1. Consistent with National Institute of Surveys and Census data, in the last trimester of
2004, levels of unemployment and underemployment
in Argentina hit 13.2% and 15.2%, respectively.The process and magnitude of unemployment and underemployment can be observed in Diagram 1, taken from
the Clarín newspaper [Diario Clarin, 2002]
If we include in this the analysis the historical
evolution of poverty and indigence, we will have a more precise picture of the process and of the social scene generated by the economical policies applied and
the context where the phenomenon of recuperated
companies is expressed. During the second semester
of 2003 (last data published by the National Institute
of Surveys and Census), the rate of Poverty reached
47.8% and that of indigence 20.5%. It can be inferred
from these numbers that income insufficiency continues to be the chief problem of the Argentinean society. Nearly half of the population is below the Poverty Line, and a quarter of it, below the Indigence Line.(Diagram In present Argentina, more than 18 million people live in a situation of poverty. Among them,
close to 8 millions have their existence further compromised since they are indigents and thus live in a state of extreme vulnerability. This vulnerability is manifested in modes of disaffiliation and social exclusion.
This process described quantitatively starts off in
Argentina with the coup in 1976 and deepens in the
90’s, producing a major restructuring of the social
work force. The fundamental characteristic of this restructuring is the fragmentation of the work force in at
least three preponderant sectors: stable work, precarious work and non-work. In line with their localization in one of these three sectors, workers are force
1. Source: Panorama Laboral, OIT. 2004.
253
254
into distinct labor conditions and health problems. In
the case of the stable work sector, a weakened social
security system, exposure to specific hazardous processes, ergonomic exigencies, increase in the working
rhythm, and work formally prescribed continuously
out of phase with work actually completed are consequences. In the case of precarious work, the workers
experience lack of social protection, multi-exposure to
hazardous processes, generalized exigencies, and the
excessive physical and psychological wear out, triggered by mobility and intermittence. Finally, in the case
of the non-work sector, workers are submitted to difficulty in the access to the health system, diverse modes of social cultural disaffiliation, and generalized deterioration of health. Moreover, it is possible to observe the intensification of infant work as a family previous survival strategy and, in a number of cases, to
movement towards illegality (Diagram 3).
Work and Health: Some Points of Departure
to Think About
In prior work we have stated that workers’
health is decided among the conditions they meet in
the two moments of their vital cycle: Production
Consumption and Wear out Reproduction.
The determining factors of health are developed
through a set of processes, which acquire a distinct
projection before health, according to the social conditioning factor of each space and time, namely in line
with the social relations in which they develop. These
conditions can be the construction of equity, maintenance, and perfection, or, in contrast, they can be elements of inequity, privation and deterioration.
In the same way, society creates processes
that acquire protective and beneficial (healthy) properties or destructive and deteriorating (unhealthy) properties. When a process grows to be beneficial, it
turns into a propitious aid to defense and support. In
time, it moves in the direction of favoring human life,
individual and/or collective, and is a protective or beneficial process; conversely, when that process grows
to be an element which provokes privation or deterioration of human life, individual and/or collective, it is a
destructive process. A process can correspond to different dimensions of the social reproduction, and can
become protective or destructive according to the
historical conditions in which the corresponding collectivity develops [Breilh, 2003]. Nonetheless, it is es-
RESTRUCTURING OF THE WORK FORCE
STABLE WORK
PRECARIOUS WORK
NON WORK
weakened social security
lack of social protection
difficulties in the access
to the health system
exposure to specific hazardous
processes
multi-exposure to hazardous
processes
infant work
ergonomic over exigencies
generalized over exigencies
psychological deterioration
prescribed work out of phase
w/completed work
255
sential to point out that both types of processes do
not exist separately; it is rather the concrete development of the processes of social reproduction that makes the preceding acquire protective or destructive
characteristics, consistent with the types of mechanisms they incite in the human genotypes and phenotypes of the group involved.
Operability in one or the other sense can have,
as well, a permanent character and not be modified
until the living style does not undergo a leading transformation, or can have a contingent or yet intermittent character. The processes, in proportion to their
relevance in the definition of the characteristics of life
and the weight these have in the corresponding living
style, can trigger alterations of major and minor significance in the epidemiological development. For instance, the working process, which has a considerable
impact in the conformation of living style, generally
brings about deep negative changes in health when it
acquires destructive characteristics. Opposite this, that
same working process can incite important protective
consequences, even developing under destructive circumstances.
This means that a process can simultaneously incite events of both types. To illustrate the contradictory character of social life facing health take the following hypothetical case, where a job, which may be
badly remunerated and possibly completed under
stressing conditions, physical postural overburden, and
chronic exposition to toxic substances (destructive facets), at the same time can contribute to the organization of time, to learning, to the construction of a meaning of life, to the attainment of a exchange value of
the work force (protective facets).
The facets are more visible in the epidemiological profile depend on the living style and the logic that
operates in the corresponding social formation. There is always that movement of protection / destruction. However, the fact of being expressed in one or
256
other direction of a particular group at a particular
moment depends on the character or logic under
which the social reproduction operates.
Critical processes, in the words of Jaime Breilh
[Breilh, 2003], are selected in line with their magnitude of intervention and their capacity to incite significant and sustainable consequences in the living style.
As in every contradiction, the fact that one or
the other pole may not be noticeable or empirically
observable does not imply it does not exist, but merely that, at that specific moment of development, it is
attenuated or dominated.
Hence, the labor process is neither intrinsically
and purely beneficial to health, nor exclusively hazardous. Its beneficial aspects and destructive facets coexist and operate in distinct manners in accordance
with the historical moment and its social group of
membership. In the working centers, subjects face
specific conditions. The capacity to deal with them depends on the capacities and supports they count upon
as a collective and the individual conditions of defense
and reserves with which they live.
Consequently, when workers accumulate and intensify in their labor process the destructive modes of
work, such as forms of shortage and deformation of
consumption derived from wages, family or cultural
alienating patterns, and the absence or weakening of
organization, there is an increase in the power of wearing and prejudicial processes. This consequently
brings the individuals and collective of workers near
the illness pole.
Opposite this, if working conditions are favorable, workers will follow more closely to the pole of
health than that of illness [Kohen, Canteros, 2000].
Favorable conditions include the content and organization of work that permits the development of creativity and freedom, a collective of workers that control and dominate the working rhythm, the establishment of democratically organized production, and a
remuneration system that allows the access to goods
and services that guarantee the satisfaction of the
range of existent human necessities at a precise and
concrete historical moment of society. At both moments, workers meet both protective and healthy
processes.
When workers realize their loss of formal jobs,
their life as unemployed takes place in the family setting and consumption and social reproduction shortages multiply. In studies carried out in 1994 and 1995,
related to labor fieldwork (Faculty of Psychology of
the National University of Rosario), and in subsequent
studies, we established that, regarding one`s mental
health, the unemployed worker moves through the following circuit:
Illusion – Anguish – Depression
Following this circuit generates a series of significant subjective impacts:
●
Identity disturbances
●
Depression
●
Depreciations
●
Rupture of liaisons
●
Collapse of existential projects
In conjunction with these aspects of the deterioration of unemployed workers’ mental health, we believe that an expression of the wear suffered and the
imprint left by labor conditions is contained in the category "labor remaining capacity". This, we have defined as the confrontation between the remaining skills
of the subject and the exigencies of the productive
process (historically and socially constructed)2. When
a worker is left unemployed, experiences a labor accident or is expulsed from the working center on account of an illness, he/she faces his/her life and establishes their way of passing through life with the labor
remaining capacity.
Workers whom are exposed to a series of hazardous processes at work and the negative impact on
their psychic configuration have to undertake restructurings in the way they transit through life.This is manifest in the set of restrictions to assume a complete
labor life and unfold their potentialities.Thus, it follows
that they must assume work from the new "normality"
attained, with the freedom permitted by the capacities
they still possess.
This gains major relevance in two senses. One is
pronounced at the time of trying to be reinserted in
the working process. As a first issue, and once he/she
has obtained the job and has finally surpassed the long
line of aspirants, the worker is put through the pre-occupational exam and/or the occupational medical-psychological tests and this is where the social difficulties
become evident and the labor remaining capacities are
sturdily expressed. This test illustrates explicitly how
much capacity the worker has left and what percentage of incapacity the worker has. A large amount of
workers are disqualified in this exam, prevented from
acceding to the jobs.
Furthermore, the worker transits having restructured his/her living style. Namely, all the wear accumulated at work restructures the worker’s normality
from the frame of restrictions. For this reason, we
conceptualize the labor remaining capacity as an
emergent where the historicity of labor courses remains imprinted and is empirically manifest in the suffering, symptoms and illnesses which workers present.
2. Concept developed by Jorge Kohen and Mariano Musi in Reflexiones sobre Salud y Trabajo en la Carrera de Especialización en Medicina del Trabajo, Facultad de
Ciencias Médicas UNR Inédito; Rosario, 2004.
257
To Occupy, Resist and Produce:Towards
a Definition of the Self-Managed Company
The deepening of the economical crisis and the
processes of deindustrialization prompted by the systematic application of neoliberal policies in Argentina
lead to the newest of social phenomena: the recovering by the workers of nearly 200 bankrupt and abandoned companies. The recuperated and self-managed
companies are the creative expression in front of
unemployment and its devastating effects.
The processes of recuperation and self-management emerged spontaneously in distinct locations of
the country. Subsequently, they have grouped themselves according to diverse strategies and modes of organization: the National Movement of Recovered
Companies, the National Federation of Cooperatives
of Work in Reconverted Companies, and the National
Commission of Solidarity with the Occupied Factories.
The term self-managed company relates to the
undertakings comprised in a model of organization in
which the articulation and the economical activities
are combined with property and/or accessibility to capital goods and work and with the democratic participation in management of its members. This model
promotes the cooperation of the collective of workers in the productive and administrative activities.
The productive self-management is the extension of
the principle of participative democracy to the productive dominium. In this sense, it would be insufficient that workers simply occupied or possessed a
company; it is necessary that they hold the technical
and economical knowledge which would allow them
to make it function.
Even if it is all about heterogeneous experiences,
with different models of organization and distinct levels of development, it is still possible to recognize
common features:
258
●
The capital integrally distributed among the members of the organization
●
Control of the power of decision and the management of the companies by the workers
●
The right of workers to vote and be voted for any
position, inclusively a directing position
●
The existence of democratic mechanisms of management and definition in assemblies of issues such as:
policies of remuneration, disciplinary, of human resources, forms of organization of production, and
destination of results and surplus
●
Integral development, which endeavors sustainability,
economical equity and social responsibility
Some Characteristics of
Self-Managed Companies in Argentina
In present Argentina, diverse types of self-managed companies exist, organized under different juridical forms: cooperatives, anonymous societies, of limited responsibility and other commercial.
Towards the end of 2004, more than 300 companies were registered, which employed approximately
32.000 workers, and a significant number were being
disputed, among others the Gatic company, which employed 5.000 workers from several provinces.
Consistent with data from the study center Vox
Populi, 86% of the recovered companies are part of
the industrial sector; 12,3%, of the services sector; and
1,7%, of the area of primary production.
In relation to the existing capacity of production,
48% of the recovered companies are producing a volume that oscillates between 10% and 29% of their maximum potential, 36% produce between 30% and 59%
of their capacities, and 16%, to 60% or more of their
capacities.
Regarding the levels of employment, the companies that retain the same amount of workers and the
ones that had to reduce their roster are equivalent:
each sector represents 40,4% of the totality, while
15,8% incorporated new workers starting from the
development of the productive self-management.
The two companies of Zanón and Pauny have
distinct models that constitute examples of feasibility
of this alternative mode. The first, located in the Argentinean Patagonia, has recovered its leadership in
the pottery market and develops an interesting process of cooperation with the "mapuche" communities
who participate in the elaboration of designs for the
new lines of production.
Pauny, alternatively, assumed the position of leading company in the production of tractors. Starting
off with the assignment of reconditioning a single tractor, it rapidly overtook to produce 45 tractors monthly and, at present, this quantity has increased to 70. Its
workers earn the wage established in the collective
agreement of the sector and, moreover, they have already distributed the first profits.
From Non-Salaried Work to
Productive Self-Management:
Some Questions
The experiences of recovering and self-management of companies in Argentina put forward an unheard of problem, one which challenges creativity and
the capacity of innovation of whom are involved.
From our focus on specifically health and work, we
would like to propose a set of questions that function
as the motors of our practices of intervention and research.
The first has to do with the general orientation
of the processes of productive self-management: is it
possible to think of them as processes of fragmentary
re-composition of the industrial model previous to
neoliberalism, or is it about the experiences of economical innovation that implicate productive dynamics,
which transcend neoliberalism?
Another question related to the first deals with
the organizational models that collective management
adopts: does the latter produce figures of stable leadership of traditional nature or does it develop complex multi-referential processes which, in a context of
constant change, allow the company to respond in a
flexible manner, reshaping its internal organization in line with the turbulences of its environment?
The third question is connected with the process of intellectualization of work that self-management requires: which type of devices favors the development of collective intelligence and the joint elaboration of strategies?
The fourth question is directly linked to the management of health and the working hazards: does
productive self-management sponsor the development
of a model of epidemiological monitoring self-applied
to health and working security, or does it support a
model of delegation of health care, as does the hegemonic medical model?
The fifth question refers to the modes of articulation amid distinct experiences of social economy: is
it possible to combine the resolution of quotidian problems that every experience of this sort entails with
the constitution of a new strategic temporality in
which the sharing of inventions locally produced, the
implementation of projects of cooperation among various productive units, and the design of policies of
common action in relation to the range of governmental, commercial and financial organizations is possible?
The sixth question concerns the subjectivity
problem: which devices and by what means and operations is the subjective figure produced (the self-managed worker or the freelance worker) and capable of
developing the objective production in a recovered
259
company? And, what practices obstruct this production of subjectivity?
The last question touches upon the relations
between the productive activity and the work force:
to what extent and in what points does the reshaping
of production according to the premise of self-management affects the processes of reproduction of the
work force? How does it affect the family and social
relations of the workers? What type of implications
do these alterations have in the collective processes of
health and illness?
Incubator of Companies of
Common Economy: From the Recovering of
Companies to the Self-Management of Health
and the Security at Work
In October of 2003, in the city of Rosario, convoked by the National Movement of Recovered Companies, the First National Encounter of Recovered
Companies had effect. The majority of self-managed
companies of the country participated in this event.
As a conclusion to this encounter, the creation
of the Incubator of Companies of Common Economy
was resolved in the womb of the National University
of Rosario. Its goal is to support, give attention to, and
response to the different demands of the cooperative
workers, or more specifically, to make production viable and expand it, to improve the insertion in the market, to deepen the processes of self-management and
democratization of the organization of collective
work.
The recovering process of the companies and
the self-management of production constitute a favorable element to the development of the workers’
health. With this view, an interdisciplinary crew composed of more than 30 professionals and coordinated
by the Health and Work Area of the Faculty of Medi260
cal Sciences embarked on the accomplishment of
complete studies in health and labor security.
The intervention method tends to reinforce the
process initiated by the workers of the recovered
companies themselves, who have begun to manage
their own working process.
In this mode of self-management, they participate in the planning, organization and development of
the whole productive process, controlling the timing,
the rhythm and the use of the work force. Thus, the
products are not someone else’s but their own.
The methodology that we implement combines
participative research techniques, which articulate and
consolidate the knowledge of workers, the medicalpsychological evaluations, and the analysis of security
and industrial hygiene engineers.
The instruments we apply are the following:
●
elaboration of occupational-clinical histories of each
worker (clinical exams, audiometries, electrocardiograms, thoracic x-rays, ophthalmology, and complete
urine and blood analysis)
●
completion of instrumental measurements of noises,
illumination and discharge to earth of the electrical
equipment
●
analysis of the collective processes related to mental health and organization of work (workshops in
homogeneous and heterogeneous groups, individual
semi-structured interviews, which tend to elaborate
life histories, application of queries, scales and inventories)
●
elaboration of collective surveys of healthy and hazardous processes derived from the distinct elements of the working process
●
elaboration of occupational hazards maps
The workshops and group reflection between
workers and the interdisciplinary crew have produced
preeminent results of the experience we have undertaken. The technical support of the Faculty of Engineering has been an invaluable stimulus and aid to the viability and growth of companies.
The returning of the results of the studies is an
essential component of our Methodology, since it denotes an instance of collective re-appropriation by the
workers. It consists of results on their working and
health conditions, and establishes the foundations to
implement and sustain a program of Epidemiological
Monitoring of Health and Security at Work.
It is important to underscore also that the methodology utilized permits the study of the processes
of health/illness from a structural, particular and singular perspective, through the diverse levels of analysis.
The intervention strategy starts off from the recuperation of the workers’ knowledge. As indicated
clearly by Néstor, a worker from the glassworks Cooperative VITROFIN, more than 70 years old: "I asked
the ‘compañeros’ (colleagues) about what I could do,
and they said, ‘to teach, Néstor, to teach, because 50
years of experience are not bought in any supermarket’ ". This process regains the accumulated experience of the collective of workers and reinserts it in the
new conditions as a strategy of the surmounting of the
neoliberal model.
"This process marks a new model, an anticipatory form of production. They are factories, which have reborn as the premature, before time, since they
are companies, in the word of the workers that themselves that function and are directed by freelance workers. And they have been born before time because
they represent a form of production, which anticipates
the substitution of the dominant capitalist model of
production. And that is the fundamental nature of why
we have to care for that incubator, born in the First
National Encounter of Recovered Companies. The future of our country lies in the possibility of them growing, living, and, as every living organism, reproducing"
[Kohen, 2003].
REFERENCIAS
●
BREILH, JAIME (2003). Epidemiología Crítica. Ciencia Emancipadora e Interculturalidad. , Lugar Editorial, Buenos Aires. Febrero,
p. 208- 209.
●
Concepto desarrollado por Jorge Kohen y Mariano Musi en Reflexiones sobre Salud y Trabajo en la Carrera de Especialización
en Medicina del Trabajo Facultad de Ciencias Médicas UNR Inédito; Rosario, 2004
●
DIARIO CLARIN (2002). Bs. As,Argentina.
●
DIARIO CLARÍN (2002). Bs. As., Argentina, Diciembre.
●
KOHEN J., Canteros G (2000). La Salud y el Trabajo de los Judiciales; Raymur Ediciones, Rosario.
●
KOHEN J (2003). Discurso Clausura 1er. Encuentro Nacional Empresas Recuperadas; Rosario Argentina, Octubre.
●
OIT (2004). Panorama Laboral.
261
28
Sports and
Human Emancipation
Paulo Ricardo do Canto Capela, Edgard Matiello Júnior
Presentation
In the Brazilian context, the field of knowledge known as Physical Education has been a privileged space to reflect and act upon the worldwide
mercantilist appropriation of the sports phenomenon.
Although idealized visions of sports predominate within our country which unconditionally associate them with health and living quality; with aesthetical beauty of "perfect" bodies; with an alternative to drugs in the treatment of certain diseases; with criminal rehabilitation; or even as an integrative element of nations; in fact, they ought to be examined under a different
perspective. Theoretical and practical experiences undermine those simplistic idealized conceptions. The knowledge and historical experience around
the practice of sports have come about through tortuous ways of consensus
and conflict; however, a collective resistance against the commercialization of
sports and physical practice has been gradually developing in our societies,
and has begun to confront collective, communitarian interests, with private,
monopolist interests that contribute to capitalist hegemony.
Thus, in this brief text, our contribution to the international initiative
towards a peoples’ alternative project of health and sports practice, is to state some crucial reflections, which lead to a different perspective about the
role of sports in the construction of solidary, equitable and healthy societies.
This paper reflects a collective process of debate and knowledge construction, wherein authors and actors participated at different moments, places
262
and contexts, with varying degrees of criticism, not always implying a definitive rupture with powers instituted in scientific societies, governmental organizations,
and other academic and professional spaces.
In this sense, the 1980s were paradigmatic. It was
a moment of great intellectual enthusiasm and mobilization, in which a critical mass of social debate existed
that started to question hegemonic practices and promoted a community driven project with the intention
of transforming authoritarian, unfair and inequable
structures that modeled our society. It was expressed
that a Physical Education project would require combating liberal-bourgeois ideology and conservatism
[Guiraldelli Júnior, 1991].The purpose was to find rich
formulas capable of mobilizing corporal work and movement, and to face the contradictions within the system.The reference was the concrete human being, embedded in its social context, and at the same time the
motor and the victim of the current social and productive system.
Derived from this intense and wide-ranging political process, three distinct movements emerged. The
first with the commitment to present Brazilian society
with more appropriate educational alternatives, representing an emerging trend of physical education studies, based on a dialectic conception of physical movement.The aim has been to improve the existing theoretical background about this field of human activity.
On the other hand, there were also teachers, who in
spite of their ideals about renewing this field of health
were less rigorous in their propositions. A third trend
corresponds to professionals that favor dominant conceptions and work for the commoditization of sports
[Coletivo de Autores, 2001]. It is worth mentioning a
fourth tendency, which reveals a lack of understanding
of the historic role of physical education linked to political awareness and lend themselves ingenuously to
reinforce the application of conservative domination
instruments [Freire, 1992].
Concisely, Brazilian Physical Education sustained
by a new theoretical-methodological framework, rooted in critical readings of education and society, has
provoked noticeable changes in the understanding of
sports in recent years. Of all better known contributions, those corresponding to the commitments of the
public school system are the ones more significant to
the Peoples’ World Health Assembly.
From our perspective, aside from the important
questions that can be directed toward public schools,
they still hold potential for the democratization of
knowledge and the socialization of new approaches to
physical education activities -among them sports- and
other expressions of corporal culture. If properly conducted, physical education in school would renew its
public and communitarian essence by ensuring quality
approaches, which have been referenced historically,
that link to the aspirations and numerous, complex
and urgent needs of the working class.
Thus, it is about a change of direction, which
concurrently conveys a sense of change, demanding
that the school be thought of as a cultural transformation pole [Arenhart; Capela; Matiello Júnior et al.,
2003], which expands its educational action beyond its
classroom walls, allowing the construction of a sports
project that radicalizes its proceedings in defense and
generation of life and human liberation [Freire, 1970].
A Critique of Sports from a
Liberating Perspective
Sports, being one of the most fascinating human
expressions, unfortunately, has been strangled by the
tentacles of greedy entrepreneurs and corporations,
and has been shaped by the logic of the International
Olympic Movement through mass media into the dominating element of Physical Education, especially in
schools. To have an idea of the magnitude of this in263
fluence, several professionals understand the discipline
of Physical Education as synonymous to sports, depreciating the opportunity to include any other kind of
human physical movement and activity and/or popular
culture.Without overstating, this signifies a compromise of integral education of human beings in an entire
generation!
Despite numerous advancements concerning pedagogical propositions for the innovation of sports in
various fields of professional activity, we have observed
that this new knowledge is still scantily disseminated,
and consequently its not rooted, therefore favoring a
limited conventional conception of sports. Gramsci
and other thinkers believe that when sports in school
are interpreted as a mere technical process, reproducing high-level-performance movement patterns (as
their codes, values, and ahistoric character), they can
impede, from the viewpoint of the dispossessed, the
construction of a national-peoples program, Hence, to
establish this dialogue among our allies in Latin America and the World, we stress our critical position alongside predominant academic standpoints. Our renewed
vision and discourse have already reached various important world and Brazilian Public Health forums.We
will operate as Physical Education teachers who identify with a concept that challenges the following realities: that sports operate predominantly as a symbolic
expression of capitalist values: the form of practice and
spectacle of workers subject to "Spartan" and inhumane workdays; and the audience, who are submitted to
an alienated approach that converts life into a spectacle by passive consumers of sports [Pires, 2002].
Pedagogic Possibilities in the Teaching of
Sports for Human Liberation
The capitalist mode of production has provoked
negative transformations in schools, converting them
264
into social spaces where competition becomes compulsory in all spheres of human life.Thus, games, which
have been historically linked to leisure, fun, and the
celebration of life within several cultural contexts,
now have turned into modern sports with predetermined rules and pressure to surmount limits; playing
mates having to be treated as adversaries; in brief, the
logic of playing with changes to the logic of playing
against.
From the perspective of Physical Education for
human liberation, we believe that sports content,
should not only consist of objectives for its practice,
but also should be studied, reflected upon, understood, and if necessary, transformed [Hildebrandt &
Laging, 1986]. Given the importance media currently
assumes in education for consumption, the sports
problematic may be understood as a media-created
phenomena of the "spectacle society" in which we live.
Sports, considered as a corporal and movement
experience, may be approached from an attitude of
inclusion. From this standpoint the construction/reconstruction of sports content can be created jointly
with those people engaged in the development of rules, techniques, and tactics.This approach would transcend the logic of exacerbated competition and facilitate the recovery of the ludic and party nature of these cultural forms of practice.
As teachers, we realize that changing the practice of sports is not an easy task, since it often implies
confronting false and legitimate expectations fashioned by the cultural industry throughout the decades.
In the construction of sports experiences, from
the position of human liberation, competition, physical
conditioning exigency, technique and tactic teaching
do not disappear, however they are re-signified. Competition is modified to not the obligatory anymore,
but the necessary to be established with the subjects
in order that all can play [Kunz, 1996].
Physical conditioning will not be acquired anymore by the present logic that subjects sports workers to the wearing processes of "working burden",
imposing on them a high level of sacrifice and pain,
starting from training planning prior to playing.As part
of the teaching proposal, physical conditioning will be
acquired in the playing-the-game experience itself and
by being involved in the construction of cultural experiences.
Technique does not possess a single definition; it
has served through the history of civilization as one
of humanity’s emancipating elements. Nevertheless,
in modern sports the technical issue adopts restricted meanings: repetition, homogenization, specialization, and reproduction, taking into account maximumperformance objectives. Technique should be aimed
toward facilitating participants to experiment with
numerous possibilities in order to open multiple cultural experiences during the learning process.
Tactic may not simply privilege winning and valuing "the talented" to the detriment of the rest. Playing (means) is the essential, not winning (end). The
talented may be oriented and stimulated to cooperate with and be tolerant of those who have not yet
achieved the same capacity within the game.
Notes for a Project of
Human Liberation through Sports
Thus far, we can assert that sports, as a hegemonic practice modeled by the International Olympic
Movement, are part of the expansion process of occidental capitalist modernity. It is rich businessmen/women who lead this Movement; this space has never
been open to the working class.Accordingly, this organization is a large diffuser of the world-views of those
who conduct and confer its corresponding moral and
intellectual direction [GEIA, 2002].
In order to believe that another world is possible, a propos sports practice in favor of the celebration of life among peoples, and an inversion of priorities within a capitalistic context, is mandatory. If we
review history, we will verify that an international
working organization already existed and accomplished three significant Olympic events, which were
founded on principles of class solidarity, which nonetheless did not resist the postwar [GEIA, 2002]. We
think we will be able to recover this idea and construct an International Cooperative Olympic Movement in the future.
To conclude, we indicate a number of assumptions with the intention of jointly developing the elements of this proposal, starting from the potentially
democratic space of the public school. These are reflections initially stimulated by the historic contribution of a German researcher who lived among us
[Dieckert, 1984].
●
Sports may not be a mere adaptation to the International Olympic Movement phenomenon. Didactic
transformations are indispensable, which aim at new
anthropologic, philosophic and scientific conceptions, with the goal of creating a new socialist project;
●
Sports are not limited to competition among excellent athletes; hence, it may be performed independently of genuine norms and rules of competitive
sports; it may not be narrowly thought of as a masculine field of practice with elitist values;
●
Theory and practice may configure studies and education process for Physical Education teachers; it is
necessary to surmount the excessive education of
teachers toward high-level-performance sports,
which educates more specialists in Olympic modalities, rather than actually teachers.
265
●
Schools can turn out to be important centers of dissemination of human liberation sports. To achieve
this, they need to be transformed into spaces that
foster these experiences, which do not require expensive equipment and facilities. It is perfectly feasible to perform high-quality and more stimulating human liberation sports with simple and economical
equipment;
●
Following this logic, we consider that school spaces
and equipment can constitute what we have announced, Movement Popular Culture Centers, available to and co-produced by local communities.
Finally, we underscore that the present paper
aims more at the socialization of our experiences with
comrades who struggle in defense of life and human
freedom, than the presentation of a finished proposal.
Our reflections are derived from the educational legacy of Paulo Freire, a Brazilian whose vigorous works
of revolutionary dreams never had the pretense of
being completed.
266
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DIECKERT, JÜRGEN (1984). O esporte de lazer: tarefa e chance
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GUIRALDELLI JÚNIOR, PAULO (1991). Educação física progressista: a pedagogia crítico-social dos conteúdos e a educação física brasileira. São Paulo: Loyola.
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esporte. Ijuí: Unijuí.
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Florianópolis, SC. Florianópolis: o Grupo, p.95-104.
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PIRES, GIOVANI DE LORENZI (2002). Educação física e o discurso midiático: abordagem crítico-emancipatória. Ijuí: Unijuí.
Pedagogy of the opressed. New York:
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Authors by
Chapters
1. Jaime Breilh, Ecuadorian, doctor, PhD in epidemiology; cofounder and executive director of the CEAS
(Health Studies and Advisement Center); cofounder of ALAMES (Latin American Association of Social Medicine); one of the inspirers of the critical epidemiology movement; his books in the mentioned field, in methodology, health epistemology and social medicine, several translated to Portuguese and English, have circulated
within research organizations and Master’s programs worldwide; leads research and intervention projects critical of neoliberal model; member of the editorial council of various magazines; Mater’s degree visiting professor at universities within America and Europe.
2. María Elena Labra, Chilean, Doctor of Human Sciences – Political Science; Master of Public Administration;
public administrator; participates in areas such as Health Policies and Systems, Formulation and Implementation Analysis of Public Policies, Civic Culture, Associativism, and Social Participation; in 1977, joined the FIOCRUZ (Oswaldo Cruz Foundation), Health Department, Brazil; currently, regular researcher at the Public
Health National School of the FIOCRUZ; has published numerous writings.
3. Gerardo Merino, Ecuadorian, member of the Ecumenical Commission of Human Rights (CEDHU), has developed multiple projects in the field of human rights and health. The present paper was realized with Hugo
Noboa Cruz’s collaboration, also collaborator at the mentioned organization, which is one of the organizations greatly fostering the defense of human rights in the region.
4. Adolfo Maldonado, Spanish, medical doctor, tropical medicine specialist. Since 1987, he has worked in Health
Primary Care for indigenous and peasant communities of Mexico, Guatemala and Ecuador. Since 2000, as a
member of "Acción Ecológica" (Ecological Action), he has researched the impacts of petroleum activity on the
health of population near these installations in Ecuadorian Northeast, and has studied the impacts of the Plan
Colombia fumigations in Ecuador. The results have been published in various books and magazines.
5. Saúl Franco, Colombian, doctor, Master of Social Medicine, PhD in Public Health; researcher in the fields of
Social Medicine and the subject of Violence and Health, about which he has published a number of books and
269
multiple articles. He has been visiting professor and researcher within Latin America and Europe; regional and
national adviser of the OPS (Pan-American Health Organization),ACNUR; member of the Colombian National Movement for Health and Security; currently, Coordinator of the Public Health Interfaculty Doctorate at
the National University of Colombia.
6. Mariano Noriega, Mexican, doctor, Master of Social Medicine, professor of the Master’s degree in Sciences
in Workers’ Health program of the Autonomous Metropolitan University, Unity of Xochimilco, his main research line being "New forms of labor organization and their effects in health". Adriana Cecilia Cruz, Mexican, work sociologist, Master of Labor Health, professor of the Master’s degree in Sciences in Workers’
Health program of the Autonomous Metropolitan University, Unity of Xochimilco, her main research line being
"Quotidian life, work and health". María de los Ángeles Garduño, Mexican, sociologist, Master of Social
Medicine, professor of the Master’s degree Social Medicine program of the Autonomous Metropolitan University, Unity of Xochimilco, her main line of research being "Gender, work and health". agronomer
7. Francisco Hidalgo, Ecuadorian, sociologist, Master of Social Sciences, researcher of the CEAS (Health Studies and Advisement Center), coordinator of the socio-anthropological area, specialist in social movements,
author of several books on the sociopolitical reality of the country and Latin America. Doris Sánchez, Ecuadorian, geographer (engineer), researcher of the CEAS, coordinator of the geographical analysis system. María de Lourdes Larrea, Ecuadorian, statistician, Master of Epidemiology (USP-Brazil), professor at UASB,
UPS, IEE/CAMAREN, researcher of the CEAS, consultant, social labor inspector for FLP. Orlando Felicita,
Ecuadorian, chemical engineer, researcher of the CEAS, experimental development of biological assays research. Edith Valle, Ecuadorian, librarian of the CEAS and coordinator of the documentation center, research
assistant. Juliette MacAleese, French, agronomist (engineer), specialist in social hydric systems management.
Jansi López, North American, Master in Latin American Studies, Professor of the University of California, gender in floriculture research. Alexis Handal, North American, PhD candidate in Epidemiology, University of
Michigan, pesticide and child development research. Paola Maldonado, Ecuadorian, geographer (engineer),
researcher of EcoCiencia, Jorgelina Ferrero y Stella Morel, Argentineans, Master in Social Work Program
students (University of Córdova), interns of EcoHealth Research Program (CEAS).
8. Walter Varillas, Peruvian, sociologist, Master of Political Sciences; executive director of the Health,Work and
Environment Institute of Peru (STYMA); administrator of the Security and Health Network at Work (RSST),
sponsored by the OPS/OMS (Pan-American Health Organization/World Health Organization) and the OIT
(International Labor Organization); adviser of the Peru Network of coordinating initiatives for local development; ex-mayor of the Alis,Yauyos, Lima district; coordinator of the Infantile Work Network (Red TIP) 20022003.
9. Laura Juárez, Mexican, Bachelor of Economy at the National Autonomous University of Mexico. At present,
professor-researcher of the Workers University of Mexico, she has published numerous articles on labor, employment, wages, migration and nourishing dependence deterioration within Mexico and Latin America.
270
10. Miguel Eduardo Cárdenas, Colombian, Doctor of Law, scientific adviser of the Fridrich Ebert Stiftung in
Colombia (FESCOL); has published important writings on the social and social rights situation in Colombia
and Latin America. Luz Helena Sánchez, Colombian, doctor, Master of Public Health, researcher of the Colombian Association for Health (ASSALUD). Martha Bernal, Colombian, economist, researcher of the School
Studies Center for Development (CESDE).
11. Group of Mothers from Córdoba, Argentinean, it is composed of the majority of mothers whose children suffer leukemia, malformations and cancer, due to radioactive contaminants present in their district; only
two of them are supposedly healthy. Sofía initiated the Group more than two years ago. Previously, it was
made up of other members of whom two remain and there are several being integrated.
12. Ary Carvalho de Miranda, Brazilian, BSc in Medicine (Universidade Federal Fluminense, 1977), MSc in Public Health (Escola Nacional de Saúde Pública/Fundação Oswaldo Cruz, 1997). His research field is the impact of work conditions on workers´ health. Currently, he is Vice president of the Fundação Oswaldo Cruz,
being responsible for the areas of Environment and Reference Services. Frederico Peres, Brazilian, biologist graduated from Universidade Estadual do Rio de Janeiro, with MSc (Escola Nacional de Saúde Pública/Fundação Oswaldo Cruz, 1999) and PhD in Public Health (Universidade Estadual de Campinas, 2002). Dr.
Peres has been working on environmental/human contamination by pesticides. Currently, he is a researcher
at the Fundação Oswaldo Cruz and Fellow Researcher of the Mount Sinai School of Medicine and Fogarty
International Center/NIH. Josino Costa Moreira, Brazilian, has a BSc in Pharmacy (Universidade Federal de
Juiz de Fora, 1967) and PhD in Analytical Chemistry (Loughborough University, 1991). Technologist of the
Fundação Oswaldo Cruz, he is studying the impact of environmental conditions on human health in Brazil.
René Louis de Carvalho, Brazilian, BSc in Economy (Universidade Federal do Rio de Janeiro, 1967) and
DSc in Economy (Université de Paris VIII, 1988). Professor of Agrarian Economy at the Institute of Industrial
Economy of the Universidade Federal do Rio de Janeiro.
13. Alex Zapatta, Ecuadorian, lawyer, specialist in legal water regulation and agrarian political economy, researcher of the CEAS (Health Studies and Advisement Center) and the Agrarian Research National System, coordinator of the juridical area of the Hydrologic Resources National Forum of Ecuador, coauthor of books on
the agrarian theme and the struggle for democratization of hydrologic resources.
14. Catalina Eibenschutz, Mexican, doctor, specialized in endocrinology in Cuba; candidate to PhD in Social
Sciences at the Education Institute, University of London. She is founder member of the ALAMES (Latin American Association of Social Medicine); professor researcher in Social Medicine at the Autonomous Metropolitan University, Xochimilco, since 1976; has worked in Chiapas closely to the EZLN (Zapatist National Liberation Army) since 1994. Presently, professor of the Master of Rural Development program, being her research
line the Power, Culture, Health and Indentity of Zapatista indigenous movement. Marcos Arana, Mexican,
anthropologist, and Mexican doctor. He is researcher at the Medical Sciences and Nourishment Institute "Salvador Zubirán"; founder of the Ecology and Health Training Center for Peasants in Chiapas; director of the Defense of the Right to Health; member of the IBFAN (International Network pro Infant Nourishment).
271
15. Charles L. Briggs, of the United States of America, PhD in anthropology, professor and director of the Iberian and Latin-American Studies Center of the University of California, San Diego; author with Richard Bauman of Voices of Modernity (2003); author of numerous publications in the field of critical anthropology in
health; at the moment, fosters a fundamental research line on the historical role of communication media facing hegemony in the field of health. Clara Mantini-Briggs,Venezuelan, doctor, coordinator of the National Plan of Struggle Against Dengue of the Environmental Direction and Sanitary Inspection of the Health and
Social Development Department (Venezuela); director of the Foundation for Applied Research Orinoco,
which performs scientific research and programs oriented to the improvement of health conditions in Delta Amacuro state (Venezuela).
16. Arturo Campaña, Ecuadorian, doctor, ex-professor of medical psychology at the Central University of
Ecuador, Master of Social Psychology (University of Leningrad); author of books and publications on conceptual and methodological innovation in the field of mental health; scientific director of the CEAS (Health Studies and Advisement Center); researcher of the international health certification of the fair and ecological flower program; visiting professor at universities of Latin America and North America.
17. Elizabeth Bravo, member of Acción Ecológica (Ecological Action), which is part of the International Department of the Resistance to Petroleum Network Oilwatch; coordinator of the Network for a Latin America Free of Transgenics; member of the Academic Council of the Third World Ecological Studies Institute;
professor at the Politécnica Salesiana University; Bachelor of Biology, PhD in ecology of microorganisms. She
is member of the Scientists Independent Panel concerned with genetic engineering, the Advisement Council
of the magazine "Biodiversity, Supports and Culture", the Political Ecology Magazine, and the Directing Council of the Tropical Forests World Movement.
18. Miguel San Sebastián, (MD, PhD) Spanish, has worked for 12 years in health primary care with indigenous
communities of the Amazonic region in Ecuador Currently, he teaches public health and epidemiology at the
Public Health International School of Umea, Sweden. Anna-Karin Hurtig, (MD, DrPH), Swedish doctor with
ten-year experience in health primary care in Sweden, Nepal and Ecuador; at present, teaches public health
and epidemiology at the Public Health International School of Umea, Sweden. Aníbal Tanguila, health promoter of the Sandi Yura Association. He belongs to the indigenous group Naporuna located in Orellana province, Ecuador; has occupied charges of responsibility within his community in various occasions, as well as
at the level of the FCUNAE Federation. His community, Corazón del Oriente, has suffered for several years
the contamination produced by petroleum exploitation. Santiago Santi has frequently been health promoter of the Sandi Yura Association, and its leader, as well as his community’s and the FCUNAE Federation; he
belongs as well to the ethnic group Naporuna. In his community, El Edén, petroleum is also exploited. The
Health Promoters Association "Sandi Yura" is an organization of indigenous health promoters of the Amazonic region of Ecuador. It is part of the Natives Union Communes Federation of Ecuadorian Amazonic Region
(FCUNAE), and since 1994 has been legally recognized by the Department of Public Health of Ecuador. At
present, it counts with 100 promoters distributed in 70 communities, who provide diverse health primary
care services to a population of 12.000 people.
272
19. Francisco Armada,Venezuelan, medical doctor, Central University of Venezuela, 1989; University of Carabobo, 1991; Magíster in Public Health (Epidemiology), University of Johns Hopkins, EEUUA, 1997; Doctor in
Public Policies and Health (PhD), University of Johns Hopkins, EEUUA, 2002. Minister of Health of the Bolivarian Republic of Venezuela, well know for his contributions on the transformation of the health system.
20. Asa Cristina Laurell, doctor, Master of Public Health, Doctor of Sociology (PhD); at the moment, Health
Secretary of the Government of the Federal District of Mexico. She was regular professor at the Autonomous Metropolitan University of Mexico from 1976 to 2001; one of the personages of the Latin-American
Social Medicine Movement, and of theoretical and methodological innovation in the field of health at work,
and social and health policies; author of innumerable books and studies on the mentioned types of problematic. Since 1990, she has been dedicated to the analysis of health services and policies development in the
scenario of neoliberalism; and has formulated alternative policies to guarantee the right to health.
21. Francisco Rojas Ochoa, Cuban, Doctor of Medicine, Master of Public Health, Doctor of Medical Sciences
in La Habana. He is professor of merit at the Superior Institute of Medical Sciences of La Habana; researcher of merit at the Science,Technology and Environment Department; Order "Carlos J. Finlay" of the State
Council of the Cuban Republic; regular member of the Sciences Academy of Cuba; honor member of the Cuban Public Health Society; adviser of the OPS/OMS (Pan-American Health Organization/World Health Organization) and the FNUAP. He belongs to diverse scientific societies of Cuba and other countries; has published numerous books and articles; awarded annually by the Sciences Academy of Cuba. Miguel Márquez,
doctor-pathologist; career official of the OPS/OMS (Pan-American Health Organization/World Health Organization); professor of merit at the University of Cuenca; visiting professor at the University of La Habana;
honor dean of the University of Nicaragua; coordinator of the Universitas Program PNUD/PDHL-Cuba; has
published various studies and books; honor medal at the OPS; Order "Carlos J. Finlay" of the State Council
of the Cuban Republic; Order of merit in Public Health of the Government of Ecuador; awarded annually by
the Sciences Academy of Cuba; Hero of Ecuadorian Health of XXth century; decoration Santa Ana de los
Ríos of Cuenca. Cándido López Pardo, Master of Public Health, Doctor of Health Sciences; regular professor at the University of La Habana; visiting professor at the Tropical Medicine Institute "Pedro Kourí" and
the National School of Public Health in Cuba; adviser of the OPS/OMS, PNUD and UNFPA; member of the
Scientific Council of the University of La Habana and the Economy Faculty of the Human Health and Wellbeing Studies Center of the high studies center. He has published innumerable books and articles; awarded
by the University of La Habana and annual awards of the Sciences Academy of Cuba.
22. Miguel Fernández Galeano, Uruguayan, doctor,Vice Secretary of Public Health; Doctor of Medicine; Master of Administration of Health Services; ex-professor of the discipline of Preventive and Social Medicine at
the Medicine Faculty; Councilor of the Departmental Board of Montevideo (1990-1994). Between 1995 and
2000, he was Director of the Health Division of the Municipal Intendancy of Montevideo; from 2000 to 2005,
Director of the Health and Social Programs Division of the Municipal Intendancy of Montevideo. Sergio Curto, Uruguayan, epidemiologist adviser of the Public Health Department; Coordinator of Epidemiology of the
273
Cardiovascular Health Honor Commission; epidemiologist adviser of the Interior Medical Federation; Doctor of Medicine; Master of Epidemiology; Ex-director of the Immunizations Expanded Program of Uruguay
(1986-2000); Ex-director of Epidemiology, Ex-director of Epidemiological Surveillance, Ex-director of Transmissible Illnesses Control of the Public Health Department.
23. Mónica Fein,Argentinean, medical doctor, Secretary of Public Health, Municipality of Rosario,Argentina, she
heads the technical group that conducts an ambitious health system reform project that incorporates real
community driven mechanisms and participatory methods for public health management. Débora Ferrandini, Director of the Master’s degree in Specialization in General Medicine program at the University of Rosario; professor at the Lazarte Institute; Ex-director of Primary Care, and current Coordinator of the General Direction of Health Services.
24. Mario Esteban Hernández, Colombian, doctor, Master and Doctor of History; District Secretary of
Health in charge. Lucía Azucena Forero, Colombian, public administrator specialized in Social Evaluation of
Projects; Master of Social Sciences; Specialization in the Area of Analysis, Programming and Evaluation of the
District Department of Health. Mauricio Torres, Colombian, doctor, public health specialist, adviser in the
subject of Social Participation of the District Department of Health; Coordinator of the Latin-American Social Medicine Association.
25. National Front for the Health of Ecuadorian Peoples (FNSP), organization of confluence of social, popular organizations, NGO’s, local and national organizations, women and men of Ecuadorian peoples, it constitutes a democratic and participative reference of unity, action and struggle in defense of health as a fundamental human right, which promotes structural transformations of society to reach this objective. It was officially formed in its I National Encounter realized in Cuenca from June 17th to June 19th of 2004.
26. Julio Monsalvo,Argentinean, public health doctor, Master of Sciences; activist of the Peoples’ Health World
Movement; works with peasant communities and Originating Peoples, promoting intercultural dialogue and
health primary care of ecosystems. Presently, he coordinates the Communitarian Health Program from the
Department of Human Development in Formosa province, which aims at valuing local self-managed knowledges and forms of practice.
27. Jorge Kohen,Argentinean, doctor, researcher of the Independent Research Council at the National University of Rosario; Director of the Health and Work Area at the Medical Sciences Faculty of the National University of Rosario; career Director of the specialization of occupational medicine (FCM UNR); adjunct professor of the Psychology Faculty. Germán Canteros, Argentinean, psychologist, professor at the Medical
Sciences Faculty; member of the Professional Team ASyT of the Medical Sciences Faculty at the National University of Rosario; student of the Master’s degree in Mental Health at the National University Entre Ríos,Argentina. Franco Engrassia, Argentinean, psychologist, Master of Communication Psychology; adjunct professor of the School of Psychology, Provincial University of Entre Ríos; member of the Work and Health Professional Team of the Medical Sciences Faculty at the National University of Rosario.
274
28. Paulo Capela y Edgard Matiello, Brazilians, researchers in the field of sport sciences, leaders in the transformation of the philosophy of physical education and sports, towards an emancipating form of education and
practice.They are members of the Nucleus of Pedagogical Studies in Physical Education (NEPEF), which congregates investigators of the Federal University of Santa Catarina, with the purpose of developing alternative Physical education/ Sport Sciences research. They participate in the Brazilian School of Sport Sciences the main scientific organization of this field in Brazil- and also publish the alternative journal "Motrividencia".
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Cataloging information:
614.428
B835
Breilh, Jaime (CEAS Editor)
Latin American Health Watch (Alternative Latin American Health
Report).- Jaime Breilh (CEAS Editor).-- Cuenca, Ecuador:
Editorial Fernández, 2005.
250 p. il. tabs.
ISBN-9978-44-258-8
1. PUBLIC HEALTH 2. HEALTH RIGHTS
3. NEOLIBERALISM 4. PEOPLE’S PARTICIPATION
5. LATIN AMERICA 2. HEALTH COLLECTIVE
I. t
Tiraje:
276

13 - CISAS

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