Howard Waitzkin, Celia Iriart, Alfredo Estrada, Silvia Lamadrid

Social medicine in Latin America: productivity and dangers facing the major national groups

Lancet 2001; 358: 315-23

Division of Community Medicine, Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM 87131, USA (Prof H Waitzkin MD, C Iriart PhD); Central de Trabajadores Argentinos (Central Organisation of Argentine Workers), Buenos Aires, Argentina (C Iriart); Grupo de Investigación y Capacitación en Medicina Social (Group for Research and Training in Social Medicine), Santiago, Chile (A Estrada MD, S Lamadrid MA); and University of Chile, Santiago, Chile (S Lamadrid). Correspondence to: Prof Howard Waitzkin (e-mail:[email protected] [1]).

National groups
Professional issues
Conclusions
References


There is little knowledge about Latin American social medicine in the English-speaking world. Social medicine groups exist in Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, and Mexico. Dictatorships have created political and economic conditions which are more adverse in some countries than others; in certain instances, practitioners of social medicine have faced unemployment, arrest, torture, exile, and death. Social medicine groups have focused on the social determinants of illness and early death, the effects of social policies such as privatisation and public sector cutbacks, occupational and environmental causes of illness, critical epidemiology, mental health effects of political trauma, the impact of gender, and collaborations with local communities, labour organisations, and indigenous people. The groups' achievements and financial survival have varied, depending partly on the national context. Active professional associations have developed, both nationally and internationally. Several groups have achieved publication in journals and books, despite financial and technical difficulties that might be lessened through a new initiative sponsored by the US National Library of Medicine. The conceptual orientation and research efforts of these groups have tended to challenge current relations of economic and political power. Despite its dangers, Latin American social medicine has emerged as a productive field of work, whose findings have become pertinent throughout the world.

Social medicine has become a widely respected field of research, teaching, and clinical practice in Latin America. However, achievements in this field remain little known in the English-speaking world. Major publications remain untranslated from Spanish or Portuguese into English. The field's lack of impact also reflects an erroneous assumption that the intellectual and scientific productivity of the "third world" manifests a less rigorous and relevant approach to the important questions of our age.

Case history 1

The public-health expert is about to receive torture by electric shock applied to his testicles. His crimes have been to teach medical and other health science students in a model community clinic, one of the major teaching sites for the University of Chile. A graduate of the Harvard School of Public Health, he also is accused of conducting research on the relations between poverty and health outcomes in local communities. He knows that several of his colleagues have already been killed for similar crimes. In his interrogation he has been asked to provide information about many friends and colleagues, but so far has refused.
The torturer, a clean-cut and matter-of-fact person whose military affiliation isn't quite clear, orders the public-health expert to pull down his trousers. He complies, looking at the electrodes in the torturer's right hand. Just then, the torturer glances at his watch on his right wrist. "OK", the torturer says, "it's five o'clock--time to go home", and leaves the room. The public-health expert pulls his trousers back up and waits for a guard to take him back to his cell. Recalling this experience in an interview, he mentions Max Weber's work on the sociology of bureaucracy--"bureaucratised torture", he calls it.

Many who have worked in Latin American social medicine have experienced dramatic personal histories. The three panels show how the very nature of their work--to the extent that it reveals the origins of health problems in the structure of society--can come to be seen as dangerous to sectors of the society who control wealth and wield power.

We have critically reviewed the work conducted at the major centres of social medicine in Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, and Mexico. Elsewhere, we have described the history of the field and the challenges of leadership and daily work activities, and analysed the theoretical approaches, methodological techniques, and major themes emerging from Latin American social medicine.1

National groups
Since the late 1960s, groups in several Latin American countries have worked under challenging and sometimes dangerous conditions. All groups have made major contributions in research, teaching, and public service. Figure 1 shows their locations. In addition to these groups, smaller networks have emerged in other countries, including Peru, Uruguay, and Venezuela.

Figure 1: Locations of major groups working in Latin American social medicine

Argentina

Social medicine grew rapidly in Argentina during the 1970s but soon suffered from the repressive effects of the dictatorship which took control in 1976. During the dictatorship, leaders of social medicine in Argentina lost their employment in universities and medical centres, faced imprisonment and torture, experienced the direct intervention of the military or paramilitary forces in their professional and personal lives, and feared death as increasing numbers disappeared or were killed. Many Argentines working in social medicine fled into exile. Those who remained generally tried to find employment in other fields and sought to conceal their accomplishments.

Case history 2

Salvador Allende

Pathologist, leader of social medicine, and former president of Chile, who died during the military coup of Sept 11, 1973.

The chief of surgery at a public hospital in a working class neighborhood of Santiago, Chile, sits in his dimly lit office, his tall frame bent over a notebook computer. He had trained on the surgical services at Massachusetts General Hospital. Salvador Allende chose him as Minister of Health for the Unidad Popular (Popular Unity) government. Known as an outstanding surgeon and medical educator, he convened a "council of elders" from the University of Chile's School of Public Health to advise the Ministry of Health.
On Sept 11, 1973, he was the last person in the line of government officials who walked down the stairs to the first floor of La Moneda, the presidential palace which was on fire after the Air Force's precision bombing, to surrender to the military victors of the coup. As the last person to see Allende alive, he notes simply that Allende was not killed but instead committed suicide, in the tradition of José Manuel Balmaceda, the reformist president of Chile who killed himself in 1891 rather than surrender to a military coup.
After his own arrest, the surgeon and ex-minister of health was tortured and sent to prison for a year on frigid Dawson Island near Antarctica. Later he worked in exile for 14 years as a professor of surgery in Caracas, Venezuela. After the Chilean plebiscite in 1988 that led to an elected government, he returned as chief of surgery to the same public university hospital where he worked before the coup.
He writes mainly for the clinical journal that health professionals and workers at his hospital have produced since 1953. Currently he is working on a series of articles that he has introduced with a quote from Alice in Wonderland: "Could you tell me please what road I should take?" These articles describe the deterioration of Chile's public health system under both the dictatorship and the country's subsequent civilian regime, whose policies call for the further privatisation of public industries, housing, education, and health programmes.

Since the return of electoral government in 1983, people working in social medicine have faced difficulties in reintegrating themselves into academic or medical institutions. Most leaders work in clinical or administrative positions, usually requiring two or three simultaneous jobs to support themselves and their families. Generally, research and teaching efforts in social medicine take place as unpaid work, or as activities financed by small, short-term contracts or grants. Despite these difficulties, groups in Buenos Aires, Rosario, and Córdoba have maintained high productivity.

Since returning to Buenos Aires from exile, Mario Testa has provided leadership for one social medicine group and has published influential articles and books on health planning and policy development.2 Testa's work on strategic planning emerged from a self-critical assessment of normative planning in public health. This work emphasises the importance of power in the planning process, the material interests of participating actors, and the possibilities for transformation based on current and potential alliances.3 Other members of this group, led by Celia Iriart and including Laura Nervi and Francisco Leone, have produced studies of "technobureaucracy" in public health; the policies of structural adjustment, privatisation, and public sector cutbacks required by the World Bank and International Monetary Fund; the exportation of managed care to Latin America; environmental health policies; and mental health policies such as deinstitutionalisation.4-7 Members of this group have offered courses in the faculty of social sciences at the University of Buenos Aires. They also work with labour unions on health policy issues. For instance, they have collaborated with the Asociación de Trabajadores del Estado (Association of State Workers) to reconstruct the union-controlled social security fund in Tierra del Fuego, Argentina's southernmost province. They also have worked with the Central de Trabajadores Argentinos (Central Organisation of Argentine Workers) to oppose the conversion of social security funds and health services to the control of multinational managed care organisations.

A second group in Buenos Aires has focused on environmental health, mental health, and health policy issues. Led by José Carlos Escudero, who during the dictatorship went into exile in Mexico, this group publishes the journal Salud, Problema y Debate (Health, Problem and Debate), edited by Enrique Kreplak and Matilde Ruderman. Escudero has produced influential articles on environmental health problems, the history of environmental changes since the Spanish conquest, and methodologic studies of statistical techniques.8 A subgroup coordinated by Ruderman has prioritised the mental health problems of those who suffered under the dictatorship, including families of the disappeared. Alicia Stolkiner and a subgroup in the faculty of psychology at the University of Buenos Aires have worked at the interface of mental health, primary care, and public health.7 Marcos Buchbinder has led policy studies on the impact of privatisation and cutbacks on public hospitals and clinics.9 Members of the group, coordinated by Debora Tajer and Liliana Mayoral, have provided leadership for the Asociación Latinoamericana de Medicina Social (Latin American Association of Social Medicine), which held its international meeting during 1998 in Buenos Aires.

Case history 3

The former dean of the medical school of the University of Buenos Aires tells why, at age 73 years, he lives from hand to mouth on small teaching and consulting fees and royalties, without a pension or other regular income. Before the dictatorship took control in Argentina, he had enjoyed a prominent career, applying the social sciences to medicine and public-health administration. His articles and books in health planning had achieved international recognition. He frequently was asked to consult with the WHO and the Pan American Health Organisation, and to give presentations at universities and professional organisations throughout the Americas.
When the military took control, he and his family happened to be outside Argentina. He was not to return for more than 10 years. His neighbours told him that they watched helplessly as soldiers knocked down the doors of his home and proceeded to ransack and burn his library. The burning of books and journals in this case and many others (sometimes voluntarily by the owners of the publications for fear that they would be found by the military and provide evidence of subversion resulting in imprisonment, torture, and death) makes the Argentine intellectual productivity of the 1960s through 1980s difficult to locate except in rare books collections. The ex-dean points proudly to the bookshelf that contains his own publications, many of which were given to him as gifts after his return to his homeland, by friends who had hidden them for many years.

Since 1978, the Rosario group has published the journal Cuadernos Médico Sociales (Medico-Social Notebooks; figure 2) and has operated the Centro de Estudios Sanitarios y Sociales, CESS (Center for Public Health and Social Studies). This group has received financial support and office space from the medical association of Rosario. Due to managed care, the association's financial condition deteriorated, and the future of CESS and the journal remains uncertain.

Figure 2: Cover of Cuadernos Médico Sociales (Medico-Social Notebooks)

Published in Rosario, Argentina; publication was interrupted temporarily due to the financial impact of managed care on the local medical association.

Led by Carlos Bloch, Susana Belmartino, Irene Luppi, Zulema Quinteros, and María del Carmen Troncoso, the CESS group has conducted research on the medical profession. The group also has carried out social epidemiologic research on such problems as low birthweight and infant mortality, Chagas disease, and infectious diseases affecting blood banks. These studies have emphasised the impact of class structure, poverty, and social marginalisation on health outcomes. More recently, members of the group have collaborated in research on reform policies affecting the public sector.10 Although the participants in CESS lost their academic positions during the Argentine dictatorship, they gradually have resumed teaching activities, mostly at the national university in Rosario and in collaboration with the municipal health department. They also hold periodic educational conferences that include instructors from other countries, especially Brazil.

The Córdoba group tries to maintain a social movement that began shortly before the end of the Argentine dictatorship in 1983. The Movimiento por un Sistema Integral de Salud, MOSIS (Movement for an Integral Health System) included participants from professional and student organisations, unions, community groups, religious organisations, and political parties, as well as a national minister of health and other prominent leaders. Although the national movement became fragmented over time, the Córdoba group has maintained the movement's name and goals. Leaders have included Horacio Barri, Norma Fernández, Sylvia Bermann, and Héctor Seia. Between 1983 and 1994, the Córdoba group published the journal Salud y Sociedad (Health and Society) but could not sustain its publication due to financial constraints.

Participants in the Córdoba group have pursued a wide range of activities in social medicine.11 Some have taken part in undergraduate and postgraduate medical education. Other members have addressed workplace health issues in collaboration with unions. The Córdoba group also has studied essential medications, in line with initiatives of the World Health Organization (WHO). Epidemiologists have conducted research in communities with participation of the involved populations, linked to primary care efforts. The group has collaborated in health communication efforts with local newspapers, radio, and television.

Brazil

Social medicine flowered in Brazil, where most participants refer to the field as saúde colectiva (collective health). This term, which came to prominence in the 1970s, reflects an emphasis on the positive search for health, rather than a focus on disease. The symbolism of the collective implies that the causes and solutions of health problems occur in relation to social collectivities, including both local communities and government. The same symbolism tries to move away from the medical and biological connotations of the term social medicine.12

By comparison with Argentina and Chile, the Brazilian dictatorship proved somewhat less repressive. Although some activists in collective health were imprisoned or killed, most remained in Brazil and supported themselves through employment in medical schools, schools of public health, or public hospitals and clinics. People working in collective health have achieved secure positions and infrastructure at several Brazilian universities.

Collective health emerged in the mid-1970s, with the publications and teachings of María Cecilia Donnangelo and Sergio Arouca. Influenced by European Marxist theorists, Donnangelo focused on the impact of class structure on health outcomes, as well as the ideological effects of modern medicine.13 Arouca's work dealt mainly with the unintended consequences of preventive medicine, especially its social control functions.14 In 1979, the Asociação Brasileira de Pós-Graduação em Saúde Colectiva, ABRASCO (Brazilian Association of Postgraduate Studies in Collective Health) was founded. Working groups in several cities generated a wide spectrum of research, teaching efforts, and service activities.

Leaders of collective health have continued to work at the University of São Paulo or local research institutes. Ricardo Bruno Mendes Gonçalves has emphasised the technological organisation of the work process.15 Focusing on the impact of national and international economic policies on health services, Amelia Cohn and Paulo Elías have collaborated with the Brazilian Workers Party in developing national and regional health policies.16 Lilia Shraiber has studied the political economy of medical education and professionalism.17 José Ricardo Ayres has analysed the philosophical underpinnings of epidemiology and recent conceptions of risk.18 With a focus on social reproduction as an analytic category, Paulette Goldemberg does research on women's and children's health. Rita Baradas Barata has served as national president of ABRASCO.

The group at the State University of Campinas has emerged as one of the leading centres for collective health in Latin America. About 12 students annually receive doctoral degrees from this programme. This group also has formed the Laboratório de Planejamento e Administração (Laboratory of Planning and Administration), which consults with municipal and state governments, labour unions, and the Workers Party. Leaders include Emerson Merhy, Gastão Wagner de Sousa Campos, and Everardo Duarte Nunes. In collaboration with ABRASCO, members of the Campinas group have edited an influential journal in collective health, Saúde em Debate (Health in Debate), as well as more than 100 books published with a firm in São Paulo (Hucitech).

The Campinas group has focused on health policy and planning, the history of public health, administration of health services, and microlevel processes in the delivery of services. For instance, their research traces critically the history of public health in Brazil.19 Participants have contributed studies of health administration and planning, which emphasise patients' and workers' participation in policy making.20 The Campinas group also has participated in cross-national research on managed care.

Group members have worked to enhance public sector services provided by municipal governments, often in collaboration with the Workers Party. In these efforts, they have focused on microlevel work processes in the delivery of services and have distinguished between live work--which is characterised as creative, participatory, and changeable--versus dead work--which is bureaucratic, routine, and standardised.21 As part of this effort, the Campinas group has developed a conceptual and methodological approach that emphasises the acolhimento (special reception) of patients by staff members at each stage in the health-care system, from the receptionist, to the nurse or medical assistant, to the doctor, to the laboratory or other ancillary facility, to the personnel responsible for exiting the patient. This approach clarifies microlevel barriers in patients' experience.22 Each worker analyses his or her role and capacity to resolve problems in interaction with other workers.

The Fundação Oswaldo Cruz, FIOCRUZ (Oswaldo Cruz Foundation) and the Scola Nacional de Saúde Pública (National School of Public Health) in Rio de Janeiro have provided institutional bases for collective health. FIOCRUZ is a public institution analogous to the US National Institutes of Health. As a component of FIOCRUZ, the National School of Public Health has both masters and doctoral programmes. Another important institution is the Institute of Social Medicine at the State University of Rio de Janeiro. Leaders at these institutions also have assisted collective health groups elsewhere in Brazil to obtain funding and routes of publication. Sergio Arouca, Paulo Buss, Hesio Cordeiro, Madel Luz, Sonia Fleury, and Cristina Possas have provided leadership. An editorial group at the National School of Public Health has assumed responsibility for publishing Notebooks of Public Health (Cadernos de Saúde Pública), a journal that offers an outlet for work in collective health.

The Rio de Janeiro group has focused on comparative international health policy, critical epidemiology, analysis of health-care institutions, and health-system reform. For instance, Fleury has collaborated with colleagues in Argentina and Mexico in studies of the changing public sector.23 Luz has done critical research on the relations among medical institutions, political institutions, and ideology.24 In efforts to transform the Brazilian social security system, Hesio Cordeiro has emphasised policies to encourage decentralisation and municipal control of health services.25 Possas's work has focused on social epidemiology, including the social determinants of adverse health outcomes.26

A group at the Instituto de Saúde Colectiva (Institute of Collective Health) in the Federal University of Bahía focuses on social epidemiology. Leaders have included Sebastão Loureiro, Naomar de Almeida Filho, Mauricio Lima Barreto, Carmen Fontes Teixeira, and Jairnilson Paim. This group sponsors biannual teaching conferences in epidemiology, which attract participants from countries throughout Latin America. The Institute also coordinates masters and doctoral training programmes, with concentrations in epidemiology, health planning and management, and social sciences in health.

The Bahía group has taken an innovative approach to multilevel and multimethod research and teaching in epidemiology. Trained as a physician and anthropologist, de Almeida Filho has argued that, to consider adequately the full range of social problems that affect health outcomes and mortality, epidemiology must use a variety of quantitative and qualitative methods. His work on epidemiology without numbers uses complementary methods to assess both individual and social levels of analysis.27 Other members of the group, led by Fontes Teixeira and Paim, have focused on public health planning, in the context of municipal and regional government.28

Chile

Before the Chilean dictatorship, most leaders of social medicine served as university professors or as officials in the ministry of health. Essentially all of them lost their employment after the coup. Several experienced imprisonment and torture, and most went into exile in Europe, Canada, or the United States. Some leaders have returned to Chile but usually have not been able to reintegrate themselves into the universities, medical schools, and school of public health. Most returnees to social medicine have worked unpaid, and supported themselves through clinical work, employment as administrators or epidemiologists in the Ministry of Health, or commercial activities such as clinical laboratories or retail sales. These leaders include Alfredo Estrada, Adriana Vega, Jaime Sepúlveda, Carlos Montoya, Mariano Requena, Marilú Soto, Enrique Barilari, Silvia Riquelme, and Luis Weinstein; Felipe Cabello based in New York, and Hugo Behm based in Costa Rica, also participate regularly. They have organised a non-governmental organisation in Santiago, the Grupo de Investigación y Capacitación en Medicina Social, GICAMS (Group for Research and Training in Social Medicine), which has published the influential journal, Salud y Cambio (Health and Change). GICAMS coordinates teaching conferences which attract participants from Chile and other Latin American countries.

The Chilean group members have focused on several areas of social medicine (figure 3). With an emphasis on mental health, they have worked with religious and social service agencies to deal with the effects of political repression, torture, and exile.29 To enhance work on gender and health, they have helped organise an interdisciplinary programme in collaboration with the University of Chile and have conducted research on the health and mental health problems of women, especially in low-income areas of Santiago. GICAMS participants have worked with organisations of industrial and agricultural workers to address such problems as chemical and pesticide exposure in the workplace and in communities. Research in social epidemiology has focused on epidemics and economic transition, the changing rates of infectious diseases such as tuberculosis and AIDS in relation to socioeconomic conditions, and the impact of vaccination policies.30 The group has critiqued policies of public financing for private managed care organisations and has analysed proposals to privatise the remaining public sector national health fund for low-income people without insurance.31

Figure 3: Demonstration against the privatisation of public health services organised in part by members of the social medicine group in Santiago, Chile, 1986

In foreground, Enrique Barilari

Colombia

By the early 1980s, centres of social medicine emerged in Bogotá, Medellín, and Cali. Based at National University, the Bogotá group engaged in community-based research, aimed at improving the conditions of poverty and marginalisation that exacerbated health problems.32 In Medellín, at the School of Public Health of the University of Antioquia, social medicine participants contributed studies of infectious diseases such as malaria, occupational health problems, the importance of violence as a health problem, and the impact of social class on health institutions and health outcomes.33,34 Members of the Medellín group also introduced these perspectives during popular courses at the School of Public Health. The Cali group sought to redefine work roles in community-based health-care teams and devoted attention especially to issues of gender and social class in interprofessional relationships.35

Although Colombia has maintained an electoral government, violence has affected social medicine brutally. Chronic conflicts involving drug cartels, military forces, paramilitary groups, and revolutionary organisations reached an intense level during the mid-1980s. Partly because of their work in local communities, participants in social medicine have become targets of violence. In 1987, paramilitary forces in Medellín killed three professors at the school of public health, including the dean, Hector Abad Gómez. During the terror that followed, many social medicine participants fled into exile. From Medellín these refugees included Saúl Franco, a prolific researcher and teacher, who subsequently worked with the Pan American Health Organization in Washington, DC; and Alberto Vasco, who continued work on social class and health in Spain. Although Franco later returned to Colombia, violence has led to fragility and danger for the social medicine participants who remain.

Cuba

The revolution of 1959 exerted a profound impact on social medicine in Cuba, not necessarily in a supportive direction. Rapid improvements occurred in public health, medical education, primary care, and specialty services. By the late 1970s, Cuba's morbidity and mortality indicators resembled those of economically developed countries.36 These achievements attracted wide recognition by international health organisations and by participants in social medicine.

Within Cuba, the same accomplishments led to a questioning of the need for social medicine. The revolution had achieved improved health conditions largely through broad social change. Many leaders in academic medicine and public health participated directly in the revolution, as combatants, health workers, or political activists. The medical and public health curricula included historical materialism, as well as psychology, anthropology, sociology, epidemiology, primary care, and community-based service. Against this background, the remaining challenges in Cuba seemed to require a focus on technical issues more than the social issues emphasised by social medicine.

Although knowledgeable about the advances of social medicine elsewhere in Latin America, Cuban leaders have tended to view the field as overly theoretical, despite a self-criticism that Cuban physicians have remained too "Flexnerian" and biological in their orientation. The widely circulated Cuban journals in epidemiology (Revista Cubana de Higiene y Epidemiología, Cuban Journal of Hygiene and Epidemiology) and public health (Revista Cubana de Salud Pública, Cuban Journal of Public Health) present research and interventions in occupational and environmental health, ageing, mental health, infectious diseases, and chronic health conditions. Although these publications' contents resemble those of North American, Canadian, or European journals of public health, occasional articles deal with Latin American social medicine. A Cuban commentator has called attention to the limited production of articles or books in social medicine by Cuban authors.37 Partly to increase the visibility of social medicine in Cuba, a group in Havana has initiated a journal, Boletín del Ateneo Juan César García (Bulletin of the Juan César García Center). They also have sponsored the meeting of the Latin American Association of Social Medicine during July 2000 in Havana.

Like all other Cuban workers, individuals working in social medicine are guaranteed full-time employment; they hold positions in the ministry of health or other national institutes, the school of public health, or community health centres linked to medical schools. Leaders include Francisco Rojas Ochoa, Cosmé Ordoñez, and Silvia Martínez Calvo. These leaders have assisted people from other Latin American countries who have studied social medicine in Cuba while earning masters degrees in public health. Rojas Ochoa has undertaken a comprehensive historical study of medicine since the Cuban revolution, with support from the Pan American Health Organization. Ordoñez has participated in the development of family medicine, community health centres, linkages with community-oriented medical schools in other countries, and community-based programmes for elderly people. As a leader at the national school of public health, Martínez Calvo has introduced elements of social medicine, especially the notion that family doctors can act as agents of social change in local communities, into innovative medical and public health curricula, partly to counteract the "Flexnerian" overemphasis on biological issues.

Ecuador

In Ecuador, a group based in Quito has provided national and international leadership. Participants have included Jaime Breilh, Arturo Campaña, Oscar Betancourt, Edmundo Granda, and Francisco Hidalgo. Although members of this group hold teaching appointments at the Central University of Ecuador, they have undertaken many activities through a non-governmental organisation, the Centro de Estudios y Asesoría en Salud, CEAS (Center for Studies and Consulting in Health). The group also has participated in political struggles that have opposed privatisation of health services. Group members have collaborated in a large coalition comprised of indigenous organisations, trade unions, and professional associations. One leader at CEAS, Breilh, was nominated as a national candidate for the Vice Presidency of Ecuador.

Breilh has pioneered a series of theoretical, methodological, and empirical advances in social epidemiology that have become influential throughout Latin America. These approaches have used both quantitative and qualitative methodologies to extend the scope of traditional epidemiology. This work emphasises economic production, income inequalities and distributional inequities, environmental consequences of changing production processes, and the reproductive activities associated with gender roles.

In his work, Breilh has advocated a multilevel and multimethod approach to study morbidity and mortality patterns. His epidemiologic profile conceptualises health conditions at several levels of analysis related to concrete economic and historical processes.38 This perspective has guided other studies by CEAS investigators on urban income inequality and infant mortality, the impact of petroleum production on health outcomes, occupational health problems, and gender and health.39 Breilh has also taught conferences on methodology and has produced a book for courses in social epidemiology that includes a critical appraisal of both quantitative and qualitative methods, with proposed techniques to triangulate methods at different levels of analysis.40

The CEAS group has carried out research in mental health and health policy. For instance, Campaña has focused on projects to improve mental health conditions and services, especially in low-income communities. A recent book critically analyses the social construction of mental illness by modern psychiatry, which tends to emphasise individual psychopathology as opposed to the social causation of mental health problems.41 In the area of health policy, CEAS has coordinated conferences, programmes for national radio and television, and several articles and books intended to reach policy makers and members of the general public. These efforts focus especially on the health impacts of international economic policies, such as the requirements for public sector cutbacks and privatisation imposed by international lending agencies.42

Mexico

The Mexican group has influenced theory and practice throughout Latin America. Based mainly at the masters programme in social medicine at the Universidad Autónoma Metropolitana-Xochimilco, UAM-X (Autonomous Metropolitan University-Xochimilco in Mexico City), the group's leaders include Asa Cristina Laurell, Catalina Eibenschutz, Carolina Tetelboin, Mariano Noriega, José Blanco Gil, and Oliva López. An active offshoot of this group, led by Francisco Mercado, is located at the school of public health at the University of Guadalajara. Eduardo Menéndez, an Argentine anthopologist, is based at the Mexico City Centro de Investigaciones y Estudios Superiores en Antropología Social (Centre for Research and Higher Studies in Social Anthropology). These leaders have travelled frequently to other Latin American countries to teach and to collaborate in research and policy efforts. The programme at the Autonomous Metropolitan University publishes the journal, Salud Problema (Health Problem), and attracts students from many countries.

Since its inception, the Mexican group has prioritised workplace health, community development, and health policy. Participants have collaborated with workers in several industries and in agriculture, as well as with residents in low-income communities. For instance, Laurell and colleagues have studied health conditions in the electronic, metallurgical, and petrochemical industries.43 In this work, they have refined a method using the collective questionnaire, in which workers discuss specific labour processes, risks, and adverse impacts on health. Building on techniques earlier developed in Italy, they conduct the collective questionnaire during a semistructured interview with groups of workers. This participatory research has led to such clarifying concepts as the desgaste (wearing down) of workers by specific characteristics of the labour process.

In agricultural communities, Laurell and coworkers have pioneered the comparative use of both quantitative and qualitative methods. For instance, the group assessed the impact of socioeconomic conditions on health outcomes in two Mexican villages at different stages of economic development.44 The researchers used a combination of qualitative methods, involving anthropological field work, and quantitative techniques, including a questionnaire leading to statistical findings on morbidity. Combining these methods, the investigators could explain the worse statistical indicators of morbidity in the more economically developed village; qualitative observations revealed the adverse effects of an unstable market for cash crops, varying employment, and migration. Using a similar method, a more recent anthropological study clarified the social contextual issues that led to worsened outcomes in such chronic diseases as diabetes mellitus, among low-income residents of urban barrios in the Guadalajara area.45 Other work has analysed the relations betweem poverty, national and international policies, and health and mental health outcomes in local communities.46

The Mexican group also has studied emerging health policies, and its members have been active in Mexican politics at the local and national levels. For instance, members of the group have critiqued the World Bank's proposals for privatisation and expansion of market processes in health services.47 This work has emphasised these policies' impacts on Latin American public-health systems. Likewise, the Mexican group has called attention to the adverse effects of free trade accords, such as the North American Free Trade Agreement, that increase the ability of multinational corporations to operate with little regulation in Mexico and other Latin American countries. This critique has emphasised occupational and environmental health risks linked to the multinational industries that have expanded rapidly in Mexico under the North American Free Trade Agreement. In their political efforts, members of the Mexican group have worked with the Partido de la Revolución Democrática (Party of the Democratic Revolution), an opposition party led by Cuauhtémoc Cárdenas; Laurell has served as Cárdenas' principal health advisor, and in 2000 became director of health for the Federal District of Mexico. The group also has studied and publicised the health conditions affecting indigenous populations in Chiapas, in support of the Zapatista Army for National Liberation.48

Professional issues

Financial survival

Financial support for research, educational, and service projects also varies widely among Latin American countries. Although Juan César García had orchestrated financial support for several social medicine groups from his position at the Pan American Health Organisation, after his death in 1984 this organisation became less reliable as a source of funding.1 The Canadian Association of Public Health has assisted several national groups with project-based funding over extended periods of time. Government agencies and foundations in the Netherlands, Germany, Spain, and Italy have provided support for projects in several countries.

Some groups have been able to secure financial support within their own countries, but this capability varies widely. In Mexico, for instance, researchers in the Mexico City and Guadalajara social medicine groups have received support periodically from the national council on science and technology. Brazilian leaders have participated in committees of the Oswaldo Cruz Foundation, a public institution in Rio de Janeiro that resembles the US National Institutes of Health. Scientific organisations in Brazil, such as the National Research Council, also have provided grants and contracts.

In Argentina and Chile, support from national scientific funders has proven more difficult. Social medicine workers have received some funding from non-governmental organisations and from labour unions for focused projects. For instance, the medical association in the city of Rosario, Argentina, provided financing and physical space to the local social medicine group for more than 20 years, largely to facilitate the publication of the influential journal, Cuadernos Médico Sociales. Since the mid-1990s, the impact of managed care has caused the medical association to impose major budget cuts. The Central de Trabajadores Argentinos (Central Organisation of Argentine Workers) has assisted in distribution of work by Buenos Aires researchers on privatisation policies and managed care. In addition, the Colegio Médico de Chile (Chilean Medical Association, Santiago, Chile) has provided intermittent support for work in social medicine. However, such support in Argentina and Chile remains more sporadic and unpredictable than in Brazil and Mexico.

Professional associations

Many people who work in social medicine participate in an international organisation, the Asociación Latinoamericana de Medicina Social (Latin American Association of Social Medicine). Founded in 1984, the association now has about 1000 members in Latin America, the Caribbean region, North America, and Europe. Their twice yearly conferences generally attract more than 2000 participants, who take part in plenary sessions, oral presentations, poster sessions, networking, dances, and musical events.

Although several national and regional associations maintain their own schedules of conferences and publications, the largest and most influential remains the Asociacão Brasilera de Pós-Graduação em Saúde Colectiva (Brazilian Association of Post-Graduate Studies in Collective Health), founded in 1979. With a membership of about 4000, the association organises yearly conferences that rival those of the Asociación Latinoamericana de Medicina Social in size and intensity, usually attracting more than 5000 participants. The Asociacão Brasilera de Pós-Graduação em Saúde Colectiva sponsors the publication of books and journals and also sometimes contributes financially to research and educational projects.

Publications

National groups in social medicine have published a variety of journals and books which reflect the productivity and sophistication of the field. However, institutional instability and job insecurity add to the impact of economic underdevelopment on publication efforts. Although several national groups are associated with publishers or (especially in Ecuador and Brazil) have themselves initiated publishing wings to produce books and journals, economic uncertainties have hindered these efforts.

Currently, journals in this field encounter several key problems. Costs of national and international postage make mailing the publications to subscribers difficult. Problems within the postal systems themselves lead to publications frequently not arriving at their destination. Mail subscriptions often do not function adequately in Latin American countries, partly because many people do not customarily use postal services for communication. Finally, printing journals through conventional methods is very costly. Due to these problems, two of the key journals in Latin American social medicine--Salud y Cambio and Cuadernos Médico Sociales--have had serious financial problems and long publication delays.

Since most works in Latin American social medicine have been published only in Spanish or Portuguese, they have reached few readers in North America, Europe, Africa, or Australasia. One English-language journal, the International Journal of Health Services, which Vicente Navarro edits at the Johns Hopkins School of Hygiene and Public Health, has provided a forum for Latin American social medicine. Navarro has worked closely with Latin American authors in the preparation of manuscripts suitable for publication in English. Occasional publications from Latin American social medicine also have appeared in such journals as Social Science & Medicine and the American Journal of Public Health. Despite these accomplishments, very little work in the field has reached English readers, and even the diffusion of publications in Spanish and Portuguese across borders within Latin America has proven challenging.

To address these problems, a collaboration based at several Latin American centres and the University of New Mexico, with funding from the US National Library of Medicine, is aiming to enhance the diffusion of publications from Latin American social medicine by publishing multilingual, structured abstracts from selected books and articles on the internet (http://hsc.unm.edu/lasm [2]; this site also contains a list of journals in the field). Publication of structured abstracts in English, Spanish, and Portuguese will improve access for English readers and will enhance the ability of Latin American health professionals to obtain information in their own languages. The development of full-text, online publishing capabilities will help surmount the problems of postal expenses and inefficiencies, traditional constraints limiting mail subscriptions, and high printing costs.49


Conclusions

Although social medicine groups have varying effects on medical practice, public health programmes, and medical education in their respective countries, they have built an important network of groups conducting research and intervention programmes in the tradition of social medicine. Wider knowledge of this work would prove helpful, not least because of the courage of the individuals and groups that have continued their efforts under dangerous working conditions. A focus on the social origins of illness and early death inherently challenges the relations of economic and political power. As a result, participation in social medicine has led to suffering and even death for some of its most talented and productive adherents. Despite these vicissitudes, the themes and findings of Latin American social medicine have become pertinent for problems in medicine and public health throughout the world.

Contributors

H Waitzkin contributed to the study's design, gathered, analysed, interpreted the data, and drafted the article. C Iriart contributed to the study's design, helped interpret the data, and helped revise the manuscript. A Estrada contributed to the study's design, helped analyse and interpret the data, and assisted in revision of the manuscript. S Lamadrid gathered and analysed data and participated in revision of the article.

Acknowledgments

This work was supported in part by grants from the Fulbright Commission (Senior Fellowship for Independent Research, American Republics Program), the Fogarty International Center of the National Institutes of Health (TW 01982), the Pacific Rim Program of the University of California, the American College of Physicians (George C Griffith Traveling Fellowship), the World Health Organisation (Special Programme for Research and Training in Tropical Diseases), the Dedicated Health Research Funds of the University of New Mexico School of Medicine, and the National Library of Medicine (1G08 LM06688). We thank our many colleagues and friends who offered advice, participated in interviews, and provided examples of courage in pursuing social medicine despite threats to their safety for doing so.

References

1. Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health, October 2001 (in press).
2. Testa M. Public health: its sense and meaning. In: Pan American Health Organisation. The crisis of public health: reflections for the debate. Washington, DC: The Organisation; 1992.
3. Testa M. Pensamiento estratégico y lógica de programación (el caso de salud). Buenos Aires, Argentina: Lugar Editorial; 1995.
4. Iriart C, Nervi L, Olivier B, Testa M. Tecnoburocracia Sanitaria: ciencia, ideología y profesionalización en la salud pública. Buenos Aires, Argentina: Lugar Editorial; 1994.
5. Stocker K, Waitzkin H, Iriart C. The exportation of managed care to Latin America. N Engl J Med 1999; 340: 1131-36.