Celia Iriart

Medicina social latinoamericana: aportes y desafíos

This piece presents and analyzes a number of issues related to social medicine: the context of the emergence of social medicine; the differences between social medicine and public health; the theories, methods, and debates in social medicine; the main subjects or problems considered in social medicine; and the difficulties of disseminating the concepts of social medicine among English-speaking persons and among medical and public health professionals in general. Latin American social medicine has challenged other views by contributing to an understanding of the determinants of the health-disease-health care process and by using theories, methods, and techniques that are little known in the field of public health. Introducing Latin American social medicine, especially among English speakers, will be difficult due to the conceptual complexity of this field for persons who are accustomed to the theoretical framework of public health and medicine and also due to skepticism concerning research coming from the Third World. A multidisciplinary team is facing this challenge through two primary initiatives: 1) the creation of an Internet portal and database where there are structured abstracts in English, Portuguese, and Spanish of books, book chapters, and articles on social medicine and 2) the electronic publication of two journals on Latin American social medicine.

Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School.

Academics and World Bank officials argue that, by reducing out-of-pocket expenditures, expanded private insurance may improve access to needed health services in less developed countries. In this empirical response, the authors examine this recommendation through observations from their research on privatization of health services in the United States, Argentina, Chile, and Mexico. Privatization, either through conversion of public sector to private sector insurance or by expansion of private insurance through enhanced participation by corporate entrepreneurs, generally has not succeeded in improving access to health services for vulnerable groups. Although the impact of privatization has differed among the Latin American countries studied, expansion of private insurance often has generated additional co-payments, which have increased rather than decreased out-of-pocket expenditures, thereby worsening access to needed services. Privatization usually has improved conditions for private corporations and has led to higher administrative costs. To address the devastating problems of access to services worldwide, we must find ways to enhance the delivery of public sector services and must move beyond conventional wisdom about market-based policies such as privatization.

The creation of the health consumer: challenges on health sector regulation after managed care era

BackgroundWe utilized our previous studies analyzing the reforms affecting the health sector developed in the 1990s by financial groups to frame the strategies implemented by the pharmaceutical industry to regain market positions and to understand the challenges that regulatory agencies are confronting.MethodsWe followed an analytical approach for analyzing the process generated by the disputes between the financial groups and the pharmaceutical corporations and the challenges created to governmental regulation. We analyzed primary and secondary sources using situational and discourse analyses. We introduced the concepts of biomedicalization and biopedagogy, which allowed us to analyze how medicalization was radicalized.ResultsIn the 1990s, structural adjustment policies facilitated health reforms that allowed the entrance of multinational financial capital into publicly-financed and employer-based insurance. This model operated in contraposition to the interests of the medical industrial complex, which since the middle of the 1990s had developed silent reforms to regain authority in defining the health-ill-care model. These silent reforms radicalized the medicalization. Some reforms took place through deregulatory processes, such as allowing direct-to-consumer advertisements of prescription drugs in the United States. In other countries different strategies were facilitated by the lack of regulation of other media such as the internet. The pharmaceutical industry also has had a role in changing disease definitions, rebranding others, creating new ones, and pressuring for approval of treatments to be paid by public, employer, and private plans. In recent years in Brazil there has been a substantial increase in the number of judicial claims demanding that public administrations pay for new treatments.ConclusionsWe found that the dispute for the hegemony of the health sector between financial and pharmaceutical companies has deeply transformed the sector. Patients converted into consumers are exposed to the biomedicalization of their lives helped by the biopedagogies, which using subtle mechanisms present discourses as if they are objective and created to empower consumers. The analysis of judicialization of health policies in Brazil could help to understand the complexity of the problem and to develop democratic mechanisms to improve the regulation of the health sector.

Argentina: No Lesson Learned

This article examines the political, ideological, social, and economic processes by which the Argentinean economy was transformed, the structural consequences, and the policies responsible for dismantling the welfare state. The health care system reform during the 1990s was an important component in accomplishing the last objective. Analyses of the policies adopted after the crisis of 2001 reveal that, despite the discourse against international financial institutions, President Nestor Kirchner, elected in 2002, followed the same approach by accepting and applying the second generation of health reforms recommended by the World Bank and the Inter-American Development Bank with additional pressure from the World Trade Organization and several free trade agreements. This “new reform” furthered business opportunities for multinational corporations while further shrinking the state administrations role in supplying health, education, and other social services to people who need them more than ever. Social movements have emerged that are developing alternative projects and showing that, when the base is solidarity, “another world is possible.”

How the United States Exports Managed Care to Developing Countries

As their expansion slows in the United States, managed care organizations will continue to enter new markets abroad. Investors view the opening of managed care in Latin America as a lucrative business opportunity. As public-sector services and social security funds are cut back, privatized, and reorganized under managed care, with the support of international lending agencies such as the World Bank, the effects of these reforms on access to preventive and curative services will hold great importance throughout the developing world. Many groups in Latin America are working on alternative projects that defend health as a public good, and similar movements have begun in Africa and Asia. Increasingly, this organizing is being recognized not only as part of a class struggle but also as part of a struggle against economic imperialism—which has now taken on the new appearance of rescuing less developed countries from rising health care costs and inefficient bureaucracies through the imposition of neoliberal managed-care solutions exported from the United States.

Capital financiero versus complejo médico-industrial: los desafíos de las agencias regulatorias

This article presents the structural processes that consolidated under the hegemony of the financial capital in the 90s; the dispute between the financial capital operating in the health sector and the medical-industrial complex; the strategies used by the medical-industrial complex for regaining positions; and the challenges all these processes pose for the regulatory agencies. The problems the regulatory agencies are facing lie in two central processes: 1) the hegemony the financial capital reached in the 90s in the health sector through reforms aimed at deregulating the sector in order to facilitate its entrance; and 2) the repositioning of the medical-industrial complex since the mid 90s by radicalizing medicalization. This article is based on several studies conducted by the author using qualitative methods and quantitative secondary data for understanding the historical-situational context. The theoretical approach was based on Marx, Gramsci, Benasayag, Badiou, Testa and Merhy. The analyses of the most recent reforms induced by the medical-industrial complex were the result of a bibliographic and document review.

The Latin American Social Medicine Database: a resource for epidemiology

Latin American social medicine (LASM) has become a widely respected and influential field of research, teaching and clinical practice, yet its accomplishments remain little known in the English-speaking and -reading world. Important publications have not been translated from Spanish and Portuguese into English, and the majority of LASM journals are not indexed in MEDLINE or similar bibliographic databases. The field’s development also suffers from technical difficulties of publication and distribution within Latin America. In LASM, a perspective emphasizing the social origins of illness and early death has focused on sources of these problems in relations of economic and political power. This orientation has contributed to the analysis of inequity in health and to alternative proposals for change. For instance, LASM analyses critically some of the dominant reform strategies in public health systems, offers proposals for alternative health policies and fosters research on the microand macro-political processes that affect health and health services. Likewise, LASM focuses on economic production in studies of the labour conditions that affect workers’ health. LASM uses theories and methods that distinguish its efforts from those of public health. In particular, LASM emphasizes the social and historical context of health problems, social determinants and the linkages between research and the development of responsive political ‘praxis’. In these ways, LASM offers innovative approaches to some of the most important problems of our age. Some Latin American medical and public health literature is indexed in Literatura Latinoamericana y del Caribe en Ciencias de Salud (LILACS, Latin American and Caribbean Literature in Health Sciences), an Internet-accessible database maintained by the Latin American regional library of medicine in Brazil, Biblioteca Regional de Medicina (BIREME, Regional Library of Medicine). Although the LILACS database, supported by the Pan American Health Organization (PAHO), has improved access to the Latin American biomedical and public health literature, several features limit this database’s applicability to LASM. As examples, the LILACS database covers only about half of the key journals in LASM, does not include an abstract unless it appeared in the original publication, and usually does not provide translation of Spanish or Portuguese abstracts into English. This project’s overall objective is to develop and implement an Internet-based information system to maximize access to LASM literature and to facilitate continuing publication and distribution efforts in this important field. We have constructed the system to target investigators, educators, clinical practitioners, public health professionals, historians, social scientists, specialists in Latin American studies and professionals in library and information science. In particular, we have aimed to improve access to LASM for epidemiologists who focus on the social determinants of health outcomes. Although we have reported preliminary work on these efforts, this article provides an overview of the project as a whole and clarifies its relevance for epidemiology.

El Internet y su incorporación al sector de la salud

The governmental and health sector reforms that are being carried out in the countries of the Region demand the rapid training of health personnel to face the challenges posed by the process of change. This report explores the many possibilities of the Internet to serve as a mode of communication and updating of health professionals and technicians and as a vehicle for the dissemination of information on subjects of interest to scientists and researchers.

Biomedicalización e infancia: trastorno de déficit de atención e hiperactividad

El articulo analiza criticamente el aumento de los ninos diagnosticados y tratados por el Trastorno de Deficit de Atencion e Hiperactividad (TDAH). Los analisis vinculan este creciente fenomeno con las estrategias de la industria farmaceutica para reposicionarse en el liderazgo de la conceptualizacion del proceso salud-enfermedad-atencion y en el mercado de salud. Utilizamos metodos analitico-interpretativos para estudiar datos primarios y secundarios, y realizar una extensa revision bibliografica. A la luz del concepto de biomedicalizacion analizamos los mecanismos subjetivo-ideologicos que facilitaron que este discurso se instituya como una nueva verdad sobre este trastorno y sea legitimado por los organismos gubernamentales y las organizaciones de la sociedad civil. La biomedicalizacion del sufrimiento infantil dificulta que se pongan en evidencia los profundos cambios socioeconomicos, politicos e ideologico-culturales que han transformado radicalmente nuestras sociedades en las ultimas decadas.The article critically analyzes the increasing number of children diagnosed with and treated for Attention Deficit Hyperactivity Disorder (ADHD). The analysis links this growing phenomenon with the strategies of the pharmaceutical industry to attain leadership in the health-illness-care process as well as in the health market. We utilized analytical and interpretive methods to study primary and secondary data and conducted an extensive literature review. In light to the concept of biomedicalization, we analyzed the ideological and subjective mechanisms that facilitated the institutionalization of this discourse as a new truth concerning this disease as well as its legitimization by governmental and civic organizations. The biomedicalization of childrens suffering facilitates the concealment of deeply rooted socio-economic, political, ideological and cultural changes that have radically transformed our societies over the past few decades.

The Latin American Social Medicine database.

BackgroundPublic health practitioners and researchers for many years have been attempting to understand more clearly the links between social conditions and the health of populations. Until recently, most public health professionals in English-speaking countries were unaware that their colleagues in Latin America had developed an entire field of inquiry and practice devoted to making these links more clearly understood. The Latin American Social Medicine (LASM) database finally bridges this previous gap.DescriptionThis public health informatics case study describes the key features of a unique information resource intended to improve access to LASM literature and to augment understanding about the social determinants of health. This case study includes both quantitative and qualitative evaluation data. Currently the LASM database at The University of New Mexico http://hsc.unm.edu/lasm brings important information, originally known mostly within professional networks located in Latin American countries to public health professionals worldwide via the Internet. The LASM database uses Spanish, Portuguese, and English language trilingual, structured abstracts to summarize classic and contemporary works.ConclusionThis database provides helpful information for public health professionals on the social determinants of health and expands access to LASM.