Latin America Health Watch

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.

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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). 3

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LATIN AMERICAN HEALTH WATCH Alternative Latin American Health Report Jaime Breilh CEAS (Editor)

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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.

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Section I: THE HEALTH DIVIDE:THE PEOPLES’ PERSPECTIVE Economic Dispossession (Assault) and Health

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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

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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

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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

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24.The Experience of Bogota D.C.: A Public Policy to Guarantee The Right To Health. Mario Hernández, Lucía Forero, Mauricio Torres.

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Action from the Peoples

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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

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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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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-

Observatorio Latinoamericano de Salud.

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.

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INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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.

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BREILH, JAIME (2002) El Asalto a Los Derechos Humanos y el Otro Mundo Posible. Quito: Espacios, 11: 71-82.

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HALL, GILLETTE; PATRINOS,ANTHONY (2005) Pueblos Indígenas, Pobreza y Desarrollo Humano en América Latina. Washington: Banco Mundial.

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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.

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HARVEY, DAVID (2003) The New Imperialism. Oxford: The Oxford University Press

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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

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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

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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.

Observatorio Latinoamericano de Salud.

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

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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-

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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

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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.

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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.

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COLEGIO MEDICO DE CHILE (2003). Reforma de Salud. Proyecto País. Propuestas del Colegio Médico. Santiago de Chile: Colegio Médico de Chile.

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GONZÁLEZ-DAGNINO, A. (1999). La meta sanitaria para Chile en el 2010. Cuadernos Médico Sociales, Santiago de Chile, 40:3650.

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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.

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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.

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MINISTERIO DE SALUD (2001). Reforma del Sistema de Salud. Santiago de Chile: Minsal.

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MINISTERIO DE SALUD, CUENTA PÚBLICA (2003). Santiago, MINSAL, p. 33. Cf. En 2003 Fonasa detectó 30.000 "falsos indigentes".

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MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD (2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile: Fonasa.

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MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD (2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile: Fonasa.

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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.

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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

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Inasmuch as a human right, health presents a number of important characteristics: ●

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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.

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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.

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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

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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

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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.

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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.

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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

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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.

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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.

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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.

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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

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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

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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,

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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

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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

Observatorio Latinoamericano de Salud.

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

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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-

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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

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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.

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REFERENCES ● ACCIÓN

ECOLÓGICA (2002). Nuestro Mundo no está en venta. Alerta Verde nº 117, mayo. Quito.

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CHENEY, DICK (2001). National Energy Policy, Mayo. www.soberania.info

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CHOMSKY, NOAM (2003).Video "Plan Colombia". willfree.

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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

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KLARE, MICHAEL T (2004). La nueva misión crucial del Pentágono I y II. La Jornada, México. 18-10-2004. www.jornada.unam.mx

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LA JIRIBILLA (2005). La verdad al desnudo. www.lajiribilla.cu

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MARTÍNEZ, ESPERANZA (2003). Conflictos bélicos y Petróleo. Oilwatch. Conferencia en Chiapas, México en encuentro internacional contra militarización de A.L.

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NAVARRO, GUILLERMO (2004). Geopolítica Imperialista. De la "Doctrina de los dos Hemisferios" a la "Doctrina Imperial" de George Bush. Edit. Zitra. Quito)

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OILWATCH (2001). La manera occidental de extraer petróleo. La Oxy en Colombia, Ecuador y Perú. Edit. Oilwatch. Quito.

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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

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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

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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.

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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)

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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-

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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.

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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].

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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].

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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.

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Secondly, the social-medical approach to Colombian violence has possibilities and limitations.With such a complex problem any single discipline, theory or

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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

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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.

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REFERENCES H (1970). On Violence. New York: Harcourt Brace Jo-

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FRESNEDA O, SARMIENTO L, MUÑOZ M (1991). Pobreza, violencia y desigualdad: retos para la nueva Colombia. Santafé de Bogotá: United Nations Development Programme.

BENJAMIN W (1995). Para una crítica de la violencia. Buenos Aires: Editorial Leviatán.

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GUZMÁN G, FALS-BORDA O, UMAÑA E (1980). La violencia en Colombia. Novena edición, Bogotá, Carlos Valencia Editores.

COLOMBIA. CONTRALORÍA GENERAL DE LA NACIÓN (2002). La exclusión social en la sociedad colombiana. Bogotá: Contraloría.

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MEDINA C (1990). Autodefensas, paramilitares y narcotráfico en Colombia. Santafé de Bogotá, Documentos Periodísticos.

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vanovich. ●

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COLOMBIA. INSTITUTO NACIONAL DE MEDICINA LEGAL Y CIENCIAS FORENSES (2000). Forensis 1999. Bogotá.

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OQUIST P (1978).Violencia, conflicto y política en Colombia. Bogotá: Instituto de Estudios Colombianos.

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COMISIÓN DE RACIONALIZACIÓN DEL GASTO Y LAS FINANZAS PÚBLICAS (1997). El saneamiento fiscal, un compromiso de la sociedad,Tema V. Informe Final. Santafé de Bogotá.

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PECAULT D (1995). De las violencias a la Violencia. En: Sánchez G, Peñaranda R, editores. Pasado y presente de la violencia en Colombia. 2a ed. Santafé de Bogotá: IEPRI –CEREC.

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CORTINA A (1998). Hasta un Pueblo de Demonios: Ética Pública y Sociedad. Madrid: Editorial Taurus.

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SÁNCHEZ G, PEÑARANDA R, editores (1995). Pasado y presente de la violencia en Colombia. Segunda edición. Santafé de Bogotá, IEPRI – CEREC.

DE CURREA-LUGO V (1999). Derecho Internacional Humanitario y sector salud: el caso colombiano. Comité Internacional de 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.

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FAJNZYLBER P, LEDERMAN D, LOAYZA N (1997).What causes crime and violence? Washington,The World Bank.

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FRANCO S (1999). El Quinto: No Matar. Contextos Explicativos de la Violencia en Colombia. Bogotá: IEPRI - Tercer Mundo Editores.

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FRANCO S (2000). International dimensions of Colombian violence. Int J Health Serv. 30(1):163-185.

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JG, RAMÍREZ JL, editores (1995). La violencia de las armas en Colombia. Santafé de Bogotá, Tercer Mundo Editores.

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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.

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WORLD HEALTH ORGANIZATION (2002). World report on violence and health. Geneva:WHO.

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Economic Fundamentalism, Legal Regression, Work Degradation and the Ecosystem

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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

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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

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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

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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].

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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

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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

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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.

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REFERENCES

●

LÓYZAGA, O (2002). Neoliberalismo y flexibilización de los derechos laborales. UAM/Porrúa, México.

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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.

●

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

●

BENERÍA, L (1999). "Mercados globales, género y el hombre de Davos". Revista Ventana 10. Universidad de Guadalajara. México.

●

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

●

●

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.

●

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.

●

FEO, O (2002). "Globalización y salud de los trabajadores". Salud de los Trabajadores 10(1-2): 5-15, Maracay,Venezuela.

●

FRANCO, A (2002). "La globalización de la salud: entre el reduccionismo económico y la solidaridad ciudadana (segunda parte)". Revista de la Facultad Nacional de Salud Pública; 20(2): 103-118, Medellín, Colombia.

●

GARDUÑO, M (2001). "Para estudiar la relación entre el trabajo doméstico y la salud de las mujeres". Salud de los Trabajadores 9(1): 35-43, Maracay,Venezuela.

● TEZANOS, J

(2001). El trabajo perdido ¿hacia una civilización postlaboral?. Biblioteca Nueva. Madrid. 65

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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]

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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.

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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).

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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%.

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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.

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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.

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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

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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.

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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.

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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.

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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

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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.

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REFERENCES ●

AGUIRRE, PATRICIA (2004) Effects of Pesticides on Soil Quality: The Case of Ecuadorian Floricultura. Aeche: Universitat Göttingen (D7).

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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

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GASSELIN, PIERRE (1999). La floriculture et les dynamiques agraires de la region agropolitaine de Quito (Equateur).Tesis doctoral. Instituto Nacional Agronómico, Paris.

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GIARACCA, NORMA (2001) Prólogo en "¿Una Nueva Ruralidad?". Buenos Aires: CLACSO.

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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).

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LARREA, MA LOURDES & MALDONADO, PAOLA (2005). Circuito Espacial de Producción de la Floricultura de Exportación, Caso Ecuatoriano. Quito: Programa EcoSalud CEAS/CIID.

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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).

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SÁNCHEZ, DORIS & MAC ALEESE (2005) La Dinámica de Plaguicidas y los Sistemas Hídricos en la Cuenca del Granobles. Quito: Programa EcoSalud CEAS/CIID.

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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).

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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).

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EXPOFLORES (2004). Estadísticas

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FELICITA, ORLANDO (2005) Montaje y Puesta en Marcha de un Laboratorio Comunitario de Bioensayos Para Evaluar la Toxicidad

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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.

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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

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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.

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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.

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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:

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Immaturity of organs and tissues

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Discrepancies among the indicated tasks and the completed tasks

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Higher metabolic and oxygen consumption

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Greater need for energy

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Tasks, tools, equipment and machines are designed and made for adults

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Lower physical resistance

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Exposure to dangerous physical and biological agents

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Lower physical resistance to changes in temperature

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Exposure to toxic chemical products

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Inferior manual skill to operate tools

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Inadequate psychic and social environment

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Higher capacity of absorption

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Poor hygienic conditions

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Higher psychological vulnerability

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Limited access to medical services

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Premature physical wear and incapacity, corporal injuries and fatal accidents

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Children are sensitive to hazardous attitudes, atavisms and behaviors of adults

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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

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The labor inexperience and the underprovided labor information

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Minors are not acquainted with hazards, or know less than adults, which is an important reason why they are more exposed

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In general, they are neither trained for the task they are to develop, nor to take measures of protection, being directly and overtly exposed

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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

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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.

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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.

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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.

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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.

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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

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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;

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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.

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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

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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.

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FORASTIERI V (1997). Children at work: Health and safety risks. OIT. Ginebra.

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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.

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Life and Health as Commodities

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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-

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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.

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

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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).

Observatorio Latinoamericano de Salud.

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:

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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.

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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.

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ciety, (as well as the access of all the population to integral health services). ●

●

●

●

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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

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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.

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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.

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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.)

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Integral and satisfactory maintenance of the public network is a priority of the system.

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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).

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The quality of the system and its services will be guaranteed through previous internal mechanisms, and organized forms of effective social control of services.

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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.

Observatorio Latinoamericano de Salud.

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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.

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A provision will only be excluded from the set of services if it is clearly proven to be superfluous, noxious or unnecessary.

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Public policies must provide the necessary mechanisms to attain the production and generation of knowledge, research, science and technology in the country.

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Ethnic and cultural diversity of the nation will be respected, and the autonomies acknowledged within the Political Constitution.

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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.

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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.

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The services network will have to be organized in order to guarantee the geographical accessibility to the distinct levels of care.

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The set of rights and duties of health personnel and patients will be regulated thoroughly.

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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.

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Personnel parallel nominations and contracts will be implemented to execute labor that has permanent features within the public institutions.

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A Public System of Information in Health will be organized, as an indispensable instrument for the management and control of health policies.

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INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

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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.

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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

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In the air:PVC with a high level of Phthalates (plasticizers)

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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.

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Magnetic fields: 1 micro la. This result was obtained by CEPROCOR , an organization sub-contracted by 109

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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 ● Adult, 23 years old (dead). Leukemia, Lymphocytic, Acute ● Adult, 30 years old (dead). Leukemia, Lymphocytic, 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

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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)

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2.500m away (it was never observed)

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Municipal Ordinance, which prohibits fumigation in the area of the Capital of Córdoba

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Change of water for the entire district

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Inauguration of two health centers

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Law of agrochemicals (it has neither been regulated, nor published within the official bulletin) The following has yet to be realized:

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The State to take responsibility for the situation.

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A formal study to determine the causes of the illnesses of the residents

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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

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The installation of the medium tension line (13,5 kw), which would reduce magnetic fields

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The ceasing of fumigations within the district

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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

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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-

Observatorio Latinoamericano de Salud.

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

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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.

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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

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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.

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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.

Observatorio Latinoamericano de Salud.

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

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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.).

Observatorio Latinoamericano de Salud.

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

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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

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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.

Observatorio Latinoamericano de Salud.

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

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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

Observatorio Latinoamericano de Salud.

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

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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.

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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.

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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.

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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]

Observatorio Latinoamericano de Salud.

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"

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The constitution of a continental water market that would contain the possibility of exporting it.

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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-

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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.

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Privatized in 1999, concession for 30 years

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Beneficiary company: "Aguas del Tunari" with the capital of Bechtel (USA)

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Increase in the tariffs (200%)

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Investments not fulfilled

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Peasant water sources usurped

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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

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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

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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:

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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

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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

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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

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CHANG, ADA ALEGRE (2003). Ponencia presentada en el Foro de las Américas. La Paz, Diciembre.

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CUBILLOS, GONZALO (1994): "Bases para la formulación de leyes referidas a recursos hídricos". CEPAL. Santiago de Chile.

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DECLARACIÓN DE SAN SALVADOR "POR LA DEFENSA Y EL DERECHO AL AGUA" (2003). Agosto 22.

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FAIRSTEIN, CAROLINA (2004). correo electrónico.

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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.

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Cultural Agresi n Uniculturality and Health

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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

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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?

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What tensions arise, how are they solved, and how are they surmounted?

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What did the resistance policy signify concerning the restatement of public policies?

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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.

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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.

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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).

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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.

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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-

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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]

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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

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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.

Observatorio Latinoamericano de Salud.

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.

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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.

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BLANCO F.,V (1996). "La cuestión indígena y la reforma constitucional en México". Revista Internacional de Filosofía Política. pp 121-140. México.

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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.

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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.

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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.

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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.

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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.

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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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SUB MARCOS (1994). Comunicado ¿De qué nos van a perdonar? En: La palabra de los armados de verdad y fuego Editorial Fuente Ovejuna. México, pp. 107-108.

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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

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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."

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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

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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"

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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

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Depoliticizing communication just as biological reductionism depoliticizes health and disease

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The massive consolidation of media ownership by large corporations.

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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

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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

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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

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Treat communication as a key element in the production of knowledge in medicine and public health, not just its dissemination

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Explore perspectives on communication that view it as multidirectional, with multiple sites of production of production, circulation, and reception

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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

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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

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Do not seek to subordinate voices within and outside medical and public health institutions to biomedical authority

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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

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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-

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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

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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

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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.

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FILHO, N DE (1989). Epidemiologia sem numeros : uma introducao cri tica a ciencia epidemiologica. Rio de Janeiro: Campus ● ALTHEIDE, DL (1995). An Ecology of Communication: Cultural Formats of Control. New York: Aldine de Gruyter.. ● ARMADA FRANCISCO, MONTANER CARLES,AND NAVARRO VICENTE (2002). Income Inequality and Population Health in Latin America and the Caribbean. Hispanic Health Care International. The Official Journal of the National Association of Hispanic Nurses 1(1): 42-55 ● BAER, HA, M SINGER, I SUSSER (1997). Medical Anthropology and the World System:A Critical Perspective.Westport, CT: Bergin & Garvey. ● BARROS JAC (2002). Pensando o processo saúde doença: a que responde o modelo biomédico. [Pensando el proceso salud-enfermedad: ¿A qué responde el modelo el modelo biomédico?] Saúde e Sociedade (San Pablo, Brasil) enero-julio; 11(1):67-84. ● BREILH, J (1994). Nuevos conceptos y técnicas de investigación: Guía pedagógica para un taller de metodología (epidemiología del trabajo). Quito: Centro de Estudios y Asesoría en Salud. ● BREILH, J (2003). Epidemiología crítica: Ciencia emancipadora e interculturalidad. Buenos Aires, AR: Lugar Editorial ● BRICEÑO-LEÓN R (1998). El contexto político de la participación comunitaria en América Latina. Cadernos de Saúde Pública (Río de Janeiro, Brasil); 14(2): 141-147 ● BRIGGS CHARLES Y MANTINI-BRIGGS CLARA (2003). Stories in the Time of Cholera: Racial Profiling during a Medical Nightmare. Berkely: University of California Press ● BRIGGS CHARLES Y FARMER PAUL (1999). Infectious diseases and social inequality in Latin America: From hemispheric insecurity to global cooperation (Working Paper Series Number 239). Washington, DC: Woodrow Wilson Internacional for Scholars.Center ● CALHOUN, C, ed. (1992). Habermas and the public sphere. Cambridge, MA: MIT Press ● CASTELLS, M (1996).The Information Age: Economy, Society and Culture.Vol. I,The Rise of the Network Society. Oxford: Blackwell ● EPSTEIN, S (1996). Impure Science:AIDS,Activism, and the Politics of Knowledge. Berkeley, CA: Univ. of Calif. Press ● FARMER, P (1992).AIDS and Accusation: Haiti and the Geography of Blame. Berkeley, CA: Univ. of Calif. Press ● FARMER, P (2003). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: Univ. of Calif. Press

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FOCAULT MICHEL (1987). El Nacimiento de la Clínica una arqueología de la mirada médica, siglo XXI Editores ● FOUCAULT, M (1973).The Birth of the Clinic:An Archaeology of Medical Perception.Transl. A Sheridan. London:Tavistock. ● FREIRE, PAULO (1970). Pedagogy of the oppressed New York: Seabury Press. ● HAMMONDS, EM (1999). Childhood’s Deadly Scourge:The Campaign to Control Diptheria in New York City, 1880-1930. Baltimore, MD: Johns Hopkins Univ. Press. ● HARAWAY, DJ (1997). Modest_Witness@Second_Millennium.Femaleman_Meets_OncoMouseTM: Feminism and Technoscience. New York: Routledge ● HARDING S, ed. (1993).The "Racial" Economy of Science:Toward a Democratic Future. Bloomington: Indiana Univ. Press ● LAURELL,AC (2000). Structural Adjustment and the Globalization of Social Policy in Latin America. International Sociology 15(2):306-25 ● MARTÍN BARBERO, J (1987). De los medios a las mediaciones: Comunicación, cultura y hegemonía. Mexico City: Ediciones G. Gili ● MENÉNDEZ EL (1998). Participación social en salud como realidad técnica y como imaginario social. Cuadernos Médico Sociales mayo; 73:5-22 ● MENÉNDEZ, EL (1981). Poder, estratificación y salud: Analysis de las condiciones sociales y económicas de la enfermedad en Yucatán. Mexico, DF: La Casa Chata. ● NAVARRO, V (1998). "Neoliberalism, ‘Globalization,’ Unemployment, Inequalities, and the Welfare State." International J. of Health Services. 28(4): 607–682 ● ONG,A (1995). Making the biopolitical subject: Cambodian immigrants, refugee medicine and cultural citizenship in California. Soc. Sci. Med. 40(9):1243-57 ● ROSENBERG, CHARLES (1962). The Cholera Years: The United States in 1832, 1849, and 1866, Chicago: University of Chicago Press. ● SHAH, N (2001). Contagious Divides: Epidemics and Race in San Francisco's Chinatown. Berkeley: Univ. of Calif. Press ● SINGER, M, H BAER (1995). Critical Medical Anthropology.Amityville, NY: Baywood. ● SMEDLEY, BD, STITH AY, NELSON AR, eds. (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington: Natl. Academies Press ● WARNER, M (2002). Publics and counterpublics. New York: Zone

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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

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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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

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(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,

Observatorio Latinoamericano de Salud.

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

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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

From 13 to 17 years old

22,7

20,6

Total

30,9

31,8

Younger than 6 years old

56,5

58,2

From 6 to 12 years old

50,2

49,4

From 13 to 17 years old

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,

Observatorio Latinoamericano de Salud.

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

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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-

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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.

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CAMUS ALBORNOZ GUILLERMO (1999). El suicidio como una forma de violencia societal. Ponencia presentada al XXII Congreso ALAS. Octubre.

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DAJAS, FEDERICO (2001).Alta tasa de suicidio en Uruguay, IV: La situación epidemiológica actual. Rev. Méd. Uruguay; 17:24-32

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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.

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INEC: Divorcios por año de registro, según departamento donde se dictó la sentencia, años 1987-2002.

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MONTALBÁN, ARIEL (2004). El suicidio: la urgencia de un grave problema. Rev. Méd. Uruguay; 20:91

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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

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PETRAS, JAMES (2002). Neoliberalismo, resistencia popular y salud mental. Los perversos efectos psicológicos del capitalismo salvaje. Rebelión, La página de Petras, 20 de diciembre.

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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.

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ROSSI, MÁXIMO Y ROSSI,TATIANA. Privación y pobreza en Uruguay (1989-97)

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SPREMOLLA,ALESSANDRA (2001). Persistencia en el desempleo de Uruguay. Cuad. econ., abr. 2001, vol.38, no.113, p.73-89. ISSN 0717-6821.

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Biodiversity: Destruction and Monopoly

Observatorio Latinoamericano de Salud.

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

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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

Observatorio Latinoamericano de Salud.

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

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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.

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Deutsche Bank has been advisor to AksoNobel when Hoechst, its subsidiary, to Rhone-Poulenc.

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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.

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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.

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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-

Observatorio Latinoamericano de Salud.

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

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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.

Observatorio Latinoamericano de Salud.

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

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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.

Observatorio Latinoamericano de Salud.

REFERENCES ● AGÊNCIA

CARTA MAIOR (2003). 6/11/2003

● AGROLINK

(2003). Internet, 5-5-03

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ECONOMIC RESEARCH SERVICE (2004). Sitio web accesado en octubre.

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EUROPE ACADEMIES (2004). Science Advisory Council Genomics and Crop Plant Science in Europe. May.

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GAZETA MERCANTIL (2004). Monsanto dobra valor de royalties. 02/09/2004

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GRUPO ETC (2003). Oligopolio, S.A. Concentración del poder corporativo. Comuniqué 82.

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JOENSEN, L. SEMINO, S (2004). Grupo de Reflexión Rural. Estudio de caso sobre el impacto de la soja RR. Grupo de Reflexión Rural.

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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.

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NIELSEN, N.A., JEPPESEN, L.F. (2001).The beef market in the European Union.Working Paper No. 75 The Aarhus School Of Business

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PRESTES, S (2004). September 21, GM soybean controversy: 90% of Rio Grande do Sul harvest will be GM. Agência Brasil.

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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

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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

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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

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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

Observatorio Latinoamericano de Salud.

(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

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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-

Observatorio Latinoamericano de Salud.

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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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.

Observatorio Latinoamericano de Salud.

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.

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ECUADOR. MINISTERIO DE MEDIO AMBIENTE (1999). Informe de inspección ambiental al área de las comunidades Flor de Manduro y Centro Manduro ubicadas en el bloque siete operado por la compañía Oryx. Quito: Ministerio de Medio Ambiente.

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EL COMERCIO (2002) Dos derrames de petróleo al mes en el campo Auca. octubre 18.

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FRENTE DE DEFENSA DE LA AMAZONÍA-PETROECUADOR (2003). Estudio para conocer el alcance de los efectos de la contaminación en los pozos y estaciones perforados antes de 1990 en los campos Lago Agrio, Dureno, Atacapi, Guanta, Shushufindi, Sacha, Yuca, Auca y Cononaco. Quito: Frente de Defensa de la Amazonía-Petroecuador.

(2000). ¿Es posible la transición a una economía post petrolera? En: Martínez E, ed. El Ecuador post petrolero. Quito: Acción Ecológica. (2000). El petróleo en el Ecuador: una evaluación crítica del pasado cuarto de siglo. En: Martínez E, ed. El Ecuador post petrolero. Quito: Acción Ecológica.

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(2000). Reseña sobre la historia ecológica de la Amazonía ecuatoriana. En: Martínez E, ed. El Ecuador post petrolero. Quito: Acción Ecológica.

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BRITISH MEDICAL ASSOCIATION (1998). Health and environmental impact assessment: an integrated approach. London: Earthscan.

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BRITISH PETROLEUM. ENVIRONMENT AND SOCIETY (2005). Disponible en: http://www.bp.com/ genericsection.do?categoryId=931&contentId=2016995 Accedido el 12 de enero.

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CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (1994). Violaciones de derechos en la Amazonía Ecuatoriana. Quito: Abya-Yala.

FRENTE DE DEFENSA DE LA AMAZONÍA (1999). La Texacontaminación en el Ecuador. Lago Agrio, Ecuador: Frente de Defensa de la Amazonía.

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FUNDACIÓN JOSÉ PERALTA (2001). Ecuador: su realidad. Quito: Fundación de Investigación y Promoción Social José Peralta.

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HURTIG AK, SAN SEBASTIÁN M (2002). Geographical differences of cancer incidence in the Amazon basin of Ecuador in relation to residency near oil fields. International Journal of Epidemiology; 31:1021-1027.

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HURTIG AK, SAN SEBASTIÁN M (2004). Incidence of childhood leukemia and oil exploitation in the Amazon basin of Ecuador International Journal of Occupational and Environmental Health; 10(3): 245-250.

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INSTITUTO LATINOAMERICANO DE INVESTIGACIONES SOCIALES (2005). Economía ecuatoriana en cifras, 1970–2003. Disponible en: http://www.ildis.org.ec/estadisticas/ estadisticas.htm. Accedido el 10 de enero.

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CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (1999). El petróleo no es eterno. Quito: Centro de Derechos Económicos y Sociales. CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (2000). Apertura 2000… la solución al país? Boletín número 2, Marzo. Quito: Centro de Derechos Económicos y Sociales.

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CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (2000). Una opción para el país: deuda por conservación de la Amazonía. Quito: Centro de Derechos Económicos y Sociales.

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CORPORACIÓN ESTATAL PETROLERO ECUADORIANA (CEPE) (1987).Análisis de la contaminación ambiental en los campos petroleros Libertador y Bermejo. Quito: CEPE.

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KIMERLING J (1991).Amazon crude. New York: Brickfront Graphics Inc.

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KIMERLING J (1995). Rights, responsibilities, and realities: environmental protection law in Ecuador’s Amazon oil fields. Southwestern Journal of Law and Trade in the Americas; 2(2): 293-384.

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KIMERLING J (2001). The human face of petroleum: sustainable development in Amazonia? Review of the European Community International Environmental Law; 10(1): 65-81

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LA TORRE LÓPEZ L (1998). ¡Sólo queremos vivir en paz! Experiencias petroleras en territorios indígenas de la Amazonía peruana. Copenhague: Grupo Internacional de Trabajo sobre Asuntos Indígenas.

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OILWATCH (1999). Fluye el petróleo, sangra la tierra. Quito: Oilwatch.

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OXY (2005). Social responsibility. Disponible en: http://www.oxy.com/Social%20 Responsibility/environ_main.htm Accedido el 12 de enero.

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PERÚ. DIRECCIÓN REGIONAL DE PESQUERÍA DE LORETO (2000). Monitoreo del impacto postderrame de petróleo sobre los recursos hidrobiológicos entre San José de Saramuro y Nauta, Río Marañón. Iquitos: Dirección Regional de Pesquería.

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SAN SEBASTIÁN M, ARMSTRONG M, CORDOBA JA, STEPHENS C. (2001). Exposures and cancer incidence near oil fields in the Amazon basin of Ecuador. Occupational and Environmental Medicine; 58: 517-522.

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SAN SEBASTIÁN M, ARMSTRONG M, STEPHENS C (2001). La salud de mujeres que viven cerca de pozos y estaciones de petróleo en la Amazonía ecuatoriana. Revista Panamericana de Salud Pública; 9: 375-384.

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SAN SEBASTIÁN M,ARMSTRONG M, STEPHENS C (2002). Outcome of pregnancy among women living in the proximity of oil fields in the Amazon basin of Ecuador. International Journal of Occupational and Environmental Health; 8: 312-319.

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STEPHENS C, LEWIN S, LEONARDI G, SAN SEBASTIÁN M, SHAW R (2000). Health, sustainability and equity: global trade in the brave new world. Global Change and Human Health; 1(1): 4458.

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C (2000). Sucumbios 2000. Lago Agrio, Ecuador:Vicariato de Sucumbíos.

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RAFFENSPERGER C,TICKNER J (1999). Protecting public health and the environment: implementing the precautionary principle. Washington, D.C.: Island Press.

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SAN SEBASTIÁN M (2000). Informe Yana Curi: impacto de la actividad petrolera en la salud de poblaciones rurales de la Amazonía ecuatoriana. Quito: Cicame & Abya-Yala.

P, eds (1995). Marea negra en la Amazonía: conflictos socioambientales vinculados a la actividad petrolera en el Ecuador. Quito: Abya-Yala.

ZEHNER R, VILLACRECES LA (1998). Estudio de la calidad de aguas de río en la zona de amortiguamiento del Parque Nacional Yasuní. Primera fase: monitoreo de aguas - screening Octubre de 1997. Coca, Ecuador: Laboratorio de Aguas y Suelos P. Miguel Gamboa-Fepp.

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Section II: THAT OTHER HEALTH POSSIBLE

Action From Democratic States

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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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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-

Observatorio Latinoamericano de Salud.

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.

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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-

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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

Observatorio Latinoamericano de Salud.

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

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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-

Observatorio Latinoamericano de Salud.

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.

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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

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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

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA

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

Observatorio Latinoamericano de Salud.

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

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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-

Observatorio Latinoamericano de Salud.

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

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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

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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

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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

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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

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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.

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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

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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

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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]"

Observatorio Latinoamericano de Salud.

REFERENCES ●

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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).

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GRANMA (2005), 3 de enero, p. 5.

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ILO. UNOPS, EURADA (2000) Cooperazione italiana. Local economic development agencies. Roma; ILO, UNOPS, EURADA, Cooperazione italiana. 150.

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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).

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CASTRO, F. (2003) "La gran batalla se librará en el campo de las ideas" (Discurso). Granma, jueves 30 de enero: 4-5.

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CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP) (1998). Salud en el tiempo. La Habana: MINSAP.

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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.

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MARTÍNEZ, O. (2004) "Hemos denotado las maniobras enemigas para asfixiarnos económicamente" (Discurso). Granma, lunes 27 de diciembre.

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OFICINA NACIONAL DE ESTADÍSTICAS (ONE) (1995) La economía cubana 1994. La Habana: ONE.

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OMS (2003). Informe sobre la salud en el mundo 2003. Francia: OMS.32.

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CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP). Anuario estadístico de salud 2003. La Habana: MINSAP; Cuadro 21.

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D' STEFANO, M. (2000). Dos siglos de diferendo entre Cuba y Estados Unidos. La Habana. Editorial de Ciencias Sociales.

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DE LA OSA, JA. (2005) "Cero caso de tétanos. Por primera vez en Cuba". Granma, martes 18 de enero:1. ●

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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).

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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.

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PNUD (2003). Informe sobre desarrollo humano 2003. Madrid: Ediciones Mundi Prensa. 349.

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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.

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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.

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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

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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.

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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

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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).

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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.

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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

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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

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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

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"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.

Observatorio Latinoamericano de Salud.

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..

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FERNANDEZ GALEANO M (2000). "Descentralización y participación social en salud, La experiencia de Montevideo" OPS/OMS..

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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)

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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.

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OMS/UNICEF (1978). Declaración sobre Atención Primaria emitida con motivos de la "International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September.

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PINUS R (2002). "Paradigmas de Investigación en Salud" Córdoba, Argentina. Publicado en www.monografias.com 215

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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

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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

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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.

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Strategies to achieve equity in the utilization of services.

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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

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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

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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.

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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

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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-

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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.

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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

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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

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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.

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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-

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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.

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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.

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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.

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To strengthen the exercise of citizenry in health.

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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

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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

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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

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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

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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

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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

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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.

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DANE, COLOMBIA (2003). Encuesta Nacional de Hogares, informe por departamentos.

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DANE, COLOMBIA (2004). Encuesta Nacional de Hogares, informe por departamentos.

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DANE, COLOMBIA (consolidado 2000 a 2004). Encuesta Nacional de Hogares, informes trimestrales trece áreas. Cidfas promedio del último trimestre de 2004.

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EL TIEMPO (2003). Sábado 8 de marzo: 1-18.

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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

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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

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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.

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We aim to defend health as a priority and universal right of human beings, by means of inter-institutional coordination and community participation.

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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.

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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.

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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.

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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?

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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.

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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 ●

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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

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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.

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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.

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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.

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To strengthen Health Promotion, we need to begin with new concepts, strategies and methods, making the most of the existing best potentialities within

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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.

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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.

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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. .

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Accordingly, our proposal of proper health and life for our people is supported om the principles of solidarity, equity, justice, dignity, social participation, and

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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.

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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.

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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).

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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.

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To direct health research, including genetics and the development of reproductive medicines and technologies, to people and public health, respecting universal ethical principles.

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To defend harmony with the environment, and the protection of ecosystems and our biodiversity.

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To connect the National Health System with Traditional Medicine and Alternative Medicines, respecting the biodiversity and multicultural aspects of our peoples.

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To pay the social debt by investing in health and education, primarily through reducing military expenses and the payment of external debt.

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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.

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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)

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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.

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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-

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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

Salud en Manos de la Comunidad

Montecarlo, Misiones

8

1998

Salud en Manos de la Comunidad

Reconquista, Santa Fe

9

1999

Salud en Manos de la Comunidad

Resistencia, Chaco

10

2000

Red de Redes

Eldorado, Misiones

11

2001

Salud en Manos de la Comunidad

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

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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".

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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).

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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.

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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.

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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]

Observatorio Latinoamericano de Salud.

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.

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MAX NEEF, MANFRED (1993). Desarrollo a Escala Humana, Redes, Uruguay.

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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,.

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RAMONET, IGNACIO (2005). Medios en Crisis, Le Monde Diplomatique, "el Dipló", Buenos Aires, enero.

●

REVISTA RAÍCES (2004). Nros. 30 y 31, Buenos Aires, abril.

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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

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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.

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254

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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

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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

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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.

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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

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The capital integrally distributed among the members of the organization

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Control of the power of decision and the management of the companies by the workers

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The right of workers to vote and be voted for any position, inclusively a directing position

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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

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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.

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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

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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)

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completion of instrumental measurements of noises, illumination and discharge to earth of the electrical equipment

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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)

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elaboration of collective surveys of healthy and hazardous processes derived from the distinct elements of the working process

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elaboration of occupational hazards maps

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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.

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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

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DIARIO CLARIN (2002). Bs. As,Argentina.

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DIARIO CLARÍN (2002). Bs. As., Argentina, Diciembre.

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KOHEN J., Canteros G (2000). La Salud y el Trabajo de los Judiciales; Raymur Ediciones, Rosario.

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KOHEN J (2003). Discurso Clausura 1er. Encuentro Nacional Empresas Recuperadas; Rosario Argentina, Octubre.

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OIT (2004). Panorama Laboral. 261

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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

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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

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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].

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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;

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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;

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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

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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;

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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.

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REFERENCES ●

ARENHART, D.; CAPELA, P. R. C.; MATIELLO JUNIOR, E. et al (2003).A Prática de Ensino de Educação Física em escolas de assentamentos do MST. In: I Pré-Conbrace Sul, 2003, Pato Branco, PR: Secretarias Estaduais do CBCE - PR-SC-RS & Fadep, CDROM.

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BRACHT,VALTER (1992). Educação física e aprendizagem social. Porto Alegre: Magister.

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COLETIVO DE AUTORES (1992). Metodologia do ensino de educação física. São Paulo: Cortez.

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COLETIVO DE AUTORES (2001). Carta de Carpina. Revista Brasileira de Ciências do Esporte, v.23, n.1, p.33-40, set.

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DIECKERT, JÜRGEN (1984). O esporte de lazer: tarefa e chance para todos. Rio de Janeiro: Ao Livro Técnico.

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FREIRE, PAULO (1970). Hearder and Hearder.

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FREIRE, PAULO (1992). A importância do ato de ler: três artigos que se completam. São Paulo: Autores Associados.

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GEIA (2004). Um outro mundo é possível. Disponível em: .Acesso em: 24 dez..

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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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HILDEBRANDT, REINER; LAGING, RALF (1986). Concepção de ensino aberto em educação física. Rio de Janeiro:Ao Livro Técnico.

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KUNZ, ELENOR (1994).Transformações didático-pedagógicas do esporte. Ijuí: Unijuí.

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KUNZ, ELENOR (1996). O esporte na perspectiva do rendimento. In: GTA - GRUPO DE ESTUDOS AMPLIADOS DE EDUCAÇÃO FÍSICA. Diretrizes curriculares para a educação física no ensino fundamental e na educação infantil da Rede Municipal de 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

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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

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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

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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

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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

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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

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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

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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:

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