Lasting Lessons From Social Ideas and Movements of the Sixties on Latin American Public Health

The political landmark that formed a generation of Latin Americans was the Cuban Revolution of 1959. It sparked not only important changes in the field of politics but also new social thinking and reflections on the future of the subcontinent. Public health was no exception. The Cuban accomplishment of turning the right to health into a reality for all citizens inspired a critical review of mainstream public health that assumed that economic growth would automatically improve health conditions. First, it was shown that this hypothesis did not resist concrete evidence. Later, the Cuban Revolution motivated a new methodological perspective for the study of the health–disease process, medical practice, and health policy that rested heavily on critical social science. The idea that became dominant was that they were all processes, which could only be fully comprehended if analyzed as part of a broader socioeconomic and political context.¹ Thus, contemporary Latin American social medicine—or collective health—was born, which has had a profound impact on public health until today.

REPRESSIVE DICTATORSHIPS

It should be recalled that during the sixties and seventies, many Latin American countries (for instance, Brazil and Paraguay) lived under repressive dictatorships, and others (such as Chile, Argentina, and Uruguay) were soon to experience coup d’états and even worse dictatorships. This complex situation led to two different roads to develop this new conception, social medicine: at universities and within social and political movements. For instance, in Brazil, dissidence was allowed at campuses to let off steam of the opposition. In some countries, nonviolent social movements had some space to mobilize around social questions such as health, housing, sanitary infrastructure, and education. Also, some professional associations managed to stay alive and to act. To all of these actors, Latin American social medicine offered a framework to understand and analyze the state of affairs and to take concrete action. Nevertheless, many were forced into exile and regrouped (for instance, in Mexico, Cuba, and some Central American countries) whereas many others left for Europe.

SOCIAL MEDICINE THOUGHT

The intellectual interchange between the national and exile academic communities on the one hand, and those that managed to stay in their countries on the other, led to the blossoming of social medicine thought and also crystalized in new academic institutions and journals.² Two public universities, one in Mexico and the other in Brazil, initiated postgraduate training in social medicine as early as 1975 and received students from most Latin American countries, who later conveyed new knowledge and even created similar institutions in their own countries.

Sociomedical thought tended to be influenced by the importance of the different social movements in each country and on the possibility to hold leading positions at health ministries or public social security institutes.³ For instance, the social determination of workers’ health was developed in Mexico with the democratization of unions, whereas social class as a social determinant for the constitution and distribution of epidemiological profiles was studied in Ecuador. The studies on the determinants of health practices, understood as the social response to the health–disease process, also prompted the examination of class differences in access and the role of the state in the creation of different health systems as well as the dominance of the “medical model.”⁴ Other issues explored later by social medicine–collective health scholars included gender and indigenous people’s health practices. To construct these new interpretations of health–disease and medical practices, it was necessary to conduct a deep epistemological change of the scientific paradigms that went from the construction of new scientific objects to the methodology to explore them. Authors such as Marx, Gramsci, Canguilhem, Foucault, and Bourdieu were central to this undertaking.⁵

PROGRESSIVE OR LEFT HEALTH POLICY

In Chile, the specific issue of a progressive or left health policy became crucial during Salvador Allende’s government, but the advances toward a Unified National Health Service were abruptly reversed by the coup in 1973, which also instigated the first neoliberal experiment in the world. However, the idea of a public and universal health system had once more been planted in Latin America. The questions of the right to health, the content of health practices, and health policy and systems became central with the return of representative democracy. The new Brazilian constitution of 1988 is exemplary and became ground-breaking.⁶ It declares health a universal right and obliges the state to grant it to everyone free of charge by means of a public decentralized health system. It also turned “collective health” into the dominant current of thought within Brazilian public health.

PARADOX OF RESTORED DEMOCRACIES

The paradox, however, was that the restored democracies usually came hand in hand with neoclassic economic and social policies. On the one hand, social and human rights were recognized; on the other, the reorganization of society on the principles of the market, competition, withdrawal of the state, and trade opening, as dictated by the Washington Consensus, tended to obstruct their realization. Neoliberal globalization destroyed public institutions, lowered salaries, and hampered job creation, with a profound impact on health and well-being. It also spurred neocolonial takeover of land and resources, with widespread destruction of nature and local cultures.⁷ This is the context of regressive health and social security reforms that swept Latin America and the rest of the world in the eighties, nineties, and the early 21st century. Pensions were put under private administration, and access to health care was limited to packages considered cost-effective.

The neoliberal processes opened a new cycle of popular struggle in Latin America, and health was part of it. The leftist governments that won elections as a result of this popular insurgency (e.g., in Venezuela, Ecuador, Bolivia, and El Salvador) reformed their constitutions to include the same concept of the right to health as the Brazilian one. Some also introduced the idea “To Live Well”—Buen Vivir—in harmony with Mother Earth, which envisions a different road to development and is critical of the idea of development as economic growth based on intensified consumption. In practice, those governments opened access to health services for millions of previously marginalized persons. This setting could have been the opportunity for a reencounter between social medicine–collective health and mainstream public health, with its focus on population health. Nevertheless, this opportunity was partially lost given the ideological victory of health economics in public health.

LASTING LESSONS

The current political backlash in Latin America—with right-wing governments loyal to the national and international oligarchy that has staged technical coups or waged “dirty war” on governments and leftist parties—is hastening to dismantle social and health achievements and reinstate the neoliberal model. However, the peoples of Latin America have learnt that injustice is not a natural state of affairs, and they believe that social medicine–collective health provides them with the tools to fight back.