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PEOPLE’S HEALTH ASSEMBLY 2GLOBAL HEALTH WATCHTHE PEOPLE’S MOVEMENTINTERNATIONAL PEOPLE´S HEALTH COUNCILRESEARCH MATTERSSCHOOL OF MEDICINE – U. OF CUENCANACIONAL PEOPLE’S HEALTH FRONTCENTER FOR HEALTH RESEARCH AND ADVISORY (CEAS)LATIN AMERICAN HEALTH WATCHAlternative Latin American Health ReportEditor general: Jaime BreilhEnglish Edition:Translation: Gaby Mansfield Borrero.General Reviewers: Jeremy Ogusky.Specific texts reviews: Pete Dohrenwend, Brian Epstein, JessicaFlayer, Diana Grigsby, Jon Hartough, Emmanuel Hipolito, GarrettHubbard, Jaime Jones, Lynda Lattke, Ann Miceli, Amber Middleton,Siiri Morley,Weej Mudge,Arden O´Donnell, Chris Onken,TommasoPacini,Talya Ruch, Eve MoreauSpanish Edition:Reviewers: Arturo Campaña, Francisco Hidalgo.Translation:: Gaby Mansfield Borrero.Pre-diagramming :Edith Valle© Global Health Watch – CEAS - 2005Asturias N2402 y G. de Veraceas@ceas.med.ecPhone-fax: 593 2 2506175 mobil : 099707682Quito – EcuadorISBN-9978-44-258-8Printed in: Cuenca , Ecuador"Imprenta Hernández"CuencaGlobal 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 majorinstitutions that influence health.The Watch is available for free download at the website www.ghwatch.org, and on CD, available by contacting ghw@medact.org. It will be published by ZedBooks in December 2005.Acción Global de Salud es un instrumento de campaña basado en el Primer Observatorio Global de Salud (Global Health Watch) publicadoen julio del 2005.El Observatorio es una amplia colaboración de expertos, organizaciones no gubernamentales, activistas de la sociedad civil, grupos de comunidades, trabajadoresde 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 AlianzaGlobal 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 undesafío 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 ghw@medact.org y serápublicado por Zed Books en diciembre del 2005.2

AUTHORS(Order of appearance -edition):Jaime Breilh; María Eliana Labra; Gerardo Merino; Adolfo Maldonado; Saúl Franco; MarianoNoriega / 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 / NormaHerrera / Corina Barbosa / Eulalia Ayllon / Marcela Ferreira / Fabiana Gomez / Cristina Fuentes/ Isabel Lindon; Ary Miranda / Josino Moreira / René Louis de Cavalho / Frederico Pérez; CatalinaEibenschutz / 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;MarioHernández / Lucía Forero / Mauricio Torres. Julio Monsalvo / Frente Nacional por la Salud de losPueblos; 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 deXochimilco (México); Red Trabajo Infantil (Perú); Universidad Obrera (México); FundaciónFriedrich Eberth (FESCOL, Colombia); Asociación Colombiana para la Salud (ASSALUD,Colombia); Escuela para el Desarrollo (CESDE; Colombia); Organización de Madres del BarrioUtuzaingo (Argentina); Universidad Federal de Río de Janeiro (UFRJ, Brasil); Sistema deInvestigación 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); UmeaInternacional School of Public Health (Suecia); Asociación de Promotores de Salud "Sandi Yura"(Amazonía, Ecuador); Ministerio de Salud de la República Bolivariana (Venezuela); Secretaría deSalud del Gobierno del Distrito Federal (México, D.F.); Universidad de La Habana; Academia deCiencias (Cuba); Ministerio Salud Pública (Uruguay); Secretaría de Salud Pública de laMunicipalidad 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

LATIN AMERICAN HEALTH WATCHAlternative Latin American Health ReportJaime BreilhCEAS (Editor)5

D E D I C A T I O NTo all the women of Ciudad Juarez,which have been murdered since the start of neoliberalism.May the memory of their violent disappearancebloom in multiple forms of struggleagainst this inhumane and genocidal social system,that is sold to us as "modernization" and "progress".RECOGNITION AND WORDS OF GRATITUDETo the "Research Matters" Program of theInternational Development Research Center (IDRC, Canada)for their support of this project that attempts to showthe World some relevant evidence about the healthsituation of Latin AmericaTo the Provincial Council of Pichinchafor their support of the Alternative Reports´launch and promotion.To those that made possible this Alternative Report withtheir invaluable testimonies of the struggle for healthbuilt together with our people.More than authors we consider them true allies that have honoredthis 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 memoryis 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 inspirationsthe 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 tomorrowand that paradox is what makes possible to avoidthe 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´sfamous definition of Art

C O N T E N T SIntroduction1.Alternative Health Report:A Tool for the People. Jaime Breilh.13Section I:THE HEALTH DIVIDE:THE PEOPLES’ PERSPECTIVEEconomic Dispossession (Assault) and HealthMonopoly, Inequity and Health2. 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 Security4. 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 Degradationand the Ecosystem6.The Impact of Neoliberalism in the Health of Latin-American Workers. Mariano Noriega,Angeles Garduño and Cecilia Cruz7. 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 VarillasLife and Health As Commodities9. Latin America: Neoliberalism And Survival. Laura Juárez10. Regression of Health in Neoliberal Colombia. Miguel Eduardo Cárdenas, Luz Helena Sánchezand Martha Bernal.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.222425344041526263708494950011010

12. Neoliberalism, Pesticide Use and the Food Sovereignty Crisis in Brazil.Ary Carvalho de Miranda, Josino Moreira, René Louis de Cavalho and Frederico Peres13.The Water Policies in Latin America: Between Water Bussines and Peoples´ Resistance. Alex ZapattaCultural Agression, Uniculturality and Health14.The "Zapatista" Struggle and Health: Cultural Aggression, Discrimination and Resistance asTriggers of Indigenous Potentialities. Catalina Eibenschutz Hartman and Marcos Arana Cedeño15. Communication Hegemony and Emancipatory Health: An Underestimated Contradiction (The Caseof Dengue). CharlesBriggs and Clara Mantini16. Despair in Latin America: Evidences for a psychosocial autopsy of suicide. Arturo CampañaBiodiversity: Destruction and Monopoly17. Control Over Nourishment:The Case of Transgenics. Elizabeth Bravo18. Oil Exploitation in The Amazonic Region of Ecuador: Emergency in Public Health.Miguel San Sebastián, Anna-Karin Hurtig, Anibal Tanguila and Santiago SantiSection II:THAT OTHER HEALTH POSSIBLEAction from Democratic States19. Health Program Achievements of the Bolivarian Venezuelan Republic. Francisco Armada20.The Health Policy of the Government of the City of Mexico: for the Social Rights andthe Satisfaction of Human Necessities. Asa Cristina Laurell21. Cuba Breaks through the Siege of the Imperialist. Miguel Márquez; Francisco Rojas; Cándido López22. Uruguay: Community Participation in Health and the Role of Epidemiology. Miguel Fernándezand Sergio Curto23. EReal Equity in the State´S Supply of Public Health:The Target of a Democratic Municipal Government.Mónica Fein, Déborah Ferrandini24.The Experience of Bogota D.C.: A Public Policy to Guarantee The Right To Health. Mario Hernández,Lucía Forero, Mauricio Torres.Action from the Peoples25. 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 Companiesand Public University in Argentina. Jorge Kohen, Germán Canteros, Franco Ingrassia.28. Sports and Human Liberation. Paulo Capela and Edgard Matiello.11812813813914815817017118019019219320020621422022624224324825827011

Introduction

1Alternative Health Report :A Tool For The PeopleJaime BreilhHealth reports are supposed to be knowledge and monitoring tools of publichealth (collective health) for the promotion and defense of life. If their informationis realistic, they make evident the deep wounds of inequality in peoples’current health situation.Unfortunately, most of the renowned reports on regional health, ones thatare amply disseminated through institutional health offices, allow neither a clearunderstanding of the profound deterioration that characterizes Latin-Americanpeoples’ health, nor of the relation between that decline and the unprecedentedwealth concentration that our societies experience. Despite being elaborated infancy editions and supported by important data bases, they are not conceived tounveil reality, and with the mass communication media that masks or concealsevidence of political and social inequity, official health reports hide the devastatingeffects 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 threedecades into commodities. So beyond their authors´ goodwill, and regardlessof their frequently robust solid mathematical and formal fundaments, officialhealth information and conclusions are commonly restricted to a logic that disguisesreality. From a positivist paradigm, they obscure the health situation, sincethey magnify insignificant average health outcomes of national programs, whileconcealing major problems, or presenting these problems in a manner impossibleto 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 re-13

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAgion.To illustrate our argument we could mention thefact that official health registers of countries with growinginequities and social abysses are full of statisticaltables and graphs, showing a discrete improvement ofvarious average health indicators, such as mortality inearly age. In the eyes of the specialist these do notconstitute any proof of sound improvement of children’sliving and health standards, as these averagescan be found stable or even declining slightly despiteaggravation of living quality contrasts among regionsand social classes in many places. Further, these discreteimprovements can induce the false image of sustainablehealth development. For this reason, I have inthe past thoroughly analyzed these types of fallacies inofficial reports [Breilh, 1990]. As I have frequently argued,it is not intellectual mercenaries –like CarlosMontaner- who perform these calculations. They arewell-intentioned technicians, even some with progressiveideas, who by applying a lineal reductionist methodologyand thus end up contributing to the reproductionof hegemonic interpretations of our reality. Justto reaffirm our line of reasoning we could add anotherillustrating finding. The so called human developmentindex (HDI) of the United Nations (UN) has beenused to provide a mathematical image of social wellbeing,in manifestly unfair countries. That amply citedindex elaborated by the United Nations DevelopmentProgram (UNDP), including compound indicators thatportend to reflect according to its authors "a longhealthy life, knowledge and a decent living standard"[PNUD, 2001], showed an ascending trend, suggestinga significant human development improvement(r>0.94; p=0.00) in countries such as Argentina andEcuador from the years 1984 to 200, precisely whenthe neoliberal model was unmercifully affecting theirpeoples, provoking a clear social decline and massivemalaise, all of which operated as a source of growingdissatisfaction that triggered violent outbreaks and theoverthrowing of presidents blamed for introducingthese voracious policies and further fostering inequality[Breilh, 2002].Certainly, in the last few decades of neoliberaleconomic policy, the magnitude of impoverishmentand expansion of social contrasts often rule out thosediscrete statistical maneuvers, and data cannot concealsocial corrosion. However, when deteriorated healthindicators are registered, these appear disconnectedfrom the social unjust relations that generated them.Correspondingly, the categories and variables chosento picture health, and the way they are associated, dissolvesystematically their structural determinants,such as economic concentration and social exclusion,institutionalization of repressive violence and aggression,legal deregulation and reduction of public normsfor social security, which leaves citizens and workingpopulation unprotected and at the service of greedylabor arrangements, loss of human rights and theirtransformation into merchandise, cultural aggressionand imposition, and big business destruction of biodiversityand appropriation of vital resources such aswater, energy, genetic resources.The Alternative Health Report in Latin Americathus recovers these types of categories and relationsthat tend to be overlooked by "dominant science", inorder for epidemiological analysis to become impregnatedwith reality, and so that our people can benefitfrom an analytic tool which penetrates the roots oftheir suffering, and allows for projecting, on reliable bases,a strategy to transform an inhumane and pathogenicsocial order.Alternative Reports´ Brief HistoryStarting with the recognition of the insignificanthealth achievements in the world population’s healthin the last two decades, voices arouse demanding a differenttype of health monitoring and reporting system.14

Observatorio Latinoamericano de Salud.Social forums demanded a focus on the dramatichealth problems of the socially excluded, the workersand the marginal urban masses thronged in cities, therapidly increasing rural populations submitted to extremeimpoverishment, and above all, that they be aidedby dependable organizations not representing thebiased perspective of the powerful.To begin with, specialized scientific organizationswith research experience were summoned. Facing themiddle of the 1980’s, different movements of civil societyinitiated discussions on the necessity to inject"reality" into international health policies and informationrequired to evaluate the situation of peoples’health. Following several preparatory events held indifferent places of the World, the First Peoples’ HealthAssembly was convoked in Bangladesh in December of2000 with the participation of 1.500 delegates from 75countries.They represented civil society organizations,nongovernmental organizations, social activists groups,health professional associations, and academic and researchnucleuses.The main issue of the first assembly,still envisaged as an urgent need, was, "listening to theignored".Within this fundamental meeting the well-known"Declaration for Peoples’ Health" emerged, whichsummarizes the principles of our health struggle.Briefly, it is to fight for the highest level of humanhealth under equitable access to care and preventiveresources; the conquest of an integrated and democratichealth system, with solid high-quality primarycare; to promote the right to health, as such and notas a commodity; the implementation of an integral systemconducted by collective and communitarian organizationsto their own benefit; and finally the ethicaland sanitary responsibility of understanding health developmentas a process determined by socioeconomic,cultural and political conditions, and not only bythe provision of medical care services, which hithertocontinue to be a privilege of affluent social groups. Inview of these antecedents, the organization of the SecondWorld Assembly was made possible.This urge for an alternative analysis to theWorld Health Organization’s "World Health Report"was proclaimed. There was a clamor for a type of reportto be issued independently of official powerstructures and not influenced by the agendas of internationalcooperation agencies. The need was for atool to assist the Peoples Movement on views ofhealth, an instrument for their struggle for equity andhuman/social rights, and the need to monitor internationalhealth institution policies. In short, a tool forsocial justice in the health field. The idea of an alternativereport culminated in the initiative of GlobalHealth Watch.The Watch has been coordinated by internationallyrenowned organizations, such as "Global EquityGauge Alliance" and "Medact", and has been projectedin working groups throughout all the continents. Awhole set of organizational efforts will now convergein the introduction of a First World Alternative HealthReport, during the Second Peoples’ Health Assemblyin Cuenca, Ecuador, on Wednesday, July 20th of 2005,before delegations of all continents, and simultaneouslyechoed in ten cities throughout the world.The complementary publishing of a Regional AlternativeReport for Latin America was decided onthis year, not only for the fact that the Second Assemblyis taking place in a Latin-American country, butalso in recognition of valuable contributions made bythis region´s researchers and health organizations ininnovational research and successful alternative healthprograms. The International Committee and GlobalHealth Watch designated the Center for Health Researchand Advisory of Quito (CEAS) as the centralorganizer and editor of the report. CEAS is now celebrating25 years of scientific production dedicated tothe development of critical thinking, and the fosteringof emancipatory health programs.15

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAEquity Forsaken:Conventional Reports MethodologyThe flaws of conventional reports cannot be fullyunderstood solely from an ethical perspective. Thougha number of conservative governments conceal inefficacy,or even corruption with biased statistics, the problemis that even well-intentioned experts generateflawed reports, as I have noted above, not becausetheir calculations are mistaken in themselves, but becausebiased analysis models are applied, which merelydisplay health outcomes, without evidencing the socialprocesses that generate them, or substantiating thepower relations that provoke scarcity and suffering inhealth and constitute the very barriers hindering theachievement and recognition of human rights.How can we understand the fact that conventionalhealth reports comprise a form of renunciation ofequity, when they occasionally refer to inequitableconditions? Actually, the construction of health evaluationor epidemiological models is based on concretescientific ideas organized under specific paradigms.Experts who design and plan health reports, whetherthey are cognizant of it or not, apply specific interpretativeframeworks or paradigms. What does this signify?On assembling diagnoses, we use concepts, wemake viable or prioritize various facts and relegate others,we choose several variables and not others, wedemonstrate relations among variables in a particularmanners, and we recognize certain values. This set ofmethodological decisions and operations form a matrixfrom which we describe and interpret reality. Here,I will not dwell upon an explanation of the interpretativemodels commonly used to describe health, as itis sufficient to recognize that lineal and reductionist(positivist) methodologies have posed an extremelynegative influence on health thinking.Elucidating positivist operations to readers notfamiliar with the debate on scientific ideas, epistemologicalanalysis of scientific work, is not an easy task tobe undertaken within this short paper. But some basicreflections are indispensable. In the first place, positivismis neither the only paradigm, nor does it alwaysappear in evident visible forms. Nevertheless, it is importantto highlight the interpretative consequencesof its application and its conservative nature, whichcontradict the views of the Peoples Movement. Thepositivist approach, as rigorous as it appears, presentsfacts in a fragmented or disconnected manner that separateshealth phenomena from its social historicalcontext.Variables are placed out of context, reality isatomized in many variables or factors, all of which areseparately assumed as causes of illness, although detachedfrom the processes that explain their appearanceand movement. In sum it is the outlook of a realitycrushed into pieces, mechanically associated.The Analysis of Inequality Without Inequityis a FlawTo the ruling groups, the fact that health reportinformation is shown in pieces deprived of their socialorigin is not a problem. On the contrary, it is a desirableprocedure. This type of diagnosis dissolves historicalhealth determinants and produces the illusionthat illness factors can be rigorously dealt with one byone, when in fact, those fragmented pieces of realitycannot be assembled in an integral explanation of societalhealth, and thus the image we are able to elaboratefrom that viewpoint, reality in fact, ends up beingveiled and obscured in statistical tables and sophisticatedmathematical models.On the other hand, people interested in understandingthoroughly their reality in order to be capableof transforming it, must overcome this reductionismand specific interpretation of problems. They mustemphasize the slants that constitute the health situa-16

Observatorio Latinoamericano de Salud.tion core and never neglect the association of thoseproblems with wide-ranging social relations derivedfrom the power structure and social domination relationswhich characterize hierarchical societies such asours.Referring to inequality and allowing tables andindicators to pervade our experience on urban-ruralsocial inequality, among "social strata" and genders,etc, may result in solely rhetoric if we fail to connectknowledge of the mentioned inequalities with studieson inequities and the specific social contrasts that generatethem. Hence, usually displaying inequality numberswithout an inequity analysis is an illusion, and anoperation perfectly acceptable to those not interestedin changing the world, but merely modifying its mostnegative and evident facets. The dissemination of superficialinequality indicators does not threaten thehegemonic health prescriptions of the powerful.To thecontrary, their acknowledgment of certain social differencescan convey an image of magnanimity. On theother hand, the announcement of clearly unfair socialrelations and the existence of an economical, politicaland cultural system of dominance, that operates as afundamental health determinant is for them intolerable,since it discloses the essentially inequitable natureof our societies, and points to real changes that implydemolishing those domination structures.Within Latin America, perhaps on account of historicalproximity of progressive scholars and researcherswith grassroots struggles, a renewed view oncollective health emerged as early as the 70’s in publichealth writings. Epidemiology, for instance, and theconsequent health diagnoses and reports of this discipline.Accordingly,in conjunction with the activation ofa Latin-American Movement named Social Medicine, atpresent known as Collective Health, renovation beganconcerning studies on the evaluation of health 1 ,whichseveral authors appreciate as one of the most vitalmovements toward science oriented in social justiceand rooted in a creative renovation of health paradigms[Waitzkin; Iriart; Estrada & Lamadrid, 2001].In recent years, signals of openness to a socialapproach based on health determinant processes haveresounded in First World academic nucleuses and internationalagencies. Events such as the "Conferenceon Health Impact Assessment and Human Rights" atthe Harvard School of Public Health 2 , where attentionwas drawn to the need to open health interpretationsto socioenvironmental determinants, and further linkthem to human rights and inequity; or the configurationof the Commission on Health Social Determinantsby the WHO 3 in March of this year, with the expressmandate to surmount approaches restricted toparticular illnesses, and tackle general problems derivedfrom social inequality, confirm a reaction againstpositivist schemes for which Southern movements havecalled attention for decades.In the last Health Research World Forum 4 ,theexisting distortion of the health research prioritiesallocation system was discussed a propos the "10/90research gap", since only 10% of resources are assignedto the bulk (90%) of peoples’ health problems.The "10/90 gap" has been proclaimed as a result ofcommercial reasoning that prevails within institutionsthat conduct health research investments and have theeconomic power to assign resources.The minor significanceconceded to problems affecting social massesdepicts the implicit recognition that their research is1. 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 scientificproduction of Latin-American Social Medicine and its innovating view.2. Harvard School of Public Health (2002). Conference on Health Impact Assessment and Human Rights. Boston, august 16-19.3. OMS - Comisión sobre Determinantes Sociales de la Salud (http://www.who.int/social_determinants)4. Foro Global de Investigación en Salud. México, 16-20 Noviembre del 2004.17

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAnot considered as "highly profitable". Within the sameevent, an international commission put forward a"combined approaches matrix" [Ghaffar; De Francisco;Matlin, 2004] to prioritize investments in research basedevidences. The flaws of the model depicted cannotbe fully discussed here; I can only underline that,albeit the cited matrix proposes a broader analysisfield that acknowledges the impact of macroeconomicpolicies, the health system, and other sectors such aslabor, legal standards, education, and ecological problemsas health determinants. It nevertheless reproducesthe conventional reduction of interventions to theinstitutional sphere, without putting forward any seriouscritique of the consequences of social dominanceand the associated inequitable power structure.The Alternative Report:Critical Thinking and Liberating ActionThe Alternative Health Report for Latin Americapresupposes a critique of the pathogenic effects of socialinequity and the need to transform the prevailingpower structure as a way to achieve a healthy and dignifyingquality of life for our people, and as a basis forsustainable institutional and technical changes in thehealth field.Thus, the construction of an authentic alternativeapproach presupposes a critical knowledgeparadigm and transforming view of intervention inhealth.To fulfill its commitment, in its first part the AlternativeReport penetrates the devastating effects ofthe economic accumulation model applied within LatinAmerica in the last decades. The idea is not merelyto speak of globalization, as there is no contemporaryforum in which problems are not interpreted and justifiedalluding to globalization, as an issue of worldwideeconomic and market system relations.The idea isto visualize the new characteristics of our social systemwhich distinguish it from other epochs that haveimmense weight and influence on health.In late capitalism, the technological basis of digitalcommunication and other technical resources arecrucial. Even if it is important to acknowledge the significanceof this technological revolution, we must notdisregard the fact that the roots of present social dominationreside rather in the structural processes of anew capital accumulation system, defined by Harvey asthe accumulation by dispossession [Harvey, 2003]. Accordingto this author, contemporary capitalist logicnot only exerts itself through the extraction of surplusvalue from workers and the traditional market mechanisms,but it now depends heavily on truly predatoryforms of practice, fraud and violent exaction, whichare imposed by taking advantage of inequalities andpower asymmetries to dispossess weaker countries orvulnerable groups directly.Case studies rendered throughout the differentchapters of section I ("El Modelo de Acumulación porDespojo y la Salud" - Accumulation Model by Dispossessionand Health) examine the extreme impoverishmentof peoples, the destruction of their living conditions,and the deterioration of environmental integrity.They illustrate how the logic of large corporationsoperate, whose profit increases demolishing livingconditions, while social mobilization struggles creativelyto defend human rights and health. Distinct chaptersinterweave to illustrate the expansion of monopoliesthat permanently reinvent mechanism of socialand cultural subordination and inequity; the institutionalizationof violence; the cases of deregulation of laborand social protection laws, with the ensuing degradationof working and living conditions; the gradualtransformation of human rights into commodities; thecases of cultural aggression; and the varied manners ofbiodiversity destruction.In section II ("Esa Otra Salud Posible" - That OtherHealth Which is Possible), a more optimistic or18

Observatorio Latinoamericano de Salud.progressive side of Latin American health is presentedregarding the advances accomplished by national andlocal governments of humane social nature, in spite ofthe previously cited adverse conditions.Workers’ victoriesin defense of justice and living conditions aredocumented and illuminated, like the case of recuperatedfactories in Argentina and successful self-managedcommunity driven proposals are explained. Evenfields conventionally considered as tangent to healthare taken into account, like the case of emancipatorysports programs in Brazil. And finally, experiences ofintercultural relations that tender bridges among peoples’different knowledge bases and the liberating academicknowledge that is resultant to this interchangeis illustrated.Creating this report from design to completionin a short five month period, with Spanish and Englishversions simultaneously prepared, CEAS (Health Studiesand Advisement Center, Quito-Ecuador) defined afast moving strategy, identifying key issues and callingfor the contribution of specialists and social organizationswith which it had developed fraternal work duringits two and a half decades of institutional strugglefor collective health. Overall, our summon was positivelyresponded to by 60 individual authors from tenseparate countries, and more than 30 organizations ofthe region (among the most representative academicnucleus or peoples’ organizations). Obviously, an effortof this magnitude could not achieve in such a short timeall the desirable characteristics of a complete LatinAmerican Report; however, its representativenessand authenticity are supported and justified by thescientific and political relevance of the work its authorsand their organizations have accomplished. TheAlternative Report coming from such a diverse set ofexperiences attains unity in the emancipatory natureof their resistance against the irrational, genocidal, andinhumane social system in which we live.We sincerely hope that the Alternative Reportwill accomplish the two basic goals that inspired its devising:to become part of our collective memory in theprogressive sense that the celebration of memory acquireswhen, as Subcommander Marcos stated, memoryfaces tomorrow and "…that paradox makes itpossible to avoid the same nightmares and thus recreatehappiness"; and secondly, to make clear the differencethat Brecht established between conservativerhetoric and emancipatory cultural works: not being "asimple mirror held up to reality but a hammer withwhich to shape it".The Alternative Health Report reaffirms ourright to build our collective memory, without mediationsof the powerful, as the peoples´ memory is onlyliberating when it registers the substantial side of theirpains and happiness, when it nourishes and celebratesa different tomorrow.REFERENCES● BREILH, JAIME & AL (1990). Deterioro de la Vida: Un Instrumentopara Análisis de Prioridades Regionales en lo Social y la Salud.Quito: Corporación Editora Nacional.● BREILH, JAIME (2002) El Asalto a Los Derechos Humanos y elOtro Mundo Posible. Quito: Espacios, 11: 71-82.● HALL, GILLETTE; PATRINOS,ANTHONY (2005) Pueblos Indígenas,Pobreza y Desarrollo Humano en América Latina.Washington:Banco Mundial.● GHAFFAR, ABDUL; DE FRANCISCO, ANDRÉS; MATLIN, STEP-HEN (2004) The Combined Approach Matrix: A Priority SettingTool for Health Research. Geneve: Global Forum for Health Research.● HARVEY, DAVID (2003) The New Imperialism. Oxford:The OxfordUniversity Press● WAITZKIN,HOWARD; IRIART, CELIA; ESTRADA, ALFREDO;LAMADRID, SILVIA (2001) . Social Medicine Then and Now: Lessonsfrom Latin America.American Journal of Public Health, October,Vol91, No. 10 1592-160119

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

Monopoly,Inequity and Health

2Neoliberal Reinvention of Inequality inHealth in Chile 1 María Eliana LabraThe state of compromise and health policiesUnder 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, disabilityand illness. Consequently, the more affluent sectors and the public andprivate employees (white-collars) were left with pension funds for individual capitalization.Social Security offered ambulatory medical attention and hospitalization carein establishments of the so called Public Charity, a colonial institution for indigents.In terms of Public Health infrastructure, these programs were implementedby diverse state jurisdictions. The Armed Forces had (and still has) itsown prevention and assistance regimes. Private medicine lacked gravitation andits later development was very limited.The institution of Social Security in Chile coincides with the change fromoligarchy to the Modern State and the promulgation of the Liberal Constitutionof 1925, which assured civil, political and social rights, and established as a dutyof the State, maintaining a national public health service. This determination wasinfluenced by the Rockefeller Foundation and the Pan-American Sanitary Officewho felt that Latin-American governments should organize public health in acentralized way, headed by a public health specialist.By the end of the turbulent 20’s and the beginning of the 30’s, a politicalparty system conformed by right, center and left-wing forces took shape. Thesewere governed by means of delicate compromise arrangements until the brutalrupture of 1973. From one perspective, the parties constituted the axis of the23

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAState-Society correlation and social institutions whichoverlapped with them; from another perspective, theclass bias, which differentiated them, left its mark onsocial policies, especially those related to health.The discrimination between workers and employees,instituted with Social Security, gave rise to a historicstruggle, led, since the 30’s, by the socialist doctorSalvador Allende. He was minister in the social governmentera (1939-1941), notable parliamentarian,and President of the Republic (1970). Allende pursuedthe integration of the social previsional funds or theunification of all health services in one institution, andthe rectification of geographical and class disparity.Allende believed that health iwas a universal right andthat health status is determined primarily by factorssuch as proper wages, housing, nutrition, education, leisureand culture [Allende, 1939].The disputes aroundthese issues emerged strongly during the "Socialist Republic"halfway through 1932.This occurred when progressivecurrents strove for socio-economical transformationsalong with medical groups that, influencedby the soviet health system, defended the disseminationof "sanitary factories" ("usinas") throughout thecountry. The objective was to form a universal, integrated,efficient and humane organization, directed bya "technical commanding group", with centralized planningas its main instrument.In the health sphere, these events re-created thehistoric struggle between three ideological currentsthat divided professionals and whose vestiges still persist:the right or conservative wing, defender of statemedical assistance for the poor and the needy; thecenter wing, favorable to the maintenance of provisionof medical assistance separated from public health; andthe left wing, partisan of a unique system of health, integratedand universal, inspired by social medicineprinciples. In the interim, the legal reforms of the systemof social protection resulted in a hybrid of thesepositions, due to the State of compromise.The demands for more equitable social policieswere partially acknowledged when, after eleven yearsof legislative transaction, the unification of the pensionfunds brought about the modification of the regime ofbenefits of Social Security in 1952. As part of the samelaw, by means of parliamentary artifices, an article wasimplemented that merged all the medical and hospitalservices and the jurisdictions of public health of thecountry in one institution – the National Health Service("Servicio Nacional de Salud", SNS), inspired by theNational Health Service (NHS) created in 1948 in capitalistEngland, financed by the Treasure, and whosecoverage was universal. Nevertheless, this intention ofimitating the NHS was abridged as the SNS remained apart of the Social Security and, as such, was subjectedto the same financial limitations, with restrictive coveragefor the urban workers. Consequently, the relationshipof the conjuncture revealed the power of thelandowners (right-wing) system upon impeding the inclusionof peasants, and of the center wing on opposingthe leveling of workers and employees. Thus, the healthcoverage was preserved for the urban workers withtheir dependents and for indigents who could certifythis condition. In spite of this, it should be stated thatthe SNS was a pioneer in Latin America, a paradigm forits institutional engineering, its technical competenceand territorial organization in "health zones"; for theadoption of new planning and programming methodsand for the excellence of its leading members (all ofthem educated at the Sanitary School, created in 1943).In addition to these events, the foundation of theMedical School in 1948 had an effect (presided over byAllende). This institution gained monopolistic representationof the profession, the exclusive ethical piercontrol and the rest of prerogatives of public status,turning into a crucial national and sectorial actor. Attributableto this corporative power, doctors wereable to negotiate a privileged statute by which theywere converted into civil servants.24

Observatorio Latinoamericano de Salud.In 1960, the population reached 7.4 million, with72% of the work force earning less than minimum wage.As far as the SNS, it had 95.5% of the beds in thecountry and took care of 70% of the Chileans, whichillustrated that many people without legal rights usedthese services as recourse to the indigence file.The absence of a solution to the problem of universalaccess to the SNS and the chronic financial deficitprovoked several disputes until 1968, when thedemocratic Christian government, with the socialists’support, decided to create a Unified Health System.Nonetheless, the legal project was mutilated due to arange of pressures: the employees’ associations insistedon conserving the schemes of free election administeredby the National Medical Service for Employees("Servicio Médico Nacional de Empleados", SER-MENA), established in 1942; the doctors were lookingfor an increase of their wages by way of the expansionto private practice, in agreement with the continentalmovement in favor of a higher status for the profession;the opposition parties viewed in this conflict theopportunity to confront the government. As it wasnot possible to reach more generous political agreements,the outcome was a very peculiar law that insertedthe regime of the SERMENA (and its scanty resources)in the SNS only for employees,. These employeesthus had access to the public services throughthe professional’s free election and received co-paymentfor medical action, but in a different schedulefrom traditional beneficiaries. In sum, within the SNStwo forms of management were instituted, removingthe existent unity and reinforcing the discrimination ofclass, without solving the financial issue.In 1971, president Allende raised the issue of theUnified Health System ("Sistema Unificado de Salud",SUS), whose design comprised fiscal financing, universalcoverage, communitarian participation, equity inthe access to and quality of care, and a set of redistributivesocial policies. Even so, in the prevailing environmentof ideological polarization in 1973, the SUSwas blocked by the opposition, causing the MedicalSchool’s adherence to the President’s resignation.The brutal military coup of September 1973abruptly terminated the democratic path that hadbeen expanded throughout the country for 140 years.It aborted any progressive initiative, sank the nation interror, and annihilated civil, political, and social rights,arduously conquered, sowing insecurity among citizens.The reforms of authoritarian neoliberalismThe pioneer neoliberal experiment undertakenduring the dictatorship in Chile, under the dogma ofmarket primacy and the failure of the Keynesian orprotector State, was formulated and implemented in ashort time (1978 – 1981) by the hegemonic nucleuscomposed of Pinochet and economists that derivedfrom the Chicago School. In the social field, the propositionof "modernization" in prevention and healthrelied on the active participation of the MedicalSchool, at that time in the hands of an ultra right-winggroup that had taken it by assault.In the area of Prevention, the funds accumulatedby civil workers were transferred to lucrative mercantilesocieties – the Administrators of Pension Funds("Administradoras de Fondos de Pensión", AFP). Inspite of the serious restrictions imposed by the internationalcrisis of the time, the new system was feasiblethrough the massive transference of resources fromthe social sectors to the Administrators of PensionFunds and the decree of a mandatory 10% share of thetaxable rent, from which the employers and publictreasury were exempted. It is important to note thatvia democracy and not by force, several countries areadopting the Chilean model, despite its proven promotionof inequality.25

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAAlong with the privatization of prevention, therewas freedom to introduce reforms in the health sector,which totally switched directions, institutionalizingthe principle that inequality is a "natural" phenomenonthat can only be corrected with free mercantile competitionalong with individual endurance (meaning paymentcapacity).Following this premise, the neoliberal changes inhealth can be summarized in seven points: (1) the extinctionof the NHS and the creation of the NationalHealth Service System ("Sistema Nacional de Serviciosde Salud", SNSS), regionalized in 27 services; (2) the separationamong normative functions (Department ofHealth), executive functions (regional services), and financialfunctions; (3) the formation of the NationalHealth Fund ("Fondo Nacional de Salud", FONASA), avery important autonomous ministerial entity, but subordinatedto the economical area, in charge of the financialadministration and the free care choice; (4) theintroduction of a lucrative segment of health plans,non-existent at the time, and mediated by the HealthPrevision Institutions ("Instituciones de Salud Previsional",ISAPRES); (5) the municipalization of the PrimaryCare (6) the institution of a mandatory 2% contributionfrom the taxable rent for health, raised to 7% since1987, from which employers and people affiliatedwith the Health prevention Institutions were exempted;(7) the stratification of users, according to their incomeas 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 differentmedical systems for the rich and for the poor. Atthe same time, they produced a hecatomb expressedby way of fragmentation, segmentation, and disorganizationof services, devastation of hospital infrastructure,congestion in attention and, finally, workers’ demoralizationdue to dismissal, wage depreciation, loss ofrights and political persecution. The neoliberals alsofought against the associative world under the pretextthat it inhibits free competition. In this fashion, the ancientMedical School and the rest of professional colleagueshad their privileges annulled, and were obligedto turn into "labor-union associations" of voluntary affiliation.The traditional prominence of the institutionwas affected by these facts and by the emergence of anew powerful actor with whom it still rivals when itrefers to deciding: the Association of Health ProvisionInstitutions.Hope and uncertainty in the "neodemocracy"The "modernizations" just reviewed still persist,in spite of the numerous measures democratic governmentshave taken since 1990, which tend to correctthe problems mentioned in relation to healthand to attenuate the social inequalities in general.As indicated by the Census of 2002, the Chileanpopulation reached 15.1 million, with an urban concentrationof 86,5%. Analphabetism is estimated at4%. The urban coverage of the water network is 100%and that of sewers, 91%. It is important to mentionthat poverty was 38,6% in 1990, and decreased to18,8% in 2003. However, the concentration of incomeis elevated: 10% of the rich retains 41% of revenue,while 10% of the poor, barely 1.5%. This disparity wasconfirmed in 2003 by the Human Development Reportof the PNUD, indicating the distribution of familyincome is 56.1 in Chile (measured with the Gini Index).With regard to the basic health indicators, theCensus of 2002 displays the following data: generalmortality rate per thousand inhabitants – .5.,3; maternalmortality per ten thousand inhabitants born alive –1.7; infant mortality per thousand born alive – 8.3;mortality in children younger than five per thousandborn alive – 10.2; general rate of fecundity – 2.2. Theseindicators are considered very good for an under-26

Observatorio Latinoamericano de Salud.developed country. It is on account of this that, despitethe unequal distribution of income, Chile has beenclassified 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 sanitarycoverage is currently as follows: the ministerial programsof public health reach 100% of the population;public services offer medical and hospital care to67.5%, and the Health Provision Institutions (ISAPRES)cover 18.5% with their 16,000 health plans. The restis taken care of in the Armed Forces, Police or privateinstitutions [Ministerio de Salud, Fondo Nacional deSalud, 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 authoritarianismand its getting out of hand; the role of the Statein health continues to be important.In the SNSS, two aspects of equity deserve specialattention: the stratification of access and the financing.Concerning access, and based on the premisethat every person is equal in the eyes of the market,the legal distinction between workers and employeeswas eliminated; but, all at once, the free electionco-payments were extended to the institutional caresystem. In this modality, the co-payments depend onmonthly income and, for this, users are classified in thismanner: Group A: indigents – exempted; Group B: incomeclose to 200 dollars – exempted; Group C: incomebetween 200 and 300 dollars – they pay 10% ofthe tariff; Group D: income superior to 300 dollars –they pay 20% of the tariff. The admittance to groups Aand B is done by means of an indigence certificate. Theclassification in groups C or D varies in proportion toincome and the number of dependents. In the last fewyears, free consultation in Primary Care included userswho were older than 65 and those with catastrophicillnesses. The private individuals that require assistancehave to pay 100% of the total cost of the contribution,in accordance with the tariff annually establishedby the Department of Treasury and the NationalHealth Fund (FONASA).With reference to the distribution of users,70,5% is concentrated in groups A and B, where the indigentsare 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 FO-NASA to eradicate the "false indigents", the majorityof the people prefer to assume a stigmatizing conditionthan to pay for attention.Regarding free election, the co-payments coverthe difference between the improvement allotted byFONASA and the cost of contributions, which vary inline with their complexity. To this purpose, levels of attention1, 2 and 3 were created; with Level 3 being theone which best disburses to lenders, but the most expensivefor users. It is no surprise, then, that the laterconcentrates 98% of the doctors and 75% of all theprofessionals [Ministerio de Salud, Fondo Nacional deSalud, 2004].In relation to the financing, the idea of neoliberalswas that the contribution of the State to healthwould become marginal as families progressively assumedits cost. In fact, from 1974 to 1989, the fiscal resourcesdecreased 49% while the quotations increased180% and the co-payments 50%, being that these represented,in 1989, 15% of the budget. Nevertheless,this tendency has reverted. In 2002, the compositionof health expenditure was the following: fiscal contributions– 51%; quotations – 34.4%; co-payments –8.4%; other earnings – 6.2%. These numbers also demonstratethat the co-payments did not have the expectedimpact, as their participation consisted of only6.5% on average, between 1990 and 2002 [Ministeriode Salud, Fondo Nacional de Salud, 2004].It is essential to reiterate that the current formof financing is characterized by two negative characteristics:on one hand, solidarity is very limited and circumscribedto the affiliates of FONASA, who are the27

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAones with less resources, and, on the other hand, byextreme inequality in the health system as a whole, giventhat the beneficiaries of the ISAPRES do not contributeto FONASA. As they are the ones who possessthe highest income, an effect named "descreme"("whipping of the cream") is produced in the financingof the public system. This occasions a series of distortions,mainly if we consider that public services takecare of 65.5% of the population and they also receivethose rejected by the ISAPRES (the elderly, the chronicallyill, those who need complex treatments, etc.),while these just cover 18.5% of the population. Toexemplify what was stated: 66,5% of the medicalhours corresponds to ISAPRES attention; FONASAretains 54% of quotations, the ISAPRES, 46%; the annualper capita expenditure of the public sector isequivalent to 210 dollars, the ISAPRES reach the 500dollars; [Ministerio de Salud, 2001] in 1999 the countryassigned 6,5% of the Gross National Product tohealth, from which 2,5% was the share of the publicsector and 4%, of the private sector [González-Dagnino,1999].The new reform of health in perspectiveOn arriving at the government in 2002, the currentpresident, Ricardo Lagos, undertook the task ofaccomplishing a reform guided by five principles: theright to health, equity, solidarity, efficiency in the use ofresources and social participation. To this end, thesubsequent projects of law were elaborated: SanitaryAuthority and Management; General Regime of Guarantiesin Heath or Plan of Universal Attention withExplicit Guarantees ("Atención Universal con GarantíasExplícitas", AUGE); Regulation of the ISAPRES; Financingof Fiscal Expenditure or Common Fund ofCompensation ("Fondo de Compensación Solidario");Rights and Duties of Patients. Amongst these projects,only the one related to Sanitary Authority is already alaw. Its general objectives are to equip the SNSS withan assistance network capable of surmounting institutionalfragmentation, integrating complex levels, fortifyingthe Primary Care and providing the establishmentswith autonomy of management.A propos the AUGE Plan, we can consider it arefinement of the regime of stratification of access(mentioned earlier) or a "market basket" ("canasta básica").It has as its center to guarantee the populationcontributions associated with 56 primordial pathologiesand will be mandatory for FONASA and the ISA-PRES. Even if this constituted an important innovation,it reinforces current measures related to the contractingof private services, which now would serve totake care of the AUGE patients. This would signifygreat support to the ISAPRES in a critical moment ofinvolution. Regarding the access, the classification byincome for co-payment is maintained: groups A and Bcontinue to be exempted, but for groups C and D avery complex formula is created. It is difficult to foreseethe possibilities of administration (already extremelytroublesome), of supervision of "false indigents"and the amounts to be paid, and this is a fundamentalfeature for the reason that it is expected that they increaseto compensate the rise in costs 1 . Overall, itcould be agreed with the Medical School that the PlanAUGE is a model of "administered health" already provenunsuccessful; inconvenient and unnecessary forthe country and will not solve the inequalities on thesubject of health [Colegio Médico de Chile, 2003].With respect to the Common Fund, there wasan attempt of attenuating the "descreme" effect. It1. 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 technicaldifficulties, along with elevated costs.28

Observatorio Latinoamericano de Salud.consisted of the collection of amounts proceedingfrom a universal premium to be paid by each FONA-SA and ISAPRES payer, except those who would certifya situation of indigence. In any case, as the legislativediscussion of this project was abandoned, the subjectof solidarity in the absence of financing is still pending.It is likely, however, that the negotiations will berecalled when the project of law related to the ISA-PRES is discussed again, whose objectives are the rationalizationof the chaotic and iniquitous currentmarket of health plans and the fortifying of the regulatingauthority of the Department of Health.Final ReflectionThe trajectory of health policies presented heredemonstrates that in Chile an important tension persistsbetween antagonistic currents, which, in the presentconjuncture, can be summarized in two: one thatdefends the fortifying of public service and social medicineand desires, basically, to rescue the best of theformer SNS, as a bastion of democracy and representingthe duty of being a fairer, more efficient and effectivehealth system. The other current, with a neoliberalorientation, is favorable to an even greater expansionof the private market in health, and the focalizationof the action of the State in the poorest, with efficiency.The latter, without taking into considerationfundamental issues such as the lack of solidarity andequity that affects the current health system. Moreover,this posture would reflect the individualistic changesin values introduced by the messianic neoliberalproject concerning the "re-foundation" of the nationand which came to reinforce the already deeply rootedclass bias that impales, as revealed, the Chilean societyuntil the present, leaving an indelible mark in thehealth system.REFERENCES● ALLENDE, S. (1939). La Realidad Médico-Social Chilena. Santiagode Chile: Ministerio de Salubridad.● COLEGIO MEDICO DE CHILE (2003). Reforma de Salud. ProyectoPaís. Propuestas del Colegio Médico. Santiago de Chile: ColegioMédico de Chile.● GONZÁLEZ-DAGNINO, A. (1999). La meta sanitaria para Chileen el 2010. Cuadernos Médico Sociales, Santiago de Chile, 40:36-50.● 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 Distribucióndel Ingreso en las Regiones. Serie CASEN 2003.Volumen2. Santiago de Chile: MIDEPLAN.● LABRA, M. E. (1985). O Movimento Sanitarista nos Anos 20 noBrasil. Da "Conexão Sanitária Internacional" à Especialização emSaúde Pública.Tesis de Maestría. Rio de Janeiro: Fundação GetúlioVargas, Escola Brasileira de Administração Pública.● MINISTERIO DE SALUD (2001). Reforma del Sistema de Salud.Santiago de Chile: Minsal.● MINISTERIO DE SALUD, CUENTA PÚBLICA (2003). Santiago,MINSAL, p. 33. Cf. En 2003 Fonasa detectó 30.000 "falsos indigentes".●●MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD(2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile:Fonasa.MINISTERIO DE SALUD, FONDO NACIONAL DE SALUD(2004). Boletín Estadístico FONASA 2001-2002. Santiago de Chile:Fonasa.● UNITED NATIONS DEVELOPMENT PROGRAMME (2003). HumanDevelopment Report 2003. Millennium Development Goals:A Compact Among Nations to End Human Poverty. New York:Oxford University Press.29

3The Right to Health and the Free TradeAgreement with The United StatesGerardo MerinoHealth was recognized as a basic human right in the Universal Declarationof Human Rights of 1948, whose 25th article declares: "Every personhas 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 andimprecise. Health was considered to belong to the private field, not the public.It was defined merely as the "absence of illness". This definition wasbroadened afterward. Thus, among other instruments, the International Pactof Economic, Social and Cultural Rights (1966), and the Protocol of San Salvador(1988) define it as: "the enjoyment of the highest level of physical, mentaland social well-being". In this explanation emerges the criterion thathealth is a human right and a public good, and owing to this it is a responsibilityof states to do whatever necessary to guarantee its fulfillment.30

Observatorio Latinoamericano de Salud.Inasmuch as a human right, health presents anumber of important characteristics:● InalienableAlbeit not acquainted with the full significance ofthe right to health, we, citizens, cannot resign it.Neither may the State deny it, and is obliged to makeits fulfillment certain without any kind of distinction.● IndivisibleTo enjoy the right to health we must benefit fromother rights, such as work, nourishment, dwelling,education, the opportunity to participate, and ahealthy environment.● Individual and collectiveAll that affects one individual affects the family andcommunity. Concurrently, all the damages sufferedby environment, communities, and families affecteach one of the individuals who constitute them.The right to health responds as well to severalfundamental principles:● UniversalityEvery citizen has the right to health. No one can bedenied this right. Measures as the "focalization andintervention in groups or areas of risk" demanded bythe World Bank, seek to discharge the State from theresponsibility to tend the entire population. In Ecuador,where at least 30% of the population does notaccess public or private health services these exigencieswould violate even more the right to health.● GratuitousnessThe term gratuitousness (free health programs) isrelative, and may have the connotation of "state charity".In fact, the population does not receive anythinggratuitously; they have already paid for it amply,either directly through taxation, or indirectly bymeans of the social debt, which the State accumulateswith the poorest population that has been dispossessedfrom everything owing to the process ofaccumulation-exploitation. Hence, it proves to befairer to aspire to a universal insurance system inhealth.● InterculturalityIt is necessary to establish an intercultural dialogue(of different types of health knowledge), a mutuallyrespectful interaction among experts of official, traditional,and alternative health. This principle is particularlyimportant in a country such as Ecuador,where diverse cultures, peoples, nationalities, diverseways to see the world, health and medicine coexist.It is possible to have intercultural services,wherein traditional doctors, alternative and complementarymedicine caregivers, and formal healthworkers operate with mutual respect, jointly andconsistent with needs and preferences.● Citizen participationIn order make effective the health rights, organizedparticipation must be implemented at all levels ofthe health care and prevention process.This participationwill permit the social supervision and controlof the commitments assumed in health and the qualityof services offered. Nevertheless, genuine participationis essentially local, within the district and31

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcommunity, and it is only guaranteed when organizedcommunities have control over processes whichare health determinant. The delegation of responsibilitiesto leaders is not enough: participation is afactual process of organization, education and collectiveaction.The right to health is not only related to doctors,hospitals, and/or medicines. It depends on complexsocial, economic and political processes, inwhich there are different interests at stake, such asthe ones currently affected by treaties like the FreeTrade Agreement (FTA) with the United States:which impose the logic of large scale economic accumulationby transnational corporations that operatethe pharmaceutical, tobacco, alcohol, and food companies,all of which is carried against the rights of thepeople.An Impact on Generic Medicinesand the Right to Health● The Laws of Intellectual Property and 20-year andolder patents: A Threat to Public Health.Though the defenders of the concept of intellectualproperty argue that it was originated in the necessityto defend the effort and creativity of inventors,and thus foster scientific development, various lawsconcerning intellectual property hinder researchand scientific development and endanger the rightto health of the majority of the population.When a laboratory "discovers" a medicine, the lawsof intellectual property grant it a monopoly for 20years (patent).The patents restrict other companiesfrom manufacturing, using, selling, or importing thepatented products. The essential requisite for a patentto be valid is novelty, and not having been introducedpublicly before the presentation of theoriginal petition.One of the most common arguments to justify thecommercial monopoly that patents provide is thatduring the restricted period it allows the patentholder an opportunity to recuperate the researchand developmental costs of medicines.However, medicine patents turn out to be a questionof life and death when the population or theState 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 primarilydetermined by the investment in research and developmentas transnational CEOs argue, but by marketingexpenses, and in particular by the enormousprofit margins of companies.For instance, the profit made by the anti-retroviralConvivir patented by Glaxo-Smith-Kline during itsfirst three years in the market paid for the 800 milliondollars supposedly invested in research and development(the net profit for GSK due to this medicineamounted 265 million dollars a year). Inasmuchas the exploitation monopoly of Glaxo will goon for a whole period of 20 years, its profit is ethicallyreproachable.The most serious issue is that the Free Trade Agreementintends to extend the patent protection periodfor medicines. Up to now, the twenty years ofmonopoly is triggered starting from the date of presentationof the patent petition, independently ofthe requisites each country demands before theproduct can be legally recognized.32

Observatorio Latinoamericano de Salud.The Free Trade Agreement plans to prolong theterm of effect of patents when "unjustifiable delaysin the granting of a patent" are produced, or "delaysin the granting of sanitary register". The Free TradeAgreement defines neither whom nor which argumentswill qualify as an "unjustifiable" delay.Frequently, this delay is intentionally provoked bythe petitioner laboratory on not presenting the requireddocumentation. Thus, a company may availof various artifices to dilate the patent grantingprocess for as long as five years. Subsequently, itwould allege "unjustifiable delay", and hence wouldattain a twenty five-year patent. The same couldoccur as regards the sanitary register. Every purportedly"unjustifiable delay" in procedure wouldserve the plaintiff transnational company with thecontinued benefit of extended patent periods,which would add to the twenty original patent protectionyears.● The Risk of Generics and Low Cost Medicines DisappearingWhen medicines can be produced freely, their priceis determined by various factors: demand, differentialprices, Agreement on Intellectual PropertyRights (ADPIC) protection (which permits countriesto manufacture or import medicines in termsof their development objectives), generics competition,and local production.If the measures contained in the Free Trade Agreementbetween Ecuador and the United States areapplied, which are basically a copy of the treaties alreadysigned with Central American countries, theonly factors involved in the fixing of prices will bethe small scale local demand, and the monopoly leverageof transnational corporations. Organizationssuch as "Doctors Without Frontiers" have alertedour countries that the first effect of this kind of"free trade" agreement would be the immediate increaseof the price of medicines.Despite membership to the World Trade Organization(WTO) and the obligation of member countriesto abide by the rules of WTO, different internationalinstruments 1 recognize the right of countriesto produce generic medicines in emergent circumstances.This is known as obligatory licenses.The Doha Conference and the Common Regime ofIntellectual Property of the Andean Community establishthat with a prior declaration of reasons of interests,emergency or national security, at any momentthe patent may be subjected to an obligatorylicense. Inclusively, the Agreement on IntellectualProperty Rights (ADPIC) instituted in 1995 in theframework of the WTO, leaves a door open in orderthat countries may avail of measures to omit ornot grant patents under certain suppositions, interms of their necessities and development objectives.However, the Free Agreement critically limitsthe circumstances under which a government mayissue an obligatory license.The importance of obligatory licenses became extremelyclear to George W. Bush, the United States´president.After September 11th of 2001 and underfears of biologic attacks, the United States governmentcalled for pharmaceutical companies who holdpatents for the anthrax vaccine to lower prices or1. Among them, the departmental meeting of the WTO held in Qatar in November of 2001, and the Common Regime of Intellectual Property of the AndeanCommunity.33

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAface the possibility of obligatory licensing. This eventhighlights the need for patent exceptions.Medicine parallel imports are an additional publichealth emergency protection mechanism that couldalso be obstructed by the Free Trade Agreement.This mechanism allows for a government to purchasedirectly from the producer who offers the bestprice in the international market, being either genericor brand medicines.The Free Trade Agreement broadens the circumstancesunder which a medicine may be patented.The most worrisome is the possibility of patenting amedicine again, when the legal monopoly is on theverge of expiring, through the ascription of a furtheruse distinct from the original (second use). For instance,if a medicine was patented as an anti-flu drugand later its anti-inflammatory properties are "discovered",the laboratory may claim a second 20-yearpatent in view of this new use.The Free Trade Agreement makes possible for a medicinealready patented to be presented once more,by means of the "always new" technique, which residesin that companies patent "new presentations" ofmedicine already in circulation within the market,whose patents are about to expire. As mentionedseveral times, "pharmaceutical transnational corporationsdo not patent inventions anymore, they inventpatents".Thus, it is a question of eliminating or delaying theappearance of new competitors; the lesser the competitors,the greater the prices. The difference incosts among generics and brand medicines is between100 and 1,000 percent. In Guatemala, countrythat signed a Free Trade Agreement with the UnitedStates, there are brand medicines 8,000 percent moreexpensive than generics.The Free Trade Agreement that has been proposedto Ecuador by the United States just increases thepower of transnational corporations by allowingthem to be the only ones to produce medicines, andto fix prices, to benefit their economic interests. Ina world ruled by a number of pharmaceutical corporations,there is no freedom of commerce, just monopoly.The manager of Pfizer in Ecuador (North-Americancorporation), nation which he qualified as "one ofthe countries with more advanced laws regardingpatents", declared to be satisfied with the subscriptionof the Free Trade Agreement for the reasonthat "it will compel the (Ecuadorian) government tocomply with the patent laws".Various people have questioned themselves aboutwhy the United States was so severe in its impositionson intellectual property and patents upon negotiatingthe Free Trade Agreement with CentralAmerica, considering the entire region representsless than 1% of the medicines world market.The objectcan not be anything other than creating modelsof international agreements for their benefit" 2 .Thus, the dominant trend is to eagerly claim that theFree Trade Agreement, as supported by the UnitedStates, is something "inevitable" since "many countrieshave signed it in this manner", and for this reason"we can not remain isolated from the internationalconcert".2. "Iniciativa de acceso a medicamentos esenciales de Nicaragua", en Revista Envío 269, Managua, 200434

The attainment of human rights proposed by theEcuadorian Constitution would be lost if the FreeTrade Agreement is accepted.The Free Trade Agreementwould develop into a supreme supranationaland supra constitutional law, at the disposal of economicgreed and big business interests.35

Institutionalizationof Violenceand the Hazardsof HemisphericalSecurity

4Military Occupation, Militarismand Health*Adolfo Maldonado"America" is Still Written with BloodThe history of America has been written with the blood of killing, epidemicillnesses, and famine. In North America, 15 million people have been assassinatedsince colonial days, and about 14 million in South America; some authors estimateas much as 80 million in total. However, independently of the numbers,the American Continent is affected by an endemic and well- orchestrated processof extermination.The policy of terror and the practice of extermination have been, and stillare, inherent to the continuation of capitalist rule in America. Neo-liberal policieshave 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 takeinto 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 resistanceagainst commercial, political, and cultural occupation, and against the armies thatsupport 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 thispaper, which is important; the reader must contact the author if those sources are required.37

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAThe Geopolitics of Military OccupationThe struggle for independence from Spanish ruleevolved into an increasing dependency on the ruleof the United States and its geopolitical project of forcefuloccupation of Latin America. By 1829, Simón Bolívardeclared: "The United States appear to be destinedby the Providence to infest America with miseryin the name of liberty". President Jackson confirmedthis in 1837: "Providence has chosen North-Americanpeople as the guardians of liberty, for them to preserveit in benefit of humankind". Yesterday the excusewas Providence’s will; today the U.S.A. speak of "bringingdemocracy, liberty and justice to oppressed peoples"to justify domination and war.The usurpation discourse by the United Statesruling groups is evident.Although the Monroe Doctrine(XIX century) had already raised the issue of annexationof all South America to the U.S.A. –"America forthe Americans (people from the US)"-, the geopoliticaldocuments coming from the North are increasingly demonstrativeof the greedy nature of that imperial conduct.The real interest resides in the strategic resourcesof our territory; that interest is not focused on ourpeople’s wellbeing; to the contrary they think we areungovernable and too many. "We have to protect ourresources (those of the U.S.A.), the fact that they residein other countries is only an accident, alleged GeorgeKennan, diplomat of the U.S.A. in the 50’s, statingclearly the real interests that are expressed in the UnitedStates international policies and plans, independentof which political party is in power: "The crude oil ofthe Persian Gulf is of vital interest to the U.S.A., andhas to be defended by any necessary means, includingmilitary force," said James Carter, Democratic Presidentof the U.S.A. in 1980 [Klare, 2004]. Following thesame line, the former secretary of Energy, HazleO’Leary, stated: "One should not exhibit contentmentwith regard to the security of oil supply proceedingfrom Latin America;" and the Republican VicePresidentCheney (2001-2004) announced straightforwardly:"The African and Latin-American crude oil is of nationalstrategic interest to us."[Cheney, 2001]In this sense, the words of Democrat James Schlesinger,former secretary of Energy under the Carteradministration, clearly made the point after the GulfWar in 1991: "American people have understood thatit is much easier and amusing to go to the Gulf Warand remove the oil from the Middle East by kicking thehell out of those people, than going about the sacrificesof limited imported oil consumption for the Americans."[Martinez, 2003] This attitude results from apolitical discourse and scenario where there is no placefor repentance, ethics, or respect for human rights.Violent arrogance is the norm, as indicated by GeorgeBush (senior), Republican President of the U.S.A.: "Iwill never apologize in the name of the U.S.A. I don’tcare what happened".[La Jiribilla, 2005]The interests of the U.S.A. and its corporationsin Latin America are evident:● Oil. The main strategy of multilateral banks is toseek privatization of national petroleum companies.In 1998, General Wilhelm declared that the new oilexplorations of that country increased the strategicrelevance of Colombia to the U.S.A. and of the widelyknown as "Plan Colombia". The U.S.A. governmenthas insistently manifested that they find 338points of strategic interest in that country. Somethingsimilar happens with all countries in possessionof significant oil reserves.● Biodiversity. In 1974, Kissinger proposed the appropriationof territories rich in natural resourcesand biodiversity. This is presently being accomplishedby pharmaceutical companies, which contractand finance botanical gardens or researchers, and byprivatization of protected areas through delegation38

Observatorio Latinoamericano de Salud.of their administration and management to privateNGO’s such as The Nature Conservancy; InternationalConservation; The Smithsonian Institute; theWorld Wildlife Fund (WWF), and their national associates.Also the patent control of wild varietiesand knowledge related to them favors multinationals.Moreover, one should not overlook alarmingsigns of the dispossession strategy we have beendescribing, such as the declarations of well- knowninstitutions like the Rockefeller Center for Latin-American Studies, which during the last two yearshas advocated the convenience of territorial fragmentationof countries like Chile, Argentina andBrazil, and the creation of new smaller countries,such as Belize, in order to assure the economical occupationof that territory to the timber dealers operatingin Guatemala.● Genetics. Genetic data are of fundamental interestto pharmaceutical companies , which seek homogeneityof isolated population groups (for geographical,cultural and political reasons) that makes it easierto identify genetic characteristics of economicimportance, such as those related to specific illnesses,transmitted within a family or community. Currently,the genes of the Huaorani people in Ecuadorare for sale on the Internet, and we find some of thelargest pharmaceutical transnational corporationsbehind several "public" research projects in Mexico,where various indigenous groups have been selectedas "groups of interest."● Water.Water resources are privatized by means ofaggressive policies coming from multilateral banks,which place conditions on the acceptance of loansrequested by countries. Such conditions are intendedto boost privatization policies. When the Vicepresidentof the World Bank during the late 90’s affirmedthat wars in the 21st Century would be overwater, he was not merely pretending to be a visionary;he was underscoring the main concerns of thebank and the policies they expected to promote. In2003, the income of the water industry reached46.000 million US dollars, nearly 40% of the oil sector’sincome and a third higher than that of thepharmaceutical sector. 100 thousand million liters ofwater were bottled –requiring 1.5 million tons ofplastic bottles. The price of bottled water is 1,100times greater than that of running water. Companiessuch as Coca Cola, Nestlé, Pepsi Cola and Danone,among other multinationals, are in pursuit ofprivatizations. Another aspect of enormous interestto the U.S.A. is the so called "triple frontier" betweenBrazil,Argentina and Paraguay, where the mainsweet water reserves (subterranean aquifers) of LatinAmerica and the World are located 2 .To obtain these resources, the financial controland subordination of Southern economies are imperative.In the last decades this has been accomplished byexerting pressure by means of the external debt. Likewise,the territorial military occupation conductedby the Southern Command of the USA Armed Forces,the commercial occupation by means of the Free TradeAgreements system, and the political subordinationof the Latin American states, are also crucial.The occupation of all of Latin America began duringPresident Bush’s administration. He inauguratedthe Free Trade Agreement for the Americas (FTAA)strategy.The inner nature of globalization for the creatorsof FTAA could be described by saying: "Globalizationis, in fact, another name for the dominant role ofthe United States." [Isch, 2004] As said by Henry Kissingerand confirmed by Colin Powell, both former U.S.1. Editor´s comment: no information sources were cited39

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINASecretaries of State, former: "Our objective throughthe Free Trade Agreement for the Americas is to guaranteeNorth-American companies the control of a territorythat 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 theentire hemisphere". [Acción Ecológica, 2002]The Occupation StrategyThe main figures and cadres of the U.S. governmentduring the period of 2001-2004 responded distinctlyto the commercial interests of large transnationalcompanies: oil companies—such as Harken Energy,Halliburton Chevron Texaco, British Petroleum; pharmaceuticals—suchas Pharmacia and Merck; automobileindustries—such as General Motors, Ford andDaimler-Chrysler; and armament industries such asGulfstream Aerospace.The occupation policies of thosecorporations were applied.The strategy to support this occupation and tosubsidize the neo-empire is based on three central aspects:1) financial policies of the multilateral institutions(IMF, WB) and the economical agencies of theU.S.A. (Treasury,Trade, EXIM bank, …), which force nationaleconomies to yield to their interests; 2) concealedoperations of espionage that subdue the populationand the directing political class; and 3) wars andmilitary interventions when both previous strategiesfail or become insufficient.1.-Multilateral Banks. Since the mid 1970’s, multilateralbanks approved a U.S. policy wherein the debtof countries was the first step of the intended financialsetback of Latin America. The CIA and bankingsystem were in charge of the countries becoming indebtedvia forged reports of economical bonanzaand vast future petroleum income; the strategy includedalso the recovery of companies that had beennationalized.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 of4 between 1975 and 1980 (during the period of militarydictatorships in the region), reaching 261.000million US dollars, and it again tripled between 1980and 2002, reaching 725.000 million US dollars.Totalinterest in 2002 amounted to 55.260 millions, whichis on the record as the subvention by countries ofthe south to countries of the north. Although thedebt has been paid three times already, it continuesto increase relentlessly. In 2002, the debt of eachcountry 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, CostaRica, El Salvador, Guatemala, Honduras, Jamaica,Dominican Republic, 4.000; Paraguay, 2.000; and Trinidadand Tobago, Haiti and Guyana, 1.000. The countrieswith higher debts are the petroleum countries.However, the necessity of capital accumulation isnot fulfilled with the external debt and pillage measuresare orchestrated, as manifested by the privatizationof Pension Funds, the "bankruptcy" of banks,the narco-dollars, and the pillage of local elites. Accordingto the U.S. Federal Reserve Bank., between1974 and 1982, during a period of dictatorship,84.000 million US dollars were transferred to theU.S.A. from Mexico, Chile,Venezuela, Argentina andBrazil.This system is so necessary to the maintenanceof the dollar and the North-American commercialdeficit that it continues to be employed even afterthe dictatorships. Mexico transferred more than100.000 million US dollars stolen from state loansby private firms in the 90’s. In the same period,40

Observatorio Latinoamericano de Salud.Ecuador was swindled out of 40.000 million US dollars,while in Argentina the bank fraud amounted to60.000 million US dollars, impoverishing millions ofmiddle class Argentineans, Ecuadorians and Mexicans,and benefiting the bankers who transferredtheir finances to the U.S.A.2.-Concealed Operations.The CIA, created in 1947by president Truman following the signature of theNational Security Law, was chiefly responsible forgathering and analyzing information about the externalenemies of the United States to permit thePresident, the Pentagon and Congress to respondto existing and potential menaces. Nevertheless, itsoon turned into the dirty arm of its government,transmitting the message that "the interests ofNorth-American companies in Latin America arenot to be touched," even if those companies wereinvolved in plundering, massacre, or extortion.Among more than 6,000 concealed operations, wewill mention those that stand out: the overthrowthe elected president Arbenz in Guatemala (1954),support of the United Fruit Company; the murderattempts against Fidel Castro (from 1959 to 2005);the propaganda campaign against elected Dominicanpresident Bosch, which ended in a coup (1965); themillionaire propaganda campaign against elected presidentJoão Goulart, who nationalized a subsidiary ofthe ITT in Brazil (1964); the murder of Ernesto ChéGuevara in Bolivia (1967); the three years of destabilizationof the Chilean government of elected presidentAllende and the coup which put an end to hislife (1973) by order of Kissinger-Nixon and the ITTcompany; the organization of the Cóndor operationfrom the Kissinger-Nixon axis with the collaborationof the Latin-American military dictatorships and thepurpose of eliminating all left-wing politics of SouthAmerica (1970); the murder of the first Ecuadorianpresident elected after the military dictatorship, JaimeRoldós, 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 ofthe most important contracts of its history in thecountry, one which had been denied by Roldós; themurder of Panamanian president Omar Torrijos, whowas assassinated under Nixon, as he could not bebought 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 threemore murder attempts against him. Nevertheless,on the 31st of July of 1981, his plane crashed asa result of sabotage.The United States does not believe in elections, unlessthese favor puppets who accept the policies oftheir corporations.3.-Wars and Military Interventions. The dictatorshipsof the 70’s, sponsored by the U.S.A., annihilatedthe anti-imperialists, nationalists and independents,and left in their place military and socio-economicalinstitutions which permitted the US banksand multinationals to conquer Latin-American economies.Through policies of state terror, the autonomouslabor unions were eliminated, hundreds ofthousands of expert technicians, professionals andresearchers were exiled, and simultaneously any residualresistance to these policies was avoided.The objective was to paralyze several coming generationsthrough terror, thus: 1954-Guatemala, theU.S.A. organized a coup against Arbenz, which producedfour decades of dictatorship with more than200,000 peasant and indigenous deaths and 40,00041

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAmissing people. 1961-Cuba, the U.S.A. contractedmore than 1,500 mercenaries to devastate thetriumphant revolution in Playa Girón. 1965-DominicanRepublic, the U.S.A. assassinated 3,000 peopleand overthrew the government that intended toemerge after the 30-year dictatorship of Trujillo, thebloodiest of the Caribbean. 1973-Chile, the U.S.A.carried out a coup against president Allende, resultingin the death of 17,000. 1976-Argentina, theU.S.A. established terror with more than 30,000murders, a terror which had "Operación Cóndor",an international system for coordinating the repressionof all Latin-America. 1983-Granada, 5,000 USmarines invaded the island and subdued the populationusing bayonets. 1980/90-Nicaragua, the governmentof the U.S.A. was responsible for thedeaths of more than 60,000 residents, creating theinternal war with the aid of the contras. 1980/90-ElSalvador, the U.S.A. supported the war with morethan 80,000 brutal deaths; the massacres terrorizedthe entire region. 1989-Panama, the U.S.A. invadedthe country on Christmas and slaughtered morethan 8,000 people to capture president Noriega,who had been a member of the CIA and had collaboratedwith the drug dealers under the orders ofthe U.S.A and was now accused of being a drug dealerhimself. 1991-Haiti, the U.S.A. supported thecoup against elected president Aristide and killedmore than 4,000 Haitians. 2001-Venezuela, theU.S.A. organized the coup against elected presidentChávez. 2003-Haiti, the U.S.A. invaded the countryand deported elected president Aristide to Africa.Militarism, the Base of ImperialismBeyond being an instrument and guarantee ofoccupation, militarism is a strategy of political control.It is a form of consolidating the empire. Madeleine Albright,Secretary of State of the U.S.A., in Clinton’s administration,affirmed: "McDonald’s cannot expandwithout McDonnell Douglas (military airplanes constructor).The invisible fist that guarantees the WorldSecurity of the technologies of Silicon Valley is calledthe Army of the United States of America".The military budget of all Latin America increasedin 2000 to 25.000 millions of US dollars, which, aslarge as it is, represents only 7% of the entire militarybudget of the U.S.A. More than 450.000 million USdollars were spent in 2004, the same as the rest of theworld’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 alsoespionage groups, communication posts, and arms depositsdistributed among 130 countries. Since WorldWar 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 (throughoutthe 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-Americanrulers for using their armed forces 215 times between1946 and 1975 to attain their political goals inother parts of the world.They currently have an armyof 2.2 million soldiers.The military policy of the U.S.A. concerning LatinAmerica is channeled through the South Commandof the U.S.A., an army that controls all Central America,South America, the Caribbean and the waters thatsurround them, and which was born after the creationof the Central Command, located in the Persian Gulfand established by Reagan. Its aim was and is to insureaccess to the petroleum of the Middle East. TheSouth Command seeks the same objectives in Latin42

Observatorio Latinoamericano de Salud.America and focuses on those places where their interestsreside.In Colombia, with the pretext of combating thedrug trade, the U.S.A. has invested more than 3.000million US dollars already in the Colombia Plan, and itplans to invest 700 million more by 2005 in the PatriotPlan; public opinion has criticized the credibility ofsuch justification. The U.S.A. organized the heroinmarket 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 indicatethat the intention is not to extinguish it in Colombiabut rather to once again use it as the vehicle to financeother objectives. If there were a true will to stopdrug trade, the US would confront major banks, includingCitibank, the Bank of America and the main banksof Miami and other cities, where they launder drugmoney—The U.S. Senate acknowledges between250.000 and 500.000 million US dollars a year—withabsolute impunity, in Central America and the SouthCone, the pretext is international terrorism, whichsimply is used to veil the U.S.’s economical and strategicinterests.The military strategy for Latin America designedby the South Command implies three aspects:a) Establishing a presence in the territory with militarybases, sending more than 50,000 soldiers eachyear to Latin America and the Caribbean.Althoughthe U.S.A. already owns 14 bases and there are 6more underway, smaller installations are numerousas 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 armedforces to the U.S.A., by means of joint armies (Cabañas,Águila, Unitas, Cielos Centrales, Nuevos Horizontes,Fluvial, etc.), which endangered the land,marine and aerial armies; and the programs of education,considered the chief mechanism with whichto create a dependence of Latin-American armedforces on the U.S.A. From 2000 to 2003, the U.S.A.trained 65,941 soldiers from 27 Latin-American andCaribbean countries, of which 43% (28,200) areColombian, and if one adds those coming from otherAndean countries (Bolivia, Ecuador, Perú and Venezuela),they total 64%. From Central America,9,886 soldiers were trained (15%); from the SouthCone, 9.7%; and from the Caribbean, 7.2%. This inseveral ways uncovers the interests the U.S.A. hasin the different regions.The ‘School of the Americas,’ also called the ‘schoolof dictators,’ is sadly celebrated at the moment inFort Benning, for having increased the power andimplementation of torture as a war weapon: the publicationof training manuals on torture is proof ofthat.The New York Times has mentioned the existenceof "eleven secret manuals" in the School ofthe Americas, through which "interrogatory techniques,forms of torture, blackmailing, and imprisonmentof relatives were developed". Since 1961 tothe present, more than 60,000 Latin-American soldiershave been trained in that school, of whichnearly 500 are accused of war crimes.The visible outcome is that the presidents of Hondurasand El Salvador have already requested thecreation of a regional army, under the command ofthe U.S.A. George W. Bush has proposed the creationof a multinational operative marine force of theAmericas identified as "Lasting Friendship," obviouslyunder the command of the U.S.A.c) The development of mercenary armies, which cando what international legality impedes. They are43

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAstaffed by ‘retired’ soldiers of the U.S.A., slaughterersfrom Latin-American armies, and death squads.The South Command assembles trains and indoctrinatesnational armies to serve the interests ofthe U.S.A. under that country’s direction. Doing thisavoids the use of North-American troops and reducespolitical opposition by U.S. citizens to such confrontations.Health as a Tool to Weaken PeoplesWith impoverished governments and withoutresources for education, the statistics of literacy instructionfall much lower than the anticipated objectivesand health is shattered by the loss of control overmore than 30 infectious diseases, whose incidence increasesin each country. In Latin-America and the Caribbean,there are 1.6 million infected with the AIDSvirus. Of these, only 8% receive treatment, due to thehigh costs of pharmaceuticals. 2.3 million children sufferrespiratory distress syndrome each year as a resultof urban air pollution, and 35,000 people die prematurelyin Mexico for the same reason. Tobacco, promotedby northern companies that see their markets affectedin those countries, destroys 550,000 peopleeach year in Latin America. Contaminated water causesthe deaths of more than 36,000 people annually.At the moment, 78 million people in Latin America donot have sufficient water, while 117 million lack adequatehygienic installations and 59 million suffer fromchronic hunger and famine.The strategy of occupation and militarization hasbegot consequences such as an increase in unemployment,a rise in migratory fluxes of cheap manual laborto the countries of the north, while peasants are urbanized(77% of the population is urban), escaping froma land with no supports. Violence is becoming a resource:each year 140,000 Latin-Americans are assassinated,and one in three families in the region is a victimof some type of criminal aggression. The murderrates of women in Mexico and Guatemala reach outrageousnumbers, and more than 17 million schoolagechildren work in very poor conditions in the minesof South America, are enslaved as "domestic workers,"or are sexually exploited. Simultaneously, 40 millionstreet children, victims of violence, drift throughoutthe cities, and more than 30 million of them inhalesuperglue in an attempt to run away from povertyand abandonment.The strategy of occupation, accompanied by thepolicy of debt and pillage, has been, on one side, thesource of impoverishment of Latin-American countries,leading them to abandon their industries (just rawmaterials are exported), and to the proliferation of thevolume of exportations, making products cheaper.Thenational industries purchased by multinationals wentfrom the local manufacturer system to models of pureassembly. Research diminished, the situation fosteredbrain drain, and exportation economy was prioritizedrather than production for the internal market.The destruction of health is an adjunct to the unlimiteddestruction of environment. This presupposesthe reality of pushing the population to a struggle forsurvival, where it becomes totally alienated from thefight for freedom, justice and human rights. Environmentallyspeaking, Latin America retains the highest deforestationrate in the world, having lost more than46.7 million of forest hectares in 10 years. The transgeniccrops are an important element of this deforestationand the heavy irresponsible use of pesticidesdestroys both legal and illegal crops in Colombia, throughfumigation.Mechanisms for social domination are also implementedin the health field. The "business of illness"opens doors to large pharmaceutical emporiums thathave systematically rejected any natural treatment thatis not patented. It is the case of vitamins, micronu-44

Observatorio Latinoamericano de Salud.trients and drugs used to treat AIDS or prevent cardiacillnesses that were patented and now are inaccessiblebecause of income shortage, and this inevitablyresults in millions of deaths. Likewise, the RockefellerFoundation, together with Harvard University, preventedthe success of the World Health Organization’splan (1978, Alma Ata) to regain control of healthcareand place it in the hands of the population.The WorldHealth Organization renounced to Primary HealthCare and only countries like Cuba, which have incorporatedit, have been successful.Health is Dignity and Dignity is ResistanceHealth, dignity and sovereignty are all connected.The seed of resistance is within the person who doesnot resign him or herself, but struggles for his/herrights, not just against a model, but in favor of an alternativesystem that conserves forests, keeps land in thehands of peasants, and protects cultures, dignity, and life.We are tied to a model of production and consumptionthat is economically and ecologically unsustainable,and if we do not change it, we will certainlydrown along with it.After 500 years, there has been a resurgence ofindigenous peoples, and at this point in time they leadsome of the most relevant struggles. In Mexico, theEZLN unites the indigenous peoples of the entire nationby cultivating collective memory. They assert:"Gods bestowed the peoples of corn a mirror nameddignity. In it, they see themselves equal, and becomerebellious if they do not." In Bolivia, Peru, Ecuador,Guatemala, and Mexico, the indigenous movementshave arrived at an impressive level; those ethnic groupsof America recognize the need to overcome 500 yearsof 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 andSarayacu groups in Ecuador; the peasants and indigenousgroups of Oaxactum, Guatemala; those who upholdthe ‘trail of the century’ in Ecuador against Texaco;the fishermen/women of Limón in Costa Rica, whosuccessfully declared their country "Petroleum Free;"the indigenous group of Moskitia in Nicaragua, who assertedtheir autonomy; the assured and exemplary culturalresistance of the U’wa people in Colombia, allthese exemplifying actions led the world to think beyondsimplistic environmental technical and economicalissues.Results are evident. The interruption, delay, ordeviation of large oil pipelines, as in Santa Cruz (Bolivia)and in Urucú, Brazil, have been managed. One ofthe strategies has been to cease financing, as in the caseof the Import Export Bank in Camisea, Peru, or thedeclining of projects of colonization, such as the oneagainst the re-colonization of the lands of Neuquén bythe Spanish company Repsol.Women have become renowned as "Zapatista"commanders; the ‘Mothers of the May Plaza;’ the Argentinean"piqueteras" and workers, who recover factoriesabandoned by their bosses; the Bolivian femaleworkers, street vendors and housewives of the grandcity of El Alto, who organize their district committeesof defense and fight, block by block; the thousands ofhungry Nicaraguan women, who inaugurated theirprotest march towards Managua in April of 2004; orthe Colombian women, who have created the Women’sPacific Route to convey hope to communitiesdevastated by violence; and the women who havepressured the closing of the military base of Vieques inPuerto Rico.In front of the dominant ecological policy of"protected empty lands with no people on them", theMovement of the Landless (Movimento dos Sem Terra)puts forward the re-occupation of lands in Brazil,with success. In Ecuador, the struggle for territories45

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAallows for the recovering of legal rights over those territories,while at the Latin-American level, the indigenouspeoples propose the launching of an agenda forterritorial autonomy.The struggles of Guatemalan and Colombianworkers strengthen the boycott against companiessuch as Coca Cola, which assassinates labor unionmembers in these countries while in Mexico it confrontsthe rejection of the indigenous communities ofChiapas, where it intends to seize the water sources.Other struggles receive each time more support inthe assembly plants ("maquiladoras") of Mexico andCentral America, and against privatization in Mexicoand El Salvador. In Uruguay, a coalition of workers andassociations has inhibited the privatization of water byway of a national referendum.A resistance in its full extent, with all colors,with all sexes, and with all ages has taken place. Fromthe pension holders, who would rather die in the strikesof Quito, fighting, than be neglected in their miseryby the government, to the students’ marches inArgentina. Youth is the most constant presence in thestreets, in the student strikes and in the movementsagainst the impunity of officials of past and presentdirty wars.Still, we have words, we have dreams, we havehope, we have land, we have laughter, we have singing,we have our hands, we have health, all of which wouldbe useless, unless we empower ourselves and protectour resources from corporate greed.We need to recuperateour capacity to think for ourselves, our willingnessto participate jointly in the construction ofour future. Also allowing for moments of leisure andrest, in order to recreate ourselves.We must also taketime for dancing and enjoying life, to produce art,and cultivate our identity with pride. However, wemust also maintain a firm awareness of the fact that westill lack rightful and genuine independence.46

Observatorio Latinoamericano de Salud.REFERENCES● ACCIÓN ECOLÓGICA (2002). Nuestro Mundo no está en venta.AlertaVerde nº 117, mayo. Quito.● CHENEY, DICK (2001). National Energy Policy, Mayo. www.soberania.info● CHOMSKY, NOAM (2003).Video "Plan Colombia". willfree.● ISCH, EDGAR (2004). La mayor amenaza contra la vida y la democraciaen el Ecuador. El tratado de Libre Comercio con EEUU.Memoria del taller. Coca● KLARE, MICHAEL T (2004). La nueva misión crucial del PentágonoI y II. La Jornada, México. 18-10-2004. www.jornada.unam.mx● LA JIRIBILLA (2005). La verdad al desnudo. www.lajiribilla.cu● MARTÍNEZ, ESPERANZA (2003). Conflictos bélicos y Petróleo.Oilwatch. Conferencia en Chiapas, México en encuentro internacionalcontra militarización de A.L.● NAVARRO, GUILLERMO (2004). Geopolítica Imperialista. De la"Doctrina de los dos Hemisferios" a la "Doctrina Imperial" deGeorge Bush. Edit. Zitra. Quito)● OILWATCH (2001). La manera occidental de extraer petróleo. LaOxy en Colombia, Ecuador y Perú. Edit. Oilwatch. Quito.47

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA5Social and Political Violence in Colombia:A Social-Medical ApproachSaúl Franco A.IntroductionViolence is not only a political, sociological and military problem; it isalso a public health issue. In Colombia, violence is in fact the main threat topublic health.The high rates of homicide and kidnapping, the significant reductionin the quality of life of the country’s citizens and the systematic violationof international humanitarian law and the medical mission are evidence of theenormous impact of violence on health in Colombia. Different theoreticalapproaches have been proposed to study the violence. They have emergedmainly from the social sciences.Within the health sector, epidemiology, withits different trends and different approaches, has been the discipline mostactively involved in the study of the problem. This article presents the conceptualbases, the main findings, and the conclusions of the author’s researchon this topic over the past 15 years from a social medicine perspective.Conceptual and methodological basesAcknowledgements:This articlewas translated from Spanish by Drs.Luis Franco and Paola Pinto.The concept of violence. There is no accurate and universally accepteddefinition of violence. Each of the many proposed definitions highlights specificaspects, usually related to the author’s area of expertise. The WorldHealth Organization, for instance, defines violence as "The intentional use of48

Observatorio Latinoamericano de Salud.physical force or power, threatened or actual, againstoneself, another person, or against a group or community,that either results in or has a high likelihood ofresulting in injury, death, psychological harm, maldevelopment,or deprivation" [World Health Organization,2002]. Of course this definition includes the mostessential elements of the concept. In my opinion, however,it excludes important aspects and includes particularitiesthat are not necessary in a definition. Idefine violence, more concisely, as a specific form ofhuman interaction in which, in order to achieve a givenpurpose, force is used to cause harm or injury to others.Given its implications, it is necessary to discuss thecontents of this definition: the human character of violenceimplies that it is an intelligent activity.Violence asa 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. Themost specific characteristic of violence is that it is arelationship based on the use of force. Force can bephysical or psychological. Violence always producesharm or injury.Without damage, there is no violence.Damage can be physical or psychological and it mayalso occur in different levels of intensity. Purpose is themost controversial characteristic of violence and itrefers to the intention of achieving a particular goal.Violence is not a random event. Power is one of violence’smost common purposes and the two are closelyrelated [Arendt, 1970]. However, they are very differentconcepts: while power is a goal, violence is aninstrument. Analysts of violence often refer to poweras the instrumental nature of violence [Arendt, 1970;Benjamin, 1995; Cortina, 1998]. As a consequence ofthe above, it is clear that violence is a process and thatit has a historical context. Violence is not a singleaction: it involves different steps, activities and consequencesfor both the victim and the agent, and itaffects not only individuals but also their surroundings.Violence changes: its intensity and modalities varyamong 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 haslong been recognized as one of the most importantindicators of violence because of its serious consequencesand greater reporting reliability. In the caseof Colombia’s current cycle of violence, homicide isundoubtedly the indicator that most clearly portraysthe magnitude and severity of the situation.With certainlimitations, especially in those regions of thecountry that are under the control by illegally armedgroups, homicide is the most documented form ofviolence in Colombia. Research on Colombian violenceinvolves the analysis and comparison of diverseand often variable sources of information.Structural conditions and transitional situations.Methodologically, in the study of Colombian violencewithin the framework of social medicine its useful todifferentiate between structural conditions and transitionalsituations. Structural conditions are processesof longer duration that are related to the fundamentalcomponents of the phenomenon under study.Transitional situations, on the other hand, are processesof shorter duration that exert an important butcomplementary influence over the fundamental components.In the case of violence, this differentiation isuseful when attempting to explain the phenomenonand when seeking possible solutions. The study ofColombian violence has involved a long debatebetween "structuralist" and "transitionalist" views.Thisconflict of views has had a clear impact on the country’spolicies and strategies towards violence. Thesocial-medical approach attempts to study the ways inwhich structural and transitional elements interact.This discipline avoids exclusions that initially appear tosimplify the task and emphasizes the need for a strategicsolution that integrates both doctrines for longterm effectiveness.49

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAEl estudio de la violencia colombiana ha implicadouna confrontación permanente entre los "estructuralistas"y los "coyunturalistas". Esta confrontación hatenido un impacto significativo en las políticas y las estrategiasdel país frente a la violencia. El abordaje sociomédicoprocura estudiar las formas en las cuales interactúanlos elementos estructurales con los coyunturalesy enfatiza la necesidad de una estrategia de soluciónque integre ambas dimensiones, evitando las exclusionesque aunque inicialmente parecen simplificarel trabajo, generalmente son ineficaces a largo plazo.The theory-fact-discourse approach. As anothermethodological contribution to the study ofColombian political and institutional violence from thesocial-medical perspective, I have implemented anapproach that integrates three elements: the theoreticalinsight of different schools of thought, the factualdata that arises from different sources, and the verbalor written testimony of the individuals and victimsinvolved. Although often attempted, approaches thatisolate each of these three elements are insufficientfor a useful analysis of complex problems.An integratedapproach is far more demanding but offers a morethorough view of a situation. It overcomes, at least inpart, the problems associated with an overly theoreticalor an overly subjective and emotional view and thelimitated descriptions offered by mass media.Main findings from the study of Colombia’scurrent homicide violenceThree aspects of Colombia’s current situation ofviolence are particularly outstanding: its generalization,its growing complexity and its progressive degradation.The generalization of Colombian violence refersto its expansion in time and space, as well as in thenumber and type of social settings it permeates.Whilethe problem expands, its complexity increases continuously;the agents of violence are increasingly diverse,often switch from one group to the other and themanifestations and implications of their acts of violenceare highly variable and rapidly evolve. The progressivedegradation of political violence in Colombiarefers to the disregard of any ethical or humanitarianprinciples, including those internationally acceptedunder situations of war. This degradation also coversthe methods and mechanisms of action, which includemassacres – understood as collective murders ofunarmed individuals, kidnappings – sometimes alsocollective and indiscriminate, and the destruction ofentire towns.A number of facts and figures help illustrate thesituation. Figure 1 presents the corresponding homiciderates in Colombia between 1975 and 2001. Aslow increase is evident between the late 1970’s andthe mid-1980’s. From then on, an accelerated rate ofincrease is seen, with the highest levels recorded in theearly 1990’s.A slight decrease is then seen, with a secondreactivation starting in 1998.As shown, in the pastfew years the annual homicide rate in Colombia hasoscillated around 60 per 100,000 inhabitants. In 2000,the world’s average homicide rate was 8.8 per 100,000inhabitants, about seven times less than Colombia’srate. Presently, the country’s rate is the highest of anycountry in the world.By far, the greatest impact of homicide violencein Colombia is on the male population. In 2001, malesaccounted for 92.5% of homicide victims. However,two worrisome facts should be noted. First, the percentageof women victims of homicide has been risingover the past 20 years. Second, despite a 1:12 ratiowhen compared with males, the actual number ofwomen victims of homicide is extremely high. In 2001,the National Institute of Legal Medicine and ForensicSciences (INMLCF) registered 1972 homicides infemales, so during that year an average of five femaleswere murdered in Colombia every day.50

Observatorio Latinoamericano de Salud.According to the available data, the distributionof homicides in males shows a significantly higherimpact on young adult populations. Clearly, the highestrates affect males between the ages of 15 and 44 yearsold. The murder rates for adolescents and for youngadults ages 25 to 34 are alarming. During the year1999, for example, the homicide rate for males ages 20to 34 was three times the national average.The situationis even more dramatic when analyzed in terms ofage and gender distribution by geographic location; in2001 the homicide rate for males ages 18 to 24 in theDepartment of Antioquia was 728 per 100,000, anoverwhelming the fact that portrays the extremeseverity of the problem (see figure 1).The distribution of homicides among differentregions of the country – administratively divided intoDepartments – shows striking contrasts that can behelpful in defining the origin and dynamics of the problem.Antioquia, a Department whose capital city isMedellín, has persistently led the country in homiciderates and it even tripled the national average on theyear 1991.Antioquia has been a very important settingin the armed conflict as well as in the problem of illegaldrug traffic. Interestingly, its homicide curvedecreased immediately after the time when the infamousMedellín Cartel was most severely hit by the lawenforcement authorities. In the Department of Valle,homicide rates began to increase as the rates inAntioquia began to decrease. Valle has also been animportant scenario for both the armed conflict andillegal drug traffic; an increase in drug-related activitieswas seen in Valle immediately after the Medellín CartelFIGURE 1 ANNUAL HOMICIDE RATES COLOMBIA, 1975-2001HOMICIDES PER 100,000INHABITANTSYEARSData sources: Revista Criminalidad, Policía Nacional (Publication of the Colombian National Police) INMLCF (National Institute of Legal Medicine and ForensicScience)51

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAwas dismantled.The Colombian capital city, Bogotá, hasmaintained rates below the national average, and from1993 on, has shown a steady decrease that coincideswith the implementation by the local authorities of anumber of programs for violence prevention andpeaceful social interaction. This regional distributionof homicide violence shows recent changes. In 2001Antioquia was replaced as having the leading rate ofhomicides by three other Departments – Arauca,Guaviare and Putumayo – where a significant increasein both the armed conflict and illegal drug productionand commercialization has been evident during thepast few years.The explanatory contexts ofColombian violence.What is an explanatory context? In an effort to gobeyond the descriptive level in the study ofColombian violence and attempting at the same timeto overcome the theoretical difficulties posed by theconcept of cause, I have proposed the use of explanatorycontexts as a useful theoretical tool in the studyof violence that can be extended to other areas ofsocial research.An explanatory context is the specificcombination of cultural, economic, social-politicaland legal conditions that make a phenomenon historicallypossible and rationally understandable. In thisway, the idea of explanatory contexts accounts for adescription of the origin and explanation of a phenomenon,but avoids the ideas of blame and determinismthat are so often involved when using theconcept of cause.When studying a specific phenomenon it is necessaryto identify the different components of theexplanatory context or, even better, the differentexplanatory contexts involved. It is also important tounderstand that while the phenomena being studiedare ongoing, explanatory contexts can and should beseen as provisional. Definitive explanatory contextscan be established only when dealing with events ofthe past.Based on the current state of research, on anextensive field study and on a continuous observationof the situation, I have proposed four explanatorycontexts of Colombian violence: the political, theeconomic, the cultural and the legal [Franco, 1999].● Political explanatory context. The interviewed populationin the field study assigns this context the greatestimportance. It includes four main aspects: thecharacterization and the role of the government, thepersistence of the political-military conflict, intolerance,and the role of society as a whole. The firstaspect is related to corruption. A progressive decayin the legitimacy and reliability of the governmentand its relative absence from different regions anddifferent aspects of national life, fostered by theimposition of an economic model that weakens itsrole [Pecault, 1995].The political-military conflict hasa long and complicated history. Its roots can betraced to the period of exacerbated violence of themid-20th century [Guzmán, Fals-Borda, Umaña,1980; Oquist, 1978] and its activation occurredbetween the mid-1960´s and the early 1970’s[Sánchez, Peñaranda, editors, 1995]. The conflictbegan as a military confrontation between extremeleft-wing guerrilla groups and the government. In theearly 1980’s a new actor appeared: the paramilitaryorganizations [Medina, 1990]. The paramilitarygroups began as self-defense groups led by druglords and landlords determined to take the waragainst the guerrilla groups in their own hands wereoften supported by certain sectors of the country’smilitary. Illegal drug traffic has significantly permeatedthe conflict and the armed groups involved havesustained variable and ambiguous links to the organ-52

Observatorio Latinoamericano de Salud.izations that control drug traffic.The strong multinationaleconomic interests involved in gun trade havealso been a permanent stimulus for Colombia’sarmed conflict [Tokatlián, Ramírez, editors, 1995].Over the past two decades the conflict has worsenedand the illegal armed organizations haveincreased their military power and their geographiccontrol. During the same period, several attempts toreach a negotiated solution have failed, including thedevelopment of a new Constitution in 1991[Valencia, 1998]. The participation of the internationalcommunity in these attempts to find a solutionhas been minimal.Political intolerance, understood as the inability tosolve ideological and political differences in a nonviolentmanner, has been a continuous trend inColombian affairs.The armed conflict expresses andcontinuously feeds a high level of intolerance thathas led to the extinction of several unarmed politicalorganizations and to a reduction of politics toeither biased elections or military confrontation. Asmuch as 20% of all homicidal action can be attributedto political and social intolerance [Franco,1999]. And although political intolerance manifestsitself most clearly in the armed conflict, it becomesa pattern that is easily reproducible in other areas ofsocial interaction.Two important components of the political explanatorycontext are social apathy towards violence andthe precarious levels of organization and participationto confront the problem. Despite its intensity,persistence and generalization, Colombian societyhas shown little in the way of a clear and consistentposition towards violence. The responsibilities andpossibilities of the international community are alsoincreasingly recognized [Franco, 2000].● Economic explanatory context. The fundamental economicexplanatory context for violence in Colombiais the structural inequality of Colombian society.Colombia is a good example of the fact that there isno direct relationship between poverty and violence.It is also a good example of the fact thatinequality and violence are strongly related.This relationshiphas been demonstrated at an internationallevel by the World Bank, in a study conductedbetween 1970 and 1994 in different regions of theworld [Fajnzylber, Lederman, Loayza, 1997].Inequality in the distribution of resources andopportunities has progressively increased inColombia [Fresneda, Sarmiento, Muñoz, 1991]. Somedata may be helpful in understanding the situation:60% of Colombia’s population lives under povertyand 23% under extreme poverty; 3.3 millionColombians are unemployed and informal laboraccounts for 61% of those employed; 37% of thosewho work earn less than the minimal salary and48.6% of the population is not covered by any typeof social security [Colombia. Contraloría General dela Nación, 2002].The traffic of illegal drugs towardsthe large amounts of consumers in first-worldnations, which was commonly perceived in the mid-1970’s as a path towards a more even distribution ofwealth in Colombia, has worsened the concentrationof rural property and other resources, increasingthe levels of inequality and thereby the levels ofviolence [Deas, Gaitán, 1995; Uprimny, 1995].● Cultural explanatory context. This is possibly the leaststudied of the explanatory contexts in bothColombian and international studies of violence.Violence is human, historical and social, and thereforeit is clearly immersed in the realm of culture.In the case of Colombia, this context has three mainaspects. The first refers to ethics, which are still in53

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAthe core of all matters related with violence.Thereis a gap between social values and current problems,especially violence. Even the primacy of life asa value is commonly underestimated or ignored[De Currea-Lugo, 1999]. The second aspect refersto education. It includes both the extent of coverageand the contents of the country’s public educationsystem. 83% of the Colombian population hasaccess to primary education, 63% to secondaryeducation and only 15% to higher (professional)education.There is a clear discrimination against thepoorer populations [Colombia. ContraloríaGeneral de la Nación, 2002].The third aspect refersto the psychological components of the origin anddynamics of violence. It involves the chronic accumulationof feelings of hatred and revenge betweenindividuals and groups. It also includes the individualand collective psychopathologies behind certainforms of cruelty and the behavior of some paidmurderers.● Legal context. It is closely linked to the political andcultural contexts of violence and involves two mainaspects: the inadequacy of the country’s legal structurewith respect to the type and magnitude ofpresent violence and the inefficacy of the judicialsystem. Its clearest indicator is the lack of legalaction taken against criminals, which has worsenedover the past four decades. According to officialestimates, "while the probability of charges for acrime in the mid-1960’s was 20%, this number wasdown to 5% in 1971 and has decreased continuouslysince to the current 0.5%" [Comisión deRacionalización del Gasto y las Finanzas Públicas,1997]. According to the NILMFS, 75% of homicidesin 1999 [Colombia. Instituto Nacional de MedicinaLegal y Ciencias Forenses, 2000] and 89% in 2001were unsolved. Figure 2 portrays the inverse relationshipbetween the number of homicides committedper year versus Colombian penal capabilities.As homicide rates increase, the capture andconviction of murderers decreases.This also exposesthe negative effect impunity can have on violencein Colombia..In summary, there are three structural conditions andthree transitional situations that affect the origin anddynamics of the current cycle of violence inColombia. Inequality, intolerance, and impunity arethe three structural conditions, while the internalarmed conflict, drug trafficking and the progressiveweakening and neoliberalization of the governmentare the three transitional situations that contributeto violence.ConclusionsMany conclusions can be drawn from this socialmedicalapproach to violence in Colombia, but thereare three that are particularly important.● First, homicidal violence in Colombia is a severe andcomplex process. Colombia is a country of slightlyover 40 million inhabitants, where homicide ratesremain above 60 per 100,000 and over half a millionhumans have been murdered in the past 27 yearsalone.The structural conditions and transitional situationsthat generate violence in Colombia interlink;new actors appear and combine, and conflicts ofinterest involved are increasingly strong. The caseappears to deserve a greater degree of attentionfrom Colombian society, its Government and theinternational community.● Secondly, the social-medical approach to Colombianviolence has possibilities and limitations.With such acomplex problem any single discipline, theory or54

Observatorio Latinoamericano de Salud.FIGURE 2 HOMICIDES AND INDIVIDUALS CAPTURED FOR HOMICIDESCOLOMBIA, 1975 – 1995Fuente: Franco, S. El Quinto: No Matar. IEPRI-Tercer Mundo. 1999, p:111.methodological approach can be expected to beinsufficient. The social-medical approach offers thecombination of careful permanent observation, theintroduction of new analytical categories, methodologicalresources, and the generation of integrativeand consistent data. The limitations of the socialmedicalapproach in this setting include the difficulty– and sometimes risk - of accessing valuable informationon violence in Colombia, the lack of specificindicators for certain facts and processes, the fledglingnature of some of the concepts and methodsbeing implemented, the number – still small – ofresearchers using the approach and the irregularityof communication among them. Overcoming theselimitations can be an important step towards understandingand solving the problem.● Finally, the intensity and complexity of Colombianviolence requires a greater degree of social participationand mobilization and a faster transition fromtheoretical discussion to plans for action. Thereappears to be agreement on the idea that intellec-55

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAtuals and academicians should participate in thedescriptive and analytical study of the problems, theformulation of feasible proposals for action and theeffective support of the transitional phase betweentheory and social action. Social medicine may – andshould - make a growing contribution to this effort.56

Observatorio Latinoamericano de Salud.REFERENCES● ARENDT H (1970). On Violence. New York: Harcourt Brace Jovanovich.● BENJAMIN W (1995). Para una crítica de la violencia. Buenos Aires:Editorial Leviatán.●COLOMBIA. CONTRALORÍA GENERAL DE LA NACIÓN(2002). La exclusión social en la sociedad colombiana. Bogotá:Contraloría.● COLOMBIA. INSTITUTO NACIONAL DE MEDICINA LEGAL YCIENCIAS FORENSES (2000). Forensis 1999. Bogotá.● COMISIÓN DE RACIONALIZACIÓN DEL GASTO Y LAS FI-NANZAS PÚBLICAS (1997). El saneamiento fiscal, un compromisode la sociedad,Tema V. Informe Final. Santafé de Bogotá.● CORTINA A (1998). Hasta un Pueblo de Demonios: Ética Públicay Sociedad. Madrid: Editorial Taurus.● DE CURREA-LUGO V (1999). Derecho Internacional Humanitarioy sector salud: el caso colombiano. Comité Internacional dela Cruz Roja. Plaza y Janés Editores, Bogotá.● DEAS M, GAITÁN F (1995). Dos ensayos especulativos sobre laviolencia en Colombia. Santafé de Bogotá:Tercer Mundo Editores.● FAJNZYLBER P, LEDERMAN D, LOAYZA N (1997).What causescrime and violence? Washington,The World Bank.● FRANCO S (1999). El Quinto: No Matar. Contextos Explicativosde la Violencia en Colombia. Bogotá: IEPRI - Tercer Mundo Editores.● FRANCO S (2000). International dimensions of Colombian violence.Int J Health Serv. 30(1):163-185.● FRESNEDA O, SARMIENTO L, MUÑOZ M (1991). Pobreza, violenciay desigualdad: retos para la nueva Colombia. Santafé deBogotá: United Nations Development Programme.● GUZMÁN G, FALS-BORDA O, UMAÑA E (1980). La violencia enColombia. Novena edición, Bogotá, Carlos Valencia Editores.● MEDINA C (1990).Autodefensas, paramilitares y narcotráfico enColombia. Santafé de Bogotá, Documentos Periodísticos.● OQUIST P (1978).Violencia, conflicto y política en Colombia. Bogotá:Instituto de Estudios Colombianos.● 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.● SÁNCHEZ G, PEÑARANDA R, editores (1995). Pasado y presentede la violencia en Colombia. Segunda edición. Santafé de Bogotá,IEPRI – CEREC.● TOKATLIÁN JG, RAMÍREZ JL, editores (1995). La violencia de lasarmas en Colombia. Santafé de Bogotá, Tercer Mundo Editores.● UPRIMNY R (1995). Narcotráfico, régimen político, violencias yderechos humanos en Colombia. En:Vargas R, editor. Drogas, podery 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 delValle.● WORLD HEALTH ORGANIZATION (2002). World report onviolence and health. Geneva:WHO.57

EconomicFundamentalism,Legal Regression,Work Degradationand theEcosystem

Observatorio Latinoamericano de Salud.6TheImpact of Neoliberalism on the Healthof Latin-American WorkersMariano Noriega,Cecilia Cruz,María de los Ángeles Garduño1.The application of the neoliberal model in Latin-American countries disruptsthe social fabric of the working population. One of the expressions of thisproblem is the deterioration of working conditions and, consequently, that ofhealth.Large transnational companies propose the neoliberal model to Latin-American governments as a valid alternative for development in the next centurywhen, in fact, the model leads to great sacrifices for the majority of the population.In effect, this "modernizing" project has generated disadvantageous conditionsespecially for the working population.These disadvantages are visible in notableinequalities; the political defeat of its organizations; the permanent and progressivedecline 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 decadesago, guaranteed a minimal regulation of capital –labor relations. In opposition,one of the consequences of today’s neoliberal policies and subsequent socialcrises modernization and market globalization is the dismantling of State interventionto 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 marketshave been deregulated (including the labor market) and commerce has been59

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAliberalized, but above all, foreign investment is promotedat any human and social cost. The outcomes ofsuch movement in different Latin-American countriesvary, but there are common effects: unemployment(owing to the shutdown of companies that are not inthe capacity to compete with high tech transnationalcorporations); loss of labor rights; and imposition ofhazardous working processes. [Benería, 1999]The base of this so called productive "modernization"in Latin America has not been technologicalchange, but the intensification of labor, the constantdismissal of workers and the systematic exclusion ofrural and urban workers. A report presented by theWorld Labor Association explains that, in 2003, 185,9million people throughout the world were unemployed,and that the largest part of the employed were ina situation of poverty [OIT, 2004a]. Specifically in LatinAmerica, the rate of employment amounted to8,9%, which represented a significant upsurge in relationto the past decade (7,3%) [CEPAL, 2003].Strictly in terms of labor, an analysis of modernityin Latin America is a complex task because it impliesunderstanding the connection between the newcharacteristics of the working process and legal deregulation,with the old structures and models.Thus, althoughlabor flexibility is dominating the productiveprocesses, it tends to blend and even expand previousorganizational structures of labor, such as "taylorist"labor division, benefiting at the same time from the renewedresources of automation, data processing, microelectronics,and complementary elements, such asquality control and total quality planning.2.The combination of elevated unemployment andunderemployment rates and the instability of the labormarket, with its wage depression, create a criticalsituation for workers, yet this is not all. The abovementioned modernization process has additionallylead to important modifications in other aspects of laborrelations. For example, working centers havebeen implemented with the intention of incrementingproductivity. For instance, flexibility, understood asmultiple task or polyvalence activities, is used as astrategy to augment the adaptive capacity of operators.Accordingly, these kind of measures increase hazardsand labor exigencies which deeply affect workers’health.In this sense, the neoliberal model has not onlysacrificed strife for profit increase by means of productiverecomposition, -innovative and revolutionarytechnologies (dynamic flexibility)-, but is has relied onstatic flexibility or, the "diminution of the wage cost:wage restriction, work intensification, enlargement ofthe 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 strategiessuch as temporal contracting by the hour wagespayment, and worker subcontracting that dissolves thecompanies´ labor responsibilities. In addition, companiesreceive fiscal benefits and promote instability inthe jobs and posts, divisibility of wages (salaries, bonus,incentives, grants), variable workdays, fewer breaks, collectivecontracts with lesser rights and benefits and, ofcourse, restrictions in the right to go on strike.Labor organization is one of the aspects that sufferedthe greatest change. It has portended to fomentin people a sense of possession and compromise, makingthis out as of common interest, but, in reality, thecharacteristics for the majority of workers are an accentuatedsocial and technical division, standardizationof tasks, limited assignation of jobs per person, scientificselection of personnel, individualization, drilling forthe job, objective measurement of individual performance,remuneration in function of productivity, strict60

Observatorio Latinoamericano de Salud.supervision, and lastly, reduction of the margin of autonomy[Noriega, 1995].The new polyvalent or multi-task working system,simultaneously, takes advantage of the gendercharacteristics of the workers. Several studies haverevealed that, in men for instance, there is a predominantly"vertical" polyvalence –multi-competence stagesthat need special training-, while amongst womenthere is a predominant non-qualified multi-competence,of horizontal nature, which permits the realizationof different tasks [Acevedo, 2002].In Latin America, we find a combination of structuredjobs with extensive work journeys and intensiverhythms, as well as those non-structured occupationsthat invade daily life, converting it into an undifferentiatedworkday [Cruz, Garduño, Noriega, 2003].Nevertheless, at present, the relation betweenworkers’ jobs and health should not be explained onlyfrom the scope of remunerated work, but from that ofdomestic activities, which entail no less than half theworkday. Work organization, starting from new technologiesand new types of processes has allowed, especiallyin women, to double and even triple laborhours, provoking remarkable health deteriorations.Along these lines, to elucidate the damage causedto health, one should not separate the workingand the consumption spaces to simplified scenarios,for example the interior from the exterior, or the manufacturingspace from the domestic space, as thiswould dissociate the unity of workers life. We mustovercome those predominant scientific approaches,which intend to divide everything: the factory fromthe house, emotions from energy, and productionfrom politics and culture.Furthermore, this flexibility imposes diverse labordynamics in men and women, and it additionallypromotes non-rigid working times and spaces, bringingabout the possibility of combining domestic with remuneratedwork. What actually ensues is that flexibilityleads to deregulation and the ability of companyowners to autonomously establish working conditions[Garduño, 2001].These changes of the traditional working modelof industrial society also implies a reduction in thenumber of employed workers in manufacturing companies.This situation affects principally the young andincreases the number of migrant workers to developedcountries as the sole economic solution. Thenagain, the proportion of temporary employment andpart-time work is on the raise. All told, it is a phenomenonof labor impoverishment and of long-termstructural unemployment [Tezanos, 2001; Feo, 2002].The phenomenon of "impoverishment of the labormarket" is, certainly, the most unsettling characteristicof the contemporary situation. In a different waythan in previous periods, precarious employment circumstancesare not any longer a transitory or fortuitousstate of affairs, but they tend to develop intostructural features of Latin-American societies. Thepredominance of the informal sector in the labor markethas accompanied the "tertiary industry employment",which is the growing involvement of labor forcein the services sector. A further extremely importantissue to be underscored is the prominent increasein infantile work, unsalaried employment, familyworkshops and small industries in the occupational industrialstructure.Numbers are overwhelming and illustrate wellthe situation. As indicated by the World Labor Association,at the moment, the informal sector concentrates75% of occupied workers in Latin America. In theperiod of 1990 to 2003, on average, 6 of each 10 engagedworkers were part of the informal economy.The expansion of this sector affects every worker, moreso for women though, as 85% of their employmentis affected by this characteristic [OIT, 2004]. Duringthe past twenty years, millions of job posts have beenlost in Latin America. In the region, 19,5 million wor-61

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAkers have become unemployed, equivalent to 10,4% ofthe labor force [OIT, 2004].3.A dramatic instance of this massive aggravationof working conditions has taken place in Mexico as aresult of the North American Free Trade Agreement(NAFTA), which has produced permanent negativeconsequences in the country. It has been more than10 years since this Treaty took effect under the purposedobjectives of trimming down poverty in Mexico,multiplying employments and accomplishing macroeconomicalstability. Yet, none of these benefits havebeen attained. In the field of employment, specifically,the NAFTA proposed the "improvement of the workingconditions and the living standards in the territoryof each one of the participant countries" [Samaniego,2000].That is to say, the protection of the workers,but governmental and employers’ actions havegone in the opposite direction. In 1991, three yearsbefore NAFTA, there were 10 million workers in theinformal economy and, already in 2002, this numberhas climbed to 17 million" [Castañeda, 2004].What NAFTA has accomplished, in effect, is aquick subordination of the Mexican economy to thatof the United States, but without economical growthand with no achievements in terms of welfare for theMexican one, and, in particular, for workers and theirfamilies [Ornelas, 2003].Numerous transnational companies have investedin the country, taking advantage of new nationalmarket openings. These companies were hungry forcheap labor and for legal facilities. Nevertheless, manyfull-time jobs were lost in Mexico, precarious employmentincreased (mainly contracts by the hour withlow wages) and unemployment has been boosted. Asa consequence of this situation, more and more Mexicanshave abandoned their country. One piece of indirectevidence of this phenomenon is the rapid increaseof remittances sent by workers in the UnitedStates to their relatives. In 1995, one year after theNAFTA, these remittances amounted to 3,673 milliondollars, but now in 2003, they have almost quadrupledto a high of 13,266 millions. [Arroyo, 2004]During these NAFTA years, just 58% of the necessaryemployment has been created on average annually.Amid these, 59,5% lack the benefits determinedby the law. In the manufacturing sector -which is thegreatest exporter within Mexico’s economy (87% ofthe total, and half of the foreign investment)- contraryto all declarations and expectations, jobs decreased by12.8% since the start of NAFTA. In addition, the integralcost of labor has declined 37.7%, despite a 58.6%increase in productivity [Arroyo, 2004]. With the minimumwage of 1976, nearly two basic consumer basketscould be purchased, whereas at present, only 18% of abasket can be purchased. Added to this, the absence ofcodes of conduct for transnational companies signifiesthat the Mexican government, in its urge to install directforeign investment in the country, has allowed violationsof various labor rights such as the right of organizationand freedom for the unions, the right of socialsecurity; and the rights to an adequate wage and satisfactoryworking conditions [Castañeda, 2004].4.This regressive reorganization of production impliesprofound changes which will alter the typical laborcharacteristics of the twentieth century, as muchfrom the viewpoint of people as from the perspectiveof the social system. Its instrumentation has had andwill have both direct and indirect consequences andchanges, in such areas as the modalities by which theproductive tasks are executed, the occupational structure,the available employment supply, and the socialstructure [Tezanos, 2001].62

Observatorio Latinoamericano de Salud.The corollary of this panorama is expressed infour distinct levels: a) the reduction or vanishing of variousbasic components of the development of humanwork; b) the emergence of new labor exigencies orthe intensification of the old ones characterized bytheir synergy and activity; c) stress (severe and chronic)and fatigue, as mediating elements of the pathologyassociated with the new forms of labor organization;and d) the proliferation of illness associated withthese changes, among them, mental and psychosomaticdisturbances, diverse but with common origins[Noriega, Laurell, Martínez, Méndez,Villegas, 2000].The neoliberal phenomena demand a renewedresearch framework concerning labor illnesses. Innumerablenew processes and diseases have acquired thedimension of public health problems. Thus, there is adiverse set of disturbances that are resultant of theexposure to stress, such as psychosis, major depression,pathologic fatigue, burnout, gastrointestinal disturbances(ulcerous peptic illness, gastric and duodenalulcer, non-ulcerous dyspepsia, irritable bowel syndrome),cardiovascular illnesses (coronary cardiopathy;hypertensive illness, cerebral-vascular illness),post-traumatic stress disorder, disturbances related toanxiety (anguish crisis, generalized anxiety, obsessivecompulsivedisturbance, phobia), and lastly, Karoshi (incapacitationor sudden death by excess of work).Among the many health problems derived fromergonomic exigencies are: musculoskeletal syndromesand illnesses (accumulated traumatisms in shoulderand neck, in hand and wrist, in arm and elbow, for repetitivecompressions and tensions, neuropathies forpressure), visual fatigue, physical or muscular fatigue, aswell as mental and psychological pathologies.One should also be aware of the damages producedby 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 illnessesof the nervous system generated by chemical products,capable of inducing a constant pattern of neuraldysfunction or changes in the biochemistry or structureof the nervous system [Noriega, 2004].Finally, it is necessary to take into considerationsome very recent labor health problems involving thenew computer technologies and automation in theprocesses of work; the new chemical substances andphysical energies; the hazards to heath associated withnew biotechnologies; the transferal of hazardous technologies;the aging of the working populations; the specialproblems of vulnerable and unproductive groups(chronic illnesses and invalidities), including migrantsand the unemployed; those that have to do with the intensificationin mobility of the working population;and, the advent of new labor illnesses of different origins[OMS,1995]. The situation in this field appearsdesperate or, at least, with scarce possibilities of beingovercome in the coming years.5.Upon modifying the economical and social variables,market globalization has many negative repercussionson health due to the fact that it severely affectsliving conditions. At work and in consumption,illness that had been apparently resolved has reemerged,others have been aggravated and still new oneshave arrived on the scene. The whole of this has beencompounded by the weakening of health services andthe cutback of health budgets [Franco, 2002].A summary of the main trends found in the fieldof occupational health, include:a) A wider range of worker demands, as a result of thedeterioration of the quality and content of work.b) The accidents and illnesses legally concerning laborwill become more difficult to recognize since mobi-63

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAlity and polyvalence of workers will surely providethe arguments necessary to deny labor causality.c) Labor morbidity will increase notably in those illnessesnot yet recognized as work related pathology.d) It is reasonable to forecast a disproportionate increasein morbidity in highly vulnerable groups ofworkers and their families, directly linked to thesenew working and living conditions. Obviously, atpresent, we can clearly foresee a rise in pathologicalmanifestations derived from violence.e) Deregulation or reduction of labor and social securitynorms are boosting hazardous labor and willsurely trim down, even further, the many collectivedefenses of workers.f) The fight against organized worker participation willlead to less possibilities for transforming and improvinghazardous working conditions and health.6.In the opening of the twenty-first century, despitethe advancement of microelectronics, we cannotcount on information concerning the health conditionsof Latin-American workers, information that is indispensableto evaluate working conditions adequately.The lack of an integral occupational health systemand specific programs concerning labor and healthconditions persists in several of our countries. Legislationon this subject is realistically un-observed. Further,our institutional actions are very limited, dispersed,inclusive, contradictory, and they tend to the limitany evaluation. And the behavior of companies isoriented more toward the reduction of insurance paymentsthan to the improvement of labor conditionsand the surveillance of workers’ health; and lastly, legalprovisions of a preventive nature are not monitored aspart of the inspection actions of institutions such asDepartments of Labor.The neoliberal model is in effect a clearly inefficienthealth care and health security model. Gradually,health care activities are being privatized (and consequentlybecoming increasingly inaccessible to the massof the working population), which in turn leads to avery limited capacity for medical care and treatment,and a decrease or suppression of benefits (indirect wageand social wage). This becomes evident, for example,in the policy of not recognizing work related incapacities(temporal and permanent), invalidities andpensions for unemployment, and oldness or death. Insum, we are denouncing an institutionalized policy oftoleration for a diminished social response to adverseand hazardous working conditions, and their consequentdiverse and long-lasting negative health outcomes.The modification of the policies of public institutionsand companies is indispensable in order forhealth problems of the working population to be recognized.Alternatives can and should be furnished toimprove the working conditions that provoke them.64

Observatorio Latinoamericano de Salud.REFERENCES● ACEVEDO, D (2002). "El trabajo y la salud laboral de las mujeresde Venezuela. Una visión de género". Universidad de Carabobo,Venezuela.● ARROYO,A (2004). "El México de Fox y el TLCAN. La dura realidaddel 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 deDavos". Revista Ventana 10. Universidad de Guadalajara. México.● CASTAÑEDA, N (2004). "Desmitificar el Tratado de Libre Comerciode América del Norte como instrumento de desarrollo socialy 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 deAmérica Latina, 2002-2003. Publicación de las Naciones UnidasLC/G.2209-P.● CRUZ, C; GARDUÑO, M Y NORIEGA, M (2003). "Trabajo Remunerado,TrabajoDoméstico y Salud. Las Diferencias Cualitativas yCuantitativas entre Mujeres y Varones". Cadernos de Saúde Pública19(4): 1129-1138, Río de Janeiro, Brasil.● DELCLÓS, J; BETANCOURT, O; MARQUÉS F Y TOVALÍN H(2003). "Globalización y salud laboral".Archivos de Prevención deriesgos Laborales 6(1): 4-9, Barcelona, España.● FEO, O (2002). "Globalización y salud de los trabajadores". Saludde los Trabajadores 10(1-2): 5-15, Maracay,Venezuela.● FRANCO, A (2002). "La globalización de la salud: entre el reduccionismoeconómico 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 trabajodoméstico y la salud de las mujeres". Salud de los Trabajadores9(1): 35-43, Maracay,Venezuela.● LÓYZAGA, O (2002). Neoliberalismo y flexibilización de los derechoslaborales. UAM/Porrúa, México.● NORIEGA, M (1995). "Realidad Latinoamericana. Paradigmas deInvestigación en Salud Ocupacional". Salud de los Trabajadores.3(1): 13-20, Maracay,Venezuela.● NORIEGA, M (2004). "Aportes de la medicina social a la salud enel trabajo". Salud Problema (en prensa), México.● NORIEGA, M; LAURELL, C; MARTÍNEZ, S; MÉNDEZ I;VILLEGAS,J (2000). "Interacción de las exigencias e trabajo en la generaciónde sufrimiento mental". Cadernos de Saúde Pública 16(4): 1011-1019, Río de Janeiro, Brasil.● NOVICK, M (2000). "La transformación de la organización del trabajo".TratadoLatinoamericano de Sociología del Trabajo (Enriquede la Garza, Coord.). Colmex, México; pp. 123-147.● OIT (Organización Internacional del Trabajo) (2004a). Comunicadode prensa de la OIT, 7 de diciembre de 2004 (OIT/04/54)● OIT (Organización Internacional del Trabajo) (2004b). "PanoramaLaboral 2004 América Latina y el Caribe". Lima/OIT Oficina Regionalpara América Latina y el Caribe.● OMS (Organización Mundial de la Salud) (1995). "Global Strategyon Occupational Health for All (The Way to Health at Work)".Recommendations of the Second Meeting of the WHO CollaboratingCenters in Occupational Health, 11-14 de octubre de1994, Beijing, China. Ginebra.● ORNELAS, J (2003). "El Tratado de Libre Comercio de Américadel Norte y la crisis del campo mexicano". Revista de la Facultadde Economía, Universidad Autónoma de Puebla. VIII (23):25-48,Puebla, México.● SAMANIEGO, N (2000). "El caso del Tratado de Libre Comerciode América del Norte (TLCAN)". [Disponible]www.ilo.org/public/spanish/region/ampro/cinterfor/publ/erm-_bar/pdf/saman.pdf● TEZANOS, J (2001). El trabajo perdido ¿hacia una civilización postlaboral?.Biblioteca Nueva. Madrid.65

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA7Floricultureand the Health Divide*:A Struggle for Fair and Ecological FlowersJaime 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 Ferreroand Stella Morel**Floriculture and the Contradictions of "New Rurality"The outburst of economic fundamentalism since the 80s has acceleratedcapital accumulation and social regression in Latin America. Policies werechanged to benefit big corporations. Social protection norms were dismantledand labor rights were abolished.The so-called "Keynesian" or protectorState 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") agricultureand indigenous community cultural forms evolved into a scenario of aggressiveagribusiness productivity, based on "green revolution" technical systems.The logic of competitiveness and mono-cultural agriculture exportation penetratedthe fields of Latin America, displacing community agrarian relationsand agro-ecological cultures.Great pressure has been imposed on small peasant economies, whichhave affected rural relations and socio-cultural patterns. Indigenous organizationsand rural communities that attempt to stop the concentration of land,water, financial resources, and above all, the subordination of people to foreignand non-solidarity modes of life have counteracted this imposition.Cut flower production in countries like Colombia, Costa Rica, Ecuadorand 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; ceas@ceas.med.ec66

Observatorio Latinoamericano de Salud.ral development and is an interesting subject of debatethat can be approached from opposing perspectivesabout social and human development. Some would arguein favor of agribusiness as the panacea of modernizationand progress (higher productivity; employmentsource; complementary business activation andmodernization of rural life).To many others, entrepreneurialmonopoly floriculture is a false solution thatconceals, under apparent affluence and highly rentableprivate business, serious social and ecological problems.Job supply and slight income raises do not implya real redistribution process that can encounter theaccelerated income concentration rate, the ever wideningsocial gap, and above all, the loss of human rightsand cultural identity.The impact of floriculture surpasses the economicterrain and affects communities, social organizationsand the fundamentals of life in small cities of theregion. High tech floriculture farms do not solve socioeconomicproblems, but rather take advantage ofcheap community labor and low income due to theineffectiveness of the agrarian reform process and theeagerness of traditional "haciendas" to become prosperousmodern cut-flower farms and holdings.CEAS´ EcoHealth Program operates in the GranoblesRiver Basin (North Andean Region of Ecuador),characteristically a modern floricultural area, wherehigh productivity in relatively small areas has put pressureon the land market, forcing many impoverishedpeasants to sell their properties. This has favored aprocess of land concentration, attracting labor fromnearby communities –and even other regions- andcreated and an ever-growing dependency of youngworkers. Nevertheless the transformation of peasantsto workers operates through drastic mechanisms ofcultural changes that annul the values of solidarity, ofcare of the "mother land" and of ancestors that makeup their original identity.The absence of agrarian development policiesand social support especially drives younger peasantstowards floricultural work and impedes the building ofsustainable community economical activities thatcould prosper in the area. Land ownership concentration,and corresponding access to irrigation water andto financial support close all other local alternativesand stimulate either emigration or the search for agribusinessemployment.There are two kinds of cut-flower farms (mainlyexport cut rose production): those that comply withthe international code of conduct and FLP Program(fair and ecological labor, social security, health andecological protection norms); and the majority offarms (around 80%) that unfortunately operate withoutany control and increase their capital accumulationand profit by avoiding responsibilities to theirworking force and environment.Floriculture has grown dynamically in the last 15years (refer to Figure 1). It is globalized not only sinceit 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 madebeyond the region. This decision-making process isvastly subject to global technologies: computer science,for real time electronic interchange of data, chemicalresearch and genetic research. It is neither in Cayambenor Tabacundo where issues, such as the followingare decided: what will be produced; with whomto become associated; with whom to sell; or fromwhom to purchase resources.Floriculture production circuit 1 has a previousstage in the patentees or "obtentores" (Holland, UnitedStates); 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 spatialproduction circuits defined by the circulation of goods and products, offers a dynamic perspective of the manner by which fluxes go across territory.67

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAECUADOR. EXPORT CUT FLOWER PRODUCTION AREAHECTARESFuente: Expoflores. Elab.: M. Lourdes Larrea (CEAS)dorian inter-Andean valleys, mainly on the basis of externalresources, however, employing a national workforce;subsequently postproduction and packing areperformed within the same farm, and finally flowersare sent to international markets by airfreight, especiallythe United States, followed by Europe. Technologiesand logics of multinational agrochemicals, aswell as those of variety producers determine therhythm and characteristics of productive processesand finances of companies. Flower prototypes areproduced by companies specialized in genetic researchto launch a greater number of and more sophisticatedvarieties in the highly competitive and capriciousinternational market 2 .Though floriculture receiverzones, such as the Granobles River Basin,achieve urban and agricultural modernization, they losecontrol of local production [Larrea & Maldonado,2005].Floriculture does not stem from the developmentof traditional agriculture, as would milk products,intensive agriculture, or fruit industrialization,since, in its implantation; characteristics of pre-existentproduction are not so significant. The determinantsof its installation correspond to factors, such asquantity of light per day and during the year; access toland with relatively easy credit; availability of abundantand inexpensive workforce; presence of plentiful waterin the land; access to communication services(electric power, telephone, internet, cable, etc.), andto a large extent, the proximity to markets by high-2.The operational resources almost totally imported correspond to 50% of the required. In addition, payment of royalties for the acquisition of bulbs and cuttings,and maintenance of plants reaches, consistent with several experts, 85% of culture costs (Alvarado 2002).68

Observatorio Latinoamericano de Salud.ways and airports. This indicates that floriculture isextremely dependent on public networks of moderninfrastructure.The installed production capacity is distributedin various managerial groups, from family groups to internationalholdings, and multinational branches, whichtend toward vertical integration. A sign of capitalistdevelopment is the high profitability of a majority offarms (300 farms of 10-15 has on average), with importantinvestment, use of resources and workforce.Medium or large companies have their own topologyspread within the territory: farms in diverse regions;administrative offices, and commercializing agencies inQuito or Cuenca; their own truck fleets, and evencold-storage installations at the airport. It has not accomplishedthe resolution -neither individually nor asa union– of the critical knot of airfreight transportationto destination markets.The latter constitutes oneof the higher expenditure items in the net price 3 [Alvarado,2002].Additionally, it has not succeeded in productiveresearch and intellectual property policies toconfront elevated payment to patentees. The high costof money that resulted from the "dollarization" of localcurrency is also evident [Alvear, 2000].Moreover, the floriculture spatial circuit in itsmarked dynamism requires numerous and varied resourcesand related services (packing, industrial protectionequipment, textile and shoemaking industry,graphic and paper industry, nourishing services, computerproduction and knowledge (hardware and software),personnel specialized in constructing and repairinggreenhouses and diverse machinery). The locationof farms decisively influences demographicgrowth.The axis of location of farms within the nationalterritory, and thus the main axis of fluxes, follows theroute of major roads (Panamerican Highway and otherfirst-rate ones) concentrated in the inter-Andeanvalleys, from 2600 to 2900 meters above sea level, in8 provinces, as illustrated in the map.It is confirmed that floriculture presents itself asan archipelago of areas with strong technological density–typical of globalization-, against a background oflow technological density, agricultural and traditionalpeasant zones [Larrea & Maldonado, 2005].Workers are predominantly young, with vitalityand the capacity to adapt to overtime demands, performance,high productivity, severe rhythm; with basiceducational levels that permit their training in thefarm; and a minor degree of involvement in peasant-indigenousand/or union organization. To assume workingliving modes, they must modify their cultural patterns.Albeit, their leaving the peasant community circle,or even the one of indigenous culture, implies acertain level of personal freedom and relative autonomyof a wage or income, conversely it supposessubjection to a new bond of a very strenuous proletarianworking pattern. In the case of working youngwomen, it entails a particular rupture with respect topatriarchal relations of the traditional community tofall into submission to intense demands of productivityof companies.Water And Soils: Perfect Flowers And ThreatenedLifeConsumers of the so called "First World" demand"perfect flowers" –without spots on petals or foliage.However, this symbolic value is attained by meansof plague and illness control, which could be accomplishedby integral management systems, without or3. According to Alvarado (2002), transportation corresponds to 19% to 37% of the final price of the product. The cost of management and sales (brokers, wholesalers,customers and retailers) in destination represents roughly 32%.69

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA70

Observatorio Latinoamericano de Salud.with a substantial reduction of chemical use. Unfortunately,the majority of companies (which do not participatein the FLP program) resort to irresponsible useof pesticides and other dangerous agro-toxics, due totheir profit logic. Also, the advertising of agrochemicalcompanies promotes the massive use of chemical productsand subjects them to the culture of the green revolution.Thus, the majority of flower companies,which do not work properly, contribute to contaminationin valleys. Small highland farmers, forced by theireconomic and technical needs, also have recourse tochemical control of their agriculture, especially potatoesand pastures. In numerous occasions the situationis aggravated due to low-priced and highly dangerouschemicals –red and yellow label- (refer to Table N°1).CEAS designed a sampling system 4 to differentiatethese impacts, obtaining results whose preliminaryanalysis show perturbing conclusions [Sánchez &Mac Aleese, 2005].Impact on Hydric SystemsSystems connected to La Chimba and Pesillo zones(potatoes and cattle producers) and San Pablitode Agualongo and Cananvalle (floriculture effluentscollection zone) were studied. Water of the correspondinghydric systems and sediments of the matchingriver basins are contaminated with chemical residualsin a proportion relative to their proximity tocontaminating sources: lesser in higher sectors offountains, moderate in potato, pasture and barley productionzones, and greater in the floriculture agro-industrialvalley (refer to Table N°2).TABLE Nº 1 CHEMICALS USED IN FLORICULTURE AND OTHER CROPSPRODUCTFosetil aluminioHidrocloruro de propamocarbMancozebMethiocarbMetomilCarbofuranDiazimonDemeton – S – metilMalathionMetamidefosTiociclamhidrogenoxalatoBromuro de metiloCHEMICAL GROUPPhosphateCarbamateAcetamideCarbamateCarbamateCarbamateOrganophosphatesOrganophosphatesOrganofosforadoOrganophosphatesNerehistoxinaMethyl bromidUSEFlowers-potatoesFlowers *Flowers-potatoesFlowers *Flowers *Flowers-potatoesFlowers *Potatoes *Potatoes & other *Flowers-potatoesFlowers *Flowers *TOXICITY LABELBlueGreenYellowYellowRedRedYellowRedBlueRedYellowRed4. Sampling points to study residuals in water through liquid and gas chromatography; they are explained in Table N02.71

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAResearch on highly persistent agrochemical hydro-solubleresiduals in the basin reveals importantresults. Contamination by persistent hydro-solubleresiduals reappears mostly in periods of lesser flowor dilution (July-August) and of greater productionand agricultural use of chemicals (November-December).Observing Table N°2, we verify a high concentrationof residuals in the effluents of the flower farm(T1), or in the branches of the hydric system of thevalley (P2 and P3) during December – the month inwhich there is an intense production for Saint Valentine’sDay-. Dissemination of contaminants is thusproduced by farms lacking controls (which are not apart of the FLP program), as a consequence of theirhigh productivity logic. There is no doubt that smallpotato and pasture producers pollute as well, by allowingnon-filtered superficial residuals to seep into thesoil (CH1 and CH2) (Table N°2). In addition to thepresence of detectable residuals in water, there is theincidence of heavy metals (chrome, manganese, andzinc) that are residual components in levels correlativeto the use of pesticides. Furthermore, the generaldeterioration of water quality results from the presenceof nitrogen, sulfur, and phosphorus derivedfrom fertilizers and pesticides in high grades detachedfrom agrochemicals. In other words, water from floriculturebasin hydric systems denotes a critical effectin its physicochemical and biological properties. Also,we begin to confirm the consequences that the presenceof toxic elements and residuals have on humanhealth.With the aim of strengthening the community’scapacity of early detection of water chemical contaminationand its impact on living organisms, CEAS undertookan experimental program to perfect bioassaysoriginally conceived of by an international team underthe auspices of the CIID (Canada) 5 . The first resultsshow the expected gradient in growth inhibition ofonion roots (Allium cepa L.) within high zones (potatoesand 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 chemicalsin bovine milk (bio-accumulation) were alsofound; hence, the troubling corroboration of highlydangerous chlorinated chemical residuals, such asppDDT in distinct sampling points during Decemberare an alarming and deserves continuous study by theCEAS.Albeit, floriculture is not the only source of contamination,collected evidence demonstrates it is ofmajor importance. Moreover, contamination by dangerousresiduals in water is not the only mode of impacton the ecosystem, since our study establishesthat the productive system employed in flowers contaminatessoils. The accumulation of residuals in sedimentsis effectively superior to that of water in themajority of cases (Table N°2). In farm soils, the accumulationof residuals in soils (studied by phase extraction–"solid phase extraction" SPE- and analyzed bygas chromatography) is greater as the time of productiveuse of soils passes (refer to Figure N°3) [Aguirre,2004].The mentioned process triggers soil degradation,causing loss of biodiversity, with grave alterationof its composition, diminution of metabolic rate, destabilizationand sterilization; a prolonged effect notcounterbalanced by the artificial elevation of the organiccomposition, 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 waterchemical contamination on the four biotic systems (i.e. onion/lettuce, water fleas, and algae). They are systematized in Dutka, BJ (1996) Bioessays: A HistoricalSummary of Those Used and Developed in our Laboratories at NWRI. National Water Research Institute, Environment Canada, Burlington.72

Observatorio Latinoamericano de Salud.TABLE Nº 2 STUDY ZONES : DIFFERENTIAL CONTAMINATION IN THE FLOWERPRODUCTION REGIONZONECODCH1CH2AY1AY2P1P2P3T1NAMEChahuancorralAltoChahuancorralBajoAyoraPuluvíAyoraGranoblesPisquePool areaPisque"Gorge"Pisque"Bridge"FlowerFarm TLOCATIONCHARACTERIZATIONHigh altitude, nearwater fountainsAfter potato crops,pasture and otherAfter community andbefore flowers(Low North)After community andbefore flowers(Low North)Center, after river confluenceGuachalá River& Granobles River;oxygenated river tractGorge, farm water dischargepoint (7 kmfrom P1, SouthCayambe)Basin exit pointFarm effluent(Cananvalle)CHEMICAL CONTAMINANTS& IMPACTS (*) (**)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)Water: ORG. PHOSPH/CHLOR : Endosulfan Sulphate (trace, Feb)PHYS/CHEM/BIOL: pH low; sulphur, nitrites, nitratos; c. bacter & highDBO5Sediment: CARB:3 Hidroxicarbofurán ( trace,August); ORG.PHOS/CHLOR: Betaendosulfán(trace, Feb)Water: ORG. PHOS/CHLOR :Betaendosulfán (trazas Feb)FIS/QUIM/BIOL: nitrite, nitrito, con bact & high DBO5 , hardnessSediment: ORG.PHOS/CHLOR:Betaendosulfán (trace,Augst); ppDDT (trace, Diciembre)Water: CARB: Carbofurán (high Dec. 0.08 y Feb 7.1); Metomil (high Dec 1.53 y 18.2 Feb)ORG. FOSF/CLOR: Cadusafos (August 7.59 y Feb 0.66); Dimetoato (trace, Feb);Clorpirifos (trace, Feb); Betaendosulfan (0.28 Dec y Tiabendazole (trace,August)PHYS/CHEM/BIOL: sulphate, nitrito, nitrate, hardness, very high bacter y& DBO5Sediment: CARB:3 Hidroxicarbofurán (trace,August); ORG.PHOS/CHLOR: Cadusafos(trace, Feb) & ppDDT (trace, Dic)Water: PHYS/CHEM/BIOL: nitritos, nitrate, hardness, high bacter & DBO5Sediment: ORG.PHOSP/CHLOR: ppDDT (trace, Dec)Water: ORG. PHOSP/CHLOR :Betaendosulfan & Endosulfan sulphate (trace, Dec)PHYS/CHEM/BIOL: nitritos, nitrate, hardness, high bacter & DBO5Sediment:ORG.PHOSP/CHLOR: Betaendosulfán (trace,August)Water: CARB:Carbofurán (1.5 August); ORG. FOSF/CLOR : Betaendosulfan (trace, en Dec)PHYS/CHEM/BIOL: sulphate, nitritos, nitrate, hardness, very high bacter & DBO5Sediment: ORG.PHOS/CHLOR: Betaendosulfan (trace, en August)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 & DBO5Sediment: ORG.PHOS/CHLOR: Dimetoato (trace, Feb);Alfaendosulkfán (0.09 in Dec);Betaendosulfán (78.76 in Dec); & Endosulfán sulphate ( trace, Feb)(*) 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 Laboratory73

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAFIGURE Nº 3 SOIL CHEMICAL CONTAMINANTS BY FARM TYPESCONCENTRATIONS - µG KG -1Source:Aguirre (2004)A further serious consequence in the ecosystemis the problem of water demand. To have an idea ofthe magnitude of this, we just have to contrast waterconsumption by small farmers of the zone (only 1.000liters / month / ha in peasant production), or that oftraditional "haciendas" (17.000 to 20.000 liters/ month/ ha in agriculture and livestock production), with theenormous water demand by flower farms (900.000 to1.000.000 liters / month / ha in monthly flower production)[Sánchez & Mac Aleese, 2005].In sum, our study offers evidence of severe impactof the current floriculture system, and requires reflectionupon whether this type of productive system issustainable, or if it should be continued, that it do sowithout gravely compromising future ecosystems.Health Impacts on Workers ("ex-peasants"):Selling Life at a High CostThe logic that organizes entrepreneurial floricultureprovokes serious changes in the life patterns ofcommunities and agricultural workers.A contradictionexists in their modes of living because, on the onehand, it generates employment and monthly incomeslightly above the average rural wages, while on the otherhand, unfortunately, imposes hazardous daily activitiesand exposure to dangerous chemical substances.Our study reveals that, on average, 31% of familiesof the study area 6 have at least one economicallyimportant member working in floriculture. In thosecommunities with weaker ties to this activity, as many6. Communities that made part of our sample were: "La Chimba", "Pesillo", "Agualongo" y "Cananvalle", totaling 388 families.74

Observatorio Latinoamericano de Salud.as 24% family heads work in flower farms and up to52% in those villages with closer links [Handal, 2005].In the Cananvalle Community, as many as 67% familyheads work in cut flower production. [Ferrero & Morel,2005]. Therefore, a significant proportion of villagerslive under conditions directly or indirectly definedby the floricultural system.The flower production process obeys the logicof capital accumulation: maximum profitability and surplusvalue extraction. It depends on highly demanding,chained, routinary and stressful work, with insufficientbrake periods (especially during high flower demandcycles like Saint Valentine’s Day or throughout themonths of November to January), as well as chronicexposure to chemical, physical and ergonomic hazards.Intensive pesticide use is characteristic of non-ecologicalflower production and in communities with a highproportion of flower workers, 60% to 75% of pregnantwomen used pesticides. In communities with fewerties to floricultural work, only 17% of pregnancies wereexposed to pesticides; also in the first group, 40% ofchildren were in contact with contaminated workingclothes, contrary to a lower 18% in those communitieswith weaker floricultural ties [Handal, 2005].Working conditions vary among different farmareas based on the following: the type of labor, schedules,and type of tools and equipment used.Those workingmodes vary among sections and also determineworkers’ quotidian forms of practice. Overall, cut flowerproduction rhythm is intense and permits littlecontrol on the part of the worker during the productiveprocess. Workdays are demanding, extenuatingand stressful, which leave little time for daily and periodicrest. Depending on the work area, tasks, involvefive types of hazardous processes 7 . Problems, such asphysical dynamic overload, are prominent, combinedwith static overload (as in post-harvest); repetitivemovements; thermal fluctuations; exposure to noise;respiratory irritants; dermal irritation and fungal skininfections; and above all exposure to agrochemicals–occasionally acute and generally chronic and low intensity-is due to the improper use of highly dangeroussubstances (red and yellow label products), occasionedby the absence of plague alternative and integral managementsystems, and the ineffectiveness or nonexistenceof protection mechanisms (deficiency in equipment;incorrect implementation of fumigation turnsand modes). These problems are amplified in farmsthat are not subject to FLP program controls 8 .New rurality has brought about special overloadsand problems among women, not only becauseof the "feminization of poverty", but also since peasantwomen have transformed into working women. Relationshipsbased on old patriarchal dependence havebeen substituted, on account of the tearing apart ofcultural communities, by relationships of submission toindustrial work [López, 2004].CEAS has designed an epidemiological interpretativemodel based on a critical processes matrix,which associates general floriculture production relationswith flower workers’ typical living styles, as wellas specific impacts it has on people’s organism andmental health [Breilh, 2004]. For the detection of mainimpacts, different test modules were designed 9 that7.Their classification and explanation is developed in Breilh (2003) CDROM "SaludFlor": PDI: procesos físicos derivados de la condición de los medios; PDIIa: procesosemanados 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 protectionrights, 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 – lymphocytecomet test-; erythrocyte acetylcholinesterase; control variables and nutritional condition.75

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcovered 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 hightoxicity impact rates (see figure Nº 4) in a representativesample of workers of both an FLP farm and a non-FLP farm 10 . From a preliminary analysis of databasesbeing processed, the following concerns have been established.In the first place, a very high percentage ofworkers on both farms are exposed to hazardous elementsand processes. This is the case particularly on60% of the farms, which are those that do not pertainto the FLP program.In the second place, quality and coverage of workers’protection equipment is limited, mostly in thefarm that does not comply with international standards.In the third place, all types of health exams, highpercentages of impacts on health were registered.Control and analytical variable analysis needs to beperformed prior to answering the following question:How many of these problems are attributable to floriculture?However, in this preliminary phase of analysisseveral worrying facts begin to be revealed: workersare affected in significant aspects of their health (arterialpressure, 52%; toxic anemia, 14%, low leukocytes,12%; hepatic transaminase increase –inflammation-,26%; genetic instability, 25%; neurotransmitter systemenzyme reduction –acetylcholinesterase-, 23% 11 ; and69% showed clinical signs of toxicity, moderate andsevere (refer to Figure N04). Furthermore, 56% werein a state of moderate and severe stress, and 43% ofmalnutrition (overweight); all which indicates that theworkforce has bad health conditions. When analysisadvances and we have community comparative data,we shall understand more thoroughly how much ofthis wide-ranging problematic is occasioned by floriculture;nevertheless, if we recall the higher proportionof contamination which exists in the floriculturezones and in the work settings of flower farms, wemay estimate that an important part of these healthproblems could be due to irresponsible floriculturalproduction.Current mental suffering among workers studiedreaches 38.8%, distributed between moderatesuffering (24.4%) and severe suffering (14.4%). The indexhappens to be high if one considers that in an averagepopulation, it should not be over 20%.The mentalvulnerability of this working population becomesevident when we analyze the results of the study on"local infant development self-valuation" applied tostudents of the Technical School of Cayambe, whichreveals that the majority of young people investigated(70.21%) is classified as having limited infant developmentconditions [Campaña, 2005].Neurological development of children who livein communities of the floricultural region is also affected.The mentioned neuro-motor development, alreadyinfluenced by the living modes of peasant children(low income, malnutrition, maternal and paternalneeds regarding their formal educational level, perspectiveson nurturing, infant development and stimulation)is also stricken by exposure to pesticides[Handal, 2005].A Struggle for Fair and Ecological FloricultureThe EcoHealth program and the study of theGranobles River Basin has explored, since initial design10.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 ourvalidation tests.76

Observatorio Latinoamericano de Salud.FIGURE No 4 DETECTED HEALTH PROBLEMS WORKERS TWO FARMS, 2003 n=160(ECOHEALTH PROJECT CEAS/CIID)workshops, the possibilities of an intercultural, transdisciplinaryand participative construction of knowledge,rooted in an analysis of the power structure thatconditions management, work with flowers, and communitylife. The central idea has been to perform research,with multiple subjects of knowledge and totriangulate the knowledge and instruments of academicand communitarian groups.Once this first research phase is concluded, thenext phase of intervention and incidence will be undertaken.Thus far, the project has constructed valuabletools from the perspective of communities’ interest: amost relevant geo-codified database, with characterizationand knowledge on impacts of flower productionupon workers, communities, hydric systems and soils; asolid methodology for the sampling and discriminationof distinct contaminating productive sources; the validationof test modules to study the impact on humanhealth and to demonstrate that conventional acetylcholinesteraseexams are insufficient and tend to veil abroader chronic low intensity pathology, and to evaluatethe effects on school and pre-school health; advancementsin the implementation of community bioessaylaboratories; CDROM software for workers’ health clinicalmanagement and monitoring in farms; a rigoroussystem of verification (checking list) for the FLP program;the commencement of a campaign within theUnited States to foster support of flower consumersto put pressure for fair and ecological flowers.All this effort, must be projected along the phaseof incidence in the next years, to fortify the organization,awareness and advocacy of communities; the77

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAmunicipal and national juridical transformation on floriculturesustainable management norms; the organizationof a communitarian, municipal and general floriculturemonitoring system; the construction of alternativeproposals for a non-monopolistic floriculture,centered in the wellbeing of communities and workersand the sustainability of their ecosystem; the updatingof study programs on cut flowers ecosystem health, atvarious educational levels and scenarios; and thestrengthening of an international campaign of "fair andecological flower".Together with the people of Cayambe and Tabacundowe are recreating in our work the idea thatbeauty of Ecuadorian flowers must not be constructedon the basis of reproducing poverty and threatening lifein our ecosystems. Research alone does not bringabout ecosystem health, but must be accompanied bywell-informed collective struggle.78

Observatorio Latinoamericano de Salud.REFERENCES● AGUIRRE, PATRICIA (2004) Effects of Pesticides on Soil Quality:The Case of Ecuadorian Floricultura. Aeche: Universitat Göttingen(D7).● ALVARADO, SILVIA (2002). El caso del comercio exterior de laflor ecuatoriana como una alternativa para la comercialización deotros● ALVEAR, LUCIANA (2000). "La Dolarización y el Sector AgropecuarioEcuatoriano", resultados del grupo taller Impactos de laDolarización en el Sector Agropecuario organizado por el ProyectoSICA-MAG / Banco Mundial (Quevedo).● BREILH, JAIME (2003). Conceptos Nuevos y Disensos Sobre laEpidemiología de la Toxicidad Por Agroquímicos en la IndustriaFloricultora en "SalufFlor: Sistema Clínico y Monitoreo de la Saluden Empresas Floricultoras – Programa en CDROM". Quito:Publicación del CEAS (formato multimedia)● BREILH, JAIME (2004). Epidemiología Crítica (Ciencia Interculturaly Emancipadora). Buenos Aires: Lugar Editorial (2da reimpresión).● CAMPAÑA, ARTURO (2005). Sufrimiento Mental y Trabajo enFloricultura en Ecuador. Quito: Programa EcoSalud CEAS/CIID.● CORDERO, FRANCISCO (2003). Caracterizaciuón de los PlaguicidasUtilizados en la Cuenca del Granobles. Quito: Tesis de Licenciaturaen Ingeniería Agronómica de la Universidad Central enasocio con el Centro de Estudios y Asesoría en Salud (ProgramaEcoSalud CEAS/CIID).● EXPOFLORES (2004). Estadísticas● FELICITA, ORLANDO (2005) Montaje y Puesta en Marcha de unLaboratorio Comunitario de Bioensayos Para Evaluar la Toxicidaddel Agua en la Cuenca del Rio Granobles (Canton Cayambe Y Tabacundo).Quito: Programa EcoSalud CEAS/CIID.● FERRERO, JORGELINA & MOREL, STELLA (2005) Informe de Pasantía(Universidad de Córdova) en Programa EcoSalud CEAS● GASSELIN, PIERRE (1999). La floriculture et les dynamiques agrairesde la region agropolitaine de Quito (Equateur).Tesis doctoral.Instituto Nacional Agronómico, Paris.● GIARACCA, NORMA (2001) Prólogo en "¿Una Nueva Ruralidad?".Buenos Aires: CLACSO.● HANDAL, ALEXIS (2005) Plaguicidas y la Salud de Mujeres y susHijos: Región Floricultora del Ecuador. Ann Arbor: Estudio delPrograma Doctoral en Epidemiología, Universidad de Michiganasociado con el Centro de Estudios y Asesoría en Salud ((ProgramaEcoSalud CEAS/CIID).● LARREA, MA LOURDES & MALDONADO, PAOLA (2005). CircuitoEspacial de Producción de la Floricultura de Exportación,Caso Ecuatoriano. Quito: Programa EcoSalud CEAS/CIID.● LÓPEZ, JANSI (2004) Gender and Floriculture: A Study of Ecuador’sCayambe-Tabacundo Region. San Diego: Masters of ArtsDegree,Thesis in Latin American Studies, University of Califórnia,associated with the Center for Health Research and Advisory(CEAS) EcoHealth Program (CEAS/IDRC).● SÁNCHEZ, DORIS & MAC ALEESE (2005) La Dinámica de Plaguicidasy los Sistemas Hídricos en la Cuenca del Granobles. Quito:Programa EcoSalud CEAS/CIID.● SANTOS, MILTON; SILVEIRA, M. LAURA (2001). O Brasil: territorioe sociedade no inicio do século XXI. Rio de Janeiro, Record.79

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA8Aspectsof Hazardous Infant Work inLatin AmericaWalter VarillasThe Network of Hazardous Infant WorkOne of the most extreme expressions of human globalization is the situationof children who work. This inhumane affect of Globalization, in conjunctionwith the egotistic policies of dominant classes in our countries, isone of the the main sources of poverty. And poverty, in combination withcultural factors and limited public policies in defense of childhood, is identifiedas the major cause of infant work. However, as we will see, virtually halfof these minors work in conditions, which can seriously affect their normaldevelopment, their health, their security, and their life itself, creating a terriblevicious circle of poverty. This paper will thus briefly address this theme.The Magnitude of Hazardous Infant WorkAccording to the Global Report "A future without infant work", publishedby the International Labor Organization (ILO) in May of 2000, by 2000approximately 351.7 million children between 5 and 17 years of age wereperforming any type of economical activity. Of that group, 170.5 millions(48,5%) were engaged in some kind of work considered hazardous 1 .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 ormorality of children.80

Observatorio Latinoamericano de Salud.TABLE 1. CHILDREN FROM 5 TO 17 YEARS OF AGE WHO PERFORM HAZARDOUS ECONO-MICAL ACTIVITIES AND WORK THROUGHOUT THE WORLD. BY AGE GROUPS.FROM 5 TO 14 YEARSFROM 15 TO 17 YEARSTOTALChildren economically active210.800.000 (100.0 %)140.900.000 (100.0 %)351.700.000 (100.0%)Children who perform hazardous work111.300.000 (52.8%)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 UNDERDEVELOPEDCOUNTRIES. BY ECONOMICAL ACTIVITY.ECONOMICAL ACTIVITIESMALE %FEMALE %TOTAL %Agriculture, hunting, silviculture, fishing68.875.370.4Manufacture9.47.98.3Commerce10.45.18.3Communitarian, social and personal services4.78.96.5Transportation, storing, communications3.8-3.8Construction2.01.91.9Mining and quarries1.00.90.8Total100.0100.0100.0Elaboration based on: ILO (2002). Page 25.The statistics of this report illustrate the magnitudeof the problem of hazardous infant work, whichrepresents 11% of the total infantile population betweenthe 5 and 17 years of age worldwide.Thus, twoout of every 10 children world-wide perform economicalactivities and one of them does so in hazardouswork.In the case of underdeveloped countries, as theyare called, infant work is primarily in rural agriculturalactivities, and secondly in the manufacture, commerce,and service sectors, particularly within the informaleconomy. Male children’s work is greater than femalechildren’s, as age increases.Paying Attention to Hazardous Infant WorkHazardous infant work is not solely a problemdue to its magnitude, but additionally because of its seriousnessand grave side effects. The mentioned GlobalReport refers to the necessity of long-term interventionsfor the reduction of poverty and the promotionof sustained economical growth. It also calls forinterventions in places where the problem originatesand where poverty creates the worst forms of infantwork.In spite of the advancements accomplished, it isstill difficult to define hazardous infant work as a spe-81

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcific work category among the group of the worstforms of infant work. With this in mind, the report ofthe ILO indicates the following:"Thus, it is not always simple to plot the limits ofhazardous work, especially when the damage beingcaused to children is not perceptible in the shortterm. Hazardous work has already been identified inthe Agreement N. 138 as work that requires a minimumage of 18 for admission…Its acknowledgementas one of the worst forms of infant work puts forwarda new urgency of action directed to its elimination"[OIT, 2002].This document mentions that work can damagethe child as a consequence of the task in itself he/shehas to perform, the instruments used, the schedules,or conditions of work. And further, other factors canalso potentially also affect the physical, mental, emotional,psychological, moral, or spiritual development ofthe minors.Minors are exposed to health and security hazardsgraver than adults. Due to their process ofgrowth and development they are more susceptible tolabor hazards and can be affected irreversibly [Forastieri,1997]. "Chronic physical tensions on bones andarticulations in process of growth can impede theirdevelopment, cause medullar injuries and other definitivedeformations" [OIT, 2002]. These hazards are accentuatedby poor states of nutrition, continuous exhaustion,decreased maturity compared to adults, andmachines and tools not adapted to the characteristicsof minors.Additionally, many hazards are unobservableto plain eyes because of their delayed effects. Such isthe case with the noxious effects of pesticides or heatstroke in agriculture.The International Labor Organization recognizesthe necessity to learn more about the short and longtermeffects of the distinct types of work of male andfemale children of diverse ages and health conditions."It is necessary to acquire that knowledge to be ableto decide what types of work are to be prohibited forchildren of less than 18 years of age and to plan theadequate rehabilitation of children who have been removedfrom hazardous works".Despite not having complete data on the injuriesand illnesses brought about by infant work, we do havethe following statistics [OIT, 2002]:●Within the United States the rate of injuries perhour of work in the case of children and adolescentsalmost doubles that of adults. In the period of1992-1998, the rate of mortality of young workersreached its maximum in agriculture, silviculture andfishing, followed by retail commerce and construction.● In a survey applied in Denmark, Finland, Norway andSweden in 1997-1998, rates of injuries between 3%and 9% in children who work before or after schoolwere observed. In Denmark, greater rates of accidentsof children were detected in agriculture thanin other sectors.● In a study of the ILO completed in 1997 in a numberof underdeveloped countries, the subsequentmean rates of illnesses and injuries among childrenwere noticed: 25,6% in construction, 18,1% in transportation,storing, communications, 15,9% in miningand excavations. All these rates were greater in femalechildren than in males with the exception oftransportation.Some explanations concerning the higherlevel of hazard in minors for occupationalaccidents and illnessesForastieri [Forastieri, 1997] and Hiba [Hiba,2002] have systematized the particular conditions of achild’s susceptibility to hazards, as compared to adults:82

Observatorio Latinoamericano de Salud.● Immaturity of organs and tissues● Higher metabolic and oxygen consumption● Greater need for energy● Lower physical resistance● Lower physical resistance to changes in temperature● Inferior manual skill to operate tools● Higher capacity of absorption● Higher psychological vulnerabilityForastieri and Hiba mention that this may be aggravatedby the long-term effects of malnutrition andwork and contagious illnesses acquired by children inhazardous working activities, and that this will in turnlead to the following consequences: chronic fatigue,physical exhaustion and mental stress, reduction of thephysical capacity to work in adulthood, delayedgrowth, damaged auditory capacity, neurological deterioration,and damages and disabilities.These authors further include some conditionswhich worsen the situation of infant work, such as:● The deficient information on the hazards at work● The labor inexperience and the underprovided laborinformation● Minors are not acquainted with hazards, or knowless than adults, which is an important reason whythey are more exposed● In general, they are neither trained for the task theyare to develop, nor to take measures of protection,being directly and overtly exposed● Equipment of personal protection for minors doesnot exist●Discrepancies among the indicated tasks and thecompleted tasks● Tasks, tools, equipment and machines are designedand made for adults● Exposure to dangerous physical and biological agents● Exposure to toxic chemical products● Inadequate psychic and social environment● Poor hygienic conditions● Limited access to medical services● Premature physical wear and incapacity, corporal injuriesand fatal accidents● Children are sensitive to hazardous attitudes, atavismsand behaviors of adults● Minors wish to "stand out" and thus demonstratethat they are equal to or capable as adults; they arenot conscious of the major risks this attitude involvesPiedrahita [Piedrahita, 2002] explains that themajority of information on the health effects of workingchildren applies to occupational accidents; nevertheless,professional illnesses can be a consequence ofexposure to different physical and chemical agents aswell.A pediatrics maxim indicates that "children arenot small adults". Consistent with the National ResearchCouncil, U.S.A. 1993, the biological systems ofchildren and young people are not mature until theyare 18 years old.Various differences in anatomy, physiologyand psychology distinguish children from adults,and expose them to special hazards at work. Hence,the greatest hazard to which working minors are exposedmay be explained by the special characteristics83

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAof their psychological-biological development. Thus,the following list of risk factors becomes evident:● Height: Young people vary greatly in height. A lackof adequate adjustment of machines could lead toaccidents among young workers. Costumer ProductsSafety Commission carried out in 1993 researchon the use of lawnmower machines and discoveredthat the rate of accidents was greater amidyoung people from 5 to 14 years old than amongolder ones. Similarly, accidents were more frequentwhen children were less than 60 inches high andtheir weight was inferior to 125 pounds.● Growth: It is believed that the diminution of coordinationin young people during periods of rapidgrowth could increase the risk of accident at work.●Sleep requirements: Adolescents require ninehours of sleep at night, however it has been foundthat students, which additionally work part-time,sleep an average of seven hours or less. The accumulativedeprivation of sleep and the fatigue in childrenand young people can increase the risk of accidentat work.● Psychological risk factors: Children experiencedeep psychological changes while they mature. Evenso, their bodies continue to develop physically in anaccelerated manner. This can bring about situationsin which psychological immaturity is obscured byapparent physical maturity, and therefore they areassigned to tasks for which male and female childrenare not prepared emotionally. In addition, youngworkers do not have adequate experiences to judgetheir ability for a certain job, leading to an evengreater risk of accident at work in several occasions.General Characteristics of the Problemof Infant Work in Latin AmericaAccording to the IPEC-ILO 2 and regardless ofthe scarcity of reliable studies, it could be concludedthat 7,6 million children between 10 and 14 years oldwork in Latin America. Conversely, if domestic chores,children younger than 10, and the proper statistic underestimationswere included, the total number ofworking children would be between 18 and 20 million.This implies that one out of every five children areeconomically active in Latin America.Some other significant aspects of child work inLatin America are the greater participation of malechildren (60%) than of female children (40%) and thepredominance in rural areas (55%) compared to urbanones. The majority (90%) work within the informalsector, contrasting the 10% that work in the structuredsector of economy.The proportion of salaried child workers representsbetween 60% and 70% in the urban areas androughly 50% of the totality of working children.The workdays, in nearly all of the cases, are greaterthan the maximum limits established by legislation.The mean is 45 hours per week and even those whogo to school dedicate 35 hours per week to diverse laboroccupations. The income is also very low; they receivesmaller wages than adults for similar work.General Characteristics of Hazardous InfantWork in South AmericaChildren who work are exposed to injuries andillnesses in such a high proportion that it is of majorconcern. Thus, on establishing the hazards of infant2. 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 onthe information provided by this site.84

Observatorio Latinoamericano de Salud.work, it is indispensable to broaden the concept of "laborhazard", as it is applied to adults, so it embraces infantiledevelopment as well. If working children are generallyvulnerable to hazards related to work, verysmall children –male and female- are even more so.Moreover, workdays, in the majority of the cases, arefar greater than the laws of national legislation mandate.It has been verified in different countries thatthere is a high level of infant occupation in brick factories,mines, stone quarries, markets, rocketries, domesticservice, and the agriculture sector among others.The hazards and physical damages for these minorsare obvious: toxic inhalations, burns, partial loss ofsight, mutilations, bronchopulmonary illnesses, allergicreactions, dermatologic problems, and infectious contagiousdiseases.The Response of Countries and the ILOThe International Labor Organization, as a tripartiteorganization, offers countries two tools toconfront the problem.The Agreement 138 establishesa minimum age of admission to employment, and theAgreement 182 deals with the prohibition of theworst forms of infant work and the immediate actionfor their elimination.This latter agreement states that, "The termchild designates every person younger than 18 yearsSECTORS OF HIGH LEVEL OF HAZARD IDENTIFIED BY THE IPEC. BY COUNTRY.ArgentinaBoliviaBrasilChileColombiaCosta RicaEcuadorEl SalvadorGuatemalaHondurasMéxicoNicaraguaPanamáParaguayPerúR.DominicanaBrick 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 processingFloriculture, Street work, ConstructionCuriles,Assembly plants, Pyrotechnics, Construction, Coffee plantations, Prostitution, Street work, RubbishLime sector, Coffee plantations, Mining; Pyrotechnics, Domestic service, Assembly plants, Construction,Transportation; RubbishLeather industry, Bakery, Assembly plants, Woods; Metallurgy, Construction, Army, Pharmaceutical industry,Chemical industry, Industry in generalCafés and Bars; Mechanical workshops, Brick factories,AgricultureCoffee plantations, Banana, Rice,Tobacco, Cotton, Cattle raising, Street workStreet work, Domestic service, Sugar making, LoadStreet work, Domestic servicesGold placers, Brick factories, Stonecutters, Slaughterhouses, Construction, Metallurgy, Processing of coke leaf,Pyrotechnics, Rubbish, Mining.Agriculture, Domestic service, Rubbish, Prostitution.85

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAEXAMPLES OF SOME EFFECTS OF THE EXTREME FORMS OF INFANT WORKIN MINORS’ SECURITY AND HEALTHSECTORHAZARDS TO HEALTH AND SECURITYWork in brick factoriesWork in minesWork in quarriesRocketryAgricultural workWork in marketsAccidents and lung illnessesRespiratory illnesses, musculoskeletal diseases, working accidentsLung illnesses, accidentsIntoxications, accidentsAcute and chronic intoxications, accidentsMusculoskeletal injuries, accidentsold" (article 2). It indicates in article 3 that, "the expressionthe worst forms of infant work covers:a) tall forms of slavery or analogous forms of practice, suchas children selling and dealing, servitude for debts andthe condition of servant, and forced and obligatory work,including the forced and obligatory recruitment of childrento 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 illegalactivities, in particular the production and dealing ofnarcotics, as defined by the pertinent international treaties;andd) work that, due to its nature or the conditions in which itis performed, is likely to damage health, security or moralityof children."Hazardous Infant WorkIt is precisely the group designated in the lastclause that we have named hazardous infant work.This clarification is important, differentiating it fromthe field of infant work in general, and from the set ofworst forms of infant work. The other three forms(clauses a, b, c) are named within the mentioned globalreport of the ILO as "worst forms of infant work, unquestionably".The general definition developed in the Agreement182 is broadened in the Recommendation 190(1999). This recommendation establishes activities thatowing to their nature or conditions in which they areperformed 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, indangerous heights, or in closed spaces;86

Observatorio Latinoamericano de Salud.c) the forms of work with dangerous machinery, equipmentand tools, or which incorporate the manipulation or manualtransportation of heavy loads;d) the forms of work performed in an insalubrious environmentwherein children are exposed, for instance, to dangeroussubstances, agents or processes, or to temperaturesor noise and vibration levels hazardous to health, ande) the forms of work that entail especially difficult conditions,such as prolonged or nocturnal shifts, or forms ofwork that retain children unjustifiably in the premises ofthe employer.""1.The types of work to which article 3 refers, d) must bedetermined by the national legislation or by a legallyqualified authority, with the prior consultation with theinterested organizations of employers and workers, andtaking into account the international norms on the subject,principally paragraphs 3 and 4 of the Recommendationon the worst forms of infant work, 1999.2. The legally qualified authority, with prior consultationwith the interested organizations of employers and workers,must localize where the determined types of workare practiced in accordance with paragraph 1 of this article.3.The periodic examination and, if necessary, the revisionof the list of determined types of work in accordancewith paragraph 1 of this article is required. This processis to be consulted with the interested organizations ofemployers and workers."What are Countries which Ratify Agreement182 Committed to With Respect to HazardousInfant Work?Article 4 of the Agreement reveals the commitmentassumed by countries with respect to hazardousinfant work:ConclusionMany of us, either due to economical necessity,cultural motives, or family tradition, have had to workas minors. Unfortunately, not every one of us has hadthe good fortune of working as minor without affectingour physical, mental and moral integrity. It is theduty of all of us to help create a situation where thechildren of the world do not have to work, but insteadcan study and play.We should all contribute to the surmountingof this situation of extreme injustice of minorswho work despite the hazards to their health,their security and their life.87

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAEl niño yunteroMiguel Hernández(Spanish poet and child pastor)Carne de yugo ha nacidomás humillado que bellocon el cuello perseguidopor el yugo para el cuello.Empieza a vivir y empiezaa morir de punta a puntalevantando la cortezade su madre con la yunta.Contar sus años no sabey ya sabe que el sudores una corona gravede sal para el labrador.Me duele este niño hambrientocomo una grandiosa espinay su vivir cenicientorevuelve mi alma de encina.Contar sus años no sabey ya sabe que el sudores una corona gravede sal para el labrador.Quién salvará a este chiquillomenor que un grano de avena,de dónde saldrá el martilloverdugo de esta cadena.Que salga del corazónde los hombres jornalerosque antes de ser hombres sony han sido niños yunteros.88

Observatorio Latinoamericano de Salud.REFERENCES● ALARCÓN W (2001).Trabajar y estudiar en los Andes.Aproximaciónal trabajo infantil en las comunidades rurales de Cuzco y Cajamarca.UNICEF. Lima.● ALCOCER M, FORASTIERI V (2003). Informe de actividades de laRed TIP en Centroamérica. OIT. San José.● FORASTIERI V (1997). Children at work: Health and safety risks.OIT. Ginebra.● HIBA (2002). La seguridad y salud en el trabajo infantil peligroso.Ponencia presentada en la Reunión Preparatoria de la Red TIP.OIT. Lima.●INSTITUTO NACIONAL DEL NIÑO Y LA FAMILIA-INFA(2001). Entre el barro y el juego. Proyecto de Erradicación delTrabajo Infantil en las ladrilleras del sur de Quito. Programa deprotección y educación a niños y niñas que trabajan. IPEC-OITQuito.● IPEC-OIT (2001). Niños que trabajan en la minería artesanal deoro en el Perú. Estudio Nacional sobre el trabajo infantil en la mineríaartesanal. Lima, OIT.● IPEC-OIT (2002). Criterios para la definición del Trabajo InfantilPeligroso. Documento de Trabajo. Informe del Taller Técnico deQuito, 7-9 de agosto (documento en preparación para su edición)● OIT (1973). Convenio 138. Convenio sobre la edad mínima de admisiónal empleo.● OIT (1999). Convenios 182. Convenio sobre la prohibición de laspeores formas de trabajo infantil y la acción inmediata para su eliminación.● OIT (1999). Recomendación 190. Recomendación sobre la prohibiciónde las peores formas de trabajo infantil y la acción inmediatapara su eliminación.● OIT (2002). Informe Global "Un futuro sin trabajo infantil". Informedel Director General de la OIT. Conferencia Internacional delTrabajo 90ª. Reunión 2002.● PIEDRAHITA H (2002). Algunas explicaciones sobre el mayorriesgo de los menores a accidentes y enfermedades ocupacionales.Monografía.89

Life and Healthas Commodities

Observatorio Latinoamericano de Salud.9LatinAmerica:Neoliberalism and SurvivalLaura JuárezIn the 80’s and 90’s Latin America entered the restructuring logic of theglobal market.The 80s and 90s were mired with a decline in social developmentand an alarming rate of poverty. As countries of the region are further subjectedto neoliberal restructuring and market fundamentalism the first years of thenew century continues to show a deepening of these trends.Generalized increase of poverty in the Latin-American population is expressedby various indicators of social deterioration: a rising unemployment;profound deterioration of workers’ wages; forced migration from the rural tourban areas; the intensification of the informal economy; the return of diseasesthat had previously been eradicated, like cholera; curable maladies mortality suchas itch or gastrointestinal problems (typhoid fever and gastroenteritis), respiratorytract diseases (tonsillitis, pneumonias and bronco pneumonias) among others.Theseillnesses a direct product increased poverty, linked to deteriorationof basic health, education, and housing standards, massive malnutrition and thereproduction of socio-economic barriers to public services.A majority of ruraland urban families are crammed in densely populated neighborhoods, sufferinglack of water and sewers, and forced to share community baths and to live undercardboard 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: howdid Latin America reach this critical situation? The answer lays in its economical,91

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAsocial and political history. In order pinpoint the causesthat have led to the long term crisis that the regioncurrently faces.We will analyze the recent the capitalistaccumulation system and the economic historyof Latin America.From the imports substitution model tothe secondary exportation modelThe imports substitution model arose in the periodbetween World Wars I and II. It placed industrialdevelopment as the axis of capital accumulation, butsoon certain structural limits of the economical modelbecame evident in the 60’s: an increasing paymentsdeficit, resulting from weak industrial nationalintegration; the elevated external debt; the increaseof inflation; and the low productivity of the productioninfrastructure. Even so, structural economic problemswere masked for almost two decades, by an aggressivecredit system and from rising prices of rawmaterial produced by the countries. Nonetheless,two external events have ignited the abrupt reappearanceof the socio-economical crisis of the 80’s, notallowing economies to sustain their growth. High interestrates have led to the reduction of internal credit,and secondly, the increase of the external debt ofthe zone and the collapse of the cost of raw materialfor export, such as coffee, sugar and petroleum. Economiescame to a standstill: external credit was suspended,and capital received by means of raw materialand primary products exportation decreasedconsiderably.This undermined the capacity for importingthe intermediate and capital goods that the economicapparatus demanded.The financial effects didn’ttake long to become evident including the flight offinancial resources, devaluation, interest rates increase,decreased credit, and deficit in the balance of capital.The insertion of Latin America intothe global marketIn view of the manifest crisis of the imports substitutionmodel, Latin-American governments gave wayto a new pattern of capital accumulation, based on theimpulse of the secondary exports sector, which correspondedto the new trends of international capital.Actually, this implied a direct tie of the region to globaleconomy and to the new profit strategies of nationalenterprises and large transnational corporations.This is how neoliberal economical policies wereimposed in Latin America.These policies were maintainedor ratified even in countries where there hadbeen political transitions from military to civil governments,as in Brazil, Argentina, Chile and Uruguay. Notto mention authoritarian governments, like in the Mexico,which had already signed the first letter of intentwith the International Monetary Fund in 1977. In it, theMexican state made the commitment to adopt austereeconomical policies.These policies were postponeduntil 1982, due to the momentary economic relieffrom the "oil boom".The neoliberal economic policies and the globalcapital market strategies have aimed at making theeconomical structures of countries suitable to the necessitiesof large capital investment. It is since the crisisof Latin-American external debt, during the early80’s, that generalized measures have been imposed onthe countries of the region: opening of internal marketsto external competition; the privatization of publiccompanies; the liberalization of investment policies,not only the direct foreign investment (IED), butalso the portfolio or speculative investments; the liberalizationof financial systems; the diminished State’srole in the economy; and the imposition of labor flexibilizationon companies.In sight of the financial crisis of the 80’s, the Latin-Americangovernments applied shock plans to sta-92

Observatorio Latinoamericano de Salud.bilize the economy. In response pressures from internationalcreditors, the private debt was nationalized.This in effect passed the bill to the working class. Later,they prepared themselves to deepen the reorientationof economical growth centered in the secondarysector of exportation and the national and foreignfinancial capital.This reorientation has benefitedpowerful entrepreneurial groups, while excluding thegreat majority of the working class.Latin-American economy meets structural problemsas a consequence of this new form of integrationto the international market. On one hand, theconcentration of economical growth a few financial,commercial and industrial groups belonging to transnationalcorporations, therefore dependent on the externalmarket; on the other hand, those sectors thatdepend on the internal market, with limited employmentand low wages, face unfair competition and staggerbehind in all economic rates. The dependence onexternal factors and the weakening of the internalmarket is due to the external growth model, whichdoes not confer the workers any real importance asconsumers. The purchasing power and potential employmentand subsequent demand as consumers, doesnot have any significance to the new model and its investmentstrategies. This means that the people arenot considered determinant factors of economicalgrowth. In times of global restructuring, labor force isconsidered solely as a production cost, thus somethingto be diminished in order to promote competitivenessin companies and the economy. On account of this,low wage policies and restrictive labor rights havebeen imposed through policies of labor flexibilization.Internal companies investment and consumerdemand tend to be substituted by increasing imports,in detriment of internal production. National industriesin the region, which activate the internal marketand provide the worker population sustenance is neglected.Thenew globalization tendencies do not considerthis an essential aspect. According to neoliberalideology, if national productivity of goods and servicesis lower than the international market standards, thenit has to be substituted by imported goods. Accordingto this concept, only the most competitive and productivecompanies should be backed and financed. Inothers words, the principle of "comparative advantages"is drastically applied.The role conferred to Latin-American economies is that of productive enclaves linkedto international enterprises. This is a mechanismof combining high technology with cheap and greatlydiscredited labor.Then again, the deliberate policy of attracting externalfinancing, starting from the liberalization of thefinancial systems of Latin-American countries and themanagement of internal interest rates that have supersededthe international financial costs, has signaled therestriction of internal financing due to the rise of interestrates. In addition, the overvaluation of Latin Americancurrency is geared at making imported goodscheaper.Impact on rural and urban workers,and on their survivalNeoliberal policies have failed in every facet.They haven’t been able to achieve a sustained economicalgrowth 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 systemsof the region have experienced, such as Venezuela’s; in1994, Argentina’s, Mexico’s and Paraguay’s in 1995;Ecuador’s in 1999; more recently,Argentina’s, in 2001-2002.In relation to the evolution of wage trends, theInternational Labor Organization (ILO) states that themajority of Latin-American countries have followedwage cutback policies, and explains that the purchasing93

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINApower of minimum wages in the subcontinent are nowunder the levels of the 70’s and 80’s. If we compare minimumwages in the region, taking 1980 as a referenceyear, we find that among eighteen countries, Mexicohas experienced the worst minimum wage reduction -68.6% reductions. For this reason, Mexican manpowerhas become one of the cheapest in the region. El Salvadorfollows with -68.1%; then Peru with -67.5%;Haiti with -66.3%; and, Ecuador with -58.9%.The countriesthat follow are: Uruguay -58.4%; Venezuela -53.9%; Bolivia 51.6%; Argentina 20.6%; Honduras19.1%; Brazil 12.3%; and Guatemala -7.5 %.Only a few nations have experienced a contrarytrend of wage recovery: Costa Rica, with 43%; Panama30.3%; Chile 26.9%; Colombia 12.8%; Paraguay 3.9%;and Dominican Republic 2.5%.The containment of minimum wages constitutesa referential point for the labor market, and for the reductionof the rest of the workers’ salaries is forced;deterioration of the mini-wages reflects the loss of absoluteincome of the rest.The real industrial wages, for instance, experiencea tendency similar to the behavior of the minimumwages of the region, since they diminished for nearly allcountries. Mexico is once again one of the most affected,obtaining the third place with a loss of -31.9% in2001 (taking 1980 reference). The country with thehighest reduction of industrial wages was Peru with -56.6% followed by Venezuela -56.6%.The countries thatfollow are:Argentina-22.3% and Ecuador -0.2%.The nationswhere 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 InternationalLabor Organization (ILO) points out that,in the Latin-American region, the impoverishment oflabor is accentuated. This is demonstrated in the factthat just six out of ten new employees have access tosocial security, and only two out of ten workers of theinformal sector obtain social protection.The organizationrecounts that the deceleration of economies andthe strong recession provoked by the model (particularlyin Argentina, Venezuela, Uruguay and Paraguay)was clearly expressed in the decline of social and laborindicators. In other words, the recuperation of thecompanies in this region has been based more in theintensive use of the working factor, the reduction of laborrights, low wages, than in the increase of socialproductivity of work. This occurs mainly in times ofeconomical crisis.The International Labor Organization (ILO) acknowledgedin 2002, that the deficit of decent work, relativeto an insufficient supply of working posts, inadequatesocial protection, and systematic violation of socialrights of workers, affected 93 million urban employees.Thisfigure increased by 30 since 1990.[OIT, 2002]As we have said before, economic neoliberalismin Latin America confers the work force factor, theresponsibility of bringing down the costs of productionand increasing productivity, by imposing low wagesand restricting labor rights. By this means, it offsetsthe general inefficiency of the economy.Regarding the employment levels in Latin America,the minimal product growth reproduces high levelsof unemployment in the region.According to the Economic Commission for LatinAmerica (CEPAL), the Latin-American Gross NationalProduct (GNP) hardly accumulated a growthmean rate of 3.2% during the 90’s.This was below therates registered in 1950 and 1980, of 5.5%.Likewise, the International Labor Organization(ILO) indicated that in 2001 and 2002, the decelerationof economies was accentuated, due to the slowgrowth of the world economy (particularly of theUSA); the diminished capital flow into the region(where the input of Direct Foreign Investment is affectedthe most).The was also accentuated by the political,economical and financial instability with Argentina94

Observatorio Latinoamericano de Salud.as the most noteworthy case, as four presidentialchanges were provoked in a month by the social outburstsproduced by that instability. The organizationreveals that this instability and the adjustment generateda situation of recession and inflation with severalconsequences: a strong collapse of the Gross NationalProduct (10.6 for 2001); a considerable increase onthe open unemployment rate 17.4%, (as a proportionof the economically active population, reaching its highestlevel history; an increase in the inflation rate; anunusual upsurge of interest rates; and a depreciation ofthe national currency ("peso").The International LaborOrganization (ILO) indicates that the strong contractionof the country affected the economies of its maincommercial partners of the Mercosur, particularly Braziland Uruguay.Moreover, the Economic Commission for LatinAmerica (CEPAL) admits that the mean growth rate ofthe Gross National Product in 2001, of 1.7% [CEPAL,2002-2003] for Latin America, proved to be unsatisfactoryin terms of generating employment and wages 1 .The International Labor Organization (ILO) explainedthat the moderate increase of the estimated productin the subcontinent, 5% in 2004 and 3.5% in 2005, wasalso unsatisfactory in front of a larger labor supply. Forthe same reason, this institution projects an unemploymentrate of 10.1% for the region in 2005, and ascertainsthat 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 thelowest open unemployment rate, it is important topoint out that ILO declared, in the International LaborConference (2002), there are 25.5 million Mexicans,employed in the informal economy. Among them, thenumber of men is 17 million (67%), and the number ofwomen is 8.5 million (33%). [OIT, 2002] Seemingly, officialMexican statistics, register these people as employedIn addition, Mexico is one of the foremost manpowerexporters.Finally, it is substantial to consider that ILO reportsthat, between 1990 and 2003, in the urban areasof the region, six out of each new ten employed peopleworked in the informal economy. [OIT, 2002]In relation to agricultural workers of the region,neoliberal policies drive them to a severe crisis. Thecause is the subordinated integration to the globalagro-nutritional market. Our countries have becomesimple importers of food (especially from the UnitedStates, with its enormous alimentary surplus and theirmultimillionaire subsidies), and exporters of crops(fruit, vegetables, flowers, etc.).[Trápaga, 1996] Theabrupt commercial opening of agricultural sectors andthe progressive withdrawal of agricultural promotionprograms, leads to a decrease of food and industrialgoods production.The consequences include a loss ofnutritional sufficiency of nations along with the migrationof thousands of producers in the region, forced toabandon their land for economical reasons. [JuárezSánchez, 2003-2004]The neoliberal structural adjustment has variousaspects that impact workers directly. The policies areimpoverishing and affecting them economically andmorally. Examples include wage contention; the openingof national productive sectors to internationalcompetitiveness, with the resulting disintegration ofnational productive chains and the systematic bankruptcyof micro, small and medium companies; thecut in social expenditure. All of these affect the foundationsof workers´ social reproduction (housing, education,health, subsidy to nourishing consumption,etc.); the forceful integration of national productionunits to external chains, that employ the Latin Ameri-1. CEPAL, Una década de luces y sombras: América Latina y El Caribe en los años noventa95

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcan population, paying them misery wages; the limitedemployment generation, in most cases precarious, as aresult of the imposition of labor flexibility, to adjust forlesser labor demand (personnel adjustment); and thedecrease in salaries, not proportional to workers’ productivity.The region has experienced the bitter experienceof two decades of neoliberal policies, and the onlyclear results are an ever increasing poverty that alarminglyrose from 1980 to 2002, poverty increased65.6% in the region, passing from 135.9 to 220 millionpeople.This means that 89.1 million new poor peoplehave been aggregated.This number includes 37.6 indigentsand 51.5, not indigent, but poor. For the year2002, the number of poor people rose to 220 millions;this amount includes 95 million indigents and 125 millionpoor.In 2003, according to the statistical projectionsof the ILO, poverty in Latin America reached 225 millionpeople, of which 100 million were indigent (meaningthere 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 countrythat showed evident deterioration of living conditions.Its poverty rate in the urban area duplicated between1999 and 2002, rising from 23.7% to 45.4%.This the indigencerate increased by three times from 6.7% to20.9%.This alarming increase was mainly related to thecrisis of 2001.As well, it sets forth that a significant raisein poverty was registered in Uruguay, which wentfrom 9.4% to 15.4%, although indigence affected only2.5% of the population.Additionally, the United Nations demonstratedthat the major reason for migrations in the World iseconomic. In 1992, 125 million people moved, fromwhich 86% (107 millions) were labor migratory purposes,while 13.4% (18 millions) were for political or religiousmotives, or natural disasters.[ La Jornada, 1996]It also revealed that 150 million migrants existed in theyear 2002. One out of every ten migrant was born inLatin American or a Caribbean country. [ONU-CE-PAL, 2002]The movement of Mexican, Central and SouthAmerican workers to the United States is becomingone of the most important and dynamic human migrationsin the world.The remittances or savings that aresent by the Latin American workers to their countriesof origin are fundamental to their families’ survival andto the regional economic sustainability.[Waller Meyers,2000]It is in this context that workers from LatinAmerica have been forced to search for a variety ofsurvival mechanisms. Among these mechanisms: theirengagement in the informal economy; the migration toother regions and countries in the world; their employmentin sweat shops and assembly plants ("maquiladoras").Thesweat shops offer employees low wagesand hazardous working conditions.The employees areexpected to work long hour. They have had to reducetheir consumption habits, and increasing, at the sametime, the enrollment of family members in the formalor informal labor markets.The subordination of Latin-American to a globalmarket controlled by transnational capital results in increasedunderdevelopment and dependence. It alsoaugments the loss of national sovereignty of our countriesand the depredation of our natural strategic resources.Allof this is at an extremely high social cost.The new century starts under social unrest andprofound economical, political and social crisis.The collapseof the neoliberal program in most countries,illustrates the evident failure of a historical project basedon greed and the subordination to the interests oflarge transnational companies.96

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 Caribeen los años noventa.● JUÁREZ SÁNCHEZ, LAURA (2003-2004). Los exiliados económicosde América Latina. En Revista Trabajadores No 39 noviembre-diciembre2003 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 producciónde alimentos en el mundo en El reordenamiento agrícola enlos 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 LATINA10Regression of Health inNeoliberal Colombia*Miguel Eduardo Cárdenas, Luz Helena Sánchez, Martha BernalThe introduction of the neo-liberal model at the end of the 80’s and beginningof the 90’s in Latin America, unleashed a process of legal regressionand deregulation that paved the way for profound change in social policy conception.According to neo-liberal reformers, an efficient use of resourceswould be promoted, and economical growth would be accelerated. But thesereforms were oriented towards endowing the market as a main distributorof 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 marketsmore flexible.In the framework of this new model characterized by the hegemony offinancial capital, and with the argument that States hinder the access to socialservices of the poorest population (the reason being it was an inefficientand corrupt State), the social policy adopted the following guidelines: to reducethe role of the State (in the stipulation of social rights), to allot greaterprominence to the private sector; to cut public expenditure in order to preservefiscal balance; to leave in the hands of the market the assignation andregulation of these social rights; to focus expenditure, through subsidies todemand, and to decentralize competence and resources of these services toterritorial entities.* Document prepared in the context of activities of the Working Round Table ‘The social reforms Colombiarequires’, 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 Cárdenasof the Friedrich Ebert Stiftung in Colombia –FESCOL.98

Observatorio Latinoamericano de Salud.Social Rights in the Frameworkof Structural ReformsUnder the auspices of neo-liberalism, the meaningof social policy has shifted from being considereda policy of universal and redistributive nature, to becominga focalized, transitory and merely complementarypolicy. Severe social problems such as poverty arenow common issues; no longer considered important.They are treated as "mitigation programs" against poverty,marginal issues, which no longer require integralpolicies from the State.Public discussion on the importance of the improvementof living and working conditions for low incomegroups has been abandoned and substitutedwith approaches related to macro-economic balance.Other issues, like inflation reduction, have become ofgreater concern than public health to technocrats andentrepreneurs.Thus, within the current economical model, socialpolicy ends up being subordinated to financial capitalin two ways: (1), financial intermediation becomespivotal in the network of the resources flux for theprovision of social services, (2) from the fiscal perspective,the payments to the financial sector prevail oversocial expenditures; and (3) the financial predominance,debilitates the productive apparatus, which bringsabout negative social effects, such as unemploymentand poverty.Neoliberal Reform to HealthWithin this context, health reforms for LatinAmerica are sponsored by international agencies. TheWorld Bank acquires great influence in the formulation,conception, planning and financing of health systems.The State has reduced the task of implementingbasic or limited public health programs and investedinstead in only elemental clinical services. In the languageof reformers, the State has intervened exclusivelyin the "pure public services"; namely the ones thatcan only be furnished by actions of the State.In Colombia, this health reform was instigatedwith the argument that more than 70% of the populationwas excluded from access to health services.The National Health System fostered the existenceof inequalities at that time due to the manner of subsidiesdistribution, and the low quality and inefficiencyin the use of resources. The reform was consolidatedthrough the counter reforms established by the socalled "Law 100" (1993), which established the NationalSystem of Social Security (integrated by the GeneralSystem of Pensions and the System of Social Securityin Health, Occupational Risks and ComplementarySocial Services). These are fancy denominationsthat hide the real regressive nature of the reforms.The new law bases its principles on the prescriptionsof the World Bank: self-financing; decentralization; financialseparation; provision and focalization functions.The new System of Social Security in Health hassought advances in universality, solidarity and efficiencyin the utilization of resources and health servicesprovision, hence, consistent with the Law 100,every person theoretically has the "right" to acquire ahealth services package and may choose the insureraffiliate. People with purchasing power become affiliatedwith the "contributory regime", by means ofhealth promoter companies called "EPS"- and thepoor population becomes affiliated with the "subsidizedregime", through administrator agencies called"ARS".These intermediary organizations contract theprovision of services from service provision institutionscalled the "IPS". Depending on the regime withwhich anyone affiliates, one can have access to a packageof services included in the obligatory health plancalled the "POS". Moreover, to select the poorest99

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINApeople, a beneficiaries system was created called SIS-BEN.This instrument identifies and selects the "poorest"populations.The Law 100:A BalanceAfter more than a decade of its application, theLaw 100 (1993) has not furnished satisfactory healthresults. Controversial effects have triggered the demandfor debate. During 2004, a reform was discussed,which made evident a contradictory finding: resourcesfor health increased meaningfully.(In 2003 resourceswere directed amounting to 15 billion Colombianpesos (more than 10% of gross national product),however there was no real, positive effect onthe improvement of the health conditions. Subsequently,some of the problems evidenced came to thesurface.In terms of coverage, it was expected that all thepopulation would have become affiliated with any ofthe regimes by the year 2001. Despite the fact thatone of the major efforts of Law 100 was oriented tothe affiliation of the poor population, defined by thepoverty line (LP), the results (Table 1) illustrate that bythe year 2000 only 37.3% of the poor had become affiliatedwith the subsidized regime. By the year 2003,only 62% of the population had become affiliated, andthe remaining 38% were on the outside of the system.At the same time, roughly 40% to 50% of the populationin each of the three quintiles with lesser resourceshad not become affiliated with any regime (Table2).A disturbing issue in terms of coverage, is that asignificant sector of the population not qualifying asbeneficiary of subsidies, wouldn’t qualify for contributoryregime on account of its socioeconomic conditionsand the precariousness of their work.YEAR1996TABLE 1COVERAGE PERCENTAGE INTHE SUBSIDIZED REGIMEBY POVERTYCOVERAGE NBI40.0COVERAGE PL29.4TABLE 2AFFILIATION WITH THE SGSSS BY REGIME,BY INCOME QUINTILES 2003QUINTILESCONTRIBUTORY%RÉGIMESUBSIDIZED%NOT AFFILIA-TED %199719981999200047.055.559.759.835.541.941.237.312345TOTAL6.116.236.157.478.938.940.536.322.111.93.822.953.547.541.838.717.338.2100

Observatorio Latinoamericano de Salud.Another fundamental problem of the system refersto financing. In the case of the subsidized regime,there is dispersion in the management of resources,which contributes to the deviation of their originaldestination. Thus, resources directed to the ARS’s arenot directed to the care of "clients"; they remain in thefinancial intermediation sphere, provoking prejudicialeffects on the IPS’s, especially in the public hospitals.Furthermore, resources from the solidarity accountthat contributions to the financing of the subsidizedregime have stagnated due to the economic crisis,unemployment, and the high levels of poverty, in conjunctionwith the non fulfillment of the government ondisbursing the corresponding resources.In regards to the contributory regime, one of themain problems is related to evasion and elusion. Similarly,the number of contributors has been reduced,owing to the increase of unemployment and the growingcomposition of informal work in the labor market.One of the central arguments to justify the neoliberalreform is connected with the so called freechoice. The original promise stated that free electionwould improve the quality of services (through thecompetitiveness of insurers and providers), and consequentlywould respond to user’s interests. Recent studiesof the Research Center for Development (CID)of the National University of Colombia demonstratethat free election is not possible in small municipalitieswhere there is only one IPS.These are just some of the problems that appearwhen one analyses the current social security in healthsystems of Colombia. But there are other relevantproblems concerning public health including epidemiologicalconsequences, like the reemergence of diseasesthat hade already been controlled, the extreme weaknessof the health information system. ( the carelessextrapolation of a client-centered administration withinthe system creates barriers to the access of the affiliatedpopulation; among others).Upon observing the outcome of the reform, itmay be concluded that guaranteeing the right tohealth has encountered serious difficulties; that healthpolicy and its results are intimately associated withthe economical, political and social process of Colombia(chiefly when this system is based on the criterionof purchasing power of people). In addition to the upsurgein health resources resulting from Law 100, thelogic with which these reforms were inscribed is corroboratedby the logic of "financialization" of economy.Evaluation of the Health System fromthe Equity ViewpointDuring the last decade, the living conditions ofthe Colombian population have deteriorated. From1997 to 2000, the line of poverty has passed from50.3% to 59.8%.This signifies that more than half of thepopulation is poor. The line of indigence, also passedfrom 18.1% to 23.4% for the same period (Table 3).As well as the economical conditions influencingextensively the deterioration of the population’s wellbeing,war has been another contributing factor. Anexpression of this is the forced displacement that hadits major manifestation between 1995 and 2000, when1.123.000 people were displaced.The deterioration of working conditions whichare a product of labor flexibilization, originated from asubstantial proliferation of the working population inthe informal sector (Table 4), (primarily in the segmentsof population with lesser incomes).Coverage however, within the System of SocialSecurity in Health from 1993-1997 augmented andfestered from 1997-2003, as a consequence of theeconomical and sociopolitical crisis of the country.Problems facing equity persisted as well, which revealsan orientation of social policy that was pro-cyclic to101

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATABLE 3POPULATION UNDER THE LINE OFINDIGENCE AND POVERTY (%)NATIONAL AND BOGOTÁ 1997 – 2000NATIONALBOGOTÁLINE OFPOVERTY1997 1999 200050.332.456.346.359.849.6LINE OFINDIGENCE199718.16.1199919.613.2200023.414.9the behavior of the economy, and did not produce redistributiveimpacts.The coverage of the contributory regime, in thesame period, passed from 39.5% to 35.4%, and of thesubsidized regime, from 17.7% to 16.9%. Nevertheless,in the subsidized regime, equity problems wereevident at the time of assignation of subsidies; hence,while the percentage of subsidized poor populationdecreases from 27% to 20,3%, the percentage of subsidizednon-poor population augmented from 9.2% to13.4% (Table 5).In the face of services provision for the periodof 1993-2000, the percentage of people who felt sickTABLE 4CREATION AND DESTRUCTION OF EMPLOYMENT IN THE FORMAL AND INFORMALSECTORS SEVEN CITIES 1992–2000 AND THIRTEEN CITIES 2001–2003(THOUSANDS OF PEOPLE)PERÍOD FORMAL INFORMAL TOTAL % FORMAL % INFORMAL1992 – 19941463918576.0520.951994 – 1996675712454.2745.731996 – 1998142983124.3795.631998 – 2000- 254368113-224.67324.672001 – 20025723729419.3580.652002 – 20031429423660.1239.88and were taken care of diminished in all the quintiles(in this manner general care was reduced from 67% to51%). The inequalities between the richest and poorestquintiles are also evidenced; while the poor population,more vulnerable to illnesses, receives minor care,the quintiles with higher incomes concentrate majorcare.In 1993, within the first quintile 48% of the peoplewho felt sick were taken care of, while in the lastquintile, 80% were taken care of. By the year 2003, the102

Observatorio Latinoamericano de Salud.QUINTIL12345TOTALTABLE 5HEALTH INSURANCE1993, 1997, 2003AFFILIATED1993 1993 1993528.2831.349.6232.026.5692.407.5332.460.0388.772.0464.052.4754.296.5874.781.4504.634.5664.936.74122.701.8194.069.9714.589.4125.092.7946.052.6627.226.87527.031.714TABLE 6AFFILIATION BY REGIME,WITH COMPLEMENTARY PLANS OR HEALTHINSURANCE 2003RÉGIMEESPECIALCONTRIBUTORYSUBSIDIZEDTOTAL%AFFILIATION5.8657.0737.07100% WITH COMPLE-MENTARY PLANS ORINSURANCE9.1211.161.617.50TABLE 7INCOME DISTRIBUTION, HEALTH COVERAGE AND UTILIZATION OF SERVICES.BY POPULATION QUINTILESQUINTILESBY HOME12345TOTALINCOMETOHEALTH2.205.9210.4418.0563.38100AFFILIATED CONTRIBUTORYREGIME15.5616.1119.0322.2227.081003.177.8617.9329.6841.35100SUBSIDIZEDREGIME36.5930.1120.919.552.85100NON-AFFILIATEDAND WITHOUTINSURANCE27.8126.5821.4316.158.03100UTILIZATIONOF HEALTHSERVICES15.1316.8521.8023.8022.41100situation improved for the people who showed illness,so that 60% of the first quintile and 77% of the last onereceived care (Table 9).One of the main barriers to the access, for peoplewho do not seek professional care even if they aresick, is the lack of money. In the period 1994-2000, thepercentage of sick, who were not taken care of on accountof a lack of funds, increased from 43% to 62%. Bythe year 2003 it decreased to 39%, despite the fact thatthis continues to be the reason why people do not receivecare (Table 8). It is demonstrated that the currentsystem of social security in health does not contributeto the reduction of socioeconomic inequity; on thecontrary, the system maintains it.A further factor that expresses inequity throughoutthe health system is pocket expenditure . Accor-103

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATABLE 9PROBABILITY OF GETTING SICK, RECEIVING CARE AND ACCESSING AN INSTITUTION1993/1997/2003Quintil Get sick%12345Total15.215.315.916.117.215.81993 1997 2003Receivecare %15.215.315.916.117.215.8Access aninstitution %15.215.315.916.117.215.8Get sick%15.215.315.916.117.215.8Receivecare %15.215.315.916.117.215.8Access aninstitution %15.215.315.916.117.215.8Get sick%15.215.315.916.117.215.8Receivecare %15.215.315.916.117.215.8Access aninstitution %15.215.315.916.117.215.8TABLE 8PEOPLE WHO FELT SICK IN THE LAST 30 DAYS AND DID NOT REQUESTOR RECEIVE MEDICAL CARE 2003REASONSICK PEOPLEWITHOUT CARE %SICK PEOPLE WITHOUT CARE, NON-AFFILI-ATED AND WITHOUT INSURANCE %Falta de dineroCaso leveNo tuvo tiempoCentro de atención queda lejosMal servicioMuchos tramitesNo confías en médicosConsultó y no resolvieron problemasNo lo atendieronTotal39.0337.15.14.13.73.52.92.51.810076.3238.6426.1243.7015.3327.7564.0341.8633.2052.48ding to calculations obtained in Ramón Abel Castaño’sstudy on equity for the period 1993-1997, within thequintile of lower incomes the pocket expenditure hadan increment of 6.700 pesos, while that of the quintilewith higher incomes had a decline of 20.000 pesos approximately.By the year 2003, 55% of the sourcesused to cover care costs were their own or family resources(Graph 1).104

Observatorio Latinoamericano de Salud.GRAPH 1SOURCES USED TO COVER HEALTH CARE COSTS ECV 2003ProposalsThe construction of a new System of Social Securityin Health must start by guaranteeing every personwho lives within the national territory the right tohealth, as a fundamental, individual and collective humanright. Consequently, this system will be universaland will be organized as a Public System of Health, autonomousand democratic, unified, with decentralizedmanagement by regions.Subsequently, some guidelines of this new systemare presented:● The set of services, provisions or benefits, individualor collective, which the health system grants will beequal for every person, independent of their purchasingcapacity and any other economical, geographicalor social condition.● The Health System will be reorganized in order tostop exclusivity in a system of illnesses care and betransformed into a Public System of Health: whichprioritizes prevention, promotion, education, andthe fostering of health at every one of its levels, andguarantees Public Health as a primordial good of so-1. El gasto de bolsillo son los pagos directos que hacen las familias a los proveedores de servicios de salud cuando demandan atención.105

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAciety, (as well as the access of all the population tointegral health services).● Every citizen will be required to contribute to theextent that his/her economical possibilities forhealth financing permit. (The mechanisms of controlof contribution will be completely separated fromthe access to services.)● The public system of health will be directed by a collegiateorganization, for a fixed period, (autonomous,formed democratically), in an attempt to guaranteethe representation of regions, sectors bymeans of their social organizations and workers.● Neither the public system of health, nor its regulatingor directing organizations will depend hierarchicallyon the government. This will not designatethem, or give tutelary control over their decisionsof the autonomous institution. Moreover, administrative,budgetary and financial autonomy will beguaranteed.● In regards the provision of services, territorial unitsdistinct from the existing will be organized, with theintention that they consult the population of the differentregions in relation to their cultural, economicaland communicative reality. Concerning the organizationand planning of services, the affiliationwith the system will be performed by the place ofresidence of the family. A municipality may decidedemocratically which region to appoint.● The financing of the system will be based on statepublic funds having as their source the profits of thenation, the contributions of employers and workers,the current quotation for occupational risks, the incomefavoring the private sector, and the rest of localor departmental tributes, as well as the profits ofbondholder monopolies.● All the resources of the health system, including thequotations of salaried people and people with purchasingpower, will be collected and administeredthrough a National Unified Public Fund.● The health resources may not be oriented to any otherdestination, and may not be used to finance thenational government, or to nurture and strengthenthe private financial sector.●The System of ‘Subsidies to Demand’ will be suppressed.Public hospitals and the rest of institutions ofthe health services public network will be financeddirectly by the State, by way of the National PublicFund. (Demanding from the public network the sellingof services, or criterions of economical profitability,or financial self-sustaining is prohibited, as acondition to gain access to the necessary resourcesfor the functioning of services.)● Integral and satisfactory maintenance of the publicnetwork is a priority of the system.● Humanization of services, which emphasizes humanbeings’ dignity over any other consideration, will bethe ruling criterion (that all the people, officials orworkers, will observe within their activity as membersof the public system of health).●The quality of the system and its services will be guaranteedthrough previous internal mechanisms, andorganized forms of effective social control of services.● Within the health system, the poor treatment ofclients (or any other that fails to recognize the principleof humanization, or that intends to impair thepublic nature of the system with the purpose ofadopting business or commerce policies or criterions)is forbidden.106

Observatorio Latinoamericano de Salud.● People and communities have the right to the totalityof supplies, medicines, means of diagnosis, andprofessional care, in proportion to the major gradeof technology or the advance of science available inthe country.● A provision will only be excluded from the set ofservices if it is clearly proven to be superfluous, noxiousor unnecessary.● Public policies must provide the necessary mechanismsto attain the production and generation ofknowledge, research, science and technology in thecountry.● Ethnic and cultural diversity of the nation will be respected,and the autonomies acknowledged withinthe Political Constitution.● Alternative therapeutics will be incorporated intothe set of forms of practice implemented by thehealth system. These will be subjected to qualitycontrols, analogous or similar to the ones demandedfrom traditional therapeutics.● The education and training of human resources insocial security will be activated in line with the principlesand requirements of the system. Rigorousmechanisms of control regarding the training of professionalpersonnel will be applied to guarantee qualityand capacity of health workers.● Health plans for each region will be adapted to theirspecific needs and the epidemiological profile of thepopulation.● The services network will have to be organized inorder to guarantee the geographical accessibility tothe distinct levels of care.● The set of rights and duties of health personnel andpatients will be regulated thoroughly.● The health workers will be selected in accordancewith an objective system, and their employment stabilitywill be assured to prevent and combat clientcenteredstructures.● Personnel parallel nominations and contracts will beimplemented to execute labor that has permanentfeatures within the public institutions.● A Public System of Information in Health will be organized,as an indispensable instrument for the managementand control of health policies.107

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA11Destruction of Urban Space: "ConcealedGenocide" in The Ituzaingó DistrictMaría Godoy, Norma Herrera, Sofía Gatica, Corina Barbosa,Eulália Ayllon, Marcela Ferreira, Fabiana Gómez,Cristina Fuentes, Isabel LindonThe Annexed Ituzaingó district is located in the south west of Cordoba,Argentinain the urban periphery.This impoverished area has nearly 5,000people living in 1,200 residencies.Serious environmental violations are being carried out by various agriculturalindustries that threaten the health of the residents of this area. Researchand data has been collected by a concerned group of citizens knownas The Group of Mothers.This organization, a collection of female residents,has helped uncover some of the environmental atrocities that have occurredand still occur in this region.The Group of Mothers has helped determine apossible link between water, soil and air pollution by these industries and incidencesof leukemia, birth defects, and other forms of cancer in both newborn babies and current residents of this region.HistoryThe struggle began at the end of 2001 when Sofia Gatica, one of themothers of The Group of Mothers, noticed that several women used handkerchiefsto cover their baldness and several children covered their mouthand nose with surgical masks to breathe. Ms. Gatica surveyed various householdsin the neighborhood for approximately four months. She collecteddata that included: the name of the resident, age, address, ailment, diagnosis108

Observatorio Latinoamericano de Salud.and the hospital where the resident received medicaltreatment.With the help of two neighbors, Ms. Gatica presentedher data to the Department of Health. Theyused the information to create a map of the locationof the sick residents and the location of electric transformersand possible sources of soil, air and watercontamination.Water samples were taken in the neighborhoodand agrochemicals such as Agrosulfan were found.Theresidents of these areas have documented cases ofleukemia and other cancers where the water and otherforms of pollution has occurred.Roberto Chuit, the Secretary of Health, helpedimprove the water quality in the area. However, to accomplishthis goal, the residents of the area were forcedto sign a waiver stating that legal action would notbe sought against the various groups responsible forthe 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 conductedon the transformers to determine the presenceof PCB, dioxins and furans in the transformers.Measurements of the harmful magnetic fields producedby the transformers were also not tested prior toremoval.A few days after the initial meeting, Mr. Chuitsent a team consisting of doctors, social workers, psychologistand some less skilled members, such as a kitchenassistant, to conduct a survey.This document wasinadequately completed.The Group of Mothers conducted its own surveyand determined the environmental and health situationto be extremely grave. An appeal to the Justicewas made by The Group of MothersAs a result of the research by The Group ofMothers, the advocate of the agricultural industries,the local farmers and the agronomic engineer wereunaware of the harmful effects of the chemical on thehuman body that were found in the fumigation sprays.Gliphosate and endosulfan are harmful chemicals inthe sprays that have the ability to enter the humanbody upon exposure. According to Raul Montenegro,specialist in environmental management at the NationalUniversity of San Luis, these substances are endocrinaldisruptors and may alter the hormonal mechanismsin humans.The Group of Mothers demanded that the soilwas tested for pollutants, the sediment of tanks weretested for pollutants, the transformers were tested forPCB and other cancer causing agents, the air was testedfor air born toxins and the surrounding regionmonitored for harmful magnetic fields. By the end2002 the following results were obtained:● In the domiciliary tanks, agrochemicals (endosulfan,heptachlor), and heavy metals (lead, chrome, and arsenic)were found.● In soils::Sample 1: Malathion, Chlorpyrifos,Alpha-endosulfan,Cis-chlordane, DDT isomerSample 2: Malathion, Chlorpyrifos,Alpha-endosulfan,Beta-endosulfanSample 3: Alpha-endosulfan, DDT isomersSample 4: HCB (Hexachlorobenzene), DDT isomerSample 5: DDT isomer, Beta-endosulfan● In the air:PVC with a high level of Phthalates (plasticizers)● In transformers: PCB 281 ppm.The Group of Mothersobtained a transformer that had PCB.This onewas different from the one tested by the EPEC.● Magnetic fields: 1 micro la.This result was obtainedby CEPROCOR , an organization sub-contracted by109

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAthe Government. The Group of Mothers did notconduct a sampling of the magnetic field by a thirdparty as a result of the lack of funds. The groupquestions the validity of the results of the researchconducted by CEPROCOR.The number of incidents of cancer and otherhealth issues increased in the neighborhood. TheGroup of Mothers decided to travel to Buenos Airesto present their case of environmental violations tothe following organizations: Human Rights of the Nation,Defender of People of the Nation, Environment,and Department of Health of Nation. The Group ofMothers were under constant surveillance by policeand threatened by authorities with firearms to notpresent the data in Buenos Aires.The effort by The Group of Mothers in front ofCongress produced the Project of Law which prohibitedfumigations of harmful chemicals near residencies.Protests were used to help ensure delivery ofcancer fighting medicines and the continuation of datacollection on environmental pollutants in the region.In 2004, a doctor verified 150 cases of cancerand other diseases in the neighborhood to the Municipaland 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,Tumorsand Leukemia.There have also been documentedincidences of brain tumors with individualshaving over 30 tumors. Some of the most numerouscases of leukemia have been reported in the neighborhoodthat lies between two transformers and the soycrop in the district.This is a portrait of thirteen of the cases in theregion that helps illustrate the atrocities suffered as aresult of the environmental pollution:● 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.Theseinclude:● 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 Federal110

Observatorio Latinoamericano de Salud.Judge sent the case to the District Attorney’s office IV,Turn 2.This case was appealed and later presented tothe Supreme Court Justice of the Nation.A technical report was completed by the Departmentof Health of the Province. The Group ofMothers questioned the validity of the data and sentan appeal to a Corpus Data.The Group of Mothers plans to present civil demandsto the district for damages.The Group of Mothers want the following actionsto be carried out by the Government: the distributionof adequate medicines, the acknowledgementby the government as the main contaminator, the creationof a healthy environment, the immediate end tofumigations over people and the exposure of PCB andHeavy Metals into the water and soils.The following has been accomplished as a resultof the demanding efforts by The Group of Mothers:● Elimination of the PCB (throughout the province ofCórdoba)● 2.500m away (it was never observed)● Municipal Ordinance, which prohibits fumigation inthe area of the Capital of Córdoba● Change of water for the entire district● Inauguration of two health centers● Law of agrochemicals (it has neither been regulated,nor published within the official bulletin)The following has yet to be realized:● The State to take responsibility for the situation.● A formal study to determine the causes of the illnessesof the residents● The construction of the public transportation line toreach the contaminated area. Currently, other citizensfear that they could become infected with eventhough cancer is not contagious● The installation of the medium tension line (13,5kw), which would reduce magnetic fields● The ceasing of fumigations within the district●The Secretary of Health, Roberto Chuit, to admit hismistake publiclyThe Different EnvironmentalProblems Detected● Endosulfan, a prohibited pesticide, and high levels ofsulfate and carbonates were found in the water suppliedby the water company, SABIA SRL. The companydistributes the contaminated water undergroundand the residents of this area continue topay for the use of this polluted water.● The Group of Mothers determined through their researchthat pesticide chemicals such as Beta-endosulfan,DDT, DDT isomers, Malthion, Cis-chlordane,Alfa-endosulfan, Beta-endosulfan, BHC and Chlorpyrifosare harmful to human health.Ariel and terrestrialapplications of these pesticides and agrochemicalswere being conducted on two private cultivationproperties of soy and other grain in fields adjacentto the Annexed Ituzaingo district.Studies conducted by the CEPROCOR revealedthat there was neither chrome, nor arsenic. Howeverin other studies of the same area, it was found that 25parts per million (ppm) of arsenic were found in homes.Thelimit established by the law is 30 ppm. Arsenicmay also be derived from agrochemicals.111

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAEdgardo Schider, founder and president of theArgentinean Society of Environmental Medicine, explainedthat health issues caused by exposure to environmentaltoxin usually have two elements: predisposingand unleashing causes. In this case, the exposureto pesticides was the unleashing element.The predisposingelement was the fact that the district was constructedin an insalubrious place, where there had beenno urban planning and where people had drunk intoxicantwater for 40 years.This produced an accumulativeeffect. He also added: "here we are witnessingsomething that already appeared in some developedcountries, what has been named the zone of ecologicalor environmental catastrophe".Those AffectedThe Group of Mothers of the Annexed ItuzaingoDistrict, consisting of approximately 5.000 people, havedocumented the different incidences of illness. Studieswere conducted by group member that went homeby home and listed all the know cases of illness.Atfirst it was a list of 28 sick people in a radius of 400 m.However, more documented cases of individuals withcancer appear as more time passes.Those ResponsibleThe following groups have been identified by TheGroup of Mothers as wholly or partially responsiblefor the environmental catastrophe in the Annexed ItuzaingoDistrict that has left so many people seriouslyill with cancer or other life threatening ailments.1.The Municipality of Córdoba, which allowed the urbansettlement to exist in an area where there is extensivecultivation. The Municipality should have enforcedthe ordinance that prohibits fumigation within2.500m of residential areas.2.The Province of Córdoba, especially the Agriculture,Livestock and Natural Resources Undersecretary’sOffice, did not enact limits over fumigations in accordancewith the provincial Law N.6629 and its regulationdecree N.3786/94. This governing body isresponsible for monitoring and enforcing the lawsconcerning fumigations in the Province. An advisorneeded to be present when fumigations occurrednear residential areas as outlined in Article 13 of thelaw of agrochemicals.3.The Department of Health of the Province, includingHealth Secretary Roberto Chuit), did not closelymonitor the health of the residents. Mr. Chuit continuallyhid evidence of health issues of the residentscaused by the environmental pollution. Mr. Chuitcreated confusion within this serious situation andconcerned himself more with the devaluation of homesthan to human life.4. The DIPAS (Provincial Office of Water and Sanitation)is in charge of the provision of potable wateramong the inhabitants of the province. DIPAS outsourcedthe water provision to SABIA that did notmonitor the water quality correctly.5. Metallurgical factories owned by such companies asFiat, Materfer, Iveco,TuboTranseléctrica, and Machiarolapolluted the water, air and soil with know chemicalsharmful to the health of humans.6.The agriculture and livestock company that operatesin the zone supported the laboratories by purchasingherbicides that are potentially harmful to humanhealth. This company used these herbicides inorder to increase the yields of the harvests with lit-112

Observatorio Latinoamericano de Salud.tle attention paid to the harmful effects of theseherbicides on human health.7. The EPEC (Electric Power Provincial Company ofCórdoba) denied that the transformers, owned bytheir company contained PCB. The EPEC claimedthat there were only 36 transformers distributed inopen areas. However, further research by TheGroup of Mothers confirmed that all of the transformersin the area contained PCB.ConclusionThe Annexed Ituzaingo District is home to residentsof low socio-economic standing. Besides thesehardships, the residents must endure environmentalcontamination which dramatically decreases the alreadylow standard of living of this region. Many residentialareas adjacent to soy crops experience thesesame unnecessary hardships. Environmental degradationhas an effect on many aspects of peoples’ lives andthe Ituzaingo District faces this reality.Argentina experienced rapid expansion of agriculturalmarkets as the country produced more andmore transgenic crops during the 1990’s.The results ifthis immense growth from world demand is easily noticeable.Hundreds of indigenous peoples were forcedto move from their territories and over 400.000 smallagricultural producers went under. Some small farmersaccumulated large debts as a result of the need to purchasenew machinery that was required by this industrialmethod of farming. Farmers needed to purchasetransgenic seeds and herbicides manufactured byMonsanto to produce the high yields required by globalmarkets.The agriculture industry spent large amounts ofenergy and resources to conceal these environmentalatrocities that resulted in the degradation of humanhealth.The Group of Mothers focused on exposing theharmful effects the actions of these companies and governmentalorganizations have had on the people ofthe Ituzaingo District.The impact on the health and quality of life ofthe people of the Annexed Ituzaingo District could begeneralized to include nearly all Argentinean citieswhere 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 constantthreat to numerous Argentineans.Many questions remain unanswered.What is theresponsibility of the State to protect its citizens? Whocontrols the demands required by farmers to adopthigh-impact farming practices? Who controls the useof biotechnology?There may be a need to adopt these high impactfarming practices, but the negative impact as a resultof the use of this agro-exporter model that heavily focuseson the use of transgenic crops cannot be ignored.Currently, soy crops cover nearly 14 million hectaresof some of the best agricultural land in Argentina.As a result of converting this land to soy crops, nativeforests have been destroyed, food cultures havebeen displaced, water cycles have been ruined, the biodiversityhas been destroyed and thousands of poorpeasants have sufferedThe Group of Mothers within the Annexed ItuzaingoDistrict of Córdoba, has helped to uncover someof the environmental impacts on human health asa result of negligence by the State and the adoption ofhigh-impact farming techniques. There have been negativeimpacts on both the people and the environmentas a result of ignoring health risks for the sake ofprogress. Many victims have been impacted as a resultof large corporations and government personnel seekinga record harvest.113

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAThe existence of PCB in the soil, air and drinkingwater had been confirmed by Adrian Calvo, spokesmanfor the EPEC. Mr. Calvo said that PCB was usedbecause it was cheap. As a result, the use of PCB hascontaminated the area and left many people in theDistrict with cancer. PCB accumulates in the fatty tissuesof the body. Even if transformers are chemicallystable, fire and high temperatures may produce molecularrearrangements as many transformers explodeddaily, thus possibly freeing highly carcinogenic dioxinsand furans.The Department of Health performed only twoanalysis of maternal milk and one of bone marrowamong 5.000 inhabitants. The Department of Healthshowed little interest in conducting further researcheven though several children had mental illness and otheradolescents had learning disabilities, lupus, proteobacteria,testicular ascent and respiratory problems.The reality of the situation is that cancer causingagents are entering the environment.The residents ofthe Ituzaingo District are dying of cancer and other illnessesas a result.These incidents of cancer and othersevere illnesses have been thoroughly documented.There is an apparent connection between the use ofpesticides and herbicides by the large agricultural corporationsand the use of PCB in the transformers bythe EPEC on the health of the residents.The Group ofMothers would like compensation, medical attentionfor the residents, an open apology by the Secretary ofHealth and the exposure of these harmful chemicalsto end. There is no denying that the quality of life ofthe residents of the Ituzaingo District has been impacted.Thegoal of this campaign is to make sure that thechildren do not suffer the same horrible fate as theirparents and grandparents.114

Observatorio Latinoamericano de Salud.12Neoliberalism, Pesticide Use andthe Food Sovereignty Crisis in BrazilAry Carvalho de Miranda, Josino Costa Moreira,René Louis de Cavalho y Frederico PeresSince the nineties, Brazilian economic policies have gradually moved towardsneoliberalism.As everyone knows, neoliberals assume that market regulationis the most efficient way of controlling economic activity. Microeconomicmanagement, allocation of resources in space and in time – includingthe balance between investments and consumption – and the setting of priceswere the main economic functions transferred to the market by the Braziliangovernment during that period.The process has also led to the privatization of assets, extensive economicderegulation, and liberalization of exchange rate movements, foreigntrade 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 Stateto monetize its deficits.The combination of policies can indeed eliminatehigh inflation efficiently, but at a high cost.The neoliberal consensus was that these measures would create a favorableenvironment for foreign capital to enter the country and for investmentsto increase. However, the opposite has happened in Brazil:The investmentrate declined in tandem, from an average of 22.2 percent of the GDPin the eighties to 19.5 percent in the nineties and 18.8 percent in 2000-03.115

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAUnder neoliberal policies, Brazil received large foreignresource 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 insufficientto compensate for the contraction of public and privateinvestments.Therefore, the investment rate fell andgrowth petered out. Between 1994 and 2003, Brazilhad an average 2.4 percent annual economic growthrate; in contrast, between 1933 and 1980, the economyexpanded an average 6.3 percent per year [Mollo& Saad-Filho, 2003].Low economic growth rates over an extendedperiod necessarily affect the level of employment.Theunemployment rate has increased substantially, especiallyin the six largest metropolitan areas. In São Paulo,open unemployment went from six percent in thelate eighties to thirteen percent in recent years.Takingprecarious employment, hidden unemployment anddiscouraged workers into account, unemployment ratesreached 20 percent of the labor force.The destabilizationof the Brazilian labor market can also beseen through the rapid increase of irregular employmentsince the late nineties.The declining income level and its inequitabledistribution are other important factors contributingto the increase of poverty and marginalization.Averageincomes have recently steadily declined, largely becauseof the economic slowdown. Brazilian per capitaincome fell from 21.6 percent of the average incomein developed countries in 1980 to 16.5 percent in1995, and 15.5 percent in 2001. Furthermore, Brazil isstill one of the most unequal countries in the worldand neoliberalism has worsened inequality [Mollo &Saad-Filho, 2003].Thus, the economic changes that marked the90’s are still affecting the country. Brazil has inheritedmajor structural weaknesses that continue to constrainthe economic development and decrease thepossibility of developing more independent policies,that is, an increased external frailty and the acceleratedgrowth of its domestic debt. External debt serviceand the increasing deficits on capital and service accountsunderline Brazilian dependence on external capital.Thescope of financial actions carried out by thegovernment is, thus, violently diminished by the expandedprimary surplus necessary for paying domesticdebts.Therefore, the indispensable sustained growth innational economic development presumes the generationof increased external commercial surpluses and achange in plans as to the internal debt.The external scenario favors trade (the growthof international trade and a relative improvement inthe terms of trade) and has helped the country’s positiveexternal economic results, particularly in 2004.Agricultural exports were the major causes of thisprogress.Agribusiness external sales totaled 39 billiondollars in 2004, 27 percent more than the previousyear. These exports represent 40 percent of Brazil’stotal exports, which greatly contributed to the surplusof the country’s balance of trade.Thus, Brazil has been claiming its position as animportant exporter of agricultural commodities. However,the recent and favorable evolution in prices andquantity of products exported shouldn’t let us overlookthe important structural weaknesses of the Brazilianagricultural sector, since the scenario may changeat any time. Some aspects of this situation are ofparticular concern. Brazilian agricultural and cattle exportsstill concentrate on a restricted number of primaryproducts, which are found in a slow growing phaseof their life cycle (soy beans, coffee, sugar, beefmeat, chicken meat and wood pulp).The country’s exportsin the sectors of agroindustrial products, qualityproducts and products with more aggregate value havebeen growing slowly. The possibility of increasingexports rapidly remains attached to a favorable evolutionof prices in the international market.116

Observatorio Latinoamericano de Salud.Together with Brazil’s integration in the internationalagribusiness trading scene came a regressivespecialization.The country entered the 70’s as an exporterof primary items and left it exporting agroindustrialproducts. With globalization, however, Brazil’sexports – particularly soy-related products – arechanging into less industrialized products.To produce the necessary machinery, equipmentand input products internally was a premise for themodernization of Brazilian agriculture. From the 90’son, however, Brazil is becoming increasingly dependenton importing inputs. Besides that, the balance of tradeas related to input products and agricultural equipmenthas been showing a deficit.The major asset for Brazil’s agriculture competitivenessin the world market is the large availability ofland, which allows the country to expand its productionrapidly and at low costs.This competitive advantage,however, is not sustainable and strongly pressuresthe environment.The fact that new lands are beingused for agriculture, especially for harvesting soy (thesoy areas grew 30 percent in the South and Southeasternregions and 66 percent in the Center-Westernregion in the last three years), contributes to deforestation(almost seven thousand square miles of forestswere lost in 2002 and 2003). The new soy areas occupyland previously dedicated to cattle raising, pushingthe cattle into areas with native vegetation. Severalstudies have dealt with the impact of the expansionof soy harvesting lands in Brazil (Indicadores de DesenvolvimentoSustentável [Index of Sustainable Development][IBGE, 2004]; Agriculture and Environment[WWF, 2002].According to the Research Program entitledAgriculture and Environment, funded by the WWF,"the production of soy involves around 32 billion dollarsper year, employs around 5.4 million people andis an important generator of foreign exchange. However,this success in trading has also brought along social,economic and, in a particular way, environmentalproblems and unbalances.The increase in soy harvestingresulted in the use of virgin soil for production aswell as the substitution of other products by soy. Besidesthat, inadequate intensive harvesting practiceshave caused serious environmental degradation, suchas erosion and loss of fertile soils, shallowing and pollutionof important rivers, the disappearance of watersprings and decrease in biodiversity." [WWF, 2002]The price increase in the international market and theexpectation of producing more at lower prices, causedby the introduction of the genetically modified soy, wereresponsible for the increase in production. Since theBrazilian government decided to stimulate the productionof soy as a commodity, Brazil is now one of thelargest soy producers in the world. In Brazil, soy is basicallydestined for export, since it is not part of theBrazilian’s culinary habits.The harvesting of genetically modified soy firstbegan illegally in Brazil in 1997 and was later legalizedin 2003 by the Medida Provisória [Presidential Decree]223/04.According to data obtained by the InternationalService for Acquisition of Agri-biotech Applications(ISAAA), the area planted with genetically modifiedsoy in Brazil increased 66 percent in 2004, reaching31 thousand square miles – consequentially followedby an increase in the use of herbicides.The areaincludes approximately 22 percent of all soy plantationsin the country. Between 2003 and 2004, the increasein the use of genetically modified soy was largerin developing countries (35 percent) than in developedcountries. ISAAA estimated that 90 percent offarmers planting genetically modified soy are from developingcountries and that most of these are familyproducers [Folha de São Paulo, 01/13/2005].This is of particular concern (without taking intoaccount all the potential hazards of the disseminationin nature of genetically modified plants) since themost widely available seed of genetically modified soy117

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAin the market (Soja RR®), which is resistant to theherbicide glyphosate, and both the seed and herbicideare produced and marketed by Monsanto Co.Besides the ethical aspects involved in cultivating/marketinggenetically modified plants, the possiblethreats these plants may pose for human health andfor the environment have been neglected.The deteriorationof biodiversity, the decrease in the variety ofand nutrients in food crops and the fact that farmersmay become dependant on the biotechnology andchemical compounds produced by certain companies(by the commerce of sterile seeds and/or chemicalproducts which must be acquired yearly) is disregarded.Doubts on the impact of genetically modifiedplants on human health are also ignored.These doubtsinclude: allergenic potential, gene transfer – especiallythe transfer of genes related to antibiotic resistancefrom GMOs to bacteria and cells of the intestinal tractor the exchange of genes between genetically modifiedand non-modified plants, which poses indirect threatsto food safety [Lancet, 2002]. The "PrecautionPrinciple" is, therefore, being ignored and economicand/or foreign trade aspects are being used as excuses.Thus,the interests of capital overrule the health ofthe populations and environmental preservation.In Brazil, the increase in agricultural exportationis not incompatible with the increase in the amount offood produced for domestic consumption. Most of thetime, the increase in exportation – caused by favorableinternational prices – elevates domestic prices, butallows the production system to improve. Decreaseddomestic demand is not a necessary condition for exportation.On the contrary: the low increase in the domesticdemand, as occurs today, increases the differencesbetween potential production capacity and actualproduction and results in domestic agriculture beinggrowingly dependent on external demands.However, despite the present production capacityof the Brazilian agricultural sector, relevant segmentsof the population have difficulties in having a regularand secure access to the food they need. Thiscontradiction shows that, as to Brazil, the access tofood is no longer a matter of supply, but fundamentallyof demand, that is, of income distribution, in order togrant everyone access to essential foods.Another aspect to be considered about the Brazilianagrarian situation is the "development of a surplusof workers without any known destination, sincethe collapse of the traditional policulture, which allowedstable occupation of land, was not accompaniedby a change in the structure of property.The collapsewas not replaced by a modern agriculture based onsmall farms, which would also be able to assure stableoccupation of land.As a consequence, employment opportunitiesdecreased because of the increasing mechanizationand the process of urbanization was acceleratedby the expelling of workers from the ruralareas" [Benjamin et al, 1998]. Having that been presented,we face the battle field in which this reality is confrontedby another one, built in the last 21 years andstemming from the organization of workers expelledfrom the land by the capital.These workers were organizedby the Landless Workers’ Movement (MST),which mobilizes thousands of workers with a high degreeof organization and political consciousness.Theirprogram assumes the following general objectives:1.To build a society without exploitation where laboroverrules capital.2.To assure that land is everyone’s and serves the societyas a whole.3.To assure that everyone is employed, with a fair distributionof land, income and wealth.4. To permanently seek social justice and equality ofeconomic, political, social and cultural rights.118

Observatorio Latinoamericano de Salud.5.To propagate humanist and socialist values in socialrelations.6.To fight all forms of social discrimination and to seekan equal participation of women.A political alternative for dealing with these problemswas the creation of a rural credit line ("linha deAção PRONAF Crédito Rural") by the Brazilian governmentin 1995.As a part of the so called "ProgramaNacional de Fortalecimento da Agricultura Familiar" –PRONAF – (National Program to Strengthen FamilyFarming), it intends to provide better financial supportfor agrarian activities developed with the direct laborof the farmer and his/her family. Family farming in Brazilemploys 75 percent of the work force in rural areas,is responsible for 31 percent of all rice produced, 67percent of beans and 52 percent of milk. Family farmerswere also responsible for 1/3 of the 50 million tons ofsoybeans produced last harvest. Until the year 2000,the program produced around four million credit contractsand cost around ten billion reais (approximately4 billion dollars). The government announced aroundseven billion reais (2.8 billion dollars) to support familyfarming in 2004 and 2005.In order to collect data to analyze the impact ofthis project, questionnaires were handed to familieswith a family income of 220 dollars or less. These familiesowned small farms and had or not received financingfor the 2000/2001 crop. The survey involved2,299 small farms in 21 different municipal districts ineight different states (Alagoas, Bahia, Ceará, Maranhão,Espírito Santo, Minas Gerais, Santa Catarina and RioGrande do Sul) and showed a connection betweenPRONAF and both the increase of erosion and the useof pesticides. No positive associations were observedbetween PRONAF and actions to recover environmentallydeteriorated areas.The study recommended,among other things, that PRONAF should be mindfulof the possible human and environmental damagesconnected to productivist and technological actionsthat stem from the intensive use of pesticides.Therefore,the study recommended that PRONAF not onlyfinance production but also stimulate changes in theproduction system and diminish the dependence onforeign input products. Moreover, the study also observedno significant association between the programand the decrease of poverty in the households analyzed[Kageyama, 2003].The connection between the action carried outby PRONAF and the increase in erosion and use ofpesticides shows the lack of specialized technical guidancegiven to these farmers. This has also been observedin countless other studies [Moreira et al, 2002,Rozemberg & Peres, 2003] and poses elevated risksto human health and the environment.We shall latersee that this happens because the farmer is beingtransferred the responsibility over the correct use ofthis input.The use of the input usually requires specialattention that has not been given and has, thus, contributedto human exposure beyond acceptable levels.The model of chemical dependence adopted inBrazilian agricultural policies was first introduced inthe 60’s and boosted in the 70’s through the "PlanoNacional de Defensívos Agrícolas" (National Plan forAgrochemicals), which supported the modernizationof the rural economy [Augusto, 2003].The world’s expenditureson pesticides between the years of 1983and 1997 jumped from 20 to 34 billion dollars per year[Yuldeman et al., 1998].These pesticides contaminate,according to the World Health Organization, betweenthree and five million people per year. The picture iseven more concerning in developing countries such asBrazil, where the use of technologies based on the intensiveuse of chemicals occurs without clearly definedpolicies as to marketing, transportation, storage,use, safety measures and knowledge of the risks asso-119

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAciated to its use.Therefore, these countries consume20 percent of all pesticides used in the world and house70 percent of all patients contaminated with theseproducts.Latin America is the fastest growing region in theplanet in terms of pesticide use (approximately 120percent), mostly due to Brazil, which is responsible forhalf of the region’s use. Between 1964 and 1991, theuse of pesticides by the country jumped 276.2 percent.In the same period, the planted area grew only 76percent (MMA, 2000). Between 1991 and 2000, theconsumption of these products increased 400 percentand the planted area was increased in 7.5 percent[FAOSTAT, 2005].The country spent 28.4 million dollars importingpesticides in 1989 only, which is approximately five timesmore what was spent in 1964 (5.12 million dollars),when these products began appearing in the domesticmarket. Expenses with pesticide imports increased638 percent between 1990 and 2000, jumpingfrom 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 associatedwith the use of pesticides and consequently neglectbasic safety precautions, the widespread use ofthe products results in severe levels of human poisoningand environmental pollution observed in Brazil.This situation is worsened by a lack of constraints onsales, by heavy pressures from distributors and producersand by the social problems existing in underdevelopedrural areas. These problems are aggravated bythe absence of technical assistance and/or supervision.Farm workers are firmly blamed for the problem, worseningthe scenario of one of the most serious publichealth problems in rural areas, particularly in developingnations [Pimentel, 1996].In addition to the severity of many cases of poisoningin rural areas, nearby residents and possiblyeven urban dwellers are also being affected, due to environmentalpollution and residues in food.The impact caused by the use of these productsin rural workers in Brazil is reflected in data issued bythe Ministry of Health: In 2001, there were 7,900 casesof 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 thisproblem, as they are issued by Poison Control Centerslocated in urban hubs; these centers are not found inmany of the major agricultural areas, and are, therefore,of difficult access to rural communities.Some studies assessing occupational contaminationlevels by pesticides in Brazil, focusing on certainspecific aspects [Almeida & Garcia, 1991; Faria et al,2000; Gonzaga & Santos, 1992], showed human contaminationlevels varying from 3 to 23 percent.Taking thenumber of rural workers involved in ranching and farmingactivities in Brazil into account – estimated ataround 18 million (data from 1996) – and applying thelowest pesticide poisoning percentage reported in thesepapers (3 percent), the number of individuals contaminatedby pesticides in Brazil should hover around540,000, with approximately 4,000 deaths each year.Besides that, it is necessary to take into accountthe chances of long term exposure and effects such asendocrine disruption, effects on the nervous system,etc. which were not mentioned above.It is important to stress that, other than majorexporters, farming activities near large urban hubstend to be carried through in small-scale family farms,where children and adults work the land together.Thisplaces children and young people at significant environmentaland occupational risk for pesticide poisoning.This situation causes even more concern, sincelittle is known of the prolonged effects of these compoundson the developing human body or even on thehuman body under special circumstances (pregnancy,etc.).120

Observatorio Latinoamericano de Salud.In family farming, it is men, with significant involvementof children and young people, who do labor.Asto child labor, the participation of young women is alsosignificant. Surveys conducted in an agricultural areaof the state of Rio de Janeiro, in the southeast of Brazil(Table 1), presented some of the social, economicand cultural characteristics of rural workers in this region.Thepatterns are also observed in other regionsof Brazil.According to specific Brazilian Law (NR 7), whencholinesterase enzyme activity test results are lowerthan 75 percent of the reference value, tests should berepeated; if this figure is confirmed in the second test,the individual is considered possibly poisoned. Usingthis criterion to indicate poisoning, some 12 percentof adults and 17 percent of the children of the studiedgroup showed low levels of cholinesterase activity,which could represent exposure. The possibility ofpoisoning is not excluded.The improvement in the level of education isbeing noticed, as is the increase in use of certain basicprecautions for individual protection. However, it isclear that there is a large lack of training and guidancefor handling these substances.The fact that farm workers are properly trainedand guided associated with intensive marketing activities,places the responsibility for correct pesticide useand disposal solely on rural workers, which is leadingto human poisoning and environmental pollution.Therural workers’ low levels of education result in a seriouslack of awareness of the correct way of applyingthese products. Consequentially, they are almost completelyunable to comprehend instructions and thusimplement safety precautions. The industry exemptsitself of the responsibility over its aggressive sellingstrategies, casting the blame for an accident on the ‘unsafeprocedure’ of the worker.Final CommentsAdopting the neoliberal model of developmenthas worsened large national problems, particularly thehuge social and economic disparity. Complying with internationalagreements, especially when related to thedemands of the financial capital, is prioritized over fightingthe major structural problems of our society.Thefact that huge tracts of land remain in the hands offew, together with the constant inflow of technology,expels thousands of farm workers to the urban centers.Thiscontributes to a chaotic and accelerated urbanizationand a significant increase in unemploymentand underemployment. This, in turn, associated withthe lack of investments for maintenance or improvementof basic social infrastructure (such as housing, sewagesystems, access to healthy food, road conservation,etc.) or its deterioration has contributed to worseningthe country socially and economically.As stated in the book "A Opção Brasileira" (TheBrazilian Option): "what we need, most of all, is a culturalchange. With low self-esteem and an identity incrisis, we won’t be capable of building an environmentin which great ideas can blossom and options are madepossible. To ponder upon an alternative way is, inthe first place, to question once again which ends ourinstitutions and economy should serve. Specifying thefive principles we should be committed to should helpsolving the problem: commitment to sovereignty, representingour will, in face of ourselves and the world,to advance in the process of building the nation, seekingto attain enough autonomy in the process of decision-making;commitment to fraternity, in order tobuild a nation of citizens, eradicating all social exclusionsand the shocking inequalities in wealth, income,power and culture distribution; commitment to development,expressing the decision to put an end to the121

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATABLE 1SOME CHARACTERISTICS OF THE RURAL WORKERS IN THE STATE OF RIO DE JANEIRO, INTHE SOUTHEAST OF BRAZIL [MOREIRA ET AL, 2002]Age (average)Gender (%)Level of education (%)CHARACTERISTICUse of individual protection equipment: (%)MasksClothes (gloves, etc)Activities (% involved)PreparationApplicationHarvestTransportationReported contact of pesticide with skin (%)Received any kind of training in handlingpesticides (%)Reported symptoms after application (%f = frequently; s = sometimes and n = neverADULTS34.9 year (s.d =10.26)85.2 (masc.); 14.8 (fem.)< 4 years – 32.14-8 years – 64.9> 8 years – 337.7 (yes); 62.3 (no)8 (f); 3(a); 89 (n)5 (f); 2(a); 93 (n)82.388.996.562.398.647.847.8CHILDREN13.6 year (s.d = 2.37)69.7(masc.); 30.3(fem.)< 4 years – 19.84-8 years – 76.1> 8 years – 3.161.4 (yes); 38.6 (no)13 (f); 5 (a); 82 (n)8 (f); 3 (a); 89 (n)33.375.875.522.478.052.034.0tyranny of the financial capital and to cease being a peripheraleconomic force; commitment to sustainability,referring to the need of searching a new form of development,not based on any of the previous sociallyunfair and environmentally unfeasible models, in orderto form a link to future generations and; commitmentwith extended democracy, pointing at resettling theBrazilian political system, laying it in new broadly participativeand plural foundations, with the goal of reestablishingthe value of political functions on all levels.122

Observatorio Latinoamericano de Salud.REFERENCES● ALMEIDA,WF & GARCIA, EG (1991). Exposição dos trabalhadores rurais aos agrotóxicosno Brasil. Rev. Bras. Saude Ocup., 19, 7 – 11.● AUGUSTO. L.G.S (2003). Uso dos Agrotóxicos no Semi-árido Brasileiro. In: PERES, F. & MO-REIRA, 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 OpçãoBrasileira [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 DevelopmentIndexes – 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 PRONAF-Crédito,Agric. São Paulo, 50(2), 1-13.● LANCET (2002). Editorial, 360 (9342), October.● MMA (2000). Informativo MMA [Bulletin from the Ministry of the Environment], Número15. 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 BrazilianEconomic 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 douso 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 theTotal 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 productionlooking to the future. Food,Agriculture and Environment Discussion Paper 25.Washington:IFPRI.Available: http://www.ifpri.org/2020/dp/dp25.pdf123

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA13The Water Policies in Latin America:Between Water Bussines and Peoples´ResistanceAlex ZapattaWater policies and in general public management of water are determinedby two kinds of processes:a) Structural conditions of the economic and social formation of Latin-Americancountries ; andb) Economic accumulation model of our societies, which is currently expressedin neoliberal structural adjustment policies.Owing to the limits of the present work, the analysis will be centeredin the problems caused by the adjustment policies regarding water managementin Latin America.In the framework of the adjustment and stabilization policies fosteredby multilateral credit institutions (World Bank, Inter-American DevelopmentBank 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 throughoutLatin-America –including the firm and dignified exception of Cuba-To this purpose, the adjustment experts have recognized three types ofconstitutional and legal issues:a) The dominion over hydric resources. All through Latin-American legislation,water from the juridical point of view is characterized as "nationalgood of public use".124

Observatorio Latinoamericano de Salud.b) The right to the use and availability of water. WithinLatin-America, there are a variety of modes,which range from the granting of rights strongly regulatedby the State, to those whose concession isregulated by the logics of the market –the Chileancase being the most representative.c) The provision of public services derived from theavailability of water, such as those for irrigation, consumption,sanitation, hydroelectricity, etc. –whereinLatin-American legislation combines the possibilityof establishing services of direct provision (State)with the possibility of establishing services of indirectprovision (private enterprise).Subsequently, a synthetic revision of each one of thesethree levels is given.The Dominion over Water Resources"According to the majority of legislations consulted inLatin America, water water resources are acknowledged asgoods of public dominion, national goods, namely goodswhose dominion and use belong to the entire nation".[Cubillos,1994]"Moreover, the qualification of inalienable and notprescriptive is included in referring to water resources, signifyingthey neither can be sold, nor lose their juridic natureof national goods, even if there is a sustained use by privateindividuals through time." [Cubillos, 1994]The above mentioned declaration is normally inthe constitutional texts, Leaving the implementationto the laws that regulate water use.In this respect, it is suitable to underscore theconstitutional reform approved in Uruguay by way of areferendum. With the intention of preventing the privatizationof water and sanitation of public services,and affirming national sovereignty over water resources,important reforms to the constitutional text havebeen incorporated. Its core component indicates: superficialwater, as well as subterranean (with the exceptionof pluvial) integrated to the hydrologic cycle, constitutea unitary resource, subordinated to the generalinterest which is a part of state public dominion.The right to the use and availability of waterThe yielding of the right to the use and availabilityof water to individuals is executed by the State, bymeans of administrative actions (assignations, adjudications,concessions, authorizations, permits, licenses,etc.).These are conferred in terms of distinct criterions:priorities of use (human consumption, animalwatering, productive uses, etc.), water consumption(consuming, non-consuming), intensity of use (permanentor contingent), etc.These rights are defined by volume (liters persecond, generally) and by time (occasional, of determinedor undetermined length).Every granting of rights to the use and availabilityestablishes the object of that granting (for the supplyingof water in a certain locality, for the watering ofanimals of a particular herd, for the irrigation of a specificproperty, for the use of one factory, etc.).Frequently, the concession of the rights to theuse and availability of water occasions the obligation ofthe properties situated between the place of harnessingof water and the place where it is availed of. Thecited obligations are natural or forced.These rights are not absolute: they are conditionedby the fulfillment of definite regulations and criterions,whose inobservance may imply their loss (revocationis possible).125

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAThus far, these are (generally speaking) the attributesof the rights to the use and availability of waterwithin the different legislations of Latin America.The leading difference between a legislation thatguarantees a strong regulation of these rights by theState, and another whose orientation is that they beregulated by the market resides in the conditions andlimitations of the rights to use and benefit from water.Which are the characteristics that ensure a marketof rights to the water? As maintained by Holdenand Thobani, they are the following: [Holden y Thobani,1995]Negotiable Elements of the Regimesof Water Rights● They are secure and may be negotiated in accordancewith the guidelines established by an institutionaland legal regulating framework.● The rights over water are separated from the rightsover land, and thus may be negotiated independently.● In an ideal situation, it should be viable to sell therights over water to anyone, with any purpose, andat 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 andlegal 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 atprices freely negotiated.● Every so often countries impose restrictions, such as demanding that the buyer utilize water for the generalgood, 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 relativeto the quality of water, or concerning the maintenance the maintenance of a certain minimum volume withenvironmental and recreational purposes, as well as the non-impairment of the water rights of third partiesby the transactions of the market.● The negotiable water rights may be directed volumetrically, as a proportion of the volume, or of the volumeof 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 traditionalwater rights.● The rights are notarized in a public register.126

Observatorio Latinoamericano de Salud.● Every so often countries impose restrictions, such asdemanding that the buyer utilize water for the generalgood, or that these rights be sold exclusivelyto a public organization at a price determined by theState.●The owners of the negotiable water rights must abideby the laws and regulations, such as those relativeto the quality of water, or concerning the maintenancethe maintenance of a certain minimum volumewith environmental and recreational purposes,as well as the non-impairment of the water rights ofthird parties by the transactions of the market.● The negotiable water rights may be directed volumetrically,as a proportion of the volume, or of the volumeof water in a dam, or by a transfer.● The application may be effected using the samemeans and institutions that are used to regulate thetraditional water rights.● The rights are notarized in a public register.The mentioned elements, if incorporated intothe legal frameworks of Latin-American countries,would imply the recognition of the rights to the useand availability of water as real rights. Such is the layingout of Peruvian advocate Ada Alegre Chang, whoin line with the "hydric adjustment" believes that theattributes of the rights to the use and availability ofwater should be the same as those of any real right,specifically:● Rights over goodsWHAT ARE THE MAIN CHARACTERISTICS OF WATER RIGHTS?USETake possession,manageENJOYMENT ACCESS DEMANDTake advantage,to benefitSell, mortgage,transferRecuperateany lost goodRESOURCECHARACTERISTICSLEGALCHARACTERISTICSElaborado por Ada Alegre Chang.127

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA● 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 establishedthrough "concession" and "assignation"● They facilitate the creation of a market of rightsIn general, the civil legislation refers to real rightsas the ones that we have over something, not in respectto a certain person. Real rights are: dominion,inheritance, usufruct, use or inhabitation, active obligations,pledging, and mortgage. From these rights, thereal actions are derived 1In this sense, Chang asks , what attributes maythe rights to the use and availability of water have?Her answer is: rights to use, to benefit from, to disposeof, and to vindicate.[Chang, 2003]The provision of public services derivedfrom the availability of waterOne of the axes of the policies of structural adjustmenthas been to privatize public services. Thisprocess, though with nuances has been verified in themajority of Latin-American countries.ADMINISTRATION CONTRACTSCartagena de Indias (Colombia)Lara (Venezuela)Monagas (Venezuela)DISPLAY CASE EXPERIENCES OF THE IADBCONCESSION CONTRACTSLa Paz (Bolivia), Montería (Colombia),Buenos Aires (Argentina), Santa Fé (Argentina)Guayaquil (Ecuador)SELLINGGeorgetown (Guyana)Pereira (Colombia))SELLING OF ASSETSSantiago de ChileValparaíso (Chile)To orchestrate such policies, it was necessary toreform the corresponding constitutions and laws becamenecessary. In the new constitutional and legalframework it is established that the provision of publicservices, 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. Inthis case, several legal mechanisms have been provided:the transformation of public companies into mixedcompanies; or the concession and privatization ofpublic companies, etc. The modes have varied fromone sector to another and obviously from one countryto another.To demonstrate the diverse options -whichcould be labeled "personalized"- of privatization of potablewater and sanitation services, the Inter-AmericanDevelopment Bank exhibits the menu of "successful"experiences to be imitated: [Traverso, 2004]1.Artículo 614 del Código Civil ecuatoriano.128

Observatorio Latinoamericano de Salud.The free trade treaties and waterThe contingent constitution of an Area of FreeTrade of the Americas would entail a dramatic accentuationof the "hydric adjustment" within the Region.In the matter of water, the principles of "free trade"wielded by the United States are oriented towards2 :● The constitution of a continental water market thatwould contain the possibility of exporting it.● The incorporation of commercial mechanisms tendingto the loss of public control over water by theState.● The favoring treatment to North-American companies,similar to the one donated to any national, publicor private company, which wants to avail of waterwith commercial ends.Although the possibilities of implementation ofthe Area of Free Trade of the Americas seem each timemore remote –owing to popular resistance throughoutthe continent, as well as the rise of governmentsof left-wing tendency within Latin America-, thefact that those principles are integrated in the texts offree trade treaties –the "TLC" (Treaty of Free Trade)-that the United States is subscribing with the countriesof the Region should not be overlooked.Under the same tendency of water commerce isthe General Agreement of Trade of Services of 1994by the World Trade Organization, which estimated thelucrative world market of services in 3,5 trillion USDin health; 2 trillion USD in education; and 1 trillionUSD regarding water 3 .Popular Resistance to the"Hydric Adjustment"In the menu of the IADB (Inter-American DevelopmentBank) inserted previously, there is no reference,obviously, to the rejection provoked by the privatizationof the sector of water provision in El Alto (Bolivia),where recently a popular uprising was generated,which demanded the expulsion of the company "Aguasdel Illimani", subsidiary of the multinational Suez –Lyonnaise. Neither there is any allusion to the rejectiongenerated by the presence of the company"Aguas del Tunari" subsidiary of another multinationalBechtel in Cochabamba, Bolivia. This popular rejectionwas manifest through a formidable uprising that mana-PRIVATIZATION OF THE WATERSERVICE IN COCHABAMBABOLIVIA● Privatized in 1999, concession for 30 years● Beneficiary company: "Aguas del Tunari" withthe capital of Bechtel (USA)● Increase in the tariffs (200%)● Investments not fulfilled● Peasant water sources usurped● Contract does not respect the presence ofdistrict local systems of harnessing and distributionof water. Bechtel is expulsed in April,2000, as the result of a social revolt● Currently, a trial is discussed within the CIADI(World Bank)Elaboración: Juan Carlos Alurralde (2004)2. Taken from the paper of Maude Barlow published in the Internet under the title of "El ALCA una amenaza para los programas sociales, la sostenibilidad del medioambiente y la Justicia Social en las Américas". Revista CONTRAPUNTO. Red SAPRIN. Número 9. Quito, 2001.3. Campaña "Agua para todos". Public Citizen: www.wateractivist.org129

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAged the expulsion of the "concessionary" company.Consult the index card in page131.Moreover, the menu of the IADB does not mentionthe process the Argentina underwent during the90’s. This process of privatization of public servicesdeserved the ensuing commentary of an Argentineanerudite:The most exhaustive process of privatization of theregion has been enforced in Argentina, and now we are witnessingthe consequences: companies that did not fulfill investments;increase in tariffs; and millionaire demands beforethe CIADI by virtue of the existence of the BITs.[Fairstein, 2004]The CIADI is an instance of extrajudicial resolutionof conflicts between transnational companies andthe states, receptors of the investments of those companies.The CIADI pertains to the sphere of the WorldBank. The resolutions of the CIADI, as obviously couldbe expected, by and large are favorable to transnationalcompanies.If we should revise the cases submitted to theCIADI regarding conflicts derived from the State andthe companies which benefited by the privatizationprocesses during the "menemato" (Menem’s presidency),it may be appreciated that 19% of the cases arerelated to water services and sanitation. Refer to thefollowing chart in the next column [Alurralde, 2004]The government of Néstor Kirchner began aprocess of re-nationalization of water services whichwere transferredin concession by the government ofMenem. Evidently, the process of re-nationalization isnot as simple as one should desire....within those places where service shifted from privateto public hands, as in Tucumán (very similar to whatoccurred in Cochabamba in terms of the provision of theservice), due to the lack of financing, companies once moreplunge into the logic of the IADB and the World Bank,which condition the granting of loans to a series of termsin the line of privatization. [Fairstein, 2004]CASES SUBMITTED TO THE CIADI,WHICHIMPLICATE THE ARGENTINEAN STATESERVICESPetroleum and gasElectricityPortsWater and sanitationData processing servicesOthers not privatizedTotalSource: Juan Carlos Alurralde (2004)Then again, it is to be assumed that the IADBand the World Bank would rather keep absolute silencein front of the astounding success of the Uruguayanpeople, who won the popular consultation to reformthe Political Constitution of the eastern country, wherebyan important overturning of the national policiesconcerning the water and sanitation sector is guaranteed.On October 31st of 2004 more than 60% of thecitizenry voted in favor of the project of ConstitutionalReform promoted by the National Commission inDefense of Water and Life. On account of the relevanceof this popular achievement, subsequently is thetranscription of the text of the Reform included in theUruguayan Constitution:Article 47.To be included:PERCENTAGE37%22%3%19%6%13%100%Water is a natural resource essential to life.The accessto potable water and the access to sanitation constitutefundamental human rights.1) The national policy of Water and Sanitation will be basedon:130

Observatorio Latinoamericano de Salud.a) the organization of territory, conservation and protectionof the Environment and the restoration of nature.b) the sustainable management, jointly responsible for futuregenerations, of the hydric resources, and the preservationof the hydric cycle, which represent issues ofgeneral interest.The users and civil society will participatein all the instances of planning, management andcontrol of hydric resources, establishing the hydrographicwaterheds as the basic units.c) the institution of priorities for the use of water by regions,waterheds, or parts of them; being the supplyingof populations with potable water the first priority.d) the principle by which the provision of potable waterand sanitation services is to be executed must be thatof putting before the reasons of social nature to theones of economical nature. Every authorization, concession,or permit that violates these principles in anymanner is to be considered without effect.2) Superficial water, as much as subterranean, with the exceptionof pluvial, integrated to the hydric cycle, constitutea unitary resource subordinated to the general interest,which is part of the state public dominion, as hydricpublic dominion.3) The sanitation public service and the water supply publicservice for human consumption will be provisionedexclusively and directly by state legal entities.4) The law, through the three fifths of votes of the totalcomponents of each chamber will be able to authorizethe provision of water to another country, when this isleft without supplies, or for solidarity reasons.Article 188.- To be included:The dispositions of this article (as regards the associationsof mixed economy) will not be applicable to the essentialservices of potable water and sanitation.Transitory and Special Dispositions.- To be included:Z’’) The reparation corresponding to the enforcement of thisreform 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 "hydricadjustment" in Latin America could be made, fromthe experiences on communitarian management ofwater systems and conservation of hydric resourcesby populations throughout Our America, the Ecuadorianexperience of the Forum of Hydric Resources, theexperience of great mobilizations of activists withinMexico, Central America, Brazil,Argentina, and the experiencesof insurrectional trait in Bolivia, to the Uruguayanexperience of constitutional reform.A Latin-American Platform to Confront"Water Adjustment"In August 2003, in San Salvador (El Salvador), organizationsand social movements throughout LatinAmerica, Canada, and the United States left a recordof their rejection of the processes of privatization ofwater resources and water services, putting forwardat the same time these proposals:1.The management of water resources must be basedon fundamental principles, such as social justice, sustainability,and universality.2.Water is a public good and an essential and inalienablehuman right, which must be promoted and protectedfor everyone.3.Water is not merchandise, and no person or entityhas the right to get rich at its expense, consequentlywater must not be privatized.131

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA4.Water must be protected from all contaminating humanactivities, particularly mining and industrial andagroindustrial processes. The protection of ecologicalsystems and the integral managing of the resourceis imperative.5. Water must be totally excluded from the negotiationsof the World Trade Organization, the Area ofFree Trade of the Americas, and the Treaties of FreeTrade, 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 arebeing implemented, as the mega-dams, which areneither ecologically nor socially sustainable; thus, alternativesmust be sought that respect the rights ofpeople and communities, ensuring a full social participation.7. On acknowledging the existent inequity betweenmen and women with regard to the access to, themanaging of, and the rights over hydric resources andpotable water, policies and forms of practice that eliminatethe mentioned inequities must be developed.8. A future with assured availability of water dependson recognition, respect, and protection of the rightsof indigenous, peasant, and fishing populations, andof their traditional knowledge.9. It is demanded that public water systems be protected,revitalized, and reinforced, in order to amelioratetheir quality level and efficiency. The participationof workers of both sexes and the community mustbe guaranteed within all of them, so as to democratizedecision making, and to make certain the transparencyand giving of accounts.10. In the case of communitarian systems of water, urbanand rural, political policies that support the economic,social, and environmental development andsustainability of these projects must be formulatedand instigated, respecting the autonomy and rightsof communities.11. Rejection to the conditioning imposed by internationalfinancing organizations to grant loans directedto the management of water, violating the sovereigntyof our peoples.Thus is the platform to confront the "hydric adjustment",from the viewpoint of popular organizations,social movements and progressive sectors of allof Our America.AGUASDicen que el agua será imprescindiblemucho más necesaria que el petróleolos imperios de siempre por lo tantonos robarán el agua a borbotoneslos regalos de boda serán grifosagua darán los lauros de poesíael novel brindará una cataratay en la bolsa cotizarán las lluviaslos jubilados cobrarán goteraslos millonarios dueños del diluviovenderán lágrimas al por mayorun capital se medirá por litroscada empresa tendrá su remolinosu laguna prohibida a los foráneossu museo de lodos prestigiosossus postales de nieve y de rocíosy nosotros los pálidos sedientoscon la lengua reseca brindaremoscon el agua on the rocksMario Benedetti132

Observatorio Latinoamericano de Salud.REFERENCES● ALURRALDE, JUAN CARLOS (2004). Ponencia presentada en elTercer Encuentro Nacional del Foro de los Recursos Hídricos.Quito, Noviembre.● ARTÍCULO 614 DEL CÓDIGO CIVIL ECUATORIANO● CHANG, ADA ALEGRE (2003). Ponencia presentada en el Forode las Américas. La Paz, Diciembre.● CUBILLOS, GONZALO (1994): "Bases para la formulación de leyesreferidas a recursos hídricos". CEPAL. Santiago de Chile.● DECLARACIÓN DE SAN SALVADOR "POR LA DEFENSA Y ELDERECHO AL AGUA" (2003).Agosto 22.● FAIRSTEIN, CAROLINA (2004). correo electrónico.● HOLDEN Y THOBANI (1995). Citado en un documento del BIDelaborado por GARCÍA, Luis E.: Manejo integrado de los recursoshídricos en América Latina y el Caribe. Informe Técnico WashingtonDC., 1998.● TRAVERSO,VÍCTOR (2004). Ponencia presentada en nombre delBID, Quito.133

Cultural Agresi nUniculturality and Health

Observatorio Latinoamericano de Salud.14The "Zapatista" Struggle and Health:Cultural Aggression, Discrimination andResistance as Triggers of IndigenousPotentialitiesCatalina Eibenschutz y Marcos AranaAntecedentsThe uprising of the "Zapatista" Army of National Liberation ("Ejército Zapatistade Liberación Nacional,"or EZLN) in January 1994 surprised the worldfor multiple reasons: for being primarily indigenous; for its impressive originality;for using weapons in a different manner; and for making the most of moderncommunications technology. Moreover, it challenged the government and requestedthe resignation of President Carlos Salinas, declared War on the MexicanArmy, it revealed itself against the taking over of political power??, and addressedcivil society as its foremost interlocutor.A lot was rumored throughout the country about its origin, however theserumors disappeared gradually while it’s the EZLN struggle advanced and dialoguewas accepted. Armed war was substituted by a low intensity combat strategy.Eleven years after, the "Chiapaneco" indigenous people and several othersin other countries continue to struggle for their acknowledgement as peoplewith proper identity. The "Zapatista" Army of National Liberation remains thereference 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 theirincorporation to the mestizo (mixed parentage) culture [González Esponda andPólito, 1995; González Casanova, 1995; Harvey, 2000; Barabas, 2000]. Among the135

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAdemands of the "Zapatista" Army of National Liberationone must highlight the need for recognition oftheir own identity and culture, the acknowledgementof their autonomy (without separation) and free determination,[Blanco, 1996] the right to housing, healthand territory, etc. Their struggle had a impact worldwideagainst neoliberalism, and their phrases becamefamous: "Enough! A world wherein all worlds fit! Torule obeying! Everything for everyone!"So, two rationalities were openly confronted -the neoliberal logic of exclusion and the indigenous logicof inclusion-.The neoliberal, based on markets, generatedillnesses, and the indigenous struggle, based ondignity struggled for health.What has happened today to the "Zapatista"Army of National Liberation? Subcommander Marco’scommuniqués are not as frequent as they were inyears past; there are no more headlines that occupyfirst 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 enhanceorganization around their autonomy and theBoards of Good Government (JBG).Our PurposeIn the course of this work, we purport to describeand analyze the unexpected tensions, contradictionsand results of the social and sanitary struggle ofthe "Zapatistas" and of non-indigenous citizens, as ourselves,who accompanied closely the struggle forhealth of the "Zapatista" Army of National Liberationand the "Zapatista" Movement in Chiapas. Note:Whyis Zapatistas always in quotes? It minimizes its importance.In particular, we set out to delineate a broad accountof the main facts of the struggle for health thatstarted with the "Zapatista" uprising. The concerns,which guided our experience and our reflection, are asfollows:● What happens to health when people decide to takecharge of their own history 1 ?● What tensions arise, how are they solved, and howare they surmounted?● What did the resistance policy signify concerning therestatement of public policies?● How have the actions of some agents influenced the"Zapatista" struggle for health?It is essential to appreciate that the struggle forhealth has been constant within the indigenous populationof Mexico for many years. Indigenous peoplehave been the victims of discrimination, were excludedfrom the "Mestizo" (mixed parentage) National Projectproposed by the Mexican Revolution in 1910, and(with few exceptions) have been excluded from thenational public health system as well.In the state of Chiapas--more concretely in thezone of the "Lacandona" Jungle-- "health promoters",trained by all types of institutions: universities, theHealth Department, civil organizations, the church,etc. were in charge of medical care. The indigenouscommunities constructed their own clinics and healthcenters several years before the "Zapatista" uprising.Furthermore, the vindications presented in the FirstDeclaration of the Lacandona Jungle [EZLN, 1994] regardinghealth were a product of the participation ofthese communities themselves, which had alreadybeen investing and working on their health care.1.We understand taking charge of their own history as having a sense and a project of future, put forward starting from their own history.136

Observatorio Latinoamericano de Salud.There are a small number of published studieson the health situation of the "Zapatista" indigenouscommunities. However, due to the condition of povertyand marginalization in which they live and the absenceof health services, these data were rather unreliable.One of the first specific studies published afterthe uprising [Blanco, Rivera & López, 1996] qualifiestheir situation as of permanent emergency.Possibly the best health diagnosis was profiled bySubcommander Marcos on January 18th of 1994, only16 days after the uprising, in its communiqué named:"For what are they going to pardon us?""Who must ask for forgiveness and who ought togrant it? Is it the ones who during years and years sat beforea full table and satiated, while we sat before death; soquotidian, so proper that we ended up not fearing it…Thedead 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 democraticallydied of sadness since nobody did anything…….with noone pronouncing at last: ENOUGH!…….? Who must askfor forgiveness and who ought to grant it? SubcommanderMarcos, 1994.After The UprisingIt is necessary to remember that the armed confrontationslasted only twelve days (from January 1stto January 12th of 1994), owing to the fact that duringthis period there were important manifestations of civilsociety 2 in which President Carlos Salinas was urgedto suspend the war and sit at the dialogue table.The "Zapatista" Army of National Liberation acceptedthe suspension of armed actions to maintain dialogue,at the same time that it initiated a process of interlocutionwith civil society.In March of 1994, the "Zapatista" Army of NationalLiberation and the government established a seriesof peace dialogues in the Cathedral of San Cristóbalde las Casas. It seemed at the outset a promising, unquestionablyconstituted, and valuable forum for peoplefrom all over the country to participate and let theentire world know the indigenous nature of the movementand the validity of its demands. Nevertheless,the murder of the candidate of the Institutional RevolutionaryParty, who was running for President of theRepublic, precipitated the "Zapatista’s" distrust and thefailure of dialogue. As a response to this new situation,the "Zapatistas" launched a new offensive. Though inthis occasion it was about an appeal directed to its base(sympathizers of civil disobedience), which hasconstituted, the most recent fighting strategy of the"Zapatista" Army of National Liberation:"We will accept nothing that comes from therotten heart of the bad government, not even a coin,medicine, a grain of food, or the scraps of charity it offersin exchange for our worthy going. We will receivenothing from the supreme government. Even if ourpain and distress increase; even if death still accompaniesus at our tables, our beds and the earth; even ifsorrow cries in the rocks. We will accept nothing. Wewill resist…". 3 [EZLN, 1994]As an almost immediate result, health personnelof 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 againstthe 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 locationsseverely attacked by the Army.3. "Zapatista" Army of National Liberation, Second Declaration of the Lacandona Jungle, June of 1994.137

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAciety organizations to support the establishment of ahealth care system without governmental participation.The strength of the civil resistance embodied aformidable force of great propagandistic efficacy; impossibleto confront by arms. It is not disproportionateto affirm that currently the capacity of pressure andnegotiation of the "Zapatista" Army of National Liberationresides quite exclusively in its resistance, whichhas placed its military capacity as a secondary position.[Arana, 1999]The efficacy of this strategy consists primarily ofthe incapacity of governments to confront or restrainit. This form of pacific struggle constitutes the essenceof what some have called biopolitics (geopolitics??),which progressively has been adopted by numerousgroups 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 environmentalistand those who oppose market monopolyglobalization. Their struggle at the same time feeds intoand reinforces the "Zapatista" discourse of resistance,and proffers a platform of international support.The force applied by the Federal Army had acounterproductive effect, since civil resistance keptgaining strength and legitimacy, while controls, patrollingand military posts augmented.Nevertheless, on February 9th of 1995, ErnestoZedillo, president at the time, ordered a military operationof great importance, which generated a strongpresence of the Army within indigenous communities.Subsequently, the Zpatistas lost territorial controlover several regions of Chiapas.The government justifiedthe installation of innumerable military posts andcontrol stations, adducing the necessity to protect thepopulation-- which had moved out of the region in thebeginning of 1994 due to fear of confrontation. Thispopulation returned in March of 1995 accompanied bya strong military operation 4 . Once the Army, positionedfirmly in the conflict regions, laid siege to the "Zapatista"localities, a strategy of counterinsurgencycommenced.This was based on the usurpation of functionsof health, education, public institutions, and thecontrol of social expenditure in the region. With thisstrategy of a low intensity war, the actions concerninghealth, nutrition and education were usurped. In theface of the "Zapatista’s" rejection, which had declaredresistance, public funds were directed to the populationwilling to accept them, and this occasioned serioustensions among the inhabitants of the region[Arana, 1988]. This excluding development plan wasthe core strategy of the federal and state governmentsto confront "Zapatismo" until the year 2000, and itsconsequences were more devastating for the populationthan the sum of all the military actions.Another effect of this policy was that a largenumber of localities suffered internal ruptures, manifestedas violent actions, expulsions and divisions. Themilitary presence and its discriminatory behavior promotedviolent responses against the resisting population,including the formation of paramilitary groups.Until the year 2000, the regions in conflict werethe scenarios of constant violations of the principle ofmedical neutrality, and the discriminatory execution ofsocial programs, which violated the International Pacton Economical, Social and Cultural Rights, and otherinstruments 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 about1500 families remained displaced until February of 1995 and were assisted by public institutions coordinated by the Army. The "Coordinator of Civil Organizationsfor Peace" denounced repetitively the deliberated disinformation of the ones displaced on the course of the conflict and the use of health and nourishing actionsto encourage a favourable and dependent attitude of them towards the actions of the Army. (CONPAZ, Informe de la Comisión de Derechos Humanos sobre lascondiciones de los desplazados por el conflicto, Noviembre, 1994).138

Observatorio Latinoamericano de Salud.In spite of this, the "Zapatista" Army of NationalLiberation continued to count on the resolute supportof national and international civil organizations which,regardless of the blockade attempt maintained by thegovernment, persisted in the health care attention ofthe "Zapatista" indigenous populations of the zone.In the year 2000, during the first transparentelections of Mexico (won by the right wing party of VicenteFox), the "transition to democracy" allowed the"Zapatista" Army of National Liberation a respite andnew hope. Effectively, President Fox conveyed theproject law on Indigenous Culture and Rights to bediscussed in Congress. However, the resulting law didnot correspond to the principles of acknowledgementof indigenous peoples, among numerous issues, andwas not accepted by the "Zapatista" Army of NationalLiberation nor the "Zapatista" movement.As a reply to this "new treason" of the State, the"Zapatistas" decided to retreat to their territories, andcontinue their struggle from there. With a doubleidentity as Mexicans and as indigenous peoples, theydedicated themselves to constructing their autonomyin practice. The same year, the first elected Governorsince the military uprising took possession (withoutthe participation of the "Zapatistas") of Chiapas. Althoughthis fact did not lead to the resolution of theconflict, it has contributed to create an atmosphere ofless violent confrontation.Resistance and Public PoliciesThe decision to refuse the governmental resourcesand programs, particularly those related to healthand education, as part of the resistance policy, was ofgreat concern for various members of the academyand civil organizations. This was condensed in twoproblems: on one side, the negative impact that the interruptionof health actions could yield--chiefly vaccinationand care for women and children. On the otherside, the fact that the voluntary rejection of publicresources would not contribute to promoting the necessarydemand of their economic and social rights inface of the State, namely a mode of kidnapping of theircivil rights.Nonetheless, even if the intention of the "Zapatistas"never was to influence health policies by meansof resistance, their impact over them has been veryimportant, given that after the year 2000 some programsof the government of Chiapas have incorporatedthe concept of rights and the explicit commitmentnot to discriminate or cliental use of patients. The inclusionof this focus has played a part in reducing thetensions generated throughout several years betweenthe "Zapatista" and "non-Zapatista" population.One of the factors that added to this change wasthe Alternative Report of Economical, Social and CulturalRights, which the Committee of the United Nationsand national civil organizations elaborated in1999. This report included a special chapter on Chiapas,in which military interference in the health programsand the negative effects of the counterinsurgentuse of public resources was described. As a result ofthis alternative report 5 , the Committee of Economical,Social and Cultural Rights of the United Nationsmade 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 vigilanceof public policies with a valuable instrument.Presenly, the interference of the army in health actionshas practically disappeared.5. Espacio Civil de los Derechos Económicos, Sociales y Culturales, Informe Alternativo sobre la situación de los DESC en México, México 1999.6. Comité DESC de la Organización de las Naciones Unidas, Recomendaciones del Comité DESC al Gobierno de México, Ginebra, Noviembre, 1999.139

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAKnowing how the evolution of health conditionshas been since the uprising of 1994 is not simple, notonly due to the bias in presenting and interpreting theepidemiological information available, but for the reasonthat during the first years after the uprising, the informationof broad regions of Chiapas, ones of majorpoverty, were not included within official statistics.Thiscreated a false appearance of general improvement.The consequences regarding health throughoutthe first years of the conflict were extremely negative,albeit quantitative evidence is basically nonexistent.Conversely, national and international civil organizationspresent in the region could verify the deteriorationof the nutritional state of those displaced followingthe Massacre of Acteal in 1997, and the incrementincreases in numerous transmissible illnesses.The major part of that information nonetheless refersto the displaced or circumscriptive populations. Onaccount of this apprehension, between 1999 and 2002a wide-ranging study was undertaken in which healthconditions of the population in resistance were contrasted.It received official public services in three regionsof Chiapas: Los Altos, the North Region and theJungle Region. The study was developed at the domiciliarylevel in 46 localities selected randomly as a sampleof the communities in resistance.. [Sánchez,Arana,Ford, Brentliger, en prensa]On contrasting the health conditions of the populationin resistance and the general population, itwas revealed that the worst health conditions werenot from those who had rejected public health services,but of those who live in divided communities. Thisfinding was consistent throughout the study. Forexample: in the case of chronic undernourishment rates(small height in proportion to age), the rate amongminors of communities in resistance was 48.6%; therate of groups without resistance was 52.2% and thatof the divided groups was 58.6%; significantly higher inthe latter.In the same study, eight maternal deaths wereidentified, six of which corresponded to localities withoutresistance. The other two were in divided communities,and none were in localities in resistance. Therate of maternal deaths was calculated starting fromthe 1319 life born studied?. Additionally, a mortalityrate of 60.7 per 10,000 live born was obtained; this ismarkedly superior than the one indicated by officialstatistics in the country and in Chiapas. [Brentlinger,Sánchez-Pérez, y otros, en prensa]Malnutrition and maternal death rates coincidewith other studies and observations, in that the healthsituation of indigenous populations in these regionscontinues to present serious lags. This situation is notworse anymore within localities with resistance, wherepeople have compensated for the lack of servicesthrough organization. The contrary happens in communitiesthat have two or more distinct authorities asa consequence of internal divisions. Throughout these,the health situation has deteriorated because ofthe rupture of social texture and the disappearing ofmechanisms of reciprocal support, both features of indigenouspeasant societies of the region.One of the aspects not sufficiently evaluated thatcould be cause for difference among communities inresistance and the ones not in resistance, is the prohibitionof the selling and consumption of alcohol anddrugs in the Zapatista communities. The decrease ofdomestic violence and the nutritional improvementwithin families are also two important indicators thatare certainly demonstrative of the positive changes inthe health of communities in resistance.The organization around autonomous municipalitieshas intensified communitary actions, stimulating agradual improvement of life and health conditions inthese localities.Creating an atmosphere of ease, tolerance andsocial inclusion is considered indispensable for solvingthe crisis of divided communities.The more civil, paci-140

Observatorio Latinoamericano de Salud.fic, propositional, and inclusive nature attained by autonomousmunicipalities, undeniably will be a significantcontribution for communities suffering internaltensions to solve their conflicts.Within communities in resistance where healthstructures have gained a strengthened position attributableto organizational capacity, people avail themselvesof the official hospital structure and take advantageof other resources, such as vaccines, controllingtheir application by themselves.Presently, "Zapatistas" are constructing their Autonomyas the finest manifestation of the principlethey have fought for: "taking charge of their own destiny"."Zapatista" AutonomyAs any other indigenous autonomous process,the "Zapatista’s" acquires two dimensions: as a modelthat aspires to become a law and as a form of practiceof a new collective subject [Rico, 2004]. This formof practice is the one, which has led to the constructionof these autonomies and the regaining of controlof their lives and health in the "Zapatista" territory.According to Héctor Díaz Polanco (1997: 15),the Indigenous Movement of Latin America prioritizedamidst its objectives and aspirations the struggle forautonomy, and it is precisely this the key to multiethnicStates, which guarantee the acknowledgement ofdiversity without separation from the State.The "Zapatista" struggle for the acknowledgementof Indigenous Autonomy within National Legislationfailed in the Congress of 2001 with the final approvalof the so called Indigenous Law, which did notinclude autonomy or recognition of the IndigenousPeoples; thus, the "Zapatistas" decided to construct itby means of concrete resistance and facts.The Rebellious Autonomous Municipalities managetheir territories in line with their organizationalforms and communitarian assemblies, and they regulatetheir process by revolutionary laws and their ownform of government. In August of 2003, the Municipalitieshad already begun constructing conforming regions,building of the so called "Snails" as their physicalspace and the Boards of Good Government as theirsocial space.Snails are programmed regions, becoming thepolitical frame of regional development and territorialorganization. The "Zapatista" Snails are doors to enterthe communities and for communities to exit.Openings to see inside and from which to project integration,so that communities are not isolated fromthe global world. The "Zapatista" Snails are a furtherstep in Autonomy, in cohesion and in the coordinationof the movement by regions, where autonomous principlesmay share their experiences and work.The Boards of Good Government have as theirobjective to promote equitable development of all themunicipalities. They are composed of one or two delegatesfrom each Autonomous Council of the zone,and their headquarters are the ‘Snails’. These aid in thecoordination of work in all regions, though the MA-REZ ("Zapatista" Autonomous Municipalities) continueto have their own dynamics in the implementationof: justice, health care, autonomous education, housing,land, commerce, information, culture and local transit.The Boards of Good Government ensure thatthe resources reaching the national and internationalcivil society are used in the equitable development ofall the municipalities, and solves and mediates the conflictswithin communities in the regions as well. TheSnails are an organizational effort of communities notonly to face the problems of autonomy, but to build amore direct bridge between them and the world. [Rico,2000:22]141

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAFinal ReflectionsOnce the Indigenous Law approved by the Congressleft out the propositions that the "Zapatista"army of National Liberation had compelled, or theacknowledgement of autonomy, the "Zapatista" indigenouscivil bases decided, still without official recognition,to proceed in the construction of the AutonomousMunicipalities, or the Boards of Good Government.The organization and effort this task has demandedhas reinforced the nets of mutual support, whichthemselves promote equity and have a positive impacton health. For example, the training of midwives andhealth promoters adds force to the successful experiencesof several indigenous communities anterior tothe uprising, and makes them available to the developmentof a project of more ample reach.The construction of health clinics sponsored bynational and international solidarity are more thanstructures of general care and educational centers ofhuman resources; they are structures that strengthenthe organizational capacity and fortify the population’sappreciation for what they have.However, what is unquestionably more importantis the process of self-assurance in their capacities("empowerment") to direct their future destiny, whicheventually produces the amelioration of health conditions,in spite of the adversity that surrounds them."We have intelligence and capacity to direct ourown destiny."Board of the Good Government ofan autonomous municipality(H. Bellinghausen)In his article of La Jornada January 2nd, where hedevelops a report of the celebration of the 11th Anniversaryof the "Zapatista" uprising and the declarationsof the Board of the Good Government.8. Municipios Autónomos Zapatistas142

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.● BARABAS,A (2000). "La constitución del indio como bárbaro: de la etnografía alindigenismo". Rev.Alteridades.Año 10. num. 19, enero-junio. UAM-I. México, pp.9-20.● BLANCO F.,V (1996). "La cuestión indígena y la reforma constitucional en México".Revista Internacional de Filosofía Política. pp 121-140. México.● BLANCO GIL, J., RIVERA, J.A.Y LÓPEZ ARELLANO O (1996). "Chiapas. La emergenciaSanitaria Permanente" Rev. Chiapas Nº 2. Ed. ERA.. México, pp 95- 115.● BRENTLINGER P, SÁNCHEZ-PÉREZ HJ, ARANA CEDEÑO M, VARGAS MG,HERNÁN, MA, MICEK M, FORD D (En prensa, 2004). Pregnancy outcomes, siteof delivery, and community schisms in regions affected by the armed conflict inChiapas, Mexico.A community-based survey. Social Science and Medicine.● EZLN (1994). "Declaración de la Selva Lacandona" en: EZLN. Documentos y Comunicados.Vol.1. Del 1º de enero al 8 de agosto 1994. Ediciones ERA, México,pp. 33-35.● FOUCAULT, M (1994). La politique de la santé au XVIII siècle. Gallimard, Paris, p.729.● GONZÁLEZ CASANOVA, P (1995). "Causas de la Rebelión en Chiapas" La JornadaSemanal, 5 septiembre 1995. México. D.F.● GONZÁLEZ ESPONDA, J. y PÓLITO, E (1995). "Notas para comprender el origende la rebelión zapatista". Revista Chiapas, no 1, pp 101-123. ERA, México.● HARVEY, N (2000). La Rebelión de Chiapas. La lucha por la tierra y la democracia.Ed. ERA. México.● RICO MONTOYA, N.A (2004). "Naciones Indias Estado Nación Autonomía Zapatista"Ensayo del tercer trimestre Maestría en Desarrollo Rural UAM-X. México.● SÁNCHEZ, H.J,ARANA, M, FORD, D. BRENTLIGER P, y otros, Salud y conflictoen Chiapas: un análisis de las condiciones de salud y el uso de servicios desdeuna perspectiva de los derechos humanos. Informe elaborado por Physicians forHuman Rights, Ecosur y la Defensoría del Derecho a la Salud, en prensa.● SUB MARCOS (1994). Comunicado ¿De qué nos van a perdonar? En: La palabrade los armados de verdad y fuego Editorial Fuente Ovejuna. México, pp. 107-108.143

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA15Communication Hegemony andEmancipatory Health:An Underestimated Contradiction (TheCase of Dengue)Charles L. Briggs, Clara Mantini BriggsHealth constitutes a crucial link between neoliberal political-economicchanges and their deleterious effects on the lives of most of the people onthe planet.The rise in infectious and chronic diseases associated with the growingconversion of health from human right to commodity and the withdrawalof the state from one of its classic functions—safeguarding the health ofits citizens—is a key means by which global structural changes become bodilyexperiences. Mainstream medicine and public health in the United Stateshave just begun to face the issue of "health disparities" directly, particularly afterthe publication of the influential report, Unequal Treatment [Smedley,Stith, and Nelson, 2002], and the establishment within the National Institutesof Health of a National Center on Minority Health and Health Disparities.In Latin America, the social medicine and critical epidemiology movementshave drawn attention to the dialectical relationship between health-diseaseand reproduction of unequal control over capital and power for morethan three decades, and they have scrutinized the effects of neoliberal policiesand their structural adjustment programs on health and related sectors[Armada, Muntaner, and Navarro, 2002; Laurel, 2000].These scholars have demonstratedhow social class, gender, and race/ethnicity are not simply factorsthat influence individual health outcomes but structural inequalities that sha-144

Observatorio Latinoamericano de Salud.pe our ability to imagine and achieve health [Breilh,2002; Menéndez, 1981; Navarro, 1998]. Challenging thepower of "hegemonic epidemiology" to produce seeminglyobjective pictures of people and health, theydeveloped innovative quantitative and qualitative methodologiesthat reveal the suffering obscured bymainstream approaches and analyze its multiple causes[Breilh, 1994;Almeida Filho, 1989]. Finally, critical practitionershave challenged the prevailing reductionismby examining medicine and public health as ideologicalsystems that transform global social inequalities intobad individual choices [Breilh, 2002; Menéndez, 1981].Attention to dominant ideologies seems particularlycrucial. The problem here is that proponents ofsocial medicine and critical epidemiology in Latin Americajoin their colleagues in North America and elsewherein uncritically upholding ideologies that play a keyrole in creating inequalities and making them seem natural—ideologiesof communication. Along with criticalmedical anthropologists [Baer, Singer, and Susser,1997; Farmer, 2003; Singer and Baer, 1995], progressiveLatin America health scholars have shown thathealth systems produce more than modes of diagnosisand treatment—they define diseases, limit acceptableaccounts of what causes them, tell professionals andpatients alike how they should respond to disease, anddesignates the knowledge possessed by some peopleas scientific and authoritative and other knowledge assuperstition, ignorance, or misinformation. My goal inthis essay is to demonstrate that ideologies of communicationsimilarly reproduce inequalities of capital andpower.The dominant ideology of communication inhealth 1 pictures a linear process in which informationis generated by professionals who control the siteswhere authoritative knowledge about health is produced.The productive sectors are defined in terms ofspecialized training, technologies, and institutional authorityas embodied in medical researchers, epidemiologists,policy makers and administrators, clinicians, andothers.These sites are not unified and homogeneous;the "flow" of information is rather mapped accordingto epistemological and institutional hierarchies. A secondprojected phase focuses on the translation ofthis information into less technical languages and its insertionin different communicative networks. Here reportersstand in for "the public" in determining whichpress releases and other sources are "newsworthy." Aparallel but distinct channel in the translation/disseminationtrack is pursued by health promotion departmentsin transforming technical information into manuals,pamphlets, materials for public presentation.Thisideology of communication then imagines a third phasethat takes place as health-related information is"transmitted" or "disseminated" to mass audiences throughnewspapers, magazines, radio and televisionprograms and advertising, and the Internet. Finally, "thepublic" is assigned the role of assimilating this informationcognitively, restructuring their understanding ofhealth in its terms, and behaviorally, turning cognitioninto everyday conduct. Persons who are deemed tofulfill this role are construed as sanitary or biomedicalcitizens with [Hammonds 1999; Ong 1995; Shah 2001],while those who are judged to fail—often no matterwhat they say or do—become unsanitary subject[Briggs with Mantini-Briggs, 2003]. Failing to adequatelyreceive and assimilate health information can leadto broader violations of human rights, health and otherwise[Farmer, 2003].The standard story suggests that this processhelps overcome health disparities by making the distributionof knowledge about health more democratic,1. I am not referring here to the field of "health communication" but to the sum total of information in society that relates to the socially constructed categories of"health," "disease," "medicine," and "public health."145

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAproviding information needed to attain healthy stateseven people with limited or little access to healthcare.I argue that this linear model of communication inhealth is both empirically wrongheaded and politicallymisguided. Martín-Barbero (1987) suggests that we donot live simply in societies with media but in mediatedsocieties, where our identities and even our conceptof society is shaped by the media. Information abouthealth is thus shaped by mediated concepts from thebeginning, not just when it is reinterpreted by reporters.Science studies scholars demonstrate that scientificknowledge does not exist independently from socialand political life [Latour, 1993]; popular socialconstructions of race, gender, class, and sexuality informepidemiological categories and notions of causation[Haraway, 1997; Harding 1993]. My ongoing researchon health and media in the United Status andVenezuela suggests that public health institutions andsocial movement organizations are increasingly guidedby media logic [Altheide, 1995], such that media specialistsare part of the development of programs fromthe onset, and many officials work closely with mediaprofessionals 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 theencounter, which are shaped by media images, whetherthey appear in the news or soap operas. "The public"that receives media messages actually consists of reallymultiple, competing publics [Calhoun, 1992], and publicdiscourse about health actually helps create publics[Warner 2002].The CDC’s 1983 declaration thathomosexuals, hemophiliacs, heroin-users, and Haitianswere at high risk for AIDS, for example, helped separatethe U.S. population into five publics—these fourand the remaining population, which was presumablynot at high risk [Epstein, 1996, Farmer, 1992].The dominantideology also fails to take into account how individualsrespond to messages and place themselves inrelationship to them—as true believers, skeptics, critics,satirists, etc.—thereby shaping the social impactof health information.At the same time, this ideology reproduces thepower relations that progressive public health scholarsand practitioners are attempting to challenge. Foucault(1973) insisted that power is knowledge, and this hasperhaps never been as true as in "the information age,"in which, some argue, information is the most valuablecommodity [Castells, 1996].To suggest that knowledgeabout health is only produced in sites dominated byhealth professionals (even progressive ones) bolstersthe role of science and medicine in reproducing socialinequality. It also blunts critical understandings ofhealth by making it more difficult to see how scientificfacts are shaped by and shape social and political-economicrelations.This dominant ideology reinforces thenotion that laypersons can only assimilate knowledgeabout health produced by others; when persons withoutspecialized training attempt to position themselvesas producers of knowledge about health, they arebranded as resistant, non-compliant, ignorant, or evendangerous purveyors of misinformation. The linearequation allocates agency to dominant institutions andtheir professional employees, that is, the capacity tocreate ideas, devise courses of action, carry them out,and thereby affect the world. It is, in short, a magicalformula for disempowering communities. Moreover,no one can adequately undertake the role assigned tothe public—reordering their cognitive universes onthe basis of exposure to a few texts, broadcasts, or publicpresentations and then turning this information—point by point—into behavior.The real losers in this linearequation, of course, are the people with least accessto healthcare, education, and other services; evenwhen they assimilate a great deal of biomedical information,they are judged to have failed [Briggs withMantini-Briggs, 2003; Farmer, 1992].Finally, the news and in some countries advertisementscontain more and more health content. This146

Observatorio Latinoamericano de Salud.saturation forms part of the privatization of health, itstransfer from a right guaranteed by the state to a commoditythat it bought and sold by individuals. By acceptingthe ideological premise that the role of the publicis to assimilate health information, critical public healthscholars and practitioners further the health regime ofgovernability, that is, how people are governed by requiringthem to inform themselves about health andthen make rational choices among available alternatives.The dominant ideology of communication is thusparticularly amenable to neoliberal ideologies and institutionalarrangements.Achieving Equity and Justice in Health andCommunicationDifferent versions of these dominant ideologiesof communication are widely shared among medicaland public health professionals, journalists, and laypersons.Communicability operates in a roughly parallelfashion to medicalization, ideologically constructing aseparate realm of communication consisting techniquesand 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 waysin constructing health and disease as a scientific realmthat exists apart from political, cultural, and social relations,these ideologies imagine communication as aseparate domain. In spite of their lack of correspondenceto how information about health travels, theseideologies do provide the basis for what I refer to asregimes of communicability, ideological constructionsof different positions in relationship to the healthcommunication, hierarchical arrangements of theseroles, and recruitment of individuals and communitiesto fill them. Biomedical regimes of communicability generatecommunicative health inequities that are linkedto but not coterminous with health disparities.In short, the dominant ideology of communicationis an obstacle to developing genuinely emancipatingperspectives, practices, and policies for health.Progressive perspectives on health are incompatiblewith:● Ideologies that view health communication as producedby experts for consumption by "the public"● The notion that the state and its institutions are thelegitimate producers of truth and knowledge abouthealth, and that of citizens should be grateful recipientsof state informational largess● Depoliticizing communication just as biological reductionismdepoliticizes health and disease● The massive consolidation of media ownership bylarge corporations.● The notion that translators (reporters, health promoters,etc.) should be subordinated to biomedicalepistemologies and professionals; such subordinationcurtails the potential for critically evaluating dominantbiomedical perspectives and presenting alternatives● The idea that laypersons—and particularly membersof the communities who are most affected by healthdisparities—have no role in the production of legitimateknowledge about healthEffectively challenging hegemonic epistemologies,policies, and practices in health and confrontinghealth disparities thus requires combating biomedicalregimes of communicability.My goal in this essay is to make progressivehealth scholars and practitioners aware of how they147

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAfall victim to these dominant ideologies of communicationand to outline some alternatives. Here are someprinciples that may stimulate the search for waysto counter communicative inequities in health:● Stimulate research that documents how informationabout health is produced, circulates, and is received;the social impact of this process; and the impact ofnew social and political-economic relations andcommunicative technologies●Treat communication as a key element in the productionof knowledge in medicine and public health, notjust its dissemination● Explore perspectives on communication that view itas multidirectional, with multiple sites of productionof production, circulation, and reception● View communication in health as an ideologically-informedpolitical debate, one that is structured byunequal relationships to capital and technologies, asa struggle between competing voices and interests;in short, as a part of any social struggle● Foster debates about health in sites in which poweris less centralized, such as community radio and television,alternative and "ethnic" newspapers, andthe Internet● Do not seek to subordinate voices within and outsidemedical and public health institutions to biomedicalauthority●Debates about health should be forums in whichmultiple languages come together, avoiding the hegemonyof "global languages" (particularly English),national languages, and languages of specialists (medicine,public health)● Accord members of the populations that experiencethe negative effects of health disparities the status offull partners in the production, circulation, and receptionof health-related information● Rather than becoming spokespersons for marginalizedgroups, join them in challenging the barriers thatexclude them from participating in public debatesabout healthThe last thing that I would want to do would beto tell people around the world how they should conceiveof communicative processes; particularly givenmy status as a North American researcher, such a movewould simply trade one kind of hegemony for another.Nor can alternatives be devised by the health andcommunication professionals who have heretofore enforcedregimes of communicability.What are needed, Ithink, are debates taking place in a wide range of forumsand settings in which barriers are exposed andalternatives explored.To relegate these discussions toa "communication" or "communicative equities" tableat a working conference or—even worse—to hold aseparate meeting to discussion "communication"would simply reproduce the ideological separation ofthese issues from the broader debates concerning socialjustice and human rights. I hope that at the veryleast I have convinced you that they are one in the same.Preventive Education in Health orCommunication Reductionismto Maintain InequalityIn favor of obtaining a more critical and explicitperspective of the complex nature by which the communicationof graphical preventive messages are conveyedto populations, the theory exposed by CharlesBriggs throughout the paper that precedes this will beemployed. In it, the author describes how the domi-148

Observatorio Latinoamericano de Salud.nant ideology of communication in health is expressedas a linear process.Here, we will analyze how images and discoursescaptured in printed graphic materials of communicativestrategies of prevention of as much chronic as acuteillnesses are destined to failure, on account of beingframed in the perspective of ignorant individuals,which represent the population or public "under risk"and project the ingenuous conscience that continuesto support the paradigm that people will never be actorsof their own destiny, much less will they understandthemselves as real participants in the preventionof illnesses. This was the object of the struggle put forwardby Freire (1970). Individuals are thus exposed tobiological agents, the sole causers of illnesses, due totheir behaviors filled with habits deprived of "hygieneand moral". The illness will then take possession oftheir bodies making use of the threat to pay with theirlives the irreverence of not having complied with theinstructions given by the medical authority for prevention.Hence, there is a legitimating process of scientificknowledge over what is humane, as evidenced inFocault (1977). Medical knowledge therefore illustrates,educates, trains and saves the individual alertinghim/her on the mode of transmission of illnesses, theway to prevent it, and finally that preventive graphicalmessage will indicate the redeeming medical action,which produces the magical change in the conductthat each one individually must implement to recoverhealth or remain free of illnesses, and supposedly continuewith his/her life "happily" for the threat of illnesswill disappear.An entire process of medicalization, which Barros(2002) in his critical analysis considers the causeand effect of the imposition of the hegemony of thebiomedical model of the state. It could be aggregatedhere that it is the cause of the assimilation of incompetenceof individuals in the preventive tasks of illnesses.As an instance of what was rendered, we willavail ourselves of a pamphlet enclosing messages thattend to educate the population "in risk" on avoidingthe contagion of dengue fever by means of curativeand preventive measures. We will reveal through thispamphlet, "How Pedrito terminated the mosquitoes",the representation of a classic example of this alienatingand 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 contagionin 1989-90. Within this pamphlet infantilizing,ahistorical and contradictory symbolic structures canbe observed, in its characters and narratives. Not onlythe simplistic and slangy language used but also Pedrito’sgarments -with a newspaper hat on his head, ashield that is the lid of a garbage can and a sword,which he will use to combat the gigantic mosquito thatthreatens him with its enormous beak or proboscisand its aggressive look from a rubber- communicatethe same reductionist message. Moreover, tales theironical behavior images of its characters in the factthat they displace an old rubber tire from the garbageto a middle class home setting, explicitly that the normof this population/public, object of the message, is thecontact with dirt at the expense of contaminating withall kinds of germs, such as the ones that bring aboutdermatological and digestive illnesses among others.The character represents the years 36 or 40 in a ruralVenezuela, with no access to television, which not evenidentifies with the figure of children at the end of the80’s, when the outbreak of the dengue epidemic in Venezuela,and nor does it take account of the point thatthe first Venezuelan official victim was from Maracay,the capital of the Aragua State. Consequently, in viewof its scientific lexicon and formal syntax, we discernedit implicitly embodies the hegemonic discourse of thestate, delineating its origin in the biomedical sector,setting the standard of the medical preventive advice,149

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Observatorio Latinoamericano de Salud.as a case in point: "an old piece of rubber at home representsa hazard to the entire family’s health" or"When the mosquito bites you, the consequences maybe deplorable. Dengue and yellow fever can be transmittedto you…" This biomedical discourse turns explicitwhen it illustrates the reproductive cycle of themosquitoes, transmitters of filariasis, malaria, whichare illnesses that the public is supposed to be acquaintedwith and know how to prevent, and of course,dengue and yellow fever, there are no other mentioned.The classic model of graphical educational strategyfor prevention of illnesses is presented; it reflectsa systematized employment of biomedical reductionismof communication in health.Thus, the dissemination of communication producedin the framework of manufactured ideologies bythe scientific supra-sphere of the ones who get to thebottom of what is relative to the biological cause of illnesses,form of contagion, guides of treatment, life styles,and social conditions that induce the disseminationof pathologies -by no means exempt of social stereotypes-,is transmitted directly to the public in thecenters that offer health services or dispensed personallyin the communities, as a proof of the discursiveeducational or preventive action of the state. Conformingto this, the workers of the health sector translateto a puerile extreme these messages exhibitingthem as the quintessence of simplification and disseminationof scientific knowledge, which turns out to beaccessible to the comprehension of the public in general,indicating the correctives the insalubrious citizen,as described by Briggs and Martini-Briggs (2003), mustapply to reach the ideal status of a salubrious citizen.This ideology of communication creates the inequableroles of producers, diffusers and receivers ofmedical information, which places the public within animaginary space that neither corresponds plainly to thewealthy social class, nor to any other sector of society.On one side, the image of Pedrito and his mother arenot identified with the poor and rural population, dueto their denigrating and retardant features (no child orperson of the rural means would kill a mosquito witha shield and sword), and on the other side, no motherof middle class, without exposing herself to being classifiedof at least negligent, would permit her children toplay with objects collected from the garbage, which impedesthe identification of the public with the charactersand, even worse, it promotes the rejection of orinattention to the message.Continuing our analysis, we found the charactersof this story of prevention leave aside their ignoranceon assimilating passively their responsibility over theoccurrence of the illness. Without any critic, protest,or interpretation, they just incorporate the hegemonicword within their behavior, which then is integratedharmonically to the effort of the state to protect thecitizen’s health in fulfillment of its function, as expressedby Charles Rosenberg (1962). This is representedin the pamphlet through the image of an apparently regularservice of garbage collection. In this manner, citizensare placed in the position of having to repay theeffort of the state with the tacit obligation to participatein the preventive strategy, as facilitators of themedical action, according to Briceño-Leon (1998), acceptingthe medical authority that, in the name of thestate, determines the new forms of conduct and the livingtogether of individuals, and has the power to decideon the organization of housing and, furthermore,the physical situation of their bodies at a certain pointin time. This brings up Menéndez´s (1998) work inwhich he questions this type of participation as anothermeans of hegemony/ subalternation.Finally, Pedrito and his mother are portrayed asindividuals isolated from any context, depoliticized,who do not suffer the lack of basic services, nor dothey suffer, as documented by Armada, Montaner, andNavarro (2002), Briggs and Farmer (1999), the effectsof neoliberal policies, the privatization of public servi-151

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAces. These policies are imposed by international organizationsand national elites, which promote the internalbudgetary cuts of countries, that sustain basic publicservices, enforcing an order in which the risks ofcitizens are not measured, despite their living in a inequitablesociety saturated with psycho-social problems;a society, which responds to an inequitable distributionof the phenomena of health-illness.152

Observatorio Latinoamericano de Salud.REFERENCES● ALMEIDA FILHO, N DE (1989). Epidemiologia sem numeros : umaintroducao cri tica a ciencia epidemiologica. Rio de Janeiro: Campus● ALTHEIDE, DL (1995). An Ecology of Communication: CulturalFormats of Control. New York:Aldine de Gruyter..● ARMADA FRANCISCO, MONTANER CARLES,AND NAVARROVICENTE (2002). Income Inequality and Population Health in LatinAmerica and the Caribbean. Hispanic Health Care International.The Official Journal of the National Association of HispanicNurses 1(1): 42-55● BAER, HA, M SINGER, I SUSSER (1997). Medical Anthropologyand the World System:A Critical Perspective.Westport, CT: Bergin& Garvey.● BARROS JAC (2002). Pensando o processo saúde doença: a queresponde 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 deltrabajo). 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 participacióncomunitaria en América Latina. Cadernos de Saúde Pública(Río de Janeiro, Brasil); 14(2): 141-147● BRIGGS CHARLES Y MANTINI-BRIGGS CLARA (2003). Storiesin the Time of Cholera: Racial Profiling during a Medical Nightmare.Berkely: University of California Press● BRIGGS CHARLES Y FARMER PAUL (1999). Infectious diseasesand social inequality in Latin America: From hemispheric insecurityto 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 andCulture.Vol. I,The Rise of the Network Society. Oxford: Blackwell● EPSTEIN, S (1996). Impure Science:AIDS,Activism, and the Politicsof Knowledge. Berkeley, CA: Univ. of Calif. Press● FARMER, P (1992).AIDS and Accusation: Haiti and the Geographyof 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● FOCAULT MICHEL (1987). El Nacimiento de la Clínica una arqueologíade la mirada médica, siglo XXI Editores● FOUCAULT, M (1973).The Birth of the Clinic:An Archaeology ofMedical 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 Campaignto 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:Towarda Democratic Future. Bloomington: Indiana Univ. Press● LAURELL,AC (2000). Structural Adjustment and the Globalizationof Social Policy in Latin America. International Sociology15(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 realidadtécnica y como imaginario social. Cuadernos Médico Socialesmayo; 73:5-22● MENÉNDEZ, EL (1981). Poder, estratificación y salud:Analysis delas 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. ofHealth 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 UnitedStates in 1832, 1849, and 1866, Chicago: University of ChicagoPress.● SHAH, N (2001). Contagious Divides: Epidemics and Race in SanFrancisco'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: Zone153

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA16Despair in the Americas:Evidences for a Psychosocial Autopsy ofSuicide during Neoliberal DispossessionArturo CampañaThe postmortem inquiry of the personal, family and social characteristicsof suicide cases tends to be named psychological autopsy. Likewise physicalautopsy, this is a cruel, painful and unpleasant resource; however it certainlyhelps to discover and orient around the reasons of a tragic destructivedetermination. The foundation is to systematize the knowledge accomplishedthrough attentive observation, the collection of testimonies, the followingof leads, completing a typology of motivations and differentiating risksby groups, et cetera, and orchestrating measures for the reduction and controlof that death cause. A similar procedure is by some means applied to theinquiry of the reasons that took someone to be converted into the object ofhomicide or other causes of violent death. Through these inquiries, referredto individual cases, hypothesis and explanations emerge, which illustrate theenormous complexity of suicidal behavior and the remainder violent behaviors.Interpretations cover a gamut, which range from the suspicions placedwithin genetic predisposition and biochemical proclivity of the subject, passthrough considering the psychological and affective deficiencies and defectsin the individual, family and social scope of personality structuring, and arriveat the contemplation of more direct inhuman sufferings, such as unemployment,hunger and marginalization.154

Observatorio Latinoamericano de Salud.In this context, talking about "a constellation offactors leading to despair and loneliness" is growing tobe a current formula. We deem such a concept to beof value within the psychosocial field, as it concerns theidea of an assembly of one’s own determinations of differentdimensions and dynamic of human life, and bysome means directs us to avoid adhesion to causal explanationssupposedly integrating, but unilateral, primarilythe ones which tend to reduce the social into themonetary, and whose purpose is to base their explanationson simple numerical and statistical correlations,among causes of violent deaths and loose socioeconomicindicators. Nevertheless, the concept of factorialconstellation conveys an analogous danger: to lightenthe weight of social determination and dim it –evenmaking it disappear- on privileging a multiplicity of importantmediations and determinations in the analysis,but torn apart or isolated from their relation and unitywith the general and historic development of life. Thestudy of human behavior and collective mental healthcompels us not to lose sight of the role of old anthropological,cultural, emotional, and intellective referentsproper to peoples, at the same time that it compels usto track attentively the modifications, displacements,adjustments, and maladjustments of the social matrixwherein their spiritual life develops presently.For instance, if in Yucatán, México, a particular"suicide culture" prevails, associated with the spiritualimportance conceded especially by women to Ixtab,the "Mayan goddess of hanging", that cultural aspectmust be considered when interpreting the problem ofsuicide 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 nationalaverage rate has been reached, and why, in the sameway as Campeche, it shows a preoccupying increase offeminine suicide between 1990 and 2001.In addition, the famous legend of the massive suicideof the Chiapanecas in the "Sumidero" Canon, as acollective decision to deprive themselves of life ratherthan accepting the domination of Spanish conquerors,is to be remembered and appreciated now, at the momentof interpreting why Chiapas presents the lowestsuicide rate in Mexico in 2001, and why from 1990 to2001 it has reduced its population from 1,98 to 1,03per hundred thousand inhabitants. Perhaps it is notillogic to think the collectivist spirit of the masculineand feminine Chiapanecas -who played a leading rolein one of the most salient anti-neoliberal rebellionsknown in the beginning of 1990 and continuing to thepresent- found motives to believe it is not the momentof the dignifying sacrifice of death against the disgraceof slavery anymore, but of collective resistance,of the exploit of liberation, life, and hope.The epidemiological panorama of suicide in theperiod of implantation of the neoliberal model withinour countries, which we will see illustrated through afew examples afterward, invites us to consider thepossibility that beyond the numbers that support therates of "human development" controlled by the agenciesof the international capitalist system, and whichboast of the diminution of infant and maternal mortality,of the access to primary school, to vaccination, andminor coverage of basic services, the model is undoubtedlyaggravating the gap between proprietorsand non-proprietors, imposing unfair and prejudiciallabor conditions in health.This consequently generateseach time major unemployment and marginality, destroyingcommunitarian solidarity networks, family liaisons,principles of education, and human values andthe social senses of orientation and identification. Inbrief, this neoliberal model generates spaces of uncertaintyand lack of perspectives for human groups everlarger, if one takes into account the proportion of peoplewho swell the band of poverty.As indicated by a Chilean author [Camus, 1999],these "social costs" of neoliberal progress not onlywould be reflected in the increase of behaviors such as155

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAdelinquency, the abuse of drugs, alcoholism, corruption,but also in the elevation of others, which are lessvisible and less quantifiable, such as sadness and despair,but concretized in syndromes of clear depression,or masked by various forms of somatization. In theword of James Petras: "what has not received seriousattention is the psychological damage inflicted on salariedand contingent workers, which is in many aspectsas grave as material loss. The interviews, testimonies,and visits to communities reveal the mental pathologiesdue to unemployment, insecurity at work, and thedegradation of it. These pathologies are illustrated inthe rates of chronic depression, family ruptures, suicide,domestic violence, infant maltreatment, and increasedantisocial behavior, particularly if the unemployedare isolated or incapable of externalizing their hostilityand anger, by means of collective social action.The individual’ssocial and political impotence produces personalimpotence, and is expressed under the form ofloss of confidence, sexual disturbances, and the inversionof anger towards the interior, which causes selfdestructivebehavior.In my opinion," Petras states, "organization andcollective action, under the form of unemployed movements,communitarian social organizations, whichdemand collectively, have a positive effect not only onthe creation of new working opportunities, but fromthe therapeutic viewpoint as well. Collective strugglesenhance self-esteem and personal efficacy, form solidarity,and offer a social perspective, everything which reducesanomy." [Petras, 2002]As Petras states, "Mental health, more than a hereditarydisturbance or anchored in infantile experiences,is socially determined by the relations of power,which suggests that those who suffer mental illnessesor depression induced by unemployment, labor insecurity,or worsening of living standard, may access curethrough adult socializing (class conscience), either bycollective organization, or social action." [Petras, 2002]With the example of three American countriesof which there are reliable studies and current statisticson violent deaths in comparison to previous data,we will examine, in the subsequent paragraphs, the variationsof the epidemiological profile of mortality bycauses associated with depression and/or anguish.Wewill additionally begin documenting their possible connectionwith conditions typical of neoliberal macroeconomicand macropolitical exercise. And finally, wewill begin to experiment our hypothesis that says thatthe dynamics of present capitalism entail a psychopathogeniccapacity with no precedents in history. (Referto Table 1).As it is acknowledged, the rates of suicide withinAmerican countries in the past century evidence importantcontrasts. However, a tendency was noticeableof maintaining certain stability.At present, leaving asidethe case of Cuba (as this country exhibits an importantdecrease in the rates of suicide, while others display anincrease, but that deserves a contextualized analysis inthe scenery generated by the rigors of the criminal imperialblockade, as well as in the transition from capitalismto socialism, inevitably painful particularly for theproprietor classes), the majority of American countries,subjected one way or another to the pressures exercisedby the neoliberal model, have begun to show for approximatelytwenty-five years an unusual proliferationof suicide. In some cases the rates are so high they incitehealth professionals to use the term epidemic. Letus take notice, in Table 1, of the increments of suicidewithin countries such as Uruguay, Chile, Brazil, Mexico,Ecuador,Argentina and Costa Rica.In the beginning of 1980, Mexico had one of thelowest rates of suicide in the world, with 1,9 per100.000 inhabitants.Currently, according to a recentstudy [Puentes, López and Martínez, 2001], it reaches3,72. For instance, in Chiapas a rate of only 1,03 is registered–we have already suggested that Chiapas probablyillustrates the case of the protective effect of156

Observatorio Latinoamericano de Salud.TABLE 1ESTIMATED SUICIDE RATES (PER 100.00 INHABITANTS) ADJUSTED BY AGE IN SELECTEDCOUNTRIES, REGION OF THE AMERICAS, BEGINNING OF THE 80’S, END OF THE 90’S,ANDBEGINNING OF 2000.COUNTRYBEGINNINGOFTHE 80’SENDOF THE90’SBEGINNING OFFIRST DECADEOF 2000COUNTRYBEGINNINGOFTHE 80’SENDOF THE90’SBEGINNING OFFIRST DECADEOF 2000ArgentinaBrasilCanadáColombiaCosta RicaCubaChileEcuadorEl Salvador7.01.712.13.85.117.25.23.614.95.95.011.73.56.217.66.15.310.88.211.86.713.610.95.9Estados UnidosMéxicoNicaraguaPanamáParaguayPerúPuerto RicoRep.DominicanaUruguayVenezuela10.61.90.8 *2.82.90.59.43.06.110.69.73.512.25.33.72.37.32.113.95.510.44.16.37.815.0Source: 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. *!974their organized struggle, with a consequent elevation ofself-esteem and reduction of anomy 1 - and that inCampeche (9,68) and Tabasco (8,47), the national meanis practically tripled. Correspondingly, in line with datafrom the INEGI, the suicide percentage compared tothe total violent deaths in the Mexican United Statesduring the first years of 2000, remains roughly between7 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 thehigh suicide rates of Campeche and Tabasco with thedeepening of their marginalization, after the StructuralAdjustment imposed on Mexico by the World Bankand the International Monetary Fund, in combinationwith the application of the Free Trade Treaty withNorth 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 degreeof marginalization within Mexico in 2001 belongto the South Southeast region.These states are, in descendingorder, Chiapas, Guerrero, Oaxaca, Veracruz,Puebla and Yucatán, Campeche and Tabasco.The same source affirms that the largest part ofthe South Southeast inhabitants are among the 50 millionsof poor people of the country; and that 83,9%1. Anomy: lack of moral standards in a society157

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA(714) of 851 municipalities (10,6 million inhabitants),considered of high and very high marginalization, areconcentrated in the South Southeast (8 million inhabitants).Let us stress another complementary fact: althoughit is true in Mexico that the cause of suicide isgenerally unidentified (58%), according to the NationalInstitute of Statistics, Geography and Computing, beingcertain there must be a sub-register of suicides byeconomical difficulty, in 1991 and 2002 what was attributedto this cause does not exceed the 3,8 per 100suicides. Nevertheless, there has been a national peakof 5,2 per 100 in 1995, and within federative organizations,known for the expansion of poverty and marginality,there have been moments of uncommon suicidalbehavior –in the manner of microepidemics- foreconomic reasons. In 2002, in the States of Guerreroand Puebla, for example, a proportion of 14,8 and 7,9per 100 suicides respectively was reached.In Zacatecas, it was an extremely importantquestion, as their rates peaked at 23,5. A further relevantclue is that in 1991 the national percentage of suicidesby family annoyance was 6,7, and in 2002 thenumbers rose to 10,5, with Zacatecas at the head(35,3%), followed by Yucatán (19,5%). We believe thatthis would probably express an intensification of belligerenceat home, usually involving economic difficulty.Yet, what alarms Mexican researchers the most is thatthe age group with the greatest increments of suicidebetween 1990 and 2001 is the one from 11 to 19years old, in which the rate has varied from 0,8 to 2,27girls per 100.000, and from 2,6 to 4,5 boys per100.000, in only a decade. To examine the percentageof deaths by suicide, in relation to the total amount ofviolent deaths by 5 year age groups between 1990 and2003, reported by the INEGI, is also extremely revealing(see table 2).As we can see, suicide in Mexico doubled in onlytwelve years with regard to the total number of violentdeaths, though primarily at the expense of youngerages. Something that specifically draws our attentionis the near quadruplication of this indicator withinthe group from 10 to 14 years old (2,4 to 9,1 per100), and the aggravation of the problem in adolescentand young adult girls, in whom the upsurge is moreevident: from 1,8 to 10,8 –more than five times-, andfrom 8,8 to 19,4 respectively. This apparently exposesthe level of lack of motivation in life among those whoare just at the dawn of it, and the abandonment andlack of perspective and social organization of a substantialsegment of Mexican youth.In the last few years, the case of Uruguay is perhapsthe one that best allows us to analyze the demoralizingeffect of the great socioeconomic crisis. Uruguay’seconomy has undergone several transformationssince the 1970’s, when its experience of financialand commercial liberalization started. Like all LatinAmerican countries, it endures the economic crisis –asregards the demand of payment of external debt- since1982. Uruguay recovered and consolidated in thebeginning of the 90’s, with the integration to the MER-COSUR, and in 1995, it achieved the full devastation ofthe neoliberal crisis, related to the "tequila effect" inthe region, which intensified later with the Brazilianand Argentinean crisis, economies more directly connectedto the Uruguayan.Opposite other countries of the region, Uruguayhas been characterized in the past century by havingcomparatively high rates of suicide, almost always approaching9 or 10 per 100.000 inhabitants. In the secondand third decade of the twentieth century–which were decades of great depression worldwide,not only economically- the rate of suicide in Uruguaysurmounted 12 cases per 100.000 inhabitants, stabilizingagain at about 10, and lowering to 8,8 in 1988.Subsequently, it experienced a sustained escalation after1992 until the present, when numbers reached ashigh as 16 per 100.000 in 1998, 15 per 100.000 in 2001[Dajas, 2002], and a dramatic 21,7 in 2002 [Montalbán,158

Observatorio Latinoamericano de Salud.TABLE 2PERCENTAGE OF DEATHS BY SUICIDE,WITH RESPECT TO THE TOTAL NUMBEROF VIOLENT DEATHS, BY GENDER AND 5 YEAR AGE GROUPS, MEXICO,1999-2003SEXAGE GROUPSTotal10 a 14 años15 a 19 años20 a 24 añosBoys10 a 14 años15 a 19 años20 a 24 añosGirls10 a 14 años15 a 19 años20 a 24 añosSource: INEGI. Elaboración:Arturo Campaña19903.92.45.65.04.12.75.04.93.11.88.85.720037.89.112.912.78.28.411.312.46.410.819.413.92004]. In essence, Uruguay is facing the triplication ofits rate, already excessively high, in only a decade.The observation of Dajas is equally important, inthe sense that between 1975 and 1996 the initially lowproportion of Montevideans (2,5 per 100.000 versus15,0 per 100.000) in the determination of the total ratesof suicide had increased so critically, that the differencewith rural people tends practically to disappear(in 1996 the rate within Montevideans increases to11,3, and the one of rural people is about 14,0 per100.000). How to explain this marked increment ofsuicidal behavior of people from Montevideo, traditionallyless affected by self-destruction, in only two decades?As indicated by the experts in Uruguayan economy,poverty is more intense in the country, but thereare recent regional changes that may not be ignored;and they point out that albeit being in Montevideo in1991 implied a decrease in probability of being deprived;conversely, in 1997 it implied an increase in theprobability of being in the stratum of privation.They remarkthat since 1991 wage inequality and the access togoods and services of education, health, and inclusivelybasic infrastructure worsened and peaked at their mostcritical level in the last year of this study. The following159

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATABLE 3INCIDENCE OF POVERTY IN URUGUAY AND MONTEVIDEOTOTAL AND IN YOUNG AGES, 1999 AND 2003YEARGROUPURUGUAY (%)MONTEVIDEO (%)1999Total15,315,0Younger than 6 years old32,530,9From 6 to 12 years old28,326,7From 13 to 17 years old22,720,62003Total30,931,8Younger than 6 years old56,558,2From 6 to 12 years old50,249,4From 13 to 17 years old42,741,3Fuente: 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 Uruguayansinto the pit of poverty from 1999 (15 of each 100people) to 2003 (31 of each 100), (see table 3).With reference to the exclusion of urban settlementsand the agony of the open and integrationistmulti-class district, which was common in urban spaces,such as Montevideo and Maldonado (whosegrowth rates, compared to the national mean of 6,4per 1.000 between 1985 and 1996, had shot up over25 per 1.000 annually), it is noticeable that in the existingsettlements disintegrated families predominate.These families tend to be marginalized from culture,and have a prevailing composition of children and adolescentswho refuse formal education even if it is gratuitous.It is literally said that, "Montevidean society ishighly hierarchical. The extremes of richness and povertyhave been transformed into impervious ghettos.Distances among those who find their way within theformal system and those who have fallen from it, ornever reached it, are very extensive and still on the rise.The risks of violence (delinquency is simply asymptom) augment each day. Marginalization, scarceascendant mobility in the social and economic realm,160

Observatorio Latinoamericano de Salud.TABLE 4DISTRIBUTION OF THE RATE OF SUICIDES PER 100.000 INHABITANTS,BY SELECTED AGE GROUPS, URUGUAY 1985 AND 1996GROUPYEAR15-19 Y20-24 Y25-29 Y30-34 Y35-39 Y40-44 Y45-49 Y50-54 Y19852,37,08,59,011,015,511,013,0199610,013,014,015,09,021,08,524,0Source: 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 indue course the principal enemies of democracy andpacific living together" .Dajas’ acute observation permits him to underlineother crucial modifications in the current suicideprofile of Uruguayans. For example, the proliferation ofsuicides as much in women as in men, though withmasculine preeminence, and for the most part amongyoung ages and people over 70. And even if Daja istempted to explain this phenomenon as a Worldtrend of suicide, we think that in the case of Uruguayit specifically corresponds to the accelerated changesin the social profile of the Uruguayan people, due tothe direct impact of what has been called the "crisis ofthe South Cone countries", were economy became inthe last years directly dependent of inequitable Worldmarket relations, and on the economic fluctuations ofBrazil and Argentina; neighbors also fully immersed inthe neoliberal experiment. Unfortunately, we can notlook at the picture of critical recent years, due to thelack 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 followinggroups (the tendency to double their rates).Excepting the groups from 35 to 39 years old, and theone from 45 to 49, in which the statistics were lowerin 1996, all groups have perceptible increases, in particularthe last, whose rate has virtually doubled. Letus observe in the following table the absolute numberof suicides, by age and gender (see table 5).Looking at this table, we can verify the significantincrease of suicides in males within the four youngergroups, and the increase of suicides in females, whichis additionally worrisomethough it is consistently surpassedby men, in all the age groups, with the exceptionof the group from 35 to 39 years, in which thenumber diminished. Dajas is right when he questionshimself about the increment within mature men between40 and 50, and its association with the anguish ofunemployment. If we observe the evolution of the rateof Uruguayan unemployment, we notice a minimumunemployment rate of 7% in 1981, which rapidly risesto 15,4% in 1983, and gradually decreases until it arrivesat 9% from 1987 to 1994.Then, in view of the impossibilityto include in the services sector the unemployedof industry and the generation of unemploymentwithin the services sector itself, as a consequenceof the low internal and Argentinean demand -asso-161

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATABLE 5DISTRIBUTION OF THE NUMBER OF SUICIDES, BY SELECTED AGE GROUPS, IN WOMENAND MEN, URUGUAY 1990 AND 199GROUP YEAR15-19 Y20-24 Y25-29 Y30-34 Y35-39 Y40-44 Y45-49 Y50-54 Y1990 M1623191620201921F265478551998 M2524393117353529F31196414116Source: 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 to13,6% in 2000, and a dramatic 18,6% in 2003.Considering that the rate of suicide in the agegroup of 15 to 19 years has increased from 2,6 in 1985to 9,9 per 100.000 in 1996, as indicated by a digitalsupplement of Diario El País in May of 2004 [Szalmian,2004], we support [Dajas, 2002] and other authors arecorrect to advocate the need for family affectionatesupport as an ultimate originator of the psychologicaland suicidal behavior within adolescents and youngpeople. In addition, this quantitative evidences mustbe related to process of fast impoverishment and socialprivation, that Uruguayan families experienced duringthe last decades, all which evolved into a diminishingcapacity to provide for the necessary social andemotional stability that children and adolescents requirefor their mental development. Returning to Table3, we can see the affects that poverty has from1999 to 2003, within the three youngest groups, as itmoved from values of roughly 30 per 100 to 57 in thegroup of younger than six years old; to 50, in the groupfrom six to twelve; and to 43, in the group from thirteento seventeen.It is not in vain to point out that according to datafrom the National Institute of Statistics, the numberof divorces registered increased from 4.611 in 1987, ayear before the beginning of a long economic recession,to 9.800 in 1991.This number had an importantdecrease, though not under 5.700 until 1997, a year inwhich poverty involved already 23,9% of the Uruguayansand statistics radically increased to 8.347 divorces,and in 2001 and 2002, the number of divorces was7.409 and 6.761 respectively [INEC, 1987-2002].Overlooking the most appalling years, this signifies thatdivorces increased by 46,6% in Uruguay between 1987and 2002 despite the fact that there were departments,such as Maldonado, where a number of divorcesincreased by 158% in 2002, compared to 1987. Letus remember that Maldonado’s population shiftedfrom 13,1% poor people in 2000 to 27% poor peoplein 2002, as a result of the Argentinean debacle and thereduction of tourists.Let us now look at the Ecuadorian situation. Thiscountry rich in petroleum and resources, such as sh-162

Observatorio Latinoamericano de Salud.rimp, banana and flowers, in the last years of the 1990’sfell into the deepest part of its economic crisis, correspondingto the period of structural adjustment policiesinitiated in 1982.In addition to the accumulation of problems producedby the payment of the external debt (by 1999,nearly 16.000 million dollars), we must add the expendituresdue to the armed conflict of 1995 with Peru,the damages caused by the El Niño Phenomenon in1998 within its provinces of the Pacific Coast, the massivecorruption of state resource use by successive administrations,and the devastating effect of the internationalfinancial 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. Insuch circumstances, the deterioration of wages, unemployment,poverty, marginalization, and social inequitiesseverely increased to astonishing levels. Unemployment,which had remained for a long time atroughly 8% of the labor force, increased to 17% in1999.After finally rising and dropping, it established itselfat approximately 12%. Nevertheless, experts recommendus 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 unemploymentare certainly not a product of the reactivation ofthe economic apparatus [Acosta, López Olivares & Villamar,2004]. In reference to the most conservativecalculations, the average national poverty has increasedfrom 56% in 1995 to nearly 65% in 2002. However,there are rural areas where poverty afflicts morethan 90% of the population. In brief, the countrystruggles in the middle of the uncertainties created bya strategy of economic stabilization and recovery,which is seemingly sustained by a few precarious factors,for instance the international high cost of petroleumand the volume, still elevated, of the migrants’ remittances.Table 6 reveals that Ecuador’s national rate ofsuicide increased from 2,8 to 4,6 per 100.000 between1980 and 2002. Actually, between 1980 and 1996, withthe exception of the Amazonic Province of Napo, inwhich the rate had a minimum diminution, all the otherprovinces display weighty upsurges. The dramaticincrease in Carchi, the frontier province with Colombia,draws our attention. After being the one withnearly non-existent suicide (0,7 per 100.000) in 1980,it underwent an increase of almost twenty-one timesand consequently reached the highest value of thecountry (14,5 per 100.000) in 1996. And further, itcontinued (10,1 per 100.000) within the group of provincesto reach even higher suicide rates in 2002.Though on a lower scale, another province thatpresents a notable increment in the suicide rate is Bolivar.It reached 6,8 per 100.000, eleven times greaterin 1996 than in 1980, maintaining a definitely high rateof 6,2 in 2002. The comparison of 1996 and 2002 ratespresents ten provinces tending towards reduction,and eight tending to an increase of suicides.Among theones with increasing tendency, the case of Cañar andZamora Chinchipe are impressive. The first is a provincewith a high degree of migration, redoubled evenmore by the 2000 crisis. It has passed from 5,8 suicidesper 100.000 to 10,2 in 2002; the second is an Amazonicprovince, which has elevated its rate from 4,4 to11,1 in only six years. Taken from 2002 data, threegroups clearly differentiated by provinces are takingshape. The one with rate lower than 4 per 100.000:Galápagos, El Oro, Guayas, Los Ríos and Pichincha. Thegroup with an intermediate rate, from 4 to 8 per100.000: Manabí, Imbabura, Loja, Sucumbios, Chimborazo,Bolívar, Pastaza, Cotopaxi,Azuay,Tungurahua andNapo. And the group with the most elevated rate, 8per 100.000: Esmeraldas, Morona Santiago, Orellana,Carchi, Cañar and Zamora Chinchipe (table 6).Thus, all the arguments and information we haveestablished along these pages subtitled Evidence for a163

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINApsychosocial autopsy of suicide during neoliberal dispossession,were aimed at highlighting the need forscientific work which systematizes and clarifies the accumulatingevidences of varied impacts of our socialsystem over our collective mental health and over thepsychological condition of "disinherited" peoples andindividuals.Also we wanted to emphasize the need toactivate a participative construction of awareness, anda form of political organization and action that reallyopposes this societal model, based on inequity and exclusion,which permanently reproduce mental pathology.TABLE 6SUICIDE RATES IN ECUADOR, BY PROVINCES. YEARS 1980, 1996 AND 2002TOTAL COUNTRYCARCHIIMBABURAPICHINCHACOTOPAXITUNGURAHUABOLIVARCHIMBORAZOCAÑARAZUAYLOJAESMERALDASMANABILOS RIOSGUAYASEL OROSUCUMBIOSORELLANANAPOPASTAZAMORONA SANZAMORA CHGALÁPAGOSR/100.00019802,80,71,93,52,53,60,63,72,82,51,52,21,93,73,42,26,50,02,80,00,0R/100.000199614,57,44,97,06,26,86,95,86,13,65,05,37,33,72,96,35,44,4R/100.00020024,610,14,53,76,46,86,26,010,26,45,59,54,43,12,92,75,99,97,26,29,811,10,0Increment times80/9620,73,91,42,81,711,31,92,12,42,42,32,82,01,11,30,975,44,4Increment times96/020.70,60,60,91,10,90,91,81,051,51,90,80,40,80,91,141,152,5Fuente: INEC, Ecuador.Anuarios de estadísticas vitales 1980, 1996 y 2002. Elaboración:Arturo Campaña.164

Observatorio Latinoamericano de Salud.REFERENCES● ACOSTA ALBERTO, LÓPEZ OLIVARES SUSANA Y VILLAMARDAVID (2004). Oportunidades y amenazas económicas de laemigración (IV). La Insignia, 27 Agosto.● ANDREA SZALMIAN (2004). La tragedia escondida. El País Digital.,Internet Año 9 – Nº 2826, Montevideo Uruguay. Sábado 1 demayo.● CAMUS ALBORNOZ GUILLERMO (1999). El suicidio como unaforma de violencia societal. Ponencia presentada al XXII CongresoALAS. Octubre.● DAJAS, FEDERICO (2001).Alta tasa de suicidio en Uruguay, IV: Lasituación epidemiológica actual. Rev. Méd. Uruguay; 17:24-32● DAJAS, FEDERICO (2002). Suicidio en Uruguay: el último incrementoy la continua insensibilidad de las autoridades de salud.Carta al Consejo Editorial . Revista de Psiquiatría del Uruguay.Vol. 66 Nº2, Diciembre, página 164.● INEC: Divorcios por año de registro, según departamento dondese dictó la sentencia, años 1987-2002.● MONTALBÁN, ARIEL (2004). El suicidio: la urgencia de un graveproblema. Rev. Méd. Uruguay; 20:91● Opiniones. Una sociedad fracturada. Comentarios al libro Desigualdadessociales en Uruguay, de Danilo Veiga y Ana Laura Rivoirpublicado por el Departamento de Sociología de la Facultad deCiencias Sociales de la Universidad de la República. http://www.uc.org.uy/opi0504.htm● PETRAS, JAMES (2002). Neoliberalismo, resistencia popular y saludmental. Los perversos efectos psicológicos del capitalismosalvaje. Rebelión, La página de Petras, 20 de diciembre.● PUENTES-ROSAS ESTEBAN; LÓPEZ NIETO LEOPOLDO; MAR-TÍNEZ MONROY TANIA (2004). La mortalidad por suicidios:México 1990-2001. Rev Panamericana Salud Pública vol.16 n° 2Washington Aug.● ROSSI, MÁXIMO Y ROSSI,TATIANA. Privación y pobreza en Uruguay(1989-97)● SPREMOLLA,ALESSANDRA (2001). Persistencia en el desempleode Uruguay. Cuad. econ., abr. 2001, vol.38, no.113, p.73-89. ISSN0717-6821.165

Biodiversity:Destructionand Monopoly

Observatorio Latinoamericano de Salud.17Control over Nourishment:The Case of Transgenic FoodElizabeth BravoIntroductionLarge transnational corporations assisted by their governments aspire togain each time there is a greater control over the agricultural productive systemand 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, transgeniccultures play a major role.Throughout the world, transgenic seeds are promoted as a technology thatis here to stay. It is adduced that only transgenic food will aid in the alleviationof the hunger problems "of the increasing poor population of the world".Actually, it is worth questioning ourselves on the interests behind the promotionof transgenic seeds throughout the world; if these are in fact the necessitiesof 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 asole company, Monsanto. It commercializes seeds resistant to Roundup, a Monsantoproduct whose active ingredient is glyphosate.Monsanto is the second lar-167

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAgest seed supplier in the world, the third largest sellerof agrochemicals, and the produces the most amountof transgenic seeds in the world (it controls 90% ofthis market). In 2001, it reached a total of US 5.500million dollars, of which US 1.700 millions were on accountof seeds, and US 3.760 millions for agrochemicals,being herbicide gliphosate its number one (ortop)product.RR soy is a variety into which a "genetic cassette"has been inserted that contains the gene of resistanceto the glyphosate herbicide (RR gene), originatedfrom an organism to which it is not related genetically,and thus with which it would never be able tointerchange genes. The cassette of insertion includesa series of DNA sequences (derived from virus, bacteriathat are genetic parasites), which permit soy to acceptthese strange genes. The entire "insertion cassette"is patented. The RR genes are the property ofMonsanto.These patented genes do not endow seeds withsuperior productivity; they exclusively convert agriculturiststo? dependents of a model of weed control thatintensively uses herbicide.Independently of who sells the RR soy seeds,Monsanto charges the royalties for the use of "its genes".Commercialization of Soy88% of the soy commercialized worldwide is utilizedin the production of oil. With the residuals, soypaste is manufactured, and used as forage. 25% of comestibleoil emanates from soy. Four companies dominatethe world’s soy market. Three are from theUnited States: ADM, Bunge and Cargill. The fourthcompany is French, Louis Dreyfuss. These companiespurchase soy to sell oil and powder to producers ofanimal food and fodder, and to companies that makedetergents and chemicals. They control 43% of Brazil’soil and 80% of the European Union; the three North-American companies control 75% of the soy marketwithin their country. Indistinctively of who producesthe soy, these four companies are the ones, which infact profit from the soy business.ADM is the most important receivers of corporatesubsidies in the recent history of the United States.At least 43% of ADM’s annual earnings refer toproducts that are strongly subsidized, or protected bythe 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 gainedby the ethanol operation costs tax payers US$ 30.Bunge constitutes the major processor of soy oilglobally. It is the leading company in the South Coneand has important interests in North America and Europe.Moreover, they are the largest importers ofcommodities related to soy within Asia, and the mainpurveyors of powder throughout the Middle East.Bunge purchases, processes, and sells human and animalnourishing products for domestic markets or exportation,as well as grains and seeds.Cargill has its own control over the nourishingchain, with operations in 23 countries. This companymanages 40% of all the corn exports in the United States,33% of the soy exports, and 20% of the wheat exports.The Beef Market in EuropeThe European Union, with 36.9 million tons ofsoy per year, is the first worldwide importer. Its principaluse is as cattle feed. It is possible to foresee thatin coming years the consumption of soy within Europewill increase. The production of soy as a food sourcewill rise 4.6% annually during the next 15 years. Accordingto recent industry data, by the year 2011 the168

Observatorio Latinoamericano de Salud.production of soy could reach the 260 million metrictons, which represent 33% more than current production.The meat slaughter and processing sector is sufferingan accelerated process of concentration withinthe European Union. In several countries, the numberof abattoirs decreases year by year. Instead of smalllocal abattoirs, large processing plants exist, which frequentlyestablish direct agreements with producers.For instance, in the United Kingdom, the number ofabattoirs reduced from 1.671 in 1971 to 436 in 1994.The number of processing plants presently happens tobe much smaller. This is, to some extent, due to thefact that large processors are able to comply with Europeanstandards in this field. This confirms a concentrationwithin the sector, which will continue to proliferate.The ten greatest companies in the beef businessin Europe are:1. Arcadie-Bigard - France2. Socopa - France3. Anglo-Irish Food Processors - Ireland/England4. Südfleisch - Germany5. Dawn Meats - Ireland/England6. INALCA - Italy7. Danish Crown - Denmark8. Moksel - Germany9. Kepak - Ireland/England10. SVA - FranceSource: Nielsen y Jeppesen, 2001Subsequently, large European nourishing corporationsprocess most of the world’s meat. The mostprominent are Nestlé (Switzerland), the largest worldwidein the field of foods processing, with sales ofroughly 54.254 million dollars in 2002, and Unilevel(Holland/England), the third worldwide, with sales of25.670 million dollars in 2002.The commercialization of meat throughout Europeprocessed or not, is in the hands of large supermarketor retailer chains. These companies attempt tocreate their own brands, and increase their monopolyin the sector, by means of establishing direct contractswith processing plants and cattle ranchers. The largestare:COMPANY /COUNTRYCarrefour - FranciaAhold -HolandaMetro - AlemaniaRewe - AlemaniaEdeka - AlemaniaITM - FranciaSource: ETC Group. 2001.Other Benefited CompaniesSALES IN 2000In millions of dollars59,88849,00043,37134,85428,89424,894Other focal sectors are companies that have specializedin the investment of risk capitals. These may gointo bankruptcy, or obtain extremely large profit fromtheir investments. Some have penetrated the field ofbiotechnology, among them the 3i Group plc, LloydsTSB Development Capital Ltd from England, and MidlandsVenture Fund Managers Ltd from England.169

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAAn additional sector is dedicated to advising oroperating as "brokers" for agrochemical and biotechnicalcompanies, among them include:● Credit Suisse First Boston, which has been advisorto Aztra Zeneca and DuPont. It operated as a brokerfor Rhone-Poulenc and the fusion of Hoechstwith Aventis.●Deutsche Bank has been advisor to AksoNobelwhen Hoechst, its subsidiary, to Rhone-Poulenc.● Morgan Stanley Dean Witter & Co is Dupont’s broker.All these companies profit, one way or the other,from the world commerce of transgenic soy.Meanwhile,What HappensWithin Producer Countries?United States is the world’s leading soy producer(it produces 35% of the soy in the world), followedby Brazil (27%), Argentina (17%), China (9%, allfor national consumption), Paraguay and India (2%),and Bolivia (1%). As a region, the South Cone is themost important zone for soy productionConcerning 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 theSouth Cone:●With a plow and rotation of cultures (for instance,the sorghum, corn, and soy), with or without seedsgenetically modified. When irrigation is needed, itcan be rotated with cotton. This model is practicedin some places of Argentina.●●Direct sowing, without transgenic seeds; the residualsof the culture are given to cattle. This modelis practiced in the Central West zone of Brazil. Anabundant use of herbicides is required.Direct sowing, with seeds tolerant to glyphosate(Monsanto RR soy).Two campaigns of soy are madeannually.Since the 70’s, the Southern Cone has undergonea process of expansion in soy culture, especially inBrazil, Argentina, Paraguay, and Bolivia, with very highassociated environmental costs. Between 1970 and1980, the Mata Atlántica in Brazil has practically disappeared,and at the moment there is an attempt on theParaguayan ecosystem. The Chiquitano forests, theYungas, the Pantanal, the Cerrado, and the Amazonicjungle have been affected by making way for soy plantations,in order to feed European cattle and benefitthe four companies, which control the soy world market.Since a significant increase in the consumptionof meat within Europe is predictable, large extensionsfor the expansion of this culture will be required. Afterthe analysis of the zones where the most apt soilsexist, the more adequate legislation and sufficient infrastructure,the South Cone, has been appointed asthe ideal region for soy expansion.Next, there is a summary of the areas that havebeen occupied by soy fields in the South Cone, andthe ones that may be affected in the future (see tablein this page).The underlying principle of the project of the Hidrovía(water highway) Paraná-Paraguay is the rapidand economical access of commodities to the port fortheir exportation, mainly soy.The investments, in this case, are not made byprivate capital, but by governments, which share thisproject (Argentina, Brazil, Paraguay, Uruguay, and Boli-170

Observatorio Latinoamericano de Salud.COUNTRYPRODUCER WORLDWIDEAFFECTED AREAS(ha)PROGRAMMED AREASFOR THE EXPANSIONOF SOY (ha.)BRAZIL1st exporter2nd producer.It produces 27% of the world production.21 millions in "Cerrado",tropical forests and MataAtlántica, Pantanal, Caatinga.70 y 100 millions, of which,between 30 and 40 millionsof ha could be of "Cerrado"and 7 millions in tropicalforests.ARGENTINA3rd. It produces 17% of the worldproduction. The 98% of plantedsoy is genetically modified.14,3 millions in HumidPampa,Yungas and Chaco25 millions in Humid Pampa,Yungas and ChacoPARAGUAY4th. It produces 2% of the worldproduction. 80% RR soy1.750.000 in Pantanal, MataAtlántica and Chaco.3.500.000 in Pantanal, MataAtlántica and Chaco.BOLIVIA7th. It produces 1% of the worldproduction. Free of GMO600.000 in tropical forest1.200.000 in tropical forestand ChacoFuente WWF, 2004via). To ameliorate the navigation conditions, governmentshave to start with construction sites for riverbasin dredging, to change the course of rivers, and correctand stabilize navigation channels.Then they mustpost signs and mark with buoys to permit the flux ofconvoys with a minimum depth of 10 feet, 350 metersof 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 ofgrains and fertilizers. Along the Paraná River soy processingplants have been settled, to a large extent; controlledby the companies mentioned earlier.The Impact on Productive SystemsThe expansion of soy in Argentina has ousted othercultures, such as rice, corn, sunflower, and wheat;and it has driven other activities to marginal areas.Since 1988, there has been a diminution of productiveunits of 24.5%. Farms have disappeared; 103.400.Thousands of families migrate each year from thecountryside to the urban peripheries.The number of "tambos" (productive units dedicatedto cattle raising) has also decreased, from 30.141in 1988, there were only 15.000 left in 2003. Hence,protein obtained from meat has been substituted171

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcompulsively for products derived from soy. Directplanting uses very little labor, which has generated majorrural unemployment within soy zones.Agronomic ProblemsThroughout Argentina, the use of glyphosate hasincreased since RR soy was adopted. In the campaign1991/1992, 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 perinhabitant.The profuse use of a sole type of herbicide isprovoking changes in the underbrush communities,not only numerically, but also primarily for the appearanceof certain species uncommon to these systems.Additionally, the development of several species of underbrushtolerant to glyphosate has been detected,which forces the farmers to use stronger herbicides.Inclusively during fallowing, the soy that sprouts is consideredunderbrush, and is controlled via herbicidesmore powerful than gliphosate.The practice of direct sowing of soy has causedcommon invertebrates to turn into plagues. Moreover,during the campaign of 2000/2001 the rust of soyseriously affected the soy cultures in the Northwest ofArgentina.The varieties of soy tolerant to herbicide have anaverage yield of 2.4% less than conventional varieties.The Rights of Intellectual PropertyTraditionally farmers have had at their disposalthe 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.For this reason, it has been difficult for companiesto convert it into merchandise, since the seed is aliving organism that may reproduce, different from otherproducts, and this makes its monopolized controlvery complicated. In view of that, two associated mechanismshave been created: technological changes inphyto-improvement / phyto-remediation (through thedevelopment of hybrids and the GMO’s); and the impositionof the right of intellectual property.In the United States, vegetal varieties may beprotected either by means of the rights of breeders,or by patents. Although, in 1985 the patents office ofthe USA broadened the scope of protection of patentsto include plants and non-human animals, includingseeds, plants, parts of plants, genes, genetic characteristics,and biotechnological processes. At present, itseeks the expansion of the scope of intellectual propertyin the rest of the world, through the free tradetreaties.In the subject of patents, the United States wantsthe following to be acknowledged:● about plants● animals● essentially biological processes● genetic sequences and the material contained in thosesequencesImpacts Of Intellectual Property On TheCommerce Of Soy Within The South ConeDespite the extremely high profit made by Monsantoat the expense of Argentinean agriculture, thiscompany has put pressure on that country in orderthat a system of payment for the royalties of RR soyseeds is established.172

Observatorio Latinoamericano de Salud.Within that country, the right of intellectual propertyover seeds is exercised through the right of breeders.According to the law, farmers may store seedsprotected by the right of intellectual property to resowtheir lands. Albeit the interchange of those seedswith other farmers is not allowed, in practice this cannotbe controlled. And further, with soy cultivation, itis very easy to keep the seeds to plant them again thenext year. Farmers consider this form of practice normal,since they already paid for the seed once.Although Monsanto introduced the RR soy underthis law, it believes this form of practice "deprivesthe company from its legitimate profit". Statistics ofthe 2003-2004 harvest demonstrate that farmers paidUS 75 million dollars for royalties (which correspondto 18% of the 14 million ha sowed with soy RR). It iscalculated that if all the seeds sold were certified, thisvalue would have risen to US 400 million dollars.At first, Monsanto, in Argentina, was not chargingfor seed royalties; it resided in the selling of herbicideRoundup. However, the patent of glyphosate alreadyexpired and the majority of Argentinean "soyeros" importglyphosate from China, where it is much cheaper.Is the business of Monsanto through in Argentina?By no means; at the moment Monsanto intends tocharge for a patent not registered in the country, butcertainly registered in other countries to which Argentineansoy is exported, at the time of the commercializingof grains where RR soy is patented.Monsanto has never patented RR soy within thecountry and the company is not in the position to imposethis patent to Argentina if it can impede the importof RR soy throughout those countries where ithas indeed registered this patent.The proposal of Monsanto is that producers paywhen they sell their harvest, including the productsderived from soy, such as oil. Exporters would operateas retention agents for the biotechnological company.Initially, the sum will approach 2% per each tonexported; this quantity will possibly increase to 3%.In spite of the plan not being definitive, as Monsantocontinues to negotiate with the government andthe organizations of producers, they mean to implementat once a system of charging royalties for thecampaign 2004-2005. If the propositions exposed donot make progress, Monsanto is determined to sellSoy exportation licenses.For every dollar/ton paid on account of royaltiesfor soy exports in Argentina the multinational will receiveUS 34 million dollars annually (without farmershaving purchased seeds from Monsanto).Regardless of the fact that Monsanto used Argentinaas a launching platform for the production oftransgenic soy, and this country is an excellent clientfor the company, Argentinean farmers complain thatMonsanto demanded payment in dollars for the seedsand agrochemicals sold at the end of monetary convertibility.When the importation of glyphosate fromChina initiated, Monsanto pressured Argentina togrant them a privileged treatment pertaining to tariffs.Analogous treatments have been applied to producersin Brazil and Paraguay. Once legalized, RR soycultures planted clandestinely throughout Brazil withthe endorsement of Monsanto in 2003, the "soyeros"paid the royalties, R$ 10/ton. In 2004, the royaltiesdoubled to R$ 20/ton. In Paraguay, illegal cultures werelegalized as well. In line with an agreement signedby soy producers, seed producers, cooperatives andexporters, presented to the Department of Agriculturefor approval, the producers initially will pay Monsanto$ 3 per each metric ton of soy. After 5 years, therate would increment to $ 6/ton.On the other hand, biotechnological companiesrequire varieties adapted to the conditions of thecountry, to insert the patented transgenes in them.With this purpose, they have accessed the genetic materialgenerated by public research programs, and expectto continue having free access to this material.173

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAConclusionsFar from nourishing the poor of the world, agrobiotechnologyemerges as an activity designed to incrementthe profit of large transnational biotechnologicalcorporations, through the processing, distribution,and selling of foods, and through other companiesinvolved in the nourishing chain.The aggressive expansion of agro-biotechnologyhas been facilitated due to the pressure exercised bythe Government of the United States, with the intentionthat countries adopt laws on intellectual property,investments, and sign free trade treaties, which complywith the interests of their companies. All this is performedwith the aid of the impositions of the InternationalMonetary Fund and the World Bank, which compelus 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 companiesthat profit from this. Producer countries are left withtheir lands destroyed and contaminated, and its socialtexture shattered.The defense of nourishing sovereignty is an unavoidableresponsibility to confront this aggression. Tothink first in local and national production, in the satisfactionof our nourishing and cultural necessities, withthe use of a technology we may control, are some ofthe indispensable elements to achieve this objective.174

Observatorio Latinoamericano de Salud.REFERENCES● AGÊNCIA CARTA MAIOR (2003). 6/11/2003● AGROLINK (2003). Internet, 5-5-03● ECONOMIC RESEARCH SERVICE (2004). Sitio web accesadoen octubre.● EUROPE ACADEMIES (2004). Science Advisory Council Genomicsand Crop Plant Science in Europe. May.● GAZETA MERCANTIL (2004). Monsanto dobra valor de royalties.02/09/2004● GRUPO ETC (2003). Oligopolio, S.A. Concentración del podercorporativo. Comuniqué 82.● JOENSEN, L. SEMINO, S (2004). Grupo de Reflexión Rural. Estudiode caso sobre el impacto de la soja RR. Grupo de ReflexiónRural.● KING, J. HEISEY, P (2003). Ag Biotech Patents: Who is DoingWhat? Amber Waves. The Economics of Food, Farming NaturalResources, and Rural America. USDA.● NIELSEN, N.A., JEPPESEN, L.F. (2001).The beef market in the EuropeanUnion.Working Paper No. 75 The Aarhus School Of Business● PRESTES, S (2004). September 21, GM soybean controversy: 90%of Rio Grande do Sul harvest will be GM.Agência Brasil.● RIVERAS, I (2004). "Monsanto Brazil seeks royalties for illegal RRsoy " Reuters News●WWF (2004).The Soy Boom:Two scenarios of soy production expansionin South America. Commissioned by WWF Forest ConversionInitiative.175

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA18Oil Exploitation in the Amazonian Regionof Ecuador: Emergency in Public Health 1This work is dedicated to Angel Shingre, peasant andenvironmentalist, who struggled his whole life for anAmazonían Region free of contamination. He was murderedin Coca on November 4th, 2003.Miguel San Sebastián,Anna-Karin HurtigAnibal Tanguila, Santiago SantiAsociación de Promotores de Salud "Sandi Yura"IntroductionPetroleum is one of the main sources of income for Ecuador. Since 1970it has functioned as the motor of national economy. Before the explosion inpetroleum prices in 1970, Ecuador was one of the poorest countries of LatinAmerica. After that moment, the production of petroleum has beenchiefly responsible for the growth of the Ecuadorian economy (an annualmean of 7%); with per capita income increasing from US 290 dollars in 1972to US 1.200 dollars in 2000. Presently, petroleum continues to supply 40% ofthe profit by exports and of the budget of national Government [Centro deDerechos Económicos y Sociales, 1999; Instituto Latinoamericano de InvestigacionesSociales, 2005]. The majority of this petroleum comes from thenortheastern zone of the country, the Amazonian Region.This region in Ecuador, known as the "Oriente", occupies an area ofnearly 100.000 km2 of tropical forests in the source of the Amazonian fluvialnetwork. The region contains one of the most diverse collections of plants1. This chapter is based on the article: San Sebastián M, Hurtig AK. Oil exploitation in the Amazon basin ofEcuador: a public health emergency. Revista Panamericana de Salud Pública 2004; 15(3): 205-211 (authorization)176

Observatorio Latinoamericano de Salud.and animal life in the world. The Oriente is also thehome of approximately 500.000 people, 4,5% of thetotal population of the country. This half million peopleincludes eight groups of indigenous population, aswell as peasants that immigrated to the zone, havingleft the coastal and Andean regions of the country[Fundación "José Peralta", 2001]. These populationsmoved to the Oriente at the end of the 70’s and beginningof the 80’s, driven by the agrarian policies ofthe national Government.In 1967, the Texaco-Gulf consortium discoveredan abundant oil field underneath the Amazonian tropicalforest that led to petroleum "boom", which sincethen has modified the region. The Ecuadorian Amazoncurrently holds an extended network of roads, pipes,and fields. Despite the national Government havingretained the right of property over all the mineral resources,numerous foreign private companies haveconstructed and operated the greatest part of the infrastructure.At present, the petroleum production activitiesin the Oriente employ roughly a million hectares, withmore than 300 wells of production and 29 fields.Thecountry 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 participatedin the process of petroleum exploitation. At thistime, there are 16 companies operating in the country:Petroecuador, 3 national private companies, and 12 foreigncompanies [Petroecuador, 2005]. Figure 1 illustratesthe companies that operate within the countryand the blocks where they are situated.From the beginning of petroleum exploitation,foreign companies in conjunction with Petroecuadorhave extracted more than two billion barrels of oil inthe Amazonian Region. Nevertheless, in this processbillions of gallons of toxic, gas and petroleum wastehave been spilled on environment [Kimerling, 1991](see table in follow page).This chapter examines impact on environmentand health occasioned by the process of petroleumdevelopment in the Amazonian Region of Ecuador andsuggests different mechanisms that could aid in palliatingthis enormous impact.THE ENVIRONMENTAL EXPOSURESource and extension of contaminationThe extraction of petroleum comprises variouscontaminating processes. The seriousness of theseprocesses depends mainly on the environmental formof practice and technology used by petroleum companies.In Ecuador, these forms of practice have been repeatedlyargued [Kimerling, 1991; Varea, Ortiz, eds,1995].In the interior of the earth, petroleum is mixedwith natural gas and formation water. In the AmazonianRegion of Ecuador, each well that is perforatedproduces a mean of 4.000m3 of waste, largely perforationmud (used as a lubricant) and formation waters(which contain hydrocarbons, heavy metals and an elevatedconcentration of salts). These wastes are frequentlydeposited in earth pools, from where they areeither eliminated directly to environment, or spilledonto it as a result of a fracture of the pool or the overflowingdue to the rain [Kimerling, 1991]. At the moment,there are nearly 200 pools without protection inthe entire Amazonian Region [Frente de Defensa de laAmazonía-Petroecuador, 2003]. Albeit some companieshave modified this form of practice in the last 10years, by means of the construction of protectedpools, 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 waterand gas, and they are separated in a central station.177

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAIn 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 inearth pools. Moreover, originated from this process ofseparation, in the Amazon roughly 53 millions of cubicfeet of gas are burned. This gas is burned without anytype of control of emissions or temperature. An additionalcontamination of air is brought about by theevaporation of hydrocarbons from the pools or theoverflowing of oil [Kimerling, 1991; Centro de DerechosEconómicos y Sociales, 1994].It has been estimated that the maintenanceworks of more than 300 wells of production existentin the Amazonian generate more than 5 million gallons178

Observatorio Latinoamericano de Salud.(18,9 million liters) of toxic waste, which are depositedin the environment each year. Escapes emanatingfrom the wells and the overflowing of tanks are alsofrequent [Almeida, 2000]. According to a study completedby the Ecuadorian government in 1989, theoverflows of flux lines that connect the wells to thestations 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 pipelinesare numerous as well. In 1992, the Ecuadorian governmentregistered approximately 30 large overflowswith an estimated loss of 16,8 million gallons (63,6 millionliters) of petroleum [Kimerling, 1991; Centro deDerechos Económicos y Sociales, 1994]. In 1989, atleast 294.000 gallons (1,1 million liters) of petroleum,and in 1992, around 275.000 (1 million liters), broughtabout the "blackening" of river Napo (1km wide) duringa week. In 2002, it was assessed that within theregion two large overflows originated in the main oilfields occur per week [El Comercio, 2002].In total, until 1993 more than 30 billion gallons(113.700 million liters) of petroleum and toxic wastehad been spilled on the earth and the rivers of theOriente [Kimerling, 1991; Centro de Derechos Económicosy Sociales, 1994]. In contrast, the oil tanker ExxonValdez in 1989 spilled 10,8 million gallons (40,9million liters) on the coast of Alaska; one of the majorpetroleum overflows ever transpired in the sea.Environmental AnalysisSeveral reports have indicated that contaminationin the Amazonian Region in Ecuador has arisensince the beginning of petroleum exploitation [Kimerling,1991;Varea, Ortiz, eds, 1995], despite the inexistenceof longitudinal data on the levels of exposure ofpopulation during this period.In 1987, a study undertaken by the Ecuadoriangovernment found high levels of grease and petroleum,in 36 samples taken from rivers and streamsnear places of petroleum production [CorporaciónEstatal Petrolero Ecuatoriana (CEPE), 1987]. Througha further study of the Government in 1987, it wasfound that petroleum coming from 187 wells was regularlyspilled on the bodies of water and soils of theregion [Ecuador. Dirección General de Medio Ambiente,1989].In 1994, the Center of Economical and SocialRights, a national organization of human and environmentalrights, published a report documenting dangerouslevels of contamination due to petroleum in therivers of the Ecuadorian Amazon. Throughout thisstudy, concentrations of polycyclic aromatic hydrocarbonswere found in the water that population drankand used to bathe or fish, 10 to 10.000 times superiorto the limits permitted by the Agency of EnvironmentalProtection of the United States [Centro de DerechosEconómicos y Sociales, 1994].In 1998, an independent laboratory habituallyused by petroleum companies examined 46 rivers inthe Oriente region. The study discovered contaminationby petroleum total hydrocarbons in the areaswith petroleum exploitation, while no contaminatedwater was observed in the areas without exploitation[Zehner,Villacreces, 1998].In 1999, the Institute of Epidemiology and CommunitarianHealth "Manuel Amunárriz", a local nongovernmentalorganization, performed the analysis ofwater for petroleum total hydrocarbons in communitiesnear oil fields and in communities far from them.The analysis revealed elevated concentrations of petroleumtotal hydrocarbons in the rivers of communitiesnear the fields. In some rivers, the concentrationsof hydrocarbons exceeded by more than 200 timesthe limit permitted by the regulation of the EuropeanUnion [San Sebastián, 2000].179

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINASince 1992, according to law, petroleum companiesmust monitor regularly the levels of environmentalcontamination and send the corresponding reportsto the national Government of Ecuador. This informationis not accessible to public opinion. However,when one of these reports was presented in 1999 toa community that had constantly complained to theDepartment of Environment for the environmentalcontamination by petroleum, concentrations of petroleumtotal hydrocarbons superior by 500 times to thelimit permitted by the regulation of the EuropeanUnion were found in the rivers of the mentioned community.The petroleum company and the representativeof the Ecuadorian Government maintained thatthe levels of petroleum total hydrocarbons were normal[Ecuador. Ministerio de Medio Ambiente, 1999].Within the Amazonian Region of Ecuador thedata available on the contamination of soil and its possibleimpact is scarce, and not one study has been doneon the impact that petroleum development has onboth fish and fishing. Nevertheless, studies of theAmazonian Region in Peru found high concentrationsof petroleum total hydrocarbons in the stomach andmuscles of fish after an overflow of petroleum in theriver Marañón [Perú. Dirección Regional de Pesqueríade Loreto, 2000].Effects in HealthFor several years, the residents in areas of petroleumexploitation in the Amazonian Region in Ecuadorhave expressed their concerns in relation to contaminationcoming from the exploitation. Many indigenousand peasant communities have declared that numerouslocal rivers and streams, which used to be plentifulfor fishing, at present lack aquatic life.They have observed,as well, how cattle die after drinking the waterof those rivers and streams. These are the same watersthat population customarily utilizes to drink,cook, and bathe. The residents of these areas have alsostated that bathing in these rivers produces skinirritation, especially after intense rain, as this acceleratesthe flux of waste from the pools near the rivers[Kimerling, 1991; Kimerling, 1995].In 1993, an association of health promoters forthe Amazon accomplished a study that described thecommunities. The study found that communities inareas of petroleum exploitation had elevated rates ofmorbidity, with notably prevailing abortions, dermatitis,skin fungus, and malnutrition, as well as a majormortality rate compared to communities where therewas no petroleum exploitation [Unión de PromotoresPopulares de Salud de la Amazonía Ecuatoriana, 1993].In 1997, the Institute of Epidemiology and CommunitarianHealth "Manuel Amunárriz" initiated a researchprocess to evaluate the possible impact onhealth, of the contamination by petroleum in communitiesnear the oil fields. Through the first of these studies,women who lived in communities near oil fieldsshowed 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 petroleumexploitation [San Sebastián,Armstrong, Stephens,2001]. In addition, it was detected that the risk ofspontaneous abortions was 2,5 times greater in womenwho lived in the vicinity of the oil fields [San Sebastián,Armstrong, Stephens, 2002]. The research in1998 of a cluster of cancers in a community situatedin an area of petroleum exploitation in the AmazonianRegion of Ecuador uncovered an excess of cancersamong the masculine population [San Sebastián,Armstrong,Cordoba, Stephens, 2001]. In 2000, anotherstudy investigated the differences in the incidence ofcancer from 1985 to 1998 in the Amazonian Region ofEcuador. This study revealed an incidence of cancersignificantly greater, as much in women as in men wit-180

Observatorio Latinoamericano de Salud.hin cantons where there had been petroleum exploitationfor 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 leukemiain cantons where there is petroleum exploitation hasbeen noticed [Hurtig, San Sebastián, 2004].The Response of the GovernmentThe peasants and indigenous people of the AmazonianRegion have presented their complaints to thedistinct administrations of the national Government.The inhabitants of this region have claimed a better lifestandard, the availability of basic necessities such aselectricity, the supplying of water and health services,technical assistance, and above all the remediation ofenvironmental contamination. By way of their organizationsand the support of national and internationalenvironmental organizations, the residents of theOriente have solicited companies to clean contaminationand to be compensated for the damages causedby this contamination. Until the present, the measuresadopted by companies and the different administrationsof the national Government have been describedas "patches" (covering of some pools, construction ofschools, roads) without facing the root of the problem[Varea, Ortiz, eds, 1995].Various administrations of the national Governmenthave declared the principal importance of petroleumfor the development of Ecuador. Ecuador currentlyretains the record external debt per capita ofall 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 thepercentage of population in poverty (from 47% to61,3%) have increased from 1970 to 2002 [Centro deDerechos Económicos y Sociales, 1999; Instituto Latinoamericanode Investigaciones Sociales, 2005]. Theratio of the income received by 5% of the poorest populationand the richest 5% changed from 1:109 in1988 to 1:206 in 1999 [Acosta, 2000b].The AmazonianRegion has the worst infrastructure and the worst socio-economicaland health indicators of the entirecountry [Terán, 2000].As a response to the nearly US 16 billion dollarsof external debt that the country has, one of the keystrategies of the national Government and the InternationalMonetary Fund has been the expansion of petroleumexploitation within the country. The proposalsof the national Government include the ceding oftwo million hectares of primary tropical forest in theSouth of the Amazonian Region to the exploitation ofpetroleum and the construction of a pipeline of heavycrude oils in the North of the Amazon to facilitate amajor exploitation in that area [Centro de DerechosEconómicos y Sociales, 2000].WHAT OUGHT TO BE DONE?In order to be compatible with the sustainabledevelopment and well-being of Amazonian populations,modern development of petroleum and gas exploitationmust be based on an integral environmentalplanning that considers the accumulated impact ofpresent and future exploitation all through the region.To prevent serious environmental and health impact,strict environmental controls and careful monitoringof the extraction activities in the long term are necessary[Kimerling, 2001]. Five interrelated actions are urgentlyrequired:● The Government of Ecuador should perform an evaluationof the environmental situation of the AmazonianRegion. It is also indispensable to develop andsupervise the execution of a plan to remediate the181

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA●damage already produced and limit further destruction.The more contamination that continues, themore will the health of the population of the Orienteand other populations in similar circumstancesremain in risk. Some indigenous and environmentalistgroups have called attention to the necessity ofapplying the principle of precaution [Raffensperger,Tickner, 1999]. At the same time, they have askedthe national Government a moratorium in the petroleumand gas development in new areas of theAmazon. Alternatives of development have beenproposed, such as eco-tourism or the conservationof the tropical forest, which ought to be seriouslyconsidered [Centro de Derechos Económicos y Sociales,2000;Acosta, 2000a].The petroleum companies that operate at this timein the Ecuadorian Amazon should change theirforms of practice to minimize the environmental impactand construct alliances with local communitiesto promote local development. Companies shouldmake available to the communities and independentenvironmental groups the standards of environmentalprotection and plans of environmental management.Without this information, these groups continueto be ignorant of the possible risks, and theycannot participate significantly in the political decisionsor force companies to be responsible for theiractions. Additionally, an environmental monitoringsystem should be established with the participationof all the affected communities. This system shouldcomprise at least a detailed chemical sampling of theenvironment regularly completed, and the report ofthe control of emissions and waste.● The policies of petroleum development have an impacton health and their consequences must be evaluatedand taken into account.The Ecuadorian Governmentshould acknowledge the need of incorporatingevaluations of impact on health, as an essentialpart of its policies of development. Consultationwith and participation of the community are fundamental,as much in the evaluation of environmentalimpact as in the one concerning health [British MedicalAssociation, 1998].● The new Constitution of Ecuador of 1998 recognizesthe right of communities to be consulted bycompanies prior to initiating a phase of exploitation.This right to be consulted should involve the possibilityof refusal of communities to this type of exploitation.Communitarian organizations in conjunctionwith the environmentalist groups at the regional,national and international levels are crucial inthe exercising of these rights. The Ecuadorian Governmenthas made the commitment to develop themechanisms, which activate the use of laws to protectthe environment and health of citizens, despitethe fact that this development is complicated. Allthis should be considered in the context of the needto uphold human rights, combat corruption andstrengthen democratic institutions.● From an international viewpoint, the preoccupationexists that globalization of transnational commerceis not creating any benefit to the environment andhealth of populations [United Nations EnvironmentalProgram, 1999; Stephens, Lewin, Leonardi, San Sebastián,Shaw, 2000]. Urgent changes are required inthe commercial policies, in order to direct them towardthe environmental sustainability and social justice,to reach the majority in terms of the benefitsof an environmental protection, as well as those ofeconomical and health protection.182

Observatorio Latinoamericano de Salud.ConclusionThe petroleum exploitation in the AmazonianRegion of Ecuador has resulted in a public health emergency,due to its negative impacts on environment andhealth. Until now, the Ecuadorian Government has notdesigned an adequate strategy to prevent future impactson environment and health. The petroleum industryusually argues that it plays a role in the developmentof a country; however this should not be at theexpense of contamination and health damage [BritishPetroleum. Environment and Society, 2005; OXY, 2005].At a first glance, petroleum industry and public healthare not connected. Nevertheless, we have attemptedto demonstrate that they are deeply associated. Unfortunately,Ecuador is not the only country sufferingthe negative consequences of petroleum exploitationthroughout Latin America. Countries such as Colombia,Peru and Bolivia display similar situations [La TorreLópez, 1998; Oilwatch, 1999]. Public health problemsalready exist and these problems will potentially increaseif the petroleum industry expands without regulationwithin Latin America, as it has until now. The preventionof an additional hazard to health and environmentrepresents an enormous challenge, which will undeniablyrequire the coordinated action of social movementsand networks at local, national and internationallevels.183

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAREFERENCES● ACOSTA A (2000). ¿Es posible la transición a una economía postpetrolera? En: Martínez E, ed. El Ecuador post petrolero. Quito:Acción Ecológica.● ACOSTA A (2000). El petróleo en el Ecuador: una evaluación críticadel pasado cuarto de siglo. En: Martínez E, ed. El Ecuador postpetrolero. Quito:Acción Ecológica.● ALMEIDA A (2000). Reseña sobre la historia ecológica de la Amazoníaecuatoriana. En: Martínez E, ed. El Ecuador post petrolero.Quito:Acción Ecológica.● BRITISH MEDICAL ASSOCIATION (1998). Health and environmentalimpact assessment: an integrated approach. London:Earthscan.● BRITISH PETROLEUM. ENVIRONMENT AND SOCIETY (2005).Disponible en: http://www.bp.com/ genericsection.do?categoryId-=931&contentId=2016995 Accedido el 12 de enero.● CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (1994).Violaciones de derechos en la Amazonía Ecuatoriana. Quito: Abya-Yala.● CENTRO DE DERECHOS ECONÓMICOS Y SOCIALES (1999).El petróleo no es eterno. Quito: Centro de Derechos Económicosy 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.● 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.● CORPORACIÓN ESTATAL PETROLERO ECUADORIANA (CE-PE) (1987).Análisis de la contaminación ambiental en los campospetroleros Libertador y Bermejo. Quito: CEPE.● ECUADOR. DIRECCIÓN GENERAL DE MEDIO AMBIENTE(1989). Estudio de impacto ambiental 42. Quito: Dirección Generalde Medio Ambiente.● ECUADOR. MINISTERIO DE MEDIO AMBIENTE (1999). Informede inspección ambiental al área de las comunidades Flor de Manduroy Centro Manduro ubicadas en el bloque siete operado porla compañía Oryx. Quito: Ministerio de Medio Ambiente.● EL COMERCIO (2002) Dos derrames de petróleo al mes en elcampo Auca. octubre 18.● FRENTE DE DEFENSA DE LA AMAZONÍA-PETROECUADOR(2003). Estudio para conocer el alcance de los efectos de la contaminaciónen los pozos y estaciones perforados antes de 1990en los campos Lago Agrio, Dureno, Atacapi, Guanta, Shushufindi,Sacha, Yuca, Auca y Cononaco. Quito: Frente de Defensa de laAmazonía-Petroecuador.● FRENTE DE DEFENSA DE LA AMAZONÍA (1999). La Texacontaminaciónen el Ecuador. Lago Agrio, Ecuador: Frente de Defensade la Amazonía.● FUNDACIÓN JOSÉ PERALTA (2001). Ecuador: su realidad. Quito:Fundación de Investigación y Promoción Social José Peralta.● HURTIG AK, SAN SEBASTIÁN M (2002). Geographical differencesof cancer incidence in the Amazon basin of Ecuador in relationto residency near oil fields. International Journal of Epidemiology;31:1021-1027.● HURTIG AK, SAN SEBASTIÁN M (2004). Incidence of childhoodleukemia and oil exploitation in the Amazon basin of Ecuador InternationalJournal of Occupational and Environmental Health;10(3): 245-250.● INSTITUTO LATINOAMERICANO DE INVESTIGACIONES SO-CIALES (2005). Economía ecuatoriana en cifras, 1970–2003. Disponibleen: http://www.ildis.org.ec/estadisticas/ estadisticas.htm.Accedido el 10 de enero.184

Observatorio Latinoamericano de Salud.● KIMERLING J (1991).Amazon crude. New York: Brickfront GraphicsInc.● KIMERLING J (1995). Rights, responsibilities, and realities: environmentalprotection law in Ecuador’s Amazon oil fields. SouthwesternJournal of Law and Trade in the Americas; 2(2): 293-384.● KIMERLING J (2001). The human face of petroleum: sustainabledevelopment in Amazonia? Review of the European CommunityInternational Environmental Law; 10(1): 65-81● LA TORRE LÓPEZ L (1998). ¡Sólo queremos vivir en paz! Experienciaspetroleras en territorios indígenas de la Amazonía peruana.Copenhague: Grupo Internacional de Trabajo sobre AsuntosIndígenas.● OILWATCH (1999). Fluye el petróleo, sangra la tierra. Quito: Oilwatch.● OXY (2005). Social responsibility. Disponible en: http://www.oxy-.com/Social%20 Responsibility/environ_main.htm Accedido el 12de enero.● PERÚ. DIRECCIÓN REGIONAL DE PESQUERÍA DE LORETO(2000). Monitoreo del impacto postderrame de petróleo sobrelos recursos hidrobiológicos entre San José de Saramuro y Nauta,Río Marañón. Iquitos: Dirección Regional de Pesquería.● PETROECUADOR (2005). Bloques concesionados. Disponible en:http://www.petroecuador. com.ec/donde.htm. Accedido el 10 deenero.● RAFFENSPERGER C,TICKNER J (1999). Protecting public healthand the environment: implementing the precautionary principle.Washington, D.C.: Island Press.● SAN SEBASTIÁN M (2000). Informe Yana Curi: impacto de la actividadpetrolera en la salud de poblaciones rurales de la Amazoníaecuatoriana. Quito: Cicame & Abya-Yala.● SAN SEBASTIÁN M, ARMSTRONG M, CORDOBA JA, STEP-HENS C. (2001). Exposures and cancer incidence near oil fieldsin the Amazon basin of Ecuador. Occupational and EnvironmentalMedicine; 58: 517-522.● SAN SEBASTIÁN M, ARMSTRONG M, STEPHENS C (2001). Lasalud de mujeres que viven cerca de pozos y estaciones de petróleoen la Amazonía ecuatoriana. Revista Panamericana de SaludPública; 9: 375-384.● SAN SEBASTIÁN M,ARMSTRONG M, STEPHENS C (2002). Outcomeof pregnancy among women living in the proximity of oilfields in the Amazon basin of Ecuador. International Journal ofOccupational and Environmental Health; 8: 312-319.● STEPHENS C, LEWIN S, LEONARDI G, SAN SEBASTIÁN M,SHAW R (2000). Health, sustainability and equity: global trade inthe brave new world. Global Change and Human Health; 1(1): 44-58.● TERÁN C (2000). Sucumbios 2000. Lago Agrio, Ecuador:Vicariatode Sucumbíos.● UNIÓN DE PROMOTORES POPULARES DE SALUD DE LAAMAZONÍA ECUATORIANA (1993). Culturas bañadas en petróleo:diagnóstico de salud realizado por promotores. Quito:Abya-Yala.● UNITED NATIONS ENVIRONMENTAL PROGRAMME (1999).Global environment outlook. Nairobi, Kenya: Earthscan Publications.● VAREA A, ORTIZ P, eds (1995). Marea negra en la Amazonía: conflictossocioambientales vinculados a la actividad petrolera en elEcuador. Quito:Abya-Yala.● ZEHNER R, VILLACRECES LA (1998). Estudio de la calidad deaguas de río en la zona de amortiguamiento del Parque NacionalYasuní. Primera fase: monitoreo de aguas - screening Octubre de1997. Coca, Ecuador: Laboratorio de Aguas y Suelos P. MiguelGamboa-Fepp.185

Section II:THAT OTHER HEALTH POSSIBLE

ActionFrom DemocraticStates

Observatorio Latinoamericano de Salud.19Health Program Achievements of theBolivarian Venezuelan RepublicFrancisco ArmadaHealth Equity: A Pillar of Improving Quality of LifeHealth is a pillar of development, dignity, and the improvement of the qualityof life of the Venezuelan population.Our main political objectives in health have been directed toward the rearrangementof institutional structures and public health care networks. The fullenjoyment of social rights and equity should operate as a foundation of a newsocial order, one based on justice and well-being.We started improving on our inequities by reducing the care deficit and thehealth access disparity among groups; recovering the social collective nature ofthe public programs; empowering our citizens; and building the capacity of citizensand social organizations to participate in the development of alterative policies.These have shown to have a real impact on the social development of thecountry.A crucial aspect to highlight our health accomplishments is that during thefive years of the present government, seven million people have been incorporatedas beneficiaries of health projects. Thus, tendencies indicate that coveragewill progressively expand, comprising the social strata with major needs.The Consolidation of the National Public System of HealthThe Constitution of the Bolivarian Venezuelan Republic (1999) instituted animportant landmark in the change of public health conceptions. It confirmshealth as both a fundamental social right and establishes the obligation of the Stateto guarantee it. This is done by developing policies oriented to elevating the189

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINApopulation’s quality of life and free access to health relatedservices.The constitution mandated the creation of a nationalsystem of public health that is inter-sectorial, decentralized,participative, and integrated into the socialsecurity system. This system will be regulated by theprinciples of gratuitousness, universality, integrality,equity, social integration and solidarity. It presents itsfirst advancements in the promulgation of the OrganicLaw of the System of Social Security (2002), which establishedthe necessity to redefine the legal instrumentof health.Nevertheless, to undertake the consolidation ofa national public health system, it is essential to delineatea national policy that associates the governmentalapparatus with all other levels of those involved. Inview of the fact that dispersion and segmentation ofthe institutional service providers has contributed tothe absence of equity and the exclusion of significantsectors of the population, these are added to the limitedcapacity of existing services.It is also important to bear in mind that the absenceof an integral conception of the individual as abio-psychosocial being results in the lack of an integralapproach to health, one that guarantees the provisionof basic services, and also contributes to the constructionof social and sanitary equity.The health crisis in Venezuela is manifested inmany different ways: by the deterioration of sanitaryconditions, the decline of sanitary installations, the deficiencyof equipment in the care centers, the scarcecoverage of medical care, the limitations in the accessto health services, the commercialization of health, andthe medicalized education and training of health professionals,among others.Segmentation and segregation, which have characterizedthe provision of services, have conspiredagainst elementary human rights, including the right tohealth.The neoliberal proposals that advocate the privatizationof medical care and health services accentuatethe gaps and deepen the exclusion of the mostdeprived and unprotected sectors of the population.Those are the main reasons to support the changescentered in responding to social needs to attainequity as a new order of social justice and the materialsource of Venezuelan society. Hence, this objectivedemands the transformation of material and socialconditions of the majority of the population, historicallyseparate and distant from the equitable access towealth and well-being, and the construction of a newhealth paradigms based on the acknowledgement andfull exercise of rights.The actions lead to investing greater efforts inthe elimination of structures formed to promote dominationmodels of any nature. These models haveboth directly and indirectly influenced many aspects ofsociety 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 distinguisheditself as an integral social policy that intends to surmountconformism, which characterized social policyduring the implementation of neoliberal programs.These programs were rooted in the attainment of limitedgoals and partial palliative care of social problems,and had the purpose of simply restraining poverty.Therefore, governance and social stability wereseriously compromised, making it unsustainable forneoliberal actions to be applied.Foremost Achievements in HealthFrom the standpoint of an integral health approach,all important changes in the living conditionsof the population are considered part of the healthprogram, even though they are not necessarily operatedby specific health institutions. Many of the success-190

Observatorio Latinoamericano de Salud.ful social development programs that the present Venezuelangovernment has implemented in order toovercome poverty and correct health disparities arenot explained in this report, but they constitute essentialcomponents of our health program 1 .Despite endemic illnesses that continue to be animportant cause of death within our country, all actionshave been performed in order to detain the tendencyof the infected population to increase and to incorporatepreventive measures to control this type ofillness.So coming back to specific health achievementswe can start by mentioning that since 1998, the policyof access to anti-retroviral treatment (ARV) has beenorganized universally and under a no-fee for servicebasis, allowing for the introduction of generic productsto guarantee the coverage extension of the program,and thus to break with the limitations to efficaciousand opportune access.By the year 2004, 12.546 patients with HIV/AIDShad received care with high-efficiency triple therapy inVenezuela. It is noteworthy that the integration withother governmental institutions that developed parallelprograms has been accomplished, attending throughthe National AIDS Program assuming those patientswho require ARV medicines; it also providesthem with 100% care and coverage.Additionally, the funds to ensure the sustainabilityof this policy were implemented with governmentalsupport to initiate the national production of antiretroviralmedicines. And lastly, the occupational preventionprogram for HIV/AIDS and the mother tochild transmission control program are being currentlyimplemented (see Table1)The fact that starting from the year 2000 theDepartment of Health and Social Development createdthe National Commission for Anti-malaria Strugglewith permanent characteristics is prominent. The generalstrategy to combat malaria in Venezuela is composedof early diagnosis and opportune treatment, aswell as the understanding of the population dynamicsin areas with this disease.In 2004, an Action Plan for the Control of Malariawas formulated in the Delta Amacuro, Bolivar andAmazonas states. Equipment and boats were acquiredto face malarial dissemination in these high risk states.The Plan incorporates active and permanent integrationof the national, regional and local teams ofCUADRO 1. PACIENTES ATENDIDOS POR EL PROGRAMA NACIONAL SIDA-ITS AÑO 2004Año Paciente en Tratamiento2002 74282003 116892004 14264Embarazadas Seropositivas atendidas138110146Accidentes Laborales203613231Total de pacientes76561166714263Fuente: Programa Nacional de Sida MSDS1. 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 socialdevelopment programs called "misiones", implemented under community control and geared towards improving and dignifying the life of the poor.At this point wecan 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 factoryprograms.These are only examples of the resource redistribution programs that are consequences of a just allocation of profit funds coming from the oil industry.191

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAepidemiologists appointed for the services programsand the health offices of each federal institution, withthe incorporation of malaria control activities in theregular work of epidemiological surveillance, includingthe training of health personnel, community membersand volunteers, all for the diagnosis, treatment and integralcontrol of the disease. The mentioned actions,for example, yielded a 70% incidence reduction of Malariain Sucre state. Thus, the therapeutic scheme forthe Venezuelan anti-malaria treatment at the regionallevel has been successfully implemented.In the struggle against dengue significant effortshave been fulfilled, if we take into consideration thatduring the decade of the 90’s several epidemic outbreakswere registered: in 1990, 1994, 1995, 1997,1998, and more recently, during 2001 and 2002 (incidencerate, 337 per 100.000 inhabitants, and 152,96per 100.000 inhabitants respectively). In this sense, theconfiguration of the National Commission for AntidengueStruggle of the Department of Health and SocialDevelopment is notable. This institution coordinatesthe control and prevention activities against denguewithin the country, and falls under the responsibilityof the distinct institutions implicated above.Overall, it must be underscored that in Venezuelaa high quality epidemiological surveillance exists,with an excellent network of laboratories and experiencein patients’ medical care, which has facilitatedthe lethality of the illness to be maintained under onepercent.The National Plan of Vaccination is being developed,destined for the infantile population until the first192

Observatorio Latinoamericano de Salud.year of age and women in fertile age. Commencingwith an annual average of 10 million doses, the effortdoubled by the end of 2004 with the application ofmore than 20 million doses through the ExtendedProgram of Immunization, ameliorating to a great extentour national coverage rate. By the year 2005, inthe framework of the Vaccination Workdays of theAmericas, it is intended to apply 28 million doses thatprotect against 12 different illnesses.A substantial accomplishment in the preventionof yellow fever has been the immunization of 4,5 millionVenezuelans, reducing 85% of the problem by theyear 2004.An indicator of the high priority granted to ourpreventive work has been the installation of 703 immunizationcenters, in zones or areas of social exclusionand poverty, with an investment of 3,6 billon bolivares.In the agenda of women’s integral care, 2.612women received care in the Women’s National Institute(INAMUJER) for violations such as violation ofrights, violence against women, and legal advice in relationto diverse problems.An important aspect to highlight is the enforcingof the Resolutions for the "Regulation and Control ofCigarettes, of Products derived from Tobacco for HumanConsumption" and the "Regulation of CigarettePacking", by means of which the preventive responsibilityis assumed regarding the hazards that tobacco andits derivatives represent to health. Throughout theseregulations, the obligation of producer and commercializingcompanies to register before the health regulatorinstitution and to display warnings correspondingto the hazards that the consumption of their productsrepresents to health through texts and pictograms hasbeen established.Moreover, the ratification by Venezuela of theMarco Agreement of the World Health Organizationfor the control of tobacco realized in March of 2005 isadditionally noticeable.Integral Care for Indigenous PeoplesThe Civil Society for the Control of Endemic Illnessesand the Assistance to Indigenous Peoples (CE-NASAI) applied 9.729 vaccines to 5.200 indigenouspeople of all ages. It completed 24.730 consultationsconcerning endemic illnesses and 6.297 in connectionwith dental problems (44% indigenous infantile populationand 4% pregnant women).By way of the Autonomous National Service ofIntegral Care for Children and the Family (SENIFA),3.830 indigenous children of both genders were includedto the system of integral care to reach a total of24.000 children who received integral care.Additional Attainments to HighlightThe expansion of access to potable water has increasedto 2,5 million people in only four years. Infantmortality and malnutrition have also reduced considerablyin the last years.Furthermore, children have been the main beneficiariesof medical policies of the Bolivarian Government.The infant mortality rate declined from 21,4 in1998 to 17,5 in 2002 and care was enhanced. Between1999 and 2002 more than 800 cases of children withcongenital cardiac disease have been solved, and theinvestment in the acquisition of vaccines increasedfrom 3 to 28 billon bolivares.Through the Agreement between Cuba and Venezuelain the subject of health,Venezuelans with certainpathologies that cannot be treated within thecountry are granted the opportunity to obtain free carein Cuba, and thus improve their health conditionand ameliorate their quality of life. This agreement isnot part of the commercial oil agreement betweenboth countries, and it establishes no charge on accountof care provided to patients sent by Venezuela.193

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAAmong the pathologies treated by this agreementare the ones from the following specialties: cardiology,pediatrics, dermatology, infectious and parasiticdiseases, 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 signalsof recuperation of the health sector.They are productsof inter-institutional efforts of various segmentsof society, and the international cooperation harmonizedwith the fulfillment of the right to health as a fundamentalright.On of the most important components of thehealth policies executed in the current governmentalperiod is the Interior Urban District Mission ("MisiónBarrio Adentro") which was conceived with the objectiveof offering integral primary medical care to theexcluded population with non or little access to basichealth services.The State-Society relation provided by theConstitution of the Bolivarian Venezuelan Republic isthe basis of the Plan Towards the Interior Urban DistrictMission, which began on April 16th, 2003, in theframework of the Venezuela-Cuba Agreement as aresponse of the Venezuelan State to the social andhealth principal needs, constituting a point of departurein the development of an integral primary carenetwork.The Interior Urban District Mission is anchoredin the concept of integral health provision, whichtranscends the reductive vision that limits health tomedical care exclusively. For the Interior Urban DistrictMission, health is seen as composed of the socialeconomy, culture, sports, environment, education, andnourishing security. Thus, communitarian organizationsand the presence of doctors who join communitiessharing their daily life are both integral to the overallprogram.The Mission functions in an articulate mannerwithin a network of missions proposed to attend thedistinct needs concerning the promotion of integralsocial development in the nutritional, educational, andlabor areas, among others.At present, the Mission comprises 19.941 professionalsfrom diverse disciplines, among whom weunderline the existence of 15.421 doctors, of which1.060 are Venezuelan. (see Table 2)Since the beginning of the Interior Urban DistrictMission until today, 168.188.996 cases have beentaken care of; 106.028.613 consultations have beenprovided; 15.074.231 families have been visited; 24.591lives have been saved; 1.609 childbirths have been tended;and 59.660.606 educational activities have beendeveloped.Similarly, 296 Community Medical Offices wereconstructed and equipped (81% in the MetropolitanDistrict, 7% in Miranda, 8% in Carabobo and 4% in Anzoátegui),and six Popular Clinics were activated (Anzoátegui,Carabobo, Nueva Esparta and in the LiberatingMunicipality of the Metropolitan District).At the moment, Interior Urban District MissionII is being implemented, which constitutes a leap forwardin the level of health care, with the purpose ofguaranteeing specialized care to the population, throughthe activation of Integral Diagnosis Centers furnishedwith equipment for medical emergencies, diagnosisand surveillance of patients with ophthalmologicaldiseases, and the completion of fundamental diagnosticstudies (of each four diagnosis centers, one willhave surgical emergency service).And High TechnologyCenters, which will allow the implementation of MagneticResonance Spectroscopy, Computerized AxialTomography in 16 sections, Noninvasive TridimentionalUltrasound, Mammography, Video endoscope, ClinicalLaboratory, Floating Rx, and Electrocardiography.The creation of 600 Integral Diagnosis Centersis estimated at the national level, and 35 High Techno-194

Observatorio Latinoamericano de Salud.CUADRO 2. ESTADÍSTICAS GENERALESRESUMENMédicosCUBANOS14.361VENEZOLANOS1.060CUADRO 3. ESTADÍSTICAS GENERALESINDICADORES ACUMULADO ACUMULADOAÑO 2005 HISTÓRICOCasos Vistos34.722.142168.188.996Estomatólogos3.0701.341Consultas20.760.019106.028.613Enfermeras3022.610De ellos en Terreno7.743.53942.349086Optometristas1.441-Familias Visitadas2.760.59215.074.231Electromédicos161-Acciones deEnfermería4.915.77522.614.720Otras Categorías6061.014Vidas Salvadas2.90924.591Total General19.9416.2025ActividadesEducativas12.317.57559.660.606Fuente: MSDS Abril de 2005Fuente: www.barrioadentro.gob.ve .Abril 2005logy Centers (one in each federal institution, and morethan 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 togo before we can talk about universal high quality care.However, there is one thing we are sure of and it isthat we have achieved access to medical care for importantsegments of the population which did not haveany access to care before; populations that previouslythought better living conditions and healthstandards were impossible.195

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA20The Federal District of Mexico’s HealthPolicy: Social Rights and the Satisfaction ofBasic Human NecessitiesAsa Cristina LaurellThe ContextThe elections of 2000 were a historical one for Mexico. The State Partyregime was coming to its end after 71 years with the defeat of the InstitutionalRevolutionary Party, the national presidential election was won by a rightwingparty, National Action, and that of the Capital District by a left-wingparty, the Party of Democratic Revolution. Since then, two distinct politicalprojects have developed simultaneously in the Federal District area. The historicdynamic which has signified Mexican history has been again reborn.Thisis the dynamic between two opposing conceptions of society, two differentsystems of values: the vision from above, that of the privileged and the oligarchssuch as landowners, industrial and financial entrepreneurs; and the visionfrom 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 thefield of economic policy. This is especially true when you take into accounthealth policy, whereby the federal government has preserved and deepenedneoliberal orientations imposed on the country for the past two decadeswhile the Government of the Federal District (GFD) has orchestrated a policybased on guaranteeing social rights universally, ones consecrated by theConstitution, and on the strengthening and expansion of public institutions toachieve this goal.196

Observatorio Latinoamericano de Salud.The Federal District Government´sSocial PolicyOverall, the social policy of México City´s governmentis directed at decreasing the peoples impoverishment,poor people comprising two thirds of allurban inhabitants. In itself, it is a policy of health promotion,focusing on programs of social protection forchildren, women, the old, people with incapacities andthe unemployed. In addition, the policies focus on education,and housing and environmental programs,which have a positive impact in the improvement of livingconditions. These social programs are a basicpriority to the Government of the Federal District,along with public security,.The central characteristics of the programsmentioned are its massive character, including tens ofthousands of families; its redistributive nature, in channelingpublic resources to groups in need; and its lowadministrative cost. Moreover, the programs are territorializedand integrated to the Territorial IntegratedProgram (TIP) to facilitate inter-institutional operationsand to promote both citizen’s participation andcontrol. Priority is put on the more impoverishedareas, and the program design is not focused on individualsor families, but on territorial characteristics.This method has the best results in terms of inclusionexclusionand, in addition, it generates the lowest administrativecosts.the inauguration of the city´s government and currentlyreaches 371.000 citizens.This pension program instituted another socialright for the first time in the Federal District. It gainedlegal status in 2003, becoming a law and, thus a brandnew social institution was born. At the outset, its universalcharacter brought about intense debate, butwith time it has demonstrated to be an essential vehicleto achieve broad comprehension of social rights.Its penetration is such that, currently, an initiativeexists within the senate to implant the pension nationally,despite opposition by private insurance companiesand right-wing politicians.The Financing of the Social PolicyThe taxing capacity of the local government isrestricted to some taxes and local rights and by law itcannot operate with a fiscal deficit. In spite of this, theGovernment of the Federal District did not opt for increasingtaxes. The social policy financial strategy isbuilt on two approaches. One being that high bureaucracyexpenses were eliminated and salaries were reduced15%. The other involved a frontal struggleagainst corruption. It has been calculated that thesemeasures have lead to an annual saving of 300 millionUS dollars. This amount is enough, for instance, to financeamply the universal pension.Universal PensionThe citizen’s universal pension program deservesspecial attention as one of the specific programs of theFederal District. Conducted by the Health Department,it guarantees medical services and free medicinesto the city’s residents that are 70 years or older.It was launched in October 2002, three months afterThe Health PolicyThe health policy of the Federal District Governmentis a component of an integral social policywhich, due to its characteristics, represents an instrumentto ameliorate the harsh living and working conditionsof the population of the city. The specific objectiveof the Health Department of the F.D. is to gua-197

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINArantee the universal fulfillment of health protection inthe city, as much in the field of collective sanitary safetyas that of individuals.Challenges and RestrictionsBased on a comprehensive diagnosis, the HealthProgram of the Government of the Federal District(Health Department, 2002) has proposed six substantialchallenges:1. to improve general health conditions;2. to decrease inequality in health among social groupsand 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 highquality health services; and,6. to coordinate mechanisms of stable, plentiful, andequitable financing.In order to understand the policies and strategiesadopted, one must draw attention to the problemsand restrictions which condition the activity ofthe health authority of the F.D:a) the health system is segmented and the Health Departmentof the F.D. has direct command over onlya small part;b) all the public health services suffered great deteriorationafter 1983, owing to prolonged financial crisis;c) the conformation of health services does not correspondto existing morbidity and mortality profiles,nor to the distribution of population in the territory;and lastly,d) the lack of strategic planning is notorious in all keyaspects of the local system. Nevertheless, the basicprograms of public health (epidemiological surveillance,universal vaccination, combatting acute diarrheaand respiratory disease, etc.) had been preservedin the city.The Medical Care andFree Medicines ProgramThe two chief policies of the Health Departmentof the Federal District are the universality of the rightto health and, as a condition of the prior, the expansion,strengthening and improvement of existing publichealth institutions. The strategy to attain the universalityof the right to health is the Program of Medical Careand Free Medicines, which focuses on the populationwithout insurance by the public social security institutes.Upon subscription to the Program, the citizen acquiresthe right to receive all the services made availableat the health units of the government of the city andto the medicines required from the institutional medicinechart, devoid of cost. Presently, there are 710,000families subscribed or nearly 80% of eligible families. Inaddition, 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 increasein the provision of services, as displayed in Table 1.The highest increments occur in the most expensiveservices: 65% in surgeries; 53% in childbirth attention;31% in emergencies; 30% in hospitalization and 29% inx-rays. This confirms that the economic obstacle was198

Observatorio Latinoamericano de Salud.a decisive element of inequality in access to health services(table 1).At present, actions have been taken to removethe cultural obstacle to care with the promotion ofthe Medical Services and Free Medicines Program inthe most underprivileged zones of the city, where thepopulation tends to have less information on healthand the governmental programs. The socioeconomicprofiles of the rightful claimants of the Program demonstratethat they have lower income,income; inferiorschooling and that they often live in deprived zonesof the city. Taken together, these factors disprovethe myth that universal programs give preferentialtreatment to the mid-social sectors.TABLE 1. SERVICES PROVISION 2000 TO 2004HEALTH DEPARTMENT OF THE GOVERNMENT OF THE FEDERAL DISTRICTCONCEPT 2000 2001 2002 2003 2004* 2000-2004Medical office consultations 4,818,207 4,956,951 5,211,860 4,997,828 4,802,700 -0.3● General 3,488,256 3,574,767 3,731,014 3,607,253 3,469,114 -0.6● Specialized (1) 655,263 668,692 745,051 704,500 678,271 3.5● Odontological 674,688 713,492 735,795 686,069 655,315 -2.9Emergencies(2) 572,024 646,078 754,369 771,588 751,817 31.4Patients discharged 89,973 92,225 108,441 112,092 116,875 29.9Hospital occupationpercentage 56.4 59.9 68.4 66.2 68.9 22.2● General hospitals 72.6 76.2 78.6 79.5 79.9 10.1● Maternal-infantilehospitals 57.1 56.6 69.6 70.1 63.0 10.3● Pediatrics hospitals 44.1 47.8 55.8 48.9 56.4 27.9Average stay period (days) 4.4 4.2 4.1 4.0 4.0 -9.1Surgical Interventions 42,564 50,399 59,913 67,501 70,278 65.1Births 30,922 35,137 41,539 44,661 47,241 52.8● Vaginal births 23,865 26,852 31,498 33,736 35,819 50.1● Cesarean 7,057 8,285 10,041 10,925 11,422 61.8X-rays studies 404,878 452,462 469,376 501,133 522,265 29.0Laboratory studies 4,345,710 4,803,259 4,461,184 4,623,660 4,970,005 14.4Legal Medical care 576,456 568,011 622,999 538,550 546,284 -5.21/ Includes specialized and mental health consultations 2/ Includes special events, toxicological centers, administrative sanctions 3/ Includes intensive phase and permanentprogram * Preliminary data until December 2004 (a part of the information is missing) Source: SISPA, SSA, 2003199

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAAnother benefit of the Program is that it permitspeople to dedicate their scarce resources to the satisfactionof other basic necessities. Thus, even conservativeestimates conclude that savings on account ofmedical expenses by the rightful claimants of the Programamount to roughly to 170 million dollars, inroughly two and a half years.Strengthening and Expansion of ServicesThe improvement, strengthening and expansionof the health services in the city are the material supportfor the universality of the right to health and thedecrease in inequalities of access. This policy is basedon a set of actions. Epidemiological surveillance andhigh vaccination coverage (95%) have been maintained.Further, a new health care model has been introduced,derived from Health Integrated Actions by groups ofage, with emphasis in promotion, prevention, opportunedetection and control of disease. An adequate supplyof high quality and dignifying services are being guaranteedwith ample provisioning of medicines and otherresources, in addition to maintenance and preservationof the equipment and buildings, intensive personneltraining, and a sustained effort of consciousnessand human rights culture building. This is all changingthe type of relations between local government andthe public, and is anchored in the rights of citizens.It is precisely in this context where the people´sparticipation and community control play an underlyingrole. The basic conceptis that a reciprocal relationshipof rights and duties must exist between thegovernment and citizens. Hence, the government hasthe obligation to guarantee the rights to health protectionand to encourage collective participation, furnishingthe information as regards to the content ofthis right. Once this has been accomplished, the citizenshave the obligation to contribute to the efficacyin the use and control of public resources, in fact theirresources.Furthermore, services are being organized in anet which strengthens the mechanisms of referenceand counter reference to guarantee the continuity ofcare and bring this nearer the population. The expansionand reopening of services has taken effect adheringto the prioritization of actual health necessitiesand regional service inequalities. For the first time in15 years, new health centers and a public hospital hasbeen built in the city. These measures have increasedthe capacity of care by 25%.These set of actions seem to have promoted agreater confidence in services, and this fact is demonstratedby the growth in service provision (refer to Table1). In Fact, services are being used by people fromthe center of the country, despite them not being eligiblefor the Program of Medical Services and Free Medicinesand having to pay a moderate fee for services.Budgetary Expression of the Political WillThe political will of giving priority to the right tohealth is supported by a budgetary increase of 45%in2000, and at the moment this budget represents9.8% of the total budget of the Government of the FederalDistrict.The total budget of the Health Department,including the citizenry’s pension, has been increasedby 126% and represents 15.8% of the totalbudget of the city. It is remarkable that 75% of the resourcesare local and 25% federal, in contrast to otherstates where the relation is opposite.The Impact on HealthThe first and last goals of the health policy are toameliorate negative health conditions and diminish ine-200

Observatorio Latinoamericano de Salud.TABLE 2 MORTALITY BY GROUPS OF AGE FEDERAL DISTRICT, 1997-2002YearGeneralInfantPreschoolSchoolProductivePosproductiveMaternalCasesRate(1)Cases Rate (2)CasesRateCasesRateCasesRateCasesRateCasesRate(3)19971998199920002001200246,88446,77346,60146,02946,62746,9845.95.45.35.25.35.33,8483,6993,3233,1272,8942,85824.023.621.621.620.019.94254453813653843680.80.70.60.60.70.64594403764023963780.30.30.20.30.30.317,57117,33616,71116,53517,00316,8753.23.02.92.82.82.8247,56024,84025,79325,56725,93126,49052.249.549.947.847.347.09312011996101805.87.77.76.67.05.61/ Rate per 1,000 inhabitants. 2/ Rate per 1,000 LIFE BORN. 3/ Rate per 10 mil LIFE BORNNote: LIFE BORN, as a denominator, the expected births estimated by CONAPOSources: 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 mortalityhas increased lightly because of the aging of the population.Therates of mortality for different age groups,on the other hand, has dropped persistently between1997 and 2002: the infantile mortality rate by 17 % (24to 19.9); the pre-school rate by 25 % (0.8 to 0.6); theproductive age mortality by 12.5 % (3.2 to 2.8) and thepost-productive age rateby 10 % (52.2 to 47.9).The proportion of deaths in the age group 65-years or older continues to rise from 55.5% in 2000 to56% in 2001, and 57% in 2002. Opposite this, a decreasein infant deaths from 9% in 1997 to 6% in 2002 hasbeen observed. In this context it would be necessaryto remember that in 1970, the infant mortality represented34 % of the entire mortality; in 1980, 22 %; andin 1990, 13 %. This spectacular change owes itself tothe halving of number of births in the F.D. and to thedecrease in the rate of infant mortality from 75 to 20per thousand live births.This is mainly due to the loweringof mortality as a result of diarrheic, respiratory,immuno-preventive and perinatal illnesses.The greatest impact on health has been thereduction of mortality as a consequence of AIDS.From 2000 to 2002 the F.D. succeeded in loweringAIDS related mortality by 23% thanks to the integralprogram for AIDS (which includes free medical treatmentresources and medicines), while the decrease inthe rest of the country was only 9%.Finally, from 2000 to 2002, inequality wasbrought down for age groups among the 16 municipaldelegations, and consequently we have that the differencebetween the highest and lowest delegation ratesdecreased in the infantile age group, from 2.6 to 2.3 times(13%); in the productive group, from 2.16 to 1.70times (22%); and in the post-productive group, from1.25 to 1.17 times (6.4%).201

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA21Cuba Breaks Through the Siege of theImperialist BlockadeMiguel Márquez, Francisco Rojas Ochoa, Cándido LópezThe ContextThe differences between Cuba and the United States of America havetheir origins and causes from the expansionistic eagerness generated in thenineteenth century and, subsequently in the twentieth century with the dependentCuba, to the transformation, at the time of the Cuban Revolution in1959, to a policy of permanent aggression and blockade. This blockade is onthe fringe of all legal consideration and against the overwhelming internationalmajority that supports Cuba’s decade-long proposal in the General Assemblyof the United Nations to put an end to it. This support was evidentin the last voting on October 28th of 2004 in which Cuba was approved by179 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 aneconomic, financial, cultural and social asphyxia to the Cuban nation, by deprivingit of fundamental means of subsistence and inflicting distress to Cubanpeople both materially and spiritually. The aggressiveness of the blockadehas multiple manifestations and is displayed in three forms, which are acomplement to each other and act simultaneously. These three forms are asfollows: the first, the direct aggressions to Cuba; the second, the use of he-202

Observatorio Latinoamericano de Salud.mispheric mechanisms; and the last, those constitutedas the economic, commercial and financial blockade.[D' Stefano, 2000]The aggressions are directed from the ideologicalto the political; from the economy to the military;and from radio and television communications to migratoryregulations. Added to these are the aggressionsthat have recourse to hemispheric mechanisms,such as those piloted by means of the Organization ofAmerican States (OAS) and the International Treaty ofReciprocal Support (ITRS), which with the pretense ofanticommunism, justify Cuba’s exclusion from the OASafter 1962 and the unilateral decision to suspend diplomaticand consular relations of its members in1964. It also justifies the interruption of direct or indirectcommercial interchange, with the exception offood, medicine, and equipment that could be sent toCuba for humanitarian reasons. Only Mexico was opposedto the sanctions and maintained integral relationswith thorough respect to Cuba’s autonomy andsovereignty. Moreover, the utilization by the UnitedStates Human Rights Commission of the United Nationsshould be considered. By way of menaces, repressionsand retaliations to member countries, theyhave attained Pyrrhic victories on condemning Cuba inthe subject of human rights, obtaining less than 40% ofsupport.The economic, commercial and financial blockadeis the third intervention of the government of theUnited States in Cuba, which has endured, since thebeginning of 1960, the suspension of petroleum sales,until the Law Helms-Burton in 1996 and the shamelessReport of the Commission of Aid to a Free Cuba inMay of 2004.The following box illustrates the more outstandingaspects of the measures applied by the governmentsof the United States of America against Cuba.CHRONOLOGY OF THE BLOCKADE ON CUBA BY THE GOVERNMENTSOF THE UNITED STATES OF AMERICAMarch of 1960Octoberof 1960January of 1961April of 1961September of1961February-Marchof 1962President 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, andwith permanent injuries: 2.099. Loans amounting to 100 million US dollars from European and Canadianbanks are cancelled.The plans to purchase Cuban sugar are cancelled.The Eisenhower administration applies the "quarantine", prohibits exports to Cuba (except food and medicines).Blockade onset.The government of the U.S.A. ceases diplomatic relations with Cuba.The invasion through Playa Girón ("Bahía de Cochinos") was undertaken.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.The embargo expands with the prohibition of imports to the U.S.A. of Cuban products.The imports fromthird countries were included to products containing Cuban materials.203

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAFebruary of1962February of1963July of1963July of1964April of 1980October of1992March of 19962000-2004In the Eighth Meeting of Consultation of the OAS ("Punta del Este"), the incompatibility of Cuba with thepurposes and principles of inter-Americanism is deduced, and Cuba is excluded from the OAS and otherorganizations of the inter-American system.The Kennedy administration broadens the projection of extraterritorial sanctions to third countries byprohibiting boats from transporting products to the U.S.A. if they touch any Cuban port.The Department of Treasury establishes the Regulations of the Control of Cuban Capital. It freezes all Cubancapital in the U.S.A. (exonerating the capital of Batista’s dictatorship).In the Ninth Meeting of Consultation of the OAS, in Washington D.C., the following collective measuresare applied against Cuba, not including México: suspension of diplomatic and consular relations, eliminationof direct and indirect commercial interchange (except for medicines and food), suppression of all marineand aerial transport.The Reagan administration severely restricts trips of U.S. citizens to Cuba.The U.S.A. government extends the Law for Cuban Democracy (Torricelli Law), which prescribes the commerceof subsidiaries with Cuba, imposes severe restrictions to marine and aerial transport, and concedesto the Department of Treasury, for the first time, the authority to administer fines to United States citizensup to 50 thousand US dollars by violations of the "embargo".The Helms-Burton Law takes effect. Overall, it consists of four headings: strengthening of internationalsanctions, aid to a free and independent Cuba, protection of property rights of United States citizens, andexclusion of foreigners who deal with confiscated properties.● The Office of Control of Foreign Assets of the Department of Treasury tries to prohibit Cuban authorsin 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 tripsto 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 financialtransactions with Cuba.● The dispositions emanated from the Report of the Commission of Aid to a Free Cuba are approved andtake effect.The report is composed of six chapters.The first is dedicated entirely to the establishmentof guidelines on destroying the Revolution.The other five are concentrated in undertaking measures thatwould 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

Observatorio Latinoamericano de Salud.In this account, the name "free Cuba" has beengiven to the country longed for by the Miami counterrevolutionarymafia and its representatives in in Cuba.The Report of the Commission of Aid to a FreeCuba translates the hatred of the United States governmentfor Cuba and constitutes, in a frank demonstrationof interference, the masterful plan of destructionof the Cuban Revolution.The numerous and diverse forms of aggressionthat Cuba has suffered for almost 40 years -as a whole,an undeclared war, but still causing death and seriouseconomic and social effects- have been thoroughlydocumented in the country and in othercountries. [D' Stefano, 2000;Asociación Americana parala Salud Mundial, 1997; Granma, 2004; Granma,2003; Castro, 2003].Nevertheless, Cuba, its people and government,have identified more appropriate responses at eachmoment.The ResponseThe political, ethical and social principles of theCuban Revolution, a revolution with an ample and solidpopular base, have constituted the foundation of armed,diplomatic and economic defense. These havebeen applied creatively and audaciously for more thanfour decades of struggle against the powerful imperialisticenemy.In the field of public health, medicine and closelyrelated spheres, the subsequent results can be highlighted.The Cuban State and government assign the uppermostpriority to the health sector.The unique National System of Health was createdand financed by the State.This system has nationalcoverage and requires no direct payment for any servicereceived.The concepts of health promotion and preventionwere originally derived from Cuba’s National Systemof Health. The following relevant achievementscan be seen:The Health System provides one doctor forevery 165 inhabitants, with a total of 380.576 workers.[Cuba. Ministerio de Salud Pública, s.f]The prominent scientific accomplishments in thefield of health are: the attainment of the vaccineagainst meningococcal illness, the recombining interferonand streptokinase, the tetravalent diphtheria-pertussis-tetanus-hepatitisvaccine, and the Haemophilusinfluenzae type b vaccine (the first to be obtained throughchemical synthesis). [Rodríguez, 2004; Verez-Bencomo & Cols, 2004].Another Cuban achievement is the productionof the most important medicines against HIV-AIDS, likegenerics (which is provided to the patients gratuitously),and the therapeutic vaccine against lung cancer.[Rodríguez, 2004].Amid these successes, certain ones have becomeparticularly renowned. The Haemophilus influenzaevaccine originated an article in Science magazine(U.S.A.), which appeared after the restrictive dispositionson the publishing of Cuban scientists’ documentsin that country. The therapeutic vaccine against lungcancer has given base to an agreement between theCenter of Molecular Immunology of Cuba and theCANCERVAC (U.S.A.) to develop and produce vaccinesagainst cancer.As this is a totally unheard of fact itillustrates, to a great extent, the level achieved by ourresearchers and national scientific centers. [Rodríguez,2004; Verez-Bencomo & Cols, 2004]. These are theweapons our scientists use to break through the blockade.The successful immunizations program, initiatedin 1962, has eliminated illnesses (poliomyelitis, diphtheria,pertussis, measles, rubella and parotitis). Immunizationsagainst diphtheria, tetanus, pertussis, measles, tu-205

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAberculosis, parotitis, meningococcal BC illness, hepatitisb, poliomyelitis, rubella and Haemophilus influenzaetype b are given to 95.1% of children younger than 2years old. The program’s sustainability resides in thenational production of several vaccines, some of whichare unique in the world. It has been reported that2004 was the first year in which not one case of tetanushas been registered. The country also arrived atthe 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’slevel 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). Lifeexpectancy at birth is 77 years for both sexes.This succinct synthesis enumerates some of thebenefits of Cuban public health. These have been obtainedduring conditions of blockade and aggressionthat include the prohibition to acquire medical equipmentand export products from the U.S.A. Nevertheless,the political will expressed in the decision of thegovernment to sustain each accomplishment and advanceonto new projects has prevailed. A manifestationof that will is displayed in the expenses statisticsof the health sector between 1990 and 2000, a periodin which the country suffered one of the deepest crisesof its history that we now know as a special periodin times of peace (see table).Not even in that critical moment were the expensesin health reduced, nor was any hospital orhealth center closed. The number of beds in hospitalsdid not decrease, the training of professional and technicalpersonnel did not cease, and the prioritized pro-YEARSHEALTH SECTOR EXPENSES COMPARED TO THE GNP AND THE STATE BUDGET.PERIOD FROM 1990 TO 2000.EXPENSES IN HEALTH(MILLONS DE PESOS)EXPENSES IN HEALTHPER INHABITANT (PESOS)% OF THEGNP% OF THE STATEBUDGET199019911992199319941995199619971998199920001045,11038,51038,91175,81116,41221,91310,11382,91473,11553,01726,198,697,196,2107,9106,0111,1119,1125,3132,4153,5165,95,36,47,07,86,15,65,76,06,46,16,16,66,36,67,47,58,09,710,610,711,611,9Source: MINSAP.Anuario Estadístico 1998 y Centro de Investigaciones de Finanzas. Datos a precios corrientes.206

Observatorio Latinoamericano de Salud.grams of research and development were not cancelled.The ResultsIt has been demonstrated that Cuba is efficacious,efficient and equitable in the attainment of thepopulation’s health, despite the intense blockade towhich it has been subjected for more than four decades.[De La Torre & Col., 2004]With regards to efficacy –understood as the capacityto achieve objectives- [ILO. UNOPS, Eurada,2000] the present discussion concentrates in theachievement of three health objectives defined by theWorld Health Organization [OMS, 2003] within theframework of the evaluation of the Development Objectivesof the Millennium. Concerning the reductionof the infant mortality rate, Cuba reveals a markedtrend towards a decrease in rates of younger than 5years as well as a decrease overall. The current levelsof those rates (8,0 in 2003 [Cuba. Ministerio de SaludPública, 2003] and 5,8 in 2004 [Granma, 2005], respectively)are among the lowest in the world. The goal ofreducing those rates between 1990 and 2015 by twothirdswas accomplished 15 years before the establisheddeadline. In relation to maternal health, mortalitywas the ninth lowest among 36 American countriesduring the year 2000. [OPS, 2002] With regards to thecombat against AIDS, malaria and other illnesses, Cubapresents, according to criteria defined by the PNUD[PNUD, 2003], the best classification, owing to verylow rates of HIV sero-positives and AIDS cases. In addition,the last autochthonous case of malaria was producedfour decades ago. [Del Puerto, Ferrer, Toledo,2002]. Regarding tuberculosis, the incidence rate is thelowest in the Americas, equal to that of Germany andSwitzerland, and inferior to that of France, Great Britain,Austriaand Australia. [WHO, 2003]With reference to efficiency –understood as therelation between resources and results-, [ILO.UNOPS, Eurada, 2000] Cuba exhibits a prominent efficiencyindex, 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 suchas the United States and Canada. An example is thefact that Cuba has accomplished maximum efficiency,with regards to life expectancy levels at birth, infantmortality rate and mortality in children younger than5 years. It has also achieved maximum efficiency inmortality by nutritional deficiency, as well as the numberof doctors, hospital beds per inhabitant and caloriesavailability, in terms of the economic resourcesexisting. [De La Torre, López, Márquez, Gutiérrez, Rojas,2004]We will look at equity in health as the minimizationof inequalities in the population’s state of healthand its determinants (those inherent in different territoriesof a country), among groups of people living underdistinct conditions. [Braveman, 1998] Cuba, comparedto several American countries, including theUnited States, has the lowest territorial inequality asto life expectancy at birth, mortality in children youngerthan 5 years, maternal mortality, and low weight ofnewborn children, [De La Torre, López, Márquez, Gutiérrez,Rojas, 2004] provided that life expectancy atbirth, as other aspects of inequality within health, reflectstructural socio-economic inequalities. Moreover,the country is considered to be one with a low incomegap/breach. Indeed, it has been evidenced thatthe scenarios of major socio-economic disadvantagesare not just the ones of greater scarcity of resourcesand generalized poverty, but those in which there is alsoa greater inequality in the distribution of income.[OPS, 2003]The extraordinary Cuban capacity to take actionto confront health problems has been evidenced in207

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAmultiple occasions. Noteworthy are the 90s, when thesocialist field disappeared, and the critical worsening ofthe blockade by the United States caused Cuba to undergowhat has been considered the most complexmoment of its history as an independent nation. [Lage,1995] While the accumulated variation of the GNPfrom 1981 to 1990 was 39.5% (24 of 32 Latin-Americanand Caribbean countries had a less significant performancethan Cuba in the same period); from 1991 to1995, the accumulated variation of the GNP was–30.6%, the highest in the negative sense of Latin Americaand the Caribbean. In spite of this very difficulteconomical circumstance, the situation of health didnot deteriorate. We should mention that while, from1989 to 1993, the GNP decreased 34.8%, infant mortalitywas reduced by 15.3%, mortality in childrenyounger than 5 years was reduced by 10,3%, and maternalmortality reduced by 7,9%. [Oficina Nacional deEstadísticas (ONE), 1995; Cuba. Ministerio de SaludPública (MINSAP), 1998]It has been demonstrated that it is possible for acountry to be efficacious, efficient and equitable in managementof health, despite its scarce economic resources.Cuba has been subjected to economic, financialand commercial blockade for more than 40 years–with damage expenses estimated at 79.325 millionUS dollars-, [Informe de Cuba al Secretario Generalsobre la Resolución 58/7 de la Asamblea General delas Naciones Unidas. http://www.granma.cubaweb.cu,2004] but has a Health System that responds to thepopulation’s necessities. This health system does notadvocate market mechanisms by which the patientturns into patient-client. Resulting from a group of factorsmotivated by the political will of the State, whichresponds to the citizen’s interests, and their own will,Cuba has successfully (efficaciously, efficiently andequitably) managed health in the country.The BattleIn Cuba we are summoned and immersed in abattle of ideas. To this respect, Fidel Castro has said:"Thus, I firmly believe that the great battle is to be wagedin the field of ideas and not in that of weapons, howeverwe will not renounce to their employment inthe case war was imposed to our country or another.Each force, each weapon, each strategy and each tactichas an antithesis emerged from the inexhaustible intelligenceand conscience of those who struggle for aright cause… Despite the risk of tiring you, I allow myselfto repeat and reiterate: in front of sophisticatedand destructive weapons with which they intend to intimidateus and to subject us to a worldly economicand social order unfair, irrational and unsustainable,sow ideas!, sow ideas!, and sow ideas!; sow conscience!,sow conscience!, and sow conscience! [Informe deCuba al Secretario General sobre la Resolución 58/7de la Asamblea General de las Naciones Unidas.http://www.granma.cubaweb.cu, 2004]"208

Observatorio Latinoamericano de Salud.REFERENCES●●ASOCIACIÓN AMERICANA PARA LA SALUD MUNDIAL(1997). El impacto del embargo de EE.UU en la Salud y la Nutriciónen 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).● CASTRO, F. (2003) "La gran batalla se librará en el campo de lasideas" (Discurso). Granma, jueves 30 de enero: 4-5.● CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP) (1998). Saluden el tiempo. La Habana: MINSAP.● CUBA. MINISTERIO DE SALUD PÚBLICA (S/F).Anuario Estadísticode Salud 2003. MINSAP. La Habana.● CUBA. MINISTERIO DE SALUD PÚBLICA (MINSAP). Anuarioestadístico de salud 2003. La Habana: MINSAP; Cuadro 21.● D' STEFANO, M. (2000). Dos siglos de diferendo entre Cuba y EstadosUnidos. La Habana. Editorial de Ciencias Sociales.● DE LA OSA, JA. (2005) "Cero caso de tétanos. Por primera vezen Cuba". Granma, martes 18 de enero:1.● DE LA TORRE E, LÓPEZ C, MÁRQUEZ M, GUTIÉRREZ JA, RO-JAS F. (2004) La salud para todos si es posible. La Habana: SociedadCubana de Salud Pública. Cap. 4. (en imprenta).● DEL PUERTO C, FERRER H,TOLEDO G. (2002) Higiene y epidemiología;apuntes para la historia. La Habana: Editorial Palacio delas Convenciones. 169.● DIGITAL GRANMA INTERNACIONAL (2004). "Países que apoyaronnuestra resolución (179)". http//:granmai.cubaweb.com Accesoel 29 de octubre.● GRANMA (2003). Suplemento Especial. Informe de Cuba al SecretarioGeneral sobre la Revolución 57/11 de la Asamblea Generalde las Naciones Unidas. "Necesidad de poner fin al bloqueoeconómico, comercial y financiero impuesto por los Estados Unidosde América contra Cuba". La Habana, 8 de julio.● GRANMA (2004). "Cuba y su defensa de todos los Derechos Humanospor todos". (Tabloide Especial), marzo.● GRANMA (2005), 3 de enero, p. 5.● ILO. UNOPS, EURADA (2000) Cooperazione italiana. Local economicdevelopment agencies. Roma; ILO, UNOPS, EURADA,Cooperazione italiana. 150.● Informe de Cuba al Secretario General sobre la Resolución 58/7de la Asamblea General de las Naciones Unidas. "Necesidad deponer fin al bloqueo económico, comercial y financiero impuestopor los Estados Unidos de América contra Cuba". http://www-.granma.cubaweb.cu (Consulta: 17 de noviembre de 2004).● LAGE C. (1995) "Intervención en el Foro Económico Mundial deDavos, Suiza". Granma, 28 de enero, p. 6.● MARTÍNEZ, O. (2004) "Hemos denotado las maniobras enemigaspara asfixiarnos económicamente" (Discurso). Granma, lunes 27de diciembre.● OFICINA NACIONAL DE ESTADÍSTICAS (ONE) (1995) La economíacubana 1994. La Habana: ONE.● OMS (2003). Informe sobre la salud en el mundo 2003. Francia:OMS.32.● OPS (2002). Situación de salud en las Américas; indicadores básicos2002.Washington DC: OPS. (Doc. OPS/SHA/02.01).● OPS (2003). La transición hacia un nuevo siglo de salud en lasAméricas: Informe anual de la Directora, 2003.Washington DC:OPS. (Documento Oficial No. 312).8.● PNUD (2003). Informe sobre desarrollo humano 2003. Madrid:Ediciones Mundi Prensa. 349.● RODRÍGUEZ, JL. (2004) "Hoy como nunca antes, se perfilan todaslas posibilidades que se han creado para alcanzar una sociedadmejor" (Informe). Granma, lunes 27 de diciembre.● VEREZ-BENCOMO, V. Y COLS. (2004) A Synthetic ConjugatePolysaccharide Vaccine Against Haemophilus influenzae Type b.Science,Vol. 305, www.sciencemag.org Acceso el 23 de julio.● WHO (2003). Global tuberculosis control: surveillance , planning,financing. WHO Report 2003. Geneva: WHO. (Doc.WHO/CDS/TB/2003.316). 146. 171209

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA22Uruguay: Community Participation inHealth and the Role of EpidemiologyMiguel Fernández, Sergio CurtoAgradecimiento:Los autores agradecen a laBr. Lucía Fernandez la informacióny asesoramiento sobre algunos temasincluidos en este trabajo.The onset of a progressive government in our country and the proposalof health system reform, implies not only institutional transformations butalso the expansion of theoretical and ethical principles for humanistic publicpolicies and services in the health system.At the center of this change, is people’swellbeing.This scenario requires new and diverse approaches to healthcare promotion, which focuses on citizens’ social rights.Relevant background to this community driven effort is the differentprograms implemented by recent progressive administrations of the MunicipalGovernment of Montevideo. An example of this is the decentralizationand health participation that made up part of the Zonal Care Plan.This Plan was founded on the ruling principle of integrating equity andsocial justice to action, to give rise to co-management with the diverselycomposed communities and organizations.The implementation of this municipalgovernment plan was articulated in conjunction with the civil society, bymeans of a clear agreement policy, which transferred resources to the neighboringcommissions to develop services and implement programs.The Municipal Intendance of Montevideo performs the ambulatory andextra-hospital care of 300,000 people through its Zonal Multi-clinics.This populationis comprised of a high percentage of homes with their basic needsunmet.210

Observatorio Latinoamericano de Salud.The Zonal Care Plan represents a new conceptin integral health care, as expressed in its mission: "todevelop Plans of Zonal Care of health which, startingfrom the Municipal Multi-clinics in coordination withother health institutions, substantiate the basis for theLocal Health System. This presupposes a transformationor reform process of the care model and of itsmanagement, as part of a political-administrative decentralizationand social participation process, articulatedby local government agencies".Components of the Plan of Zonal Care:1) The changing of the health care model: "To make progressin the transformation process of the health caremodel, reevaluating the concept of action integrality, withan emphasis on promotion and prevention. To developcare through integral programs, oriented towards highprioritygroups of population and selected social priorityproblems. To consolidate the interdisciplinary healthteams and strengthen their coordination with social workersof the Zonal Communal Centers" (DevelopmentProgram. Department of Hygiene and Social Care.Municipal Intendance of Montevideo – 1990).2) Programs of Integral Care (Promotion and Educationin Health, Health Control, Preventive Activities,Preventive Diagnosis, Recuperation and Rehabilitation).3) Technical Interdisciplinary Health Team made up ofprofessional and administrative members of the sameMulti-clinic.4) Zonal Health Diagnosis Systems (systems of epidemiologicalsurveillance with geographical and populationcriterion). The activation of the StrategicPlanning Methodology in Montevideo (1994), identifiedthe tactically important points at the departmentaland zonal levels, determined specific prioritiesand defined short and medium-term objectivesand goals.The Zonal Care Plan includes among its purposes:"to bring about the continual diagnosis of zonalhealth, as a guide to the activities of the health teamand the community, by way of a permanent processof participative planning-action".A component of the program is the Module of BasicZonal Information.This is an instrument to permanentlyprocess district health information, in orderto monitor and understand key aspects of thehealth-illness situation and improve health management.TheModule of Basic Zonal Information alsooperates as the "historical memory" of the district,and, therefore, can be used as a tool for improvingand updating the health program.5) Intra and intersectorial coordination.6) Continual management evaluation.7) Decentralization and neighborhood participation:To have social impact there must be communitycontribution. The work of neighborhood commissionsimplies a richer transdisciplinary outlook.This outlook must incorporate the vision of thoseinvolved, encompassing innovative perspectivesfrom cultural elements and knowledge not legitimizedin the academy.Via the Zonal Plan, several programmatic linesare executed.To demonstrate this, we mention:● The Program of Children’s Integral Care provides integralhealth care to children younger than 14 years,211

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAwith priority given to preschool age children youngerthan 5 years, in the following subprograms:- Control of newborns.- Health monitoring of 12 infants up to 12 monthsof age.- Growth and development control program (youngerthan 5 years).- Expanded program of immunizations. Control ofchildren of preschool age in Community DaycareCenters● The Women’s Integral Care Program proposes a caremodel that takes into account all basic women’sneeds, the characteristics of their family and socialcontext, and promotes their active and responsibleparticipation in the social support networks. Itsponsors the training of health teams and participatingneighbors to facilitate their orienting role at thefamily and district level (Informed and Voluntary MaternityHospital; Prevention and Genital-Breast CancerControl; and Pregnancy and Post pregnancy IntegralCare).● The Program of Dental Health Care involves preventiveeducation and assistance aimed at children, adolescentsand pregnant women. The preventive actionsinclude local application of fluor-therapy, microbialplate control, education on the consumptionof carbohydrates and habits noxious to buccalhealth. The assisting actions prioritize rehabilitatingcare of permanent teeth. The zonal work, outsidethese Multi-clinics, comprises of activities in publicschools and within districts.As we have mentioned, the health plan modalitiesinvolve community participation, such as thosecoordinated amid the Municipal Intendance of Montevideo,the University and formal or informal social organizations.Among these, one can underline the researchproject "Management of Solid Remainders, a territorialapproach from the perspective of social inclusion,work and production", undertaken jointly by theConsultative Social Commission of the University ofthe Republic, the Municipal Intendance of Montevideoand the Labor Union of the Remainders Classifiers.Finally, we must refer to the agreement betweenApexCerro-University of the Republic and the MunicipalIntendance of Montevideo, which emerged fromthe decision of the latter to perform the sanitation ofthe districts "Casabó" and "Cerro Oeste". This Programhas become an excellent opportunity to enhancehealth and development in the zone with universitypersonnel and the participation of the community.Theproject includes critical zones from the sanitary viewpointof the "Casabó" and "Cerro Oeste" districts inMontevideo.Among its objectives, we see the need to characterizeand understand the social and population dynamicsof the zones, which experience a critical sanitarysituation; zones like the "Casabó" district and the "CerroOeste" zone (through sanitary census of householdsand people). To characterize the social populationdynamics, neighbors analyzed and discussed theresults of the census in workshops with technicianprofessionals.Thecommunity participation in this projectimplied 500 hours of work in neighborhoods locatedin the involved districts.The Epidemiology of Change 1As we mentioned in the beginning of this report,the humanistic spirit of the whole health program and1. Extracted from: "Voces del Frente", semanario,Año I, Nº 14, Noviembre 2004.212

Observatorio Latinoamericano de Salud.its basic assumption of the health field as a scenario ofsocial development towards people’s wellbeing and amore righteous society, requires new scientific andtechnical approaches.A special chapter of such development is takingplace in the field of epidemiology and epidemiologicalpolicies. A new paradigm must be implemented to affectdeep changes in the way we conceive the role ofthe State and the role of society in the struggle againstsocial determinants that mold the situation.In the past, the evolution of Epidemiology, particularlyin Latin America, has renovated ideas that positionthis special discipline in a correct relationshipwith its study object -the community- and with itsmain purpose -people’s wellbeing.Epidemiology, historically evolving to the influxof predominant political and social currents, identifieswith this new "social-medical" scientific discipline,whose close liaison with the social derives from theidea that "the health-illness process is made visible basicallythrough the health problems of human groups"[Martinez Calvo, 2003]. The correspondence betweenepidemiology and society is a consequence of it beingthe discipline that studies in a collective manner, theevents and processes occurring to populations.These new epidemiological currents originatedwithin innovative propositions, which aimed at recoveringthe "correct approach to the epidemiological object",by means of the practice of a "Critical Epidemiology"[Breilh, 2003]. This practice addresses inequalitiesor inequities in health, as well as introduces innovativefocuses, such as those of "eco-epidemiology" or"ethno-epidemiology", some of which have been restrictedto specific areas of medicalized conventionalEpidemiology until the present.All these visions encompass a movement of renovationof Epidemiology that considers the socialmatrix as the substratum of health problems and offerspowerful tools for approaching the new challengesthat neoliberal globalization has brought about: theaccelerated increase of poverty and indigence; feminizationand infantilization of poverty; increase of infantwork; massive unemployment; deregulation of workingand living conditions; migratory movements; and environmentalproblems.The collective standpoint opposes and at the sametime complements the classic concept of the individualclinical "case" being the study unit of health. Criticalepidemiology applies a different paradigm, whichhas a renewed rationale and logic in the constructionof interpretative models about health problems.At somemethodological point, it needs to work with empiricaldata and sets of cases, but they are analyzed in adifferent manner, and forms of stratification or groupingand searching for different sorts of relations withcontextual processes.Advocates of this perspective stress the need toexpand the limited technical resources of the classicquantitative conception (positivist paradigm) promotedby centers of scientific power, as an instrumentalresource to service political and economic interests. Inopposition to this, the new epidemiological currentswork on research approaches closer to the ethnographicmodel or paradigm (historical-anthropological)[Pinus, 2002], in order to rescue the potentials inqualitative research that originate in the "social sciences".Thus, the researcher, immersed in the socialcontext, collects and analyzes personal opinions, discourses,and actions to deeply understand their socialand cultural aspects, to know the community’s conductsmotivations and experiences, and lastly to relatethese findings to the process of health productionand deterioration. This is important because in conventionalapproaches, "The epidemiologists do not assumeat present the complexity of the social and culturalfields in which illness and care develop" [Menéndez,1998].213

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINANew epidemiology claims a greater social projectionthan that furnished by the analysis of illnessesand individual risk factors, and thus conceives a conceptualframework based on social and communitarianfactors, in correspondence with the serious problemsprovoked by the globalized market society.The new progressive government needs this renewedepidemiology in order to institute spaces, bothgovernmental and non-governmental, and constructthe foundation for the "critical monitoring" of themany determinants of health and illness. Also, it is necessarynot to leave aside methodological advancementsin statistics and mathematics, computer technologyand academic advancements conventionally developedunder the traditional schemes.These new modalities of epidemiological surveillance,both non-traditional and non-conventional, intendto make possible real social participation and social"empowerment". It recognizes the need to changethe role of the collective subject in the health controlprocess. In other words, the Epidemiology of changemust generate the scopes and mechanisms so that theorganized society participates progressively in the"evaluation and adjustment of the processes as a whole,and the scenarios of decision making" [Breilh,2003].The participation of the community in these processesis not just a way to exert a right acknowledgedby health international organizations [OMS/UNICEF,1978]. Above all, it is a means to foster a different visionwith respect to sanitary problems, which traditionalEpidemiology does not consider, and allow us toexplain economical and cultural determinants; to understandthe behaviors and interpretations of users orbeneficiaries of health services and its influence onhealth indicators; and it is an instrument to study theinteractions of social groups and their implications incollective health.Hence, the organization of activities that respondto the objectives of social justice and wellbeingin the health field, activities that are necessary to thenew progressive government, will be greatly enhancedby the application of a renewed Epidemiology.This renovatedapproach is one that approximates the healthof the community by strengthening its own disciplinarynature to reach the goal of people’s wellbeing.214

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 sobreSalud en el Trabajo y Ambiente: Integrando las Américas – Salvador(Brasil), junio 9.● BREILH J (2003). "Epidemiología crítica. Ciencia emancipadora einterculturalidad" Bs.Aires,Argentina. Editorial Lugar..● FERNANDEZ GALEANO M (2000). "Descentralización y participaciónsocial en salud, La experiencia de Montevideo" OP-S/OMS..● FERNÁNDEZ L. "Breve síntesis del trabajo con la basura en Montevideo:de hurgadores a clasificadores organizados, análisis político– institucional" monografía para publicar.● MARTINEZ CALVO S (2003). "Epidemiología y sociedad" Rev CubanaHig Epidemiol;41(2-3)● MENÉNDEZ, E (1998). "Estilos de vida, riesgos y construcción social.Conceptos similares y significados diferentes", Estudios Sociológicos,núm. 46, El Colegio de México, pp. 37-67.● OMS/UNICEF (1978). Declaración sobre Atención Primaria emitidacon motivos de la "International Conference on PrimaryHealth Care,Alma-Ata, USSR, 6-12 September.● PINUS R (2002). "Paradigmas de Investigación en Salud" Córdoba,Argentina.Publicado en www.monografias.com215

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA23Real Equity in the State´s Supply of PublicHealth:The Target of a DemocraticMunicipal GovernmentMónica Fein, Débora FerrandiniThis article is written from the perspective of those who participate inthe building of the socialist municipal administration of the city of Rosario.This administration recognizes as its main achievements becoming the onlystronghold against the neoliberal current which has devastated the region inthe last XX years/ months.This achievement is evident through the constructionof a citizen’s culture that upholds the values of equity and equality pertainingto health. Health as a basic right of all citizens is a goal built on 16years of social struggle.A praxis that was successful in reclaiming the notion of efficiency as atoken of the hegemonic discourse of market based neoliberalism, to reestablishit as a distinctive quality of the public sector, albeit, subordinated to equitableaccess.We are not speaking of a finished model, of a finishing point, of a finalconquest.We can only discuss this as a powerful trend, and highlight how ithas had the strength to resist and move ahead in spite of the neoliberalwindstorm of 90’s.Through out this account we explain the building of thisnew trend, even though we are conscious of the fact that its very difficult tocondense 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 situatedin what was one of the most important industrial settings of the ArgentineRepublic. In the past Rosario was a city known for having extensive employ-216

Observatorio Latinoamericano de Salud.ment for migrant workers. During the 80’s and 90’s, theunemployment crisis was exacerbated by an increasingnumber of rural migrants, who were not necessarily inthe search of formal work anymore, but merely seekingfor survival and striving to have some access to publicassistance. In 1989, unemployment reached 7,4%, risingto 20% in the course of the menemist decade. By 1989Rosario was the epicenter of social outbreak and thehighest hyperinflationary.In December 1989, the socialist party won thelocal elections for the first time in history.The startingpoint of the new administration, was marked by a clearcourse shift, made explicit through a new form of budgetarystructure:The budget assigned to the Secretaryof Health, rose from 8% to 25%; a similar increase occurredin the area of social promotion, which increasedform XX% to 50% in activities directly linked tothe implementation of social policies.Within the Secretary of Health, three new pillarsof administration were created: the Department ofEpidemiology, was assigned the objective of assessingthe population’s needs in health; the Department ofEducation and Professional Development, was chargedwith training the social change promoters among thehealth workers; and the Primary Care Department,was given administrative and financial self sufficiency,and began organizing around basic public heath i n districtcommunities called "barrios."The district or neighborhood interdisciplinaryhealth teams assumed the challenge of working withinbarrios on planning strategies focusing on establishingequity, social participation, and clinical resoluteness.Theautonomy of practices in the neighborhoods and districts,the confrontation between the professionalperspective and that of diverse community actors, andthe complexity of daily life health problems, fosteredthe development of an strong movement that persisteddespite its own contradictions.The team utilized theoryand reality to solve daily problems and dependedheavily on the contributions of authors and academiccenters involved with Latin-American reality, such asCESS, Mario Testa, the FIOCRUZ Foundation and thePlanning Laboratory of the University of Campinas.Critical epidemiology and strategic planning wascombined with the social participation and, like so,workers and communities expanded the perspectiveof the possible, forming an institutive movement builtupon a micro-political transformation in the organization.Thisproduced new values, new contracts amongworkers, government and citizens, sustained in eachpractice in defense of life. Universal and free health care,, constituted an target of the movement and anobligation of the local state. Moreover, the daily experienceof equitable, democratic, participative processallowed citizenry to regain its viability, incorporatingthose features to the consciousness of the right tohealth, which was constructed in unison with the conditionsfor its practice. The philosophy of PrimaryHealth Care, equity, and peoples´driven conductionwas to leave behind their theoretical condition of utopianaims, to become part of real daily work.The operationof Primary Health Care, understood at the timeessentially as a strategy for the constitution of subjectscapable of fighting against the conditions that limit life,implied primarily the possibility of dreaming and gettingengaged in change. It also meant the developmentof management strategies that would promote healthworkers’ autonomy and a diversity of perspectives andstrategies, in order to account for the diversity of problems,interests and dreams, which coexist, not withoutconflict, in the reality of the city.Learning how to value this conflict as positiveand focusing reflection, planning, and managementaround it, continue to be the most arduous and fruitfultask of the Department.Revising managerial processes entails the necessityof deconstructing the bureaucratic organization,by means of generating devices that structure the217

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAforms of practice in relation to the community’s complex,dynamic and contradictory construction requirements.Bureaucracy solves conflict: it insures the onlyvoice that prevails is that of rules and authority. In deconstructingthe bureaucracy, it was necessary to reexamineall the circuits of decisions designed aroundthis conception and substitute them for practiceswhich focused on communication and debate.It was essential to rethink the organization of theworking process restructuring all the decision circuits,however this process is distant from having attained itsmaximum objectives.Decentralization was essential in building of astrong and efficient organization. It was necessary todefine guidelines that would make clear the responsibilityeach level of the organization. Clear roles andresponsibilities guaranteed that each decision wouldbe made as closely as possible to the level in which theproblem is lived. Every decision made in the enclosureof the Secretary of Health reaffirmed the central guidelinesof equity; community participation; social efficacy(prioritized over efficiency), but not excludingprevention and health promotion.The guidelines mentioned are summarized in thethree points:●Contextualized and effective forms of practice inhealth care.● Strategies to achieve equity in the utilization of services.● Participative planning of actions in defense of healthand life.Each of these three axes of work is senseless ifnot intersected with the others, and is simultaneouslyreformulated by that intersection. The accomplishmentof equity in the utilization of services is a purposeof the local planning, which also makes propositionsthat redefine and contextualize the clinical care strategies.Accounts on each of these axes and the stepstowards their implementation are listed below.Participative Planning in Defenseof Health and LifeIt deals with forms of collective health practicedesigned by way of local processes of participativeprogramming based on a dynamic epidemiological visionof the situation in each area.This local design ofprograms and activities finds, at the district or neighborhoodlevel, a context for negotiation and consensusamong the different zonal perspectives, withinthemselves and in their relation with the political strategiesof the central level, in the bounds of the healthsector and beyond.This construction of direct democracyimplied developing knowledge of socializing processes,which would encourage a permanent dialogbetween technical information and popular knowledgeto produce a new way of understanding reality,. Thecollective construction of the problem, that is to say,of the situation to be transformed, involves retaininginformation produced locally, with simplicity and rigorousness,attentive to quantitative and non-quantitativeaspects for the description and explanation of problems,making it possible to share it with all the communitysectors. The collaboration among the diversecommunity actors, the technicians of the local healthteam and other local state representatives (from othersectors), not only makes possible the prioritizing andclarification of problems, but also the explanation ofoperations which confront them.Intentionally, we speak of planning and not justlocal programming, because we are dealing with theconstruction of a local government that thinks strategically,and includes programming as a phase in the218

Observatorio Latinoamericano de Salud.process to transform reality. And one has to ask:Which is the sense of that transformation? The onedefined by the resultant vector of the interplay of thedistinct actors that govern, along with their dreams, interestsand desires.The political decision of the municipal governmentto decentralize the management of the city insix districts meant an important framework for thedevelopment of democratizing processes. The localplanning was settled, at that point, as a essentially politicalactivity, incorporated to an integral reform ofthe municipal state. It was intended to bring the capacityof decision near that local context where theproblems are undergone. The districts are not naturallyseen as distinct physical spaces, but as spaces incontinual construction, products of a social dynamicwhere social subjects are stressed when set in the politicalarena.These districts, having been established inthe same perspectives of the municipal administration,facilitate an inter-sectorial approach. In any case,within these districts, territories are recognized wherethe programming process acquires a more humanescale, woven into the context of daily life problems. Itis around the influence area of each health center, definedas the space of interaction between the healthteam and a territory’s population.The area is definedstarting from the places of origin of the people demandingservices from the health center. From thespatial analysis of the area delimited in that manner,the co-responsibility for health between the populationand the health service was defined externally, aswell as the differences that exist in its interior, all ofwhich implies the design of strategies, equally heterogeneous,to guarantee equity in the utilization of servicesas well as in the capability of participating in thedecision making process. Every territory is much morethan a geophysical surface: it is an state of connectionsand conflicts, with diverse interests at stake,with distinct projects and actors with distinct socialinfluence and power. It embodies a particular socialweave, where the economic and politic determinantsare inscribed in culture, ways of living, views surroundingsickness and dying of the population. Each localteam has autonomy to decide, to the work project includingpriorities, strategies to tackle problems, methodsfor evaluating the changes produced. One couldsay that in the district, the different local realities holda dialogue among themselves and with the guidelinesof the central level.The participative process made it possible toconfront the political and economical crisis, into whichthe country had plunged in 2001, still with a deepeningof democracy. While twenty other Argentine intendantswere compelled to resign in midst of an absoluteloss of legitimacy of the politic class and the chaosthat monetary devaluation signified, the Intendant ofRosario, Hermes Binner, kept the alternative projectalive by discussing in the district assemblies with theneighbors, civil servants and health workers, the prioritiesand strategies that would support the defense oflife, in a moment in which the health budget had beenreduced to a quarter of its purchasing power.As a direct form of management for the municipaleconomy, the population debates in each districtthe budgetary priorities in terms of the problems itidentifies. This Participative Budget making, impelledparticipation to transcend the limits of the health sector,mobilizing the inter-sectorial practice of civil servantsand workers.In sum, it is a question of structuring capacitiesto recognize diverse and complex problems and to develop,along with people, peculiar resolutions to thoseproblems. Hence, the constant quest of a managementmodel, encourages the molding of health workers assubjects who play a leading part and operate in constantrevision, and promotes the removal of the institutionalbarriers that obstruct people’s participation inthe construction of their right to health.219

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAContextualized and Effective Formsof Practice in Health CareClinical forms of practice should be linked toclear health outcomes and not merely to rigid and abstractprotocols. A way of coping with this, is to adapteffective methods of practice to the social and culturalcontext wherein the process of health illness develops,to ensure the undertaking of each health problem withintegrality and continuity.We understand clinical healthcare as the development and sustentation of an interpersonalconnection, where the therapeutic team isconstantly responsible for the course of action of care,even if it would include inter-consultations or referencesin other levels.This clinical practice must be reformulatedpermanently in reference to the epidemiologicalsituation of the territory and be subjected to the localplanning process. In this sense, we began working inthe appointment of rightful claimants to basic teams ofreference. Each team, composed by a minimum of onedoctor and one nurse, assumes the responsibility of thehealth care of a number of families, and operates astheir agent in the net of services.To implement this, thebasic health team counts on the assistance of the restof the professionals of the local interdisciplinary team,and the resources of the service network, so as to makecertain the maximal degree of problem resolution,and the appropriate use of technology.This network includesan emergency care system; three hospitals ofmedium complexity; a maternity; a children’s hospital;an adult’s hospital equipped for high complexity problems;second and third level rehabilitation centers; anda Center for Ambulatory Medical Specialties.The laterhas the specific institutional mission of providing withthe response, with specialized inter-consultation andcomplementary studies, to the necessities submitted inthe health centers, with which patients obtain the appointmentfor specialized care without having to movefrom one place to another, and the reference/counterreferenceof patients and cases is the object of a specificmanagement. The Center of Ambulatory MedicalSpecialties houses a central laboratory where the samplestaken daily in the health centers are processed.Progressively, the assignation of responsibilities territoriallydelimited to the specialists is being worked on,with the intention that each one of them will developa stable association with a definite number of referenceteams, and will collaborate effectively in the resolutionof clinical problems by means of advising, drillingor inter-consultation procedures, depending on thebest way, defined by the situation, to combine specificknowledge with contextual knowledge.Hospitalization pursues to sustain longitudinallythe therapeutic linkage, for this reason the hospitalteams include the ambulatory reference teams in thediscussion of each therapeutic project. The developmentof domiciliary hospitalization has allowed a risingnumber of ill subjects to exercise the right to be at homereceiving a more adequate, singularized, and efficientcare than they would in the hospital context.The medicines necessary for ambulatory careand hospitalization are made available gratuitously asthrough a therapeutic formulary that contains all requiredspecifics, in different pharmaceutical modes; aguide which was constructed with the participation ofdoctors and pharmacists of the network. A significantpart of that medication is produced by the Laboratoryof Medical Specialties, a public entity that has promotednew medicine distribution policies and has confrontedthe risks of absolute dependence on the market.At present, it produces nearly the totality of parenteralsolutions that are used in the various serviceunits of the Department and forty items that consistof pills and injectable products. Processes of continuouseducation and auditing aim at rationalizing prescriptions,simultaneously they hinder the adherence tochronic treatments seeking integral devices, which ensurethat rationality.220

Observatorio Latinoamericano de Salud.Equity in the access to services entails also theequity in the access to quality and appropriate technologyand, at no rate, the state ceases assuming the responsibilityof an integral response regarding care necessities,either furnishing directly or acquiring the response.Thefact that this local initiative is developed ina provincial and national context with no commitmentof the state beyond the "basic packages" of serviceshas pervaded this decision with growing challenges inits concretion. Rosario has not abandoned this challenge,attributable to the political value inherent toinstituting as a universal right what other would considernonessential for the poor. From the municipalstate, if a technology proves to be necessary, this isworked on so that it is made available for all; if it is dispensable,this is managed so that no one has accessibilityto it. A policy concerning an appropriate technologyis founded in this principle, and this is translatedto the citizenry’s conscience of their right.Prevention and rehabilitation are conceived ofintegrated to the care process, in a manner that specificareas of support contribute with regard to mentalhealth, health of women, the AIDS problem and the addictions,tuberculosis, immunizations, the inclusion ofpeople with incapacities.The process of transformation of clinical formsof practice has permitted 22.000 women to chooseoral contraception, which they receive freely in municipalservice units, and other 3.500 annually to decideto use the DIU, IUD freely, too. Unwanted pregnancyhas reduced to a value of less than 4% of the total, thePublic Health Department having assumed the care of60% of all the births occurred in the public sector. Immunizationscoverage has reached 90% for the youngerthan two years old. In spite of the structural deteriorationof living conditions in the country, the numberof undernourished annually diagnosed in the municipalhealth centers remains stable and the census ofstature in first grade students made in 2003 have similarresults 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 changingprocess. Mortality caused by AIDS has decreased significantlyamong the residents of the city of Rosario:from 12 deaths of each 1.000 inhabitants in 1996, to 4deaths of each 100.000 inhabitants in 2003.The precedents are some of the indicators of aprocess that has initiated, which is still not entirely given,which denotes a daily struggle against the inertiaof the status quo.Strategies to achieve equity inthe utilization of servicesKeeping to the conviction that inequity makespeople ill more than poverty, the management has understoodthat equity is brought about insofar as servicesare used in function of necessity, which generallyvaries in a way inversely proportional to the capacityof supply. Pursuing equity has meant knowing the population’sdistribution of inequality in terms of livingconditions and its consequent distribution of illnessand death, and to develop strategies of positive discriminationthat are capable of accounting for the peculiaritiesof each situation and ensuring the right tohealth as well as people’s dignity and freedom, cultivatingthe capacities of listening, flexibility and dialoguebetween the health services and the heterogeneousnecessities of the community. This has implied constructing,in all the contact points of citizens and thenet of services, devices of admission that interrogatethe necessity behind the demand, and analyzing continuallythe barriers to the access to services in the spacesof local planning.It is more than enough to say that the changingprocess encounters important obstacles within the221

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAinstituted bureaucracy, public management and theeducational institutions, even having to surmount theirown subjects of transformation. Hence, we speak of aconstruction starting from its very contradictions.In the subject of the education of health workers,several experiences were exploited that intendedto install a vector against the determinations mentioned.In this sense, practice periods inside district interdisciplinaryteams were established as part of the educationalcurriculum of the basic specialties Master’sdegree. The General Medicine Residence was alsocreated with the objective of educating doctors forthem to be capable of integrating epidemiology andstrategic thinking to a clinical practice respectful of thesubject’s dimensions as a whole. Once graduated fromthis program, they carried on feeding the establishmentof the reference groups and progressively committingthemselves to the management of change.These axes are framed in an integral strategy,which considers the construction of citizenry, theconstitution of individual and social subjects capableof struggling against the limitations of life, as an ultimategoal of the work in health. Being this, a task assumedby the community all along history, which naturallyexceeds the potentialities of the health and publicsector. The implication of workers of the healthsector as much as that of civil servants has been heterogeneousand difficult. Authoritarianism, alienationand bureaucracy are raised as robust obstacles andtheir fight is within the political, organizational andsubjective dimensions. This fight does not count oneveryone, currently, not even the greater part; it canbe assured that contradiction has installed in eachworking team.The constitution of management teams in eachhealth center has been a tool to imprint dynamism intoan apprenticeship based on the problematic thathas promoted the creation of a critical mass of workersand communitarian referents. The managementteams were composed of every worker who wouldaccept deepening the discussion until the stage wherea consensus was attained, and being responsible of thedecisions produced this way.This collective of workersand actors of the community has featured the quotidianprocess of widening the limits of what is possible,seeking to overcome the contradictions, amalgamatingautonomy with responsibility. This experience constitutes,for this movement, its reserve for the future.222

Observatorio Latinoamericano de Salud.24The Experience of Bogota D.C.: A PublicPolicy to Guarantee the Right to HealthMario Hernandez, Lucía Forero, Mauricio TorresSince the beginning of 2004, Bogotá D.C. counts on a new administrationheaded by Luis Eduardo Garzón, who became Magistrate as a result ofthe "Democratic Pole" electoral coalition which brought together progressive,democratic and left-wing sectors.The government’s proposal has strengthened the Social State of Rightas its central axis, starting from the acknowledgement and advancement of aset of social rights to the population. The District Department of Health ofBogotá D.C. (SDS) had this idea at the center when constructing public policyand the main objective to advance these rights by the population of BogotáD.C.This document presents the essential elements of this proposition, balancinghealth in the city from the viewpoint of living and health standardswith population, social and institutional responses. Finally, the report definesa strategy for guaranteeing the right to health in the midst of the complexityof the current Colombian General System of Social Security in Health(SGSSS) and evidences some of the results attained through the end of 2004with the development of the public policy.A Modern and Inequitable CityBogotá has changed in several respects over the last 10 years. The sustainedinvestment in infrastructure, transportation, public services and space, inaddition to advancements in tax and culture allow us to characterize Bogotáas a modern city, or at least a city in the modernizing process. Conversely, it223

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAis a city more inequitable than ten years ago. The numberof people with unfulfilled basic needs ("necesidadesbásicas insatisfechas"-NBI) has decreased, due to superiorcoverage of basic public services and sustained investmentsin infrastructure. Nevertheless, the numberof families that are not able to pay the growing cost ofthose basic services has increased. Families often do notsucceed in accessing more complex health and educationservices. In the poorest parts of Bogotá, nearly 15%of families could not afford to consume three meals aday, as recommended by the Living Standard Survey ofJune of 2003 1 . This signifies poverty has increased; howeverthe NBI measure does not provide a comprehensiveview of the phenomenon. When we look at theline of poverty (LP), which weighs family income againstthe cost of goods and services, the problem proves tobe alarming. Between 1993 and 2003, the populationunder the LP increased from 44,9% to 50%, roughly amillion more poor people. Under the line of indigence(LI), there was an increase from 8% to 17% in the sameperiod [Alcaldía Mayor de Bogotá, 2004].Families’ incomes have been affected by unemploymentand labor precariousness. Within Bogotá, thehighest unemployment rate of the country persists, aswell as high underemployment and informal labor. In2003, the city had a working age population of5.317.000 people, a labor force of 3.558.000. A total of593.000 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 unemploymentrate of 14,8% [DANE, 2004]. These statisticsexceed the ones registered in other cities by morethan 50%. In Bogotá, 36,6% of the labor force is concentratedin the thirteen main cities and metropolitanareas of the country [DANE, consolidado 2000 a2004]. If the displaced population is included in this figure,the situation becomes even more serious.Though we face controversial data, all numbers coincidein reflecting a considerable and constant increase inforced displacement during the last decade. Accordingto the Social Solidarity Network, in charge of offeringservices to the displaced population the first sixmonths, between 1994 and February of 2005, 22.784families representing 90.643 inhabitants arrived in Bogotá[Presidencia de la República, 2005]. Consistentwith the Advisement for Human Rights and Displacement(CODHES), between 1995 and 2002 358.188 displacedpeople arrived in the city [El Tiempo, 2003] thisdifference demonstrates the great difficulty of the Stateto identify this population and respond to its needs.Opportunities to create a secure future are notequal.The progressive segmentation of the city has leftthe poor segregated in certain localities. For this reasonthe Magistrate declared a social emergency withinsix of the twenty localities. This inequality is most evidentin the health of the Bogotanos. Although preventablemortality indicators have improved, the pace isslow and has not brought equal benefit to everyone. In1993, 90 maternal deaths per 100.000 live births occurred,compared to 2003, when 61,66 were registered.During the same period, deaths of children youngerthan 1 year old decreased from 26 to 15,05 per 1.000live births. The deaths caused by preventable illnesses,such as diarrhea and pneumonia, in children youngerthan 5 years old decreased considerably. In the sameinterval, deaths from diarrhea shifted from 30,9 to5,16 per 100.000; and deaths from pneumonia droppedfrom 78,7 to 20,21 2 . These could be consideredadvancements if we did not have in mind the progressmade by other countries, which have accomplishedgreater improvements in living standard. The UnitedKingdom 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 preliminares224

Observatorio Latinoamericano de Salud.ve births, and an infant mortality of 6 per 100.000 livebirths. Chile has this last indicator in 10 per 1.000; andSweden, in 3 per 1.000.Despite these low rates, the majority of healthindicators reveal unfair and avoidable differencesamong localities. For instance, in Ciudad Bolívar, therate of mortality among children younger than 5 yearsold is 250,9 per 100.000 in 2002 3 . In Teusaquillo, it reached166,08 per 100.000. If we acknowledge the factthat this is a question of children’s lives and not merelynumbers, then the difference between 217 and 12seems intolerable. Sweden did not report any deathsof children under 5 years old in 1999. In Kennedy, aprenatal mortality rate of 809,9 per 100.000 live birthspresented in 2002, while in Teusaquillo it reached235,8 4 . In Kennedy, the proportion of pregnancy, childbirthand post childbirth related mortality, was 83,27per 100.000 live births, explicitly 11 women this year.Comparatively, in Teusaquillo no deaths were reported.These inequities constitute the foremost healthproblem of the population of Bogotá.With regard to nutrition, during 2002 it was establishedthat 11 of 100 live births had low birth weight(less than 2.500 grams). Of these, 67% presented intrauterinemalnutrition 5 . Among children younger than7 years old, the Survey of Demography and Health ofProfamilia (2002) confirmed that acute malnutritionreached 0,5%. If this analysis is applied to the populationsof strata 1,2 and 3, which consult with the socialinstitutions of the State (ESE), the mentioned prevalencegrows to 6,3% 6 .This is further evidence of social inequity.In Usme, the acute malnutrition rate for the totalpopulation was 13,8% in 2002; in Usaquén, it was only3,3%.A Discriminatory and InaccesibleHealth SystemThe General System of Social Security in Health(SGSSS), defined by Law 100 of 1993, had its major developmentin Bogotá. The percentage of the populationaffiliated with the Contributory Regime has remainednearly 55%. By December 31st of 2003, affiliatedcoverage through the Subsidized Regime in theamount of 1.369.970 was obtained, corresponding to19,95% 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 thisregime is taken, the number decreases to 1.099.164.This implies that people, for reasons not always controllableby the insurer or the SDS, do not use all theawarded quotas. There are still roughly a million and ahalf people without insurance called "connected participants."They receive care from the public networkand by contacting the non-appointed network, withresources from the Nation and the District administeredby the District Financial Fund of Health (FFDS).The supply of services has increased. In 2003,the SDS registered 12.502 providers in the city 7 . Ofthese, 2.196 correspond to health services providerinstitutions (IPS), 31 to institutions of assisting transportation,and 10.275 to independent professionals.At the end of 2003, 78% of the providers were situatedin the north zone, and 11%, 6% and 5% in the southeasternzone, central eastern zone and southern zoneof the city respectively. This distribution can be attributedto the dynamic of the services market, followingthe preferences of those making the offers morethan 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 2309of 2002.The deadline is June 30th of 2003.225

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAnized as a serious barrier for the poorest to accessservices.In line with the juridical nature, the private sectordominates: of the 2.196 IPS’s, there are 185(8,46%) public, 1.684 (76,6%) private, 326 (14,9%) nonprofitfoundations, and 1 (0,05%) mixed. The CapitalDistrict relies on 10.223 hospital beds, of which 6.304belong to the private sector, and 3.919 to the publicsector. This number illustrates an average of 1,52 bedsper 10.000 inhabitants, in accordance with the standardsobserved for the principal Latin-American countries.However, the appalling distribution contains aseries of barriers for people in the southern part ofthe city to access services, which necessitates betterdecisions regarding supply.Despite the evolution of the System, serioustroubles exist in the institutional and social responseto health problems in Bogotá. The most significant isfragmentation. Throughout various scenarios and studies,it is agreed that the health system is fragmentedin several senses: in the actions of the agents involved,be they providers, insurers, modulators, or users; inthe distribution of services, since there are differentbenefit plans in proportion to the payment capacity ofthe people, such as the obligatory health plan of theContributory Regime (POSc), the obligatory healthplan of the Subsidized Regime (POSs), other complementaryplans offered by private health insurers, theplan of occupational accidents and professional illnesses(ATEP) of the System of Occupational Risks, andthe services of the special regimes. It is also dividedby the competition of territorial institutions and theNation, which impedes territorial regulation of thesystem. Currently, it is not possible to know beyonddoubt which is the profile of tended morbidity of thepopulation of Bogotá. The SDS receives and analyzesinformation about care provided by the ESE and otherIPS, however it does not obtain information about majoritypopulations in the Contributory Regime. This situationis due to the resolution to centralize this informationwithin the Department of Social Protection,using numerous non-unified mechanisms, not allowingterritorial institutions to use it to make decisions.Hence, a sufficient information system does not existto exercise the regulation of the system in concreteterritories, and information is reduced to supervision,surveillance and control operations in the respects designatedby the rules.A second grave problem is the persistence of diversebarriers- geographical, economic, or administrative-to accessing services, especially for the poorestand most vulnerable populations. For example, wheninsurance contract providers that are distant from theresidence of the affiliated, or they establish administrativeprocedures that delay service provision and deliveryof medicines, unacceptable barriers are createdthat endanger people’s lives. The moderating fees, copaymentand recuperation fees ignore the needs of thepoorest. Emergency care has unfair economic restrictionsand administrative procedures, which diminish itto minimal and inadequate interventions. Presently, itis calculated that nearly 30% of the population is notpoor enough to achieve a State subsidy, and at the sametime, cannot count on an adequate sustainable incometo continue an affiliation with the contributoryregime. This population is increasing, largely due togrowing unemployment, underemployment, and informalof labor.In the framework of insurance and in a mode ofcare concentrated on illnesses, the emphasis has beenplaced on individual curative care services, and thepreventive capacity has been undermined. The investmentin preventive actions by insurers does not reachthe amounts established by the law, while the SDS publichealth office only received 8% of the budget in2003. This manifests as a very limited capacity to preventand intervene in primary problems of publichealth in the city. The most important indicator is re-226

Observatorio Latinoamericano de Salud.lated to vaccination coverage. Between 1998 and2003, the vaccination coverage of the Expanded Programof Immunizations (PAI) decreased between 5 and25 percentage points. Still now, in spite of campaignsand door-to-door vaccination programs, Bogotá is notguaranteed to have effective coverage, even after havingaccomplished it in the beginning of the 90’s.Though social participation in the health sectorhas increased, it continues to be excessively institutionalizedand oriented more to the needs of health institutionsthan those of the community. Additionally,existing mechanisms produce a separation betweenparticipation as a user and as a citizen, which is notconvenient. Although there is accumulated potential insome associations of users and committee participation,their articulation is scarce, representative powerreduced, and influence in public local and district decisionsis still precarious.With this panorama, the overall appraisal ofhealth in Bogotá cannot be considered positive. Growinginequities and inefficiency in the social and institutionalresponse of the System demand a reorientation.Even in the restricted framework of the currentSGSSS, the district administration has decided to takefirm steps toward supporting health as a public good,an essential human right, a duty of the State, and a socialresponsibility.A Health Public Policy to GuaranteeThis RightThe FoundationsThe three pivotal messages from Mayor LuchoGarzón give an account of his vision for the city. "Modernand humane Bogotá" acknowledges modernizationefforts, and asserts the priority of people. "Bogotáwithout hunger" puts forward a conception of povertythat recognizes the precarious situation of manypoor people and its relationship to income and employmentof families. "Bogotá without indifference",which gave a title to the District Plan of Developmentapproved by the Council of Bogotá D.C., expressesthe necessity of the Social State of Right to work withsociety to surmount poverty and exclusion. It is a callingfor collective action on the basis of solidarity, a callingfor citizens to assume others’ perspectives, startingwith human equality and dignity. The District Planof Development (PDD) is a summons to overcomeavoidable inequalities through the "construction ofconditions for the effective, progressive and sustainableexercise of integral human rights, established in theconstitutional pact and in the agreements and internationalinstruments" 8 .In this frame of reference, the District Departmentof Health of Bogotá D.C. undertook the challengeof advancing the right to health for the inhabitantsof the city. In line with the project defined by the ColombianPolitical Constitution of 1991 and the internationalpacts signed by the Colombian State, which arecompulsory for public management throughout thenational territory, the project aims to progressivelyuniversalize access to integral health care. A humanrights approach was conceived to defeat inequities, asmuch in the results as in the access to health services,and ensure fulfillment of State duties, which requiresthe conscious and systematic combination of the collectiveeffort to redistribute the resources availableand the appreciation of differences among people.This combination between redistribution and recognitionis based on four principles that support the health8.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 laexclusión. Bogotá, abril 30 de 2004.Art. 1º.227

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINApolicy in progress. Equity, understood under the maxim"from each one according to their capacity, and toeach one according to their necessity", constitutes theprinciple guiding the priorities of intervention. Solidarity,rooted in the equality of human condition, permitsus to place ourselves in the viewpoint and circumstancesof others, leaving aside our own. Autonomy as themainstay of liberty and self-determination of people,allows the acknowledgement of our nature as actingsubjects, with all the capacities available. And the recognitionof differences, which consents the comprehensionand adjustment of public decisions to cultural,ethnic, political, gender, and life cycle diversity.Basic Proposals: A Mode to Improve Living Standardand Promote Health, the APSTo move forward in guaranteeing the right tohealth, it is necessary to rearrange the working modewithin the health sector of the Capital Districts. TheSDS has adopted a mode of care "to promote livingstandard and health" 9 .This has brought about the rearrangementof all processes, both sector and transsector,institutional and communitarian, curative andpreventive, educational, protective, and rehabilitating.The processes are as much individual as collective,moving towards improving the living standard of thepeople and the facilitating the exercise of their autonomyfor the realization of their life projects.The emphasis on illnesses care, a service of individualconsumption, whose economic risk is protectedwith insurance in the frame of the current SGSSS,has produced confusion between the right to healthand the contracting rights established among agentsfound in the insurance and curative services market.On this foundation, the vision and materialization ofhealth care has gradually proliferated, akin to the buyingand selling process of merchandise. If the right tohealth were assumed in the dimension the SDS hasproposed, the SDS would be required to change theorientation of health services and undertake adequatemodels of provision.This option has entailed the passing from onemode of care based on illness –wherein the managementof curative services dominates, the demands filteredand the needs of the population identified fragmentarily-to the imperative to respond to social requirements,through a mode of promotion of livingstandard and health. The approach should be in linewith living standard and health needs by territoriesand zones (ZCCCVS). This challenge involved the developmentof living standard spheres, in which socialneeds derived from interdependent human rights areexpressed. Specifically, within the individual sphere theorganizing value is autonomy, emphasizing the capacityto manage for oneself, as well as the possibility toachieve economic independence or to exercise anemancipating political option. Within the collectivesphere, the central value is equity, the basis of redistribution.Within the institutional sphere, the valuesare trans-sector operation, integrality, and democracyto seek the maximum social efficacy possible. Withinthe subjective sphere, the construction of social potentialand imagination. Lastly, within the environmentalsphere, the key value is sustainability.The challenge to respond to social necessitieshas required detailed identification in specific territories,differentiating these necessities from care demands,and understanding particularities along the linesof social class, gender, ethnic group or life cycle.It has also demanded an evaluation of accumulated9. Expression coined by doctor Armando De Negri Filho, Brazilian doctor, ex-coordinator of health planning of the Department of Health of Porto Alegre, adviser ofthe SDS in the formulation of the district policy of health.228

Observatorio Latinoamericano de Salud.deficits in the institutional and social response, andthe registering of inequities or unfair and avoidableinequalities to arrange the strategic design of newresponses.Health Policy ObjectivesThe SDS has committed itself to the achievementof the following objectives:● To affect significantly the determining aspects of thehealth/illness process, through different sectors, andthe articulation of health and social management ofterritory.● To strengthen the exercise of citizenry in health.● To exercise the regulation of the General System ofSocial Security in Health within the Capital Districtto:Orient health care towards an integral care system,which promotes living standard and autonomyof people.Guarantee the access to emergency services, andPrimary Health Care (APS), with a family andcommunitarian stance.Consolidate the public hospital network and theservices networks of the entire system, in accordancewith the population’s care needs.Develop an integrated system of information inhealth, which permits the observation of health,equity and living standard goals, as guide to thestructuring of policies.In order to accomplish these objectives, serioustransformations have transpired in the manner of thinkingand organizing management and care processes,as much in the interior of the Department as in the relationswith other State sectors, reinforcing the frameworkof the three structural axes and the objective ofefficient and humane public management of the PDD.Currently, it has required the rearrangement of relationsbetween the SDS, other agents of the health system,and communities. To attain this transformation,the health sector has planned its actions in accordancewith the development plan, using the central programnamed "Health for a proper life", and 12 sectorialinvestment projects.The Family and Community Approach of the APSThe Department recognizes the relevance of themain characteristics of the APS in the transformationof the mode of care to meet necessities in health.Among them: accessibility, inasmuch as the APS is theentrance for easy, close and immediate access, recognizedby the population as their permanent referencepoint. Longitudinality, which presupposes a long-termrelationship between the population and the healthpersonnel in charge, is supported by the appointmentof families to a health team, and produces a close liaisonbetween health professionals and people servedby them. Integrality, which organizes the set of actionsrequired to overcome the necessities presented bythe population. Finally, continuity, along with the healthteam and the organization of APS turn become theaxis of response, either directly or by referring casesto other care locations, guaranteeing the observationand monitoring of care processes. These characteristicsof the APS are assisted by the principles of efficacy,effectiveness, and equity to ensure transformations inthe living conditions of peoples, and the ability to overcomeexisting inequalities through the optimal use ofresources available.The point of departure consisted of locating specificterritories to organize a response starting from229

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAsocial necessities. There is a recent effort to actualizethe 20 experiences of local diagnosis, with social participationand the participation of first-level hospitals ofthe public network. It served as a point of reference inthe identification of ZCCCVS within each locality. Thesezones display deficits of social response and inequitiesthat allow the orientation of priorities of sectorialand trans-sectorial intervention.From a strategy promoting higher living standardsand health, trans-sectorial government agendasare being defined in the localities, anchored in organizedsocial participation for the social management ofterritories, with communication processes betweenthe health service networks and the sectorial and socialnetworks, oriented to defeating inequities. A secondorganizing principle resides in defining the goal ofzero indifference about social needs, for which technical-scientific,economic, social and political meansexist, with the purpose of sustaining a social and governmentagenda.Family and community health teams have beenformed and trained with this intention, with the aid ofthe University of Toronto (Canada). These teams arecomprised of a doctor, a professional nurse, a nursingauxiliary, and two or three health promoters, with somevariations depending on the resources at hand andterritorial particularities. Each team is in charge of 800families, an average of 3.500 people, according to the familycomposition in Bogotá. Families were assigned toteams, and these are permanently connected with anAPS network, which includes association with the PrimaryUnits 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, thedevelopment of similar complexes regarding private IPSto progressively broaden coverage has been fostered.The first activity of teams has been identifying individuals,families and territories. Increasingly, they havecreated and expanded plans of family and communitariancare, in which the functions cited previously are integrated.This scheme undeniably allows participantsto overcome several barriers in accessing the healthservices of the current system; hence, the denomination"Health to your home" of the central programmodel (See figure 1).Family health was organically incorporated in theperspective of the APS, with the intention that teamswould not be isolated. As a matter of fact, their workhas facilitated the organization of care at the level ofservice and support networks, articulated to sectorialand social networks with the goal to promote higherliving standards and health. In the first place, we havethe APS network, but also one for specialized care,another for emergencies, and an additional for hospitalization.Among the supporting networks, we have onefor pharmaceutical services,services; one for surveillance,another for rehabilitation, and one for diagnosisassistance (refer to Figure 2). The networks will be activatedconsistent with the lines of care defined in thevertical axes, conforming to needs defined by territoriesto increase living standard and health. By majorcategories of collective problems, the goal is to makethem visible as challenges to overcome. Likewise, inthe horizontal axes, the construction of living standardand health strategic projects is represented, consideringthe interrelated set of social needs within eachphase of the life cycle (childhood, adolescence, youngage, adulthood, and old age). Vertical axes correspondto projects for the development of autonomy, by whichthe causes and determinants of health throughout thelife cycle will be combated (see figure 2).The construction of this complex structure ofnetworks, lines, and projects was conceived as a slowprocess of adaptation to the conditions and necessitiesof people in specific territories. From the operationalviewpoint, in the framework of the SGSSS, integrationof preventive and curative services has been230

Observatorio Latinoamericano de Salud.achieved by articulating benefit plans according to thefinancing sources (Basic Care Plan -PAB-, POSc, POSs,non-POS activities, promotion and prevention activitiesof the insurance regimes). The PAB resources,and in some cases those localities and occupationalrisks have allowed the completion of projects relatingto the construction of social spaces and healthy atmospheres,such as homes, schools, work places, andpublic spaces. To strengthen the exercise of citizenry,fieldwork has begun within families’ every day spacesto encourage less institutionalized participation.The APS advancementsIn December of 2004, 54 family and communityhealth teams had already been organized, operating inzones corresponding to strata 1 and 2 (the poorest).On March 7th 2005 the training of family and communityhealth teams continued with 341 members of theESE, of the professional, technical and auxiliary level.At the moment, 62 teams operate, which cover 41.072families in sixteen localities, consistent with statisticsincorporated in the database through March 11th of2005: 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 thehealth system, through which demands are identified,both the ones arising from unsatisfactory living standardand health and those that are a direct responsibilityof the health sector and other sectors. Channelingdemands to other sectors is performed in agreementwith the obligations instituted by the Law, in harmonywith the activities developed daily.FIGURA 1 COMPLEJO DE APS231

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAFIGURE 2 NETWORKS AND CARE LINESThe characterization of individuals, families andmicro-territories of the APS has been prepared throughthe handling of the respective characterizationform, delegated to health promoters and nursing auxiliariesof the basic team of family and communityhealth. The District Department of Health of BogotáD.C. has imparted clear guidelines among hospitals ofthe appointed network, with regard to the fulfillmentof minimum requisites, which the members of healthteams ought to comply with. These must include civilemployees in the payroll, with certain seniority withinthe institution, and a good level of knowledge aboutpotential problems within the zones in which theyconduct fieldwork. Health promoters, as well as thosepreceding, must be inhabitants of the micro-territoryor the zone in which they work and have experiencein community level work.The existing family and community health teamsare acquainted with the local health diagnosis, updatedunder the coordination of the District Department ofHealth of Bogotá D.C., with the participation of thecommunity during 2003 and 2004 in each one of thelocalities into which the Capital District is divided administratively.One of the criteria to select the territorieswhere the strategy of the APS has been implementedwas to belong to the most vulnerable zonesonce the local diagnosis was identified, which in thiscase correspond to the zones of Living Standard andHealth Conditions (ZCCVS) of type 1 and 2, and coincidewith the strata of the city.The worst problems have been evidenced in childrenwithout schooling, children and adults with acutemalnutrition, families that require relocation from highrisk zones, families that require the legalization of theirdwellings, and public services. All the populationgroups identified have been channeled to the appropriateorganizations: non-schooling children have beendirected to the Department of Education of the CapitalDistrict; the children and major adults with malnutritionhave been connected to the program "Bogotá232

Observatorio Latinoamericano de Salud.without hunger"; families in high risk zones or in notlegalized zones have been routed to the AdministrativeDepartment of Emergency Prevention and Care(DEPAE) and to the DAPD, respectively.Environmental problems have also been identifiedin unpopulated areas, due to dumping residualwaste into the water, the presence of rodents andarthropods, and zones devastated by environmentalcontamination from contaminated particles in the air.In this sense, from the Basic Care Plan (PAB) interventionshave been executed to control environmentalproblems for families living near unpopulated areas, inconjunction with community education. Measures havebeen taken before the Administrative Departmentof Environment (DAMA) to inform about the situationsfound regarding environmental contamination.Further problems have been detected within thecommunity and are the direct responsibility of thehealth sector, such as incomplete vaccination schemes,in response to which vaccinations have been fulfilled;growth and development problems in children, who havebeen linked with the growth and development programs;pregnant women without prenatal control, forwhom these controls have been initiated; and womenof fertile age, with whom the cervical cancer preventionprogram has begun. At the same time, those affiliatedwith the regimes of Social Security in Health have beentaught their rights and duties, along with educational actionsand information clarifying the mechanisms for accessingservices. The potential beneficiary populationhas been identified via the Beneficiaries IdentificationSystem (SISBEN) and conducted to the DAPD.The institutions that have been collaborating onstrategy development of the APS are: the ColombianInstitute of Family Well-being (ICBF), the AdministrativeDepartment of Social Well-being (DABS), the organizationsparticipating in the Program Bogotá WithoutHunger, the Department of Education of the CapitalDistrict (SED), the Operational Local Centers of LocalPlanning (CLOPS), a number of Nongovernmental Organizations(NGO), the Administrative Department ofDistrict Planning (DAPD), several Local Mayoralties, andthe Local Development Funds (FDL), among others.The Public Health perspective and the APSThe the APS strategy has been implemented inthe ZCCVS 1 and 2, where the most critical conditionswith respect to living standard and health prevail.Within these zones, the highest rates of infant chronicand acute malnutrition are concentrated (20,57% inSan Cristóbal and 13,87% in Usme), the major percentagesof 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 distantfrom the average of the city, 25,3 and 3,8 per 100.000inhabitants. Traditional infectious and parasitic illnessescontinue, 52% of the cases of HIV/AIDS notified inBogotá, and 44% of deaths by AIDS. In this area we alsoseethe greatest rates of births from adolescentsbetween 10 and 19 years old (Santa Fe, 57,7 per10.000; Usme, 51,22; Candelaria, 51,22; San Cristóbal,48,83; and Rafael Uribe, 47,48). Women who live andwork in the sexual commerce region of the zones havelimited access to appropriate living conditions of typeII. Single mothers, infantile maltreatment, andschool desertion are situations directly related to sexualwork. Sixty-four percent of the population ofstrata I and II are located within these zones.Derived from the particular diagnosis of theseZones, the city’s undesirable health conditions wereidentified, which prompted the formulation of "zero visiongoals", as reference points for the joint efforts ofState and society institutions. The following were putforward for childhood and adolescence: facing low233

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAweight at birth; incomplete coverage of prenatal care;childbirth and post childbirth maternal and perinatalmortality; pregnancy in adolescents; vertical transmissionof HIV and syphilis; infant mortality; avoidablemortality by pneumonia and acute diarrheic illness inchildren younger than 5 years old; acute malnutritionin children younger than 7 years old; children with liceinfestations; scabies and parasitic intestinal diseases.Alsomorbidity by immuno-preventable illnesses; childwork problems; injuries by domestic accidents; homevicinity school and public space violence; sexual abuse;dental care and periodontal illnesses; infantile abandonmentand maltreatment:Addictions in children andadolescents; homicides in younger than 14 years oldwere also frequent as well as careless child disability .For the young population, the proposal of "zeroindifference goals" was assumed involving: homicidesand suicides, addictions, sexually transmitted diseases(including HIV/AIDS), unwanted pregnancy, incapacitywithout care, and prostitution without change alternatives.For the group of adults from 25 to 59 years old,"zero indifference goals" were presented in: cervicaland breast cancer belatedly detected, family violence,sexually transmitted diseases, infection by HIV, prostatecancer, unattended disabilities; absence of preventivemeasures for occupational accidents and occupationalillnesses, maternal mortality, traffic accidents andaddictions. For adults 60 and over the "zero indifferencegoals" correspond to: chronic and degenerativeillnesses without care or with incomplete care, abandonment,periodontal disease without care, domesticaccidents, incapacity, and mental disturbances withoutcare.Complementary to what was previously stated,nine policy guidelines were implemented for childrenand adolescents: mental health, HIV/AIDS, sexual andreproductive health, maternal mortality, oral health,environment, chronicles and schools promoting a higherliving standard. Each of these was oriented by publicsummon and the approach of promoting higher livingstandards and health toward overcoming seriousproblems.Thus, the first component of the rearrangementwas the management and care of identified needs andsectorial and trans-sectorial interventions by life cycle,from an integral care perspective. This last includesthe development of educational and protective activities,as well as those concerning health recovering andrehabilitation. Individual and collective interventionsare 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 therest of service and support networks, consistent withrequirements from the lines of care and technologicalhierarchies and agents of the SGSSS. Simultaneously,defining the context of the intervention has highlightedinteractions with institutional networks of othersectors that implement public policies along with thesocial and community networks in specific territories,in order to accomplish the territorial management ofthe city. Additionally, interventions for all cycles are integrated,since the aspects related to public health managementwithin territories in the frame of the APS,have activities leading to the development of transsectorialprogramming.Like this, the territorializing and solving of livingstandard and health problems has moved ahead, bymeans of a planning and local management exercisewith the participation of the community. Different localagents were summoned, and as a result twenty localdiagnosis processes were actualized, which serve asa basis for the identification of the ZCCVS, and to theformulation of an equivalent number of integral healthprojects, with which a solid articulation of resourcesand interventions is expected facing the problemsidentified. This perspective broadens the dialogue with234

Observatorio Latinoamericano de Salud.the strategy of APS and the social participation, throughthe proposition of social management of territoryfostered by the Department, which in comparison,is being incorporated into the other organizationsforming the Social Axis of the District DevelopmentPlan "Bogotá Without Indifference".Thus, the Capital District advances toward theimplementation of the three objectives of public policyput forward in the District Development Plan. At thesame time, the bureaucratic perspective of social participationhas been overcome, by strengthening the citizensorganized mobilization. The power of this approachis its connection to and empowerment of thecommunity to demand the fulfillment of their rights,and ensure major participation in health issues and themanagement processes. The regulatory exercise ofthe SGSSS has also been improved with agreementamong providers, insurers, and the remaining agents ofthe territorial structure, emphasizing the needs for improvedliving standards and health.REFERENCES● ALCALDÍA MAYOR DE BOGOTÁ (2004). Bogotá sin hambre. Uncompromiso social contra la pobreza. Bogotá D.C., enero de.● DANE, COLOMBIA (2003). Encuesta Nacional de Hogares, informepor departamentos.● DANE, COLOMBIA (2004). Encuesta Nacional de Hogares, informepor departamentos.● DANE, COLOMBIA (consolidado 2000 a 2004). Encuesta Nacionalde Hogares, informes trimestrales trece áreas. Cidfas promediodel último trimestre de 2004.● EL TIEMPO (2003). Sábado 8 de marzo: 1-18.● PRESIDENCIA DE LA REPÚBLICA (2005). Red de SolidaridadSocial. Registro Único de Población desplazada por la Violencia.Acumulado hogares y personas hasta el 28 de Febrero.235

ActionFrom the Peoples

Observatorio Latinoamericano de Salud.25 Health:A Human RightFrente Nacional por la Salud de los Pueblos del EcuadorHealth is a social, economic, and political issue, and primarily it is a right acquiredby society. However, the implementation of neoliberal economic schemesand their associated policies based on the dehumanized principles of the InternationalMonetary Fund have lead to an Ecuadorian crisis, particularly within thehealth and education sectors. Through mercantilist, restrictive and privatizingpolicies, neoliberalism has generated labor precariousness with the freezing ofwages, a tertiary structure, and the dismissal of workers and consequences suchas major inequities and the disrespect of human rights, value crises, violence, drugdealing, and free trade of weapons that kill popular protest. Specifically, monetarydollarization in Ecuador has created a country where efficiency and humandevelopment are measured in terms of economic success, wherein money hasseized human conscience and dignity, and where macroeconomic indicators areproportional to the growth of illness in children and old people death.In this context, the Ecuadorian National Peoples Health Front was formedby communitarian and district leaders, housewives, health workers, teachers, students,and professionals in general. It is rooted in coherent proposals on nationalreality and it intends to reestablish and reaffirm the universal right to healthwhereby all the population would have access to health services to fulfill theirneeds with equity, efficacy and efficiency. Moreover, we aim at sharing experiencesamong social movements, with a vision of change, whose mission is contributingto social transformation. From the viewpoint of the Front, we seek toconvert the community from an object to a subject and social agent with the capacityto deliberate and decide on health policy.237

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAWHAT ARE THE FRONT´S DEMANDS?● We demand the right of everyone to be heard and toshare their experiences, dreams, stories, knowledge,and wisdom. For this reason, we think all these socialagents, people who are traditionally silent and notlistened to, have to unite in order to form a commonfront.These people include shamans, healers, "hueseros",midwives, communitarian leaders, district andcommunitarian organizations, health workers, studentsand professionals in different areas.● We aim to defend health as a priority and universalright of human beings, by means of inter-institutionalcoordination and community participation.● We aim to improve the communication among organizationscommitted to our ideals to help groupssocialize ideas; listen to suggestions, share workingtools, and support social change in regards health.● We strive for the formation of new fronts withinprovinces, cantons, parishes, and distant and difficultto access communities in order to multiply ourprinciples and proposals.DECLARATION OF PRINCIPLES● Economic changes throughout the capitalist worldhave deeply affected the health of our people andtheir access to sanitary care, education, employment,housing, potable water, and social well-being.The gap between the rich and the poor, men andwomen, children, young people and old people widensseriously, presenting a panorama of marginalitythat infuriates and revolts us.● The contrast between the immense wealth generatedby peoples and derived from nature and the millionsof people suffering hunger, illiteracy, violenceand unhealthy living conditions summons us to globalizeour solidarity and the struggle for justice, withthe intention of jointly confronting the evils of thepresent century.● Violent and aggressive economic accumulation, indifferenceand even disdain for humanity, and the impositionof tariffs on account of public health services,has lead to the tragedy of the poor, who constitute85% of Ecuador`s population.● In the middle of this generalized poverty, the deteriorationof social and economic indicators, and theaccelerated increase in misery illnesses, such as infantmalnutrition, tuberculosis, malaria, diarrhea,dengue, low weight at birth, we oppose the collectionof health services user fees. From this arisesthe question: Public health to serve the poor, or thepoor to serve public health?● Furthermore, the imperialistic processes of globalizationhave disrupted people’s living styles concerningnourishment, recreation, and interpersonal relations.Thisprocess has strengthened individualism,consumerism, and violence and insecurity in homesand in the streets. This situates us as a country withhigh rates of illness, violence, and death by preventablecauses. Thus the State and society in generalshould acknowledge health as a human right, a rightwhich must prevail and be prioritized, implementingpolicies, plans and programs adequately and sufficientlyfinanced.● Concurrently, this situation has created the presenceof pathologies of development, such as diabetes,cerebrovascular illnesses, traffic accidents, traumasby violence, mental disturbances (stress and depression).Thishas lead to a mixed epidemiological profile,which will doubly require integral actions to beeradicated.238

Observatorio Latinoamericano de Salud.●Violence effected against nature by transnational corporations,timber dealer companies, shrimp dealercompanies, African palm companies, and the excessivetotal number of cars, has deteriorated extensiveterritorial areas, undermining our ecological potential.● The World Trade Organization (WTO), as an instrumentof imperialism and specifically at the service ofthe interests of North-American large transnationalcorporations, dictates policies to implement theArea of Free Trade of the Americas (ALCA). As acomponent of the agreements, the incorporation ofhealth provision as merchandise to be supplied anddemanded in conditions of total inequity has beeninstituted.An element of this strategy is the reformin the health sector executed with loans of theWorld Bank (raising the amount of external debt),which has not aided in satisfying our needs and aspirations.In effect it has contributed to the declineof health and to the conversion of institutions intorigid companies directed by managers, extractingsurplus value from workers and people’s illnesses.● Decentralization in the area of health has turned intoa process of transference of obligations to localorganizations without the resources necessary, violatingsocial participation and the principles of solidarityand equity, with which the State plans to takeno part in its responsibility which was establishedin Article 42 of the Political Constitution: "The Stateguarantees the right to health, its promotion andprotection, by way of the development of nourishingsecurity, and the provision of potable water and basicsanitation, the fostering of healthy environmentswithin families, at work, and in the community, andthe possibility of permanent access to health services,consistent with the principles of equity, universality,solidarity, quality and efficiency". What currentgovernments have accomplished thus far is the implementationof low-cost superficial measures thatseek a cosmetic effect on the health marks of a marginalizedpopulation, and a demagogic attitude withregard to human suffering.● After a decade of application of the "Reform in theHealth Sector", the sanitary crisis within the countryhas become serious, corruption in the managementof funds through MODERSA has implicatedeven Secretaries, and public hospitals do not countupon the minimum necessary to activate care andothers are sustained by the users’ money who becomeindebted or sell their minor belongings. In addition,professionals, workers, and employees of theDepartment of Public Health constantly cease activities,since their wages are not paid on time.TOWARDS A NEW HEALTH CONCEPTAND PRACTICE● In the struggle for health and life, it is essential tosubstitute the biological individualistic curative paradigm,which overemphasizes the role of hospitals andmedicines and underestimates the importance ofpreventive measures that change the working and livingconditions. . According to us, HEALTH IS A HU-MAN RIGHT, and thus it must prevail over economicissues. It is the result of people’s living standards inclose relation with nature, their working forms andconsumption. Thus, actions to be performed shouldbe integral, as much at the socioeconomic level asthe cultural and political ones, involving diverseagents.● To strengthen Health Promotion, we need to beginwith new concepts, strategies and methods, makingthe most of the existing best potentialities within239

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAour peoples to fortify and develop a social movementthat seeks greater health and living standard inour diverse groups and their territories.● Consequently, operating jointly and gathering diversesectors to achieve multiple actions makes HealthPromotion the feature of specific policy, inasmuch asit contains aspirations that imply deep transformationsof environments, individuals and groups, tochange negative conditions toward their human andappropriate development.● The Ottawa Letter signed in 1986 by 38 countries inthe International Conference of Canada indicatesthat, "Health Promotion consists in providing peoplewith the required resources to improve their healthand to exercise a major control over it." This meansthat people are the only ones who can transformtheir reality and make decisions about it.Therefore,health, politics, and power relations must be presentwithin our movement, as much to demand from theState as to exercise our right and responsibilities inthe management of health and life.● It is not a question of merely obtaining a budget increasefor the health sector, but a Public Health basedon health determinants must be concretized.There must be legitimate social space to assume thechallenge of change, from "an agenda centered in theconsumption of medical care services, towards thesocial production of health, with democracy and participation".This denotes we must operate to promotestructural transformations that modify thephysical, social, cultural, and political environmentsthat influence the determinants of living conditionsand health, as well as the individual environments. .● Accordingly, our proposal of proper health and life forour people is supported om the principles of solidarity,equity, justice, dignity, social participation, anduniversality; by the distribution of wealth through social,economic, cultural and health policies, by the guidanceand adherence to human rights, and by preservationof and respect towards environment. Wemust seek alliances, commitments, actions, projects,and platforms, with all the peoples and social agents,which are identified with the struggle and work for ahealthy country, wherein people enjoy life.We are the ones who are dissatisfied with thecircumstances in which we live, and especially with thecrisis of the sanitary system of the country.Thus, we,men and women of all ages and peoples of Ecuadorunder the National Front for the Health of EcuadorianPeoples (FNSPE), with the purpose of unifying all theagents of the health sector and society as a whole,must merge our forces to create a new world, and afree Ecuador that is sovereign and progressive. Wemust pursue being an example of democratic and participativepractice, which convenes governments toorient health policies away from the impositions of theInternational Monetary Fund, the World Bank, and otherinternational agencies encouraged by the interestsof large capitals and profit. This entails the devisal ofsovereign, independent, democratic policies, whereinthe axis is human beings that are active and participatory,not as objects of make-up programs that concealtheir actual nature.STRUGGLE PLATFORM OFTHE NATIONAL FRONT FORTHE HEALTH OFECUADORIAN PEOPLES● To guarantee the universal access to Integral HealthCare of good quality, according to the needs of thepopulation and not its payment capacity.240

Observatorio Latinoamericano de Salud.● To develop and sustain the Promotion of Health,strengthening communitarian organization and participation,inter-sectorial work, multidisciplinaryand interdisciplinary fields in health and their problems.●To struggle for economic policies that are focused onthe promotion of health, equity, gender equality, andthe protection of the environment.● To foster the elimination of criterions of cost-effectivenessas determinants of implementing healthprograms and abolishing cost-recovering projects,since they are producers of inequities and barriersto the access of services.● To curb the process of privatization of public healthservices and social security, ensuring an effectiveregulation of the private medical sector, includingcharitable medical services and others fromNGO’s.● To promote and uphold participatory health programsoriented towards women, the eradication ofintra-family violence, and the fulfillment of the Lawof Gratuitous Maternity and Infant Care.● To establish promotion and prevention programs ofhealth for young people, with emphasis on sexualand reproductive health.● To provide health care to major adults and incapacitatedpeople.● To adopt measures to guarantee health and occupationalsecurity, which comprise the monitoring ofworking conditions focused on workers, prioritizingpeople in greater risk (for instance, those who workin floriculture, assembly plants and the informal sector).● To regulate the use of technology, production, andthe sales of medicines that subordinate the needs ofthe population. To develop a national industry ofmedicine production.● To direct health research, including genetics and thedevelopment of reproductive medicines and technologies,to people and public health, respecting universalethical principles.● To defend harmony with the environment, and theprotection of ecosystems and our biodiversity.● To connect the National Health System with TraditionalMedicine and Alternative Medicines, respectingthe biodiversity and multicultural aspects of ourpeoples.● To pay the social debt by investing in health and education,primarily through reducing military expensesand the payment of external debt.● To guarantee nourishing security and the equitableaccess to foods, executing agricultural policies leadingto the satisfaction of the needs of the population,and not to the exigencies of the market.241

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA26Self Determined Peoples´ Proposals:On Local KnowledgeJulio MonsalvoNeoliberal Globalization Endeavors to Homogenize CulturesPeruvian peasant leader, Hugo Blanco, making reference to the globalizationphenomenon, affirmed during the World Social Forum 2002: "Theywant us all to drink Coca-Cola and all our children to have fun with Pockemon1 ".Feeling and thinking are neutralized by homogenizing cultures. Originalthoughts are changed from the proper values of each culture.The sought aftereffect is for all of us to have the same consumption models.Economic groups have concentrated in a small number of hands powerfulmeans of social communication.These modes of communication imposeimages of "models of beauty, of success, of prestige, and of progress" accordingto the conceptions of neoliberal consumerism.[ Ramonet, 2005]Likewise, formal education is not alien to this project. We have only toexamine the educational contents and methodologies in the majority of universitiesto realize they are functioning in the preparation of technicians andprofessionals with this logic.1. It is not a question of teaching peasants how to manage themselves, they already know! Fujimori passedlaws strengthening individual property. Peasants struggle for an agrarian reform. They struggle against thecontamination of rivers and lands. They march and block roads. The indigenous struggle undertaken in Peruis part of the indigenous struggle in other localities of the continent. It is not surprising that, in view of theattempt of homogenization of neoliberalism (they want us all to drink coca cola and all our children to havefun with Pokemon), the cultures more distant to this homogenization, the indigenous, are the ones to reactagainst it. We were optimistic at the time we left this Forum, thinking our work in favor of a different worldwould thrive. (Hugo Blanco at the Board of Testimonies, in conjunction with Rigoberta Menchú, Monday4/2/02 at the World Social Forum in Porto Alegre, Brazil)242

Observatorio Latinoamericano de Salud.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 andcontinuing into the twenty-first century , the resistancemovements world-wide become empowered andstrengthened: the proposals that emerge from theChiapas uprising, in Mexico; the anti globalization manifestationsin Seattle, Nice, Prague, among others; thecreation of coalitions, such as ATTAC, Jubileo 2000; theI World Assembly of Peoples’ Health in Bangladesh,2000; the World Women’s March; the War of Water inCochabamba; the World Social Forums; and the numerouslocal, 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 identitythrough defending cultural values. These culturessupport diverse social paradigms that teach us otherways of looking at and situating ourselves within theworld.With different characteristics, these resistancemovements are also developed daily in local settings.Resistance of Local CommunitiesHaving disposed ourselves to an attitude of interculturaldialogue, we have begun to identify processesof popular self-organization in the South Cone ofour "Abya Yala" 2 , especially in Creole peasant communitiesand of Originating Peoples.These purport to undertake integral health careby means of self-managerial forms of practice, startingmainly from local knowledge.In the viewpoint of these communities, integralhealth refers to the health of land, plants, animals, andpeople, as an interrelated whole.These processes of active resistance become visibleand are shared within diverse and multiple meetings.We will refer, in particular, to the annual meetingsdesignated as "Laicrimpo Salud" 3 ."Laicrimpos" Meetings for Peoples´ HealthIn 1990, a group of twenty-six nuns, who wereactive in the movement Religious Communities Insertedin the Popular World, became aware of the factthat their work accomplished throughout the Northwestregion of Argentina in large measure was relatedto health care.That same year, they dedicated themselves tospecifically deal with "Sanitary Reality", from the perspectiveof the poorest populations.After that, these meetings have taken place eachyear, customarily during the first weekend of November,under several mottos that lay emphasis on thesense of liberty, non-dependence, and self-managerialorganization.The first meetings were attended by representativesof groups and communities of some provinces ofnorthern Argentina. After only a few years, the presenceof delegations from other regions was alreadyremarked.In addition to the people who were there bytheir own means, was the gradual increase in participationof those who were sent as representatives oftheir communities with the intention of sharing whatthey 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 termwas 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 invaderand conqueror.3. The article "Laicrimpo Salud: Un Movimiento" presents a synthetic historical account of these Meetings. Raíces Magazine, Ns. 30 and 31, Buenos Aires,April 2004.243

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAIn several cases, the same communities attendedto the collecting, in a common form through the "minga"(teamwork), of ways to settle the transportationexpenses.In light of the significant attendance of peoplewho did not belong to any ecclesiastic structure, andtaking into account the suggestion from a nun, thisevent was named "Laicrimpo Salud" (LaicrimpoHealth) ("lai" for "laical").After 1996, health and education workers, aswell as workers of various social promotion institutionsjoined these meetings.Despite having been suggested, the designation of"Laicrimpo" was not substituted for "Meeting of PopularHealth". People from the diverse communitieswould not accept it, in keeping with the idea that "elLaicrimpo ya es nuestro" (the Laicrimpo is alreadyours).During the last years the presence of representativesof neighbor countries Uruguay and Paraguaybecame constant.In Uruguay, after 2003, a similar event is carriedout, "Healthy Fair", which originated with the foundationof the "Informal Network of Popular Health." TheInformal Network of Popular Health makes explicit itspertinence to the World Movement for Peoples’Health.Representatives of other countries, such as Brazil,Ecuador, the United States, and Puerto Rico, addedtheir contributions to the last "Laicrimpos". From thevery first meeting, in 1990, there have been fourteenshared "Laicrimpos". This news, indeed relevant, acquiresa major dimension given the non-existence ofany type of financing, or nongovernmental organizations,foundations, or "organizational commissions"that could have been credited with the formation ofthese meetings. The Laicrimpos continue to be selfmanagedas the expression of an authentic popularmovement.With the purpose of understanding the developmentof these events, we allow ourselves to include asynthesis of the chronicle of the Meetings completedin 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 theEarth summon us! ("Comunicándonos: ¡Las voces dela Tierra nos convocan!")."650 people coming from the Republics of Uruguay, Paraguay,Ecuador and fifteen Argentinean provinces participatedin the meeting. The abundant representation of theOriginating People of Pilagá stands out, as well as the artisticcontribution of the Originating People Toba Qom, bothfrom 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 postersand pictures were displayed, and other eloquent samplesof what has been done locally in support of health.The joy and hunger of sharing, narrating and listening tothe 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 Movementfor Peoples’ Health!In the afternoon, that Friday, we gathered in an amplehall to share welcome songs, the voices of originating peoplesexpressing their feelings and sufferings and narrationsthat reminded us of the history of those events.On Saturday, in an atmosphere of enthusiastic participation,34 workshops were developed simultaneously, inwhich the subsequent subjects were worked at:Plants, Bio-energetics Method, Bio-music, Gemoterapia,Art of Breathing, HealthArt, Domestic Uses of SolarEnergy, Local Policies of Sustainable Development, AgroecologicalOrchard, Micro doses, Mental Heath, Dentaland Oropharyngeal Health,Therapeutic Gymnastics, PilagáCulture, Pilagá Own System of Health, Digiti-puncture,Reflexology, Massages, Holistic Kinesthesiology/Kinesio-244

Observatorio Latinoamericano de Salud.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, AntiqueKnowledge.The sole fact of the enunciation of these themes givesan idea of the integral conception of health, enriched bythe valuable contributions of the originating peoples andpeasant communities.The meeting closed with the traditional "bonfire" Saturdaynight and the following Sunday morning, when the distinctgroups presented their conclusions and the proposalsthat had been elaborated during the workshops.After the commitment to meet the next year in El Dorado,Misiones,Argentina, we enjoyed listening to the voicesof the Young Choir of the Qom People and the contagiousjoy of the Uruguayan delegation, who offered us originalsongs. We said good-bye expressing the jubilation of theMeeting, and with the certainty of having renovated theenthusiasm in being the artisans of this Other PossibleWorld that is already beginning to show."The following table intends to provide a historicaloverview of these meetings.These meetings are annual manifestations ofwhat happens daily within multitudes of microphysicalspaces, as much in remote rural parts as in poor districtsof large cities.ENCUENTROAÑOLEMALUGAR11990Realidad SanitariaPosadas, Misiones21991Plantas MedicinalesAvellaneda, Santa Fe31992Hierbas MedicinalesEldorado, Misiones41993Líneas de Trabajo para un Proyecto de Salud PopularResistencia, Chaco51995Nutrición y Alimentación AlternativaPosadas, Misiones61996Salud en Manos de la ComunidadSan Pedro, Misiones71997Salud en Manos de la ComunidadMontecarlo, Misiones81998Salud en Manos de la ComunidadReconquista, Santa Fe91999Salud en Manos de la ComunidadResistencia, Chaco102000Red de RedesEldorado, Misiones112001Salud en Manos de la ComunidadReconquista, Santa Fe122002Todos Sabemos, no DependemosRosario, Santa Fe132003ComunicándoNOS: ¡Las Voces de la Tierra nos Convocan!Formosa, Formosa142004Integrándonos Hacia la Tierra sin Males.Eldorado, Misiones245

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAAdditionally, numerous local and zonal meetingsare carried out, frequently named "laicrimpos."The Sense of PertinenceWhere are the energies that mobilize so manypeople generated? Which force is it that leads people,families, and very poor communities to sell pastriesand turnovers ingeniously to attain the resources tobe able to travel hundreds and even thousands of kilometersto attend this meeting? What is that guidesyoung 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 themighty sense pertaining to it?It seems that in order to feel this love for life inthe universal mind, protest is insufficient; proposalsmust be added to it and to activism.This is experienced on an annual basis within the"laicrimpos": there are proposals, instances of what isdone by families and shared with their neighbors. It isa question of minority groups working locally in smallspaces, which are at the same time large, for it is demonstratedthrough these spaces that it is possible toaccomplish different things.In these meetings, it is acknowledged that "feware many", many in various parts of the country andthe world.A Proposal from the StateInspired in this quotidian popular featuring, theState of the Province of Formosa activated its Departmentof Human Development to develop a Programof "Communitarian Health" 4 .The Constitution of the Province of Formosa since1991 has recognized health as a right and adoptsthe Strategy of Primary Care of Comprehensive andIntegral Health. This signifies that the constitutionaltext incorporates the premises of the Declaration ofAlma Ata.[OMS, UNICEF, 1978] It is the only Constitutionamong the 24 Jurisdictions forming the ArgentineanRepublic which mentions the Primary Care of IntegralHealth.Throughout history, we have already experiencedtime and again that it is easier to approve a text or adeclaration or a Constitution, than to implement it. Inspite of this, we allow ourselves to share this attemptto put this strategy into operation, at least concerningsome of its aspects, by means of this Program, initiatedin the beginning of 2002.The Program is based on the following strengthideas:a) Community is all of us;b) Integral Health (Health of the Local Ecosystem);c) Addition of knowledge and doings (for the care ofintegral health).Since its launching, the objectives proposed wereas follows:1) Promoting healthy habits throughout the entire population(including the health of health workers andtheir working modes)2) Facilitating, at the local levels, the dialogue "systemof health-community", with the intention that theforms of family and communitarian practice developinto a part of the first level of care3) Encouraging within the system of health the incorporationof different types of knowledge and useful4. 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 theabsence of illness, and a fundamental human right, as much of individuals as of society, contemplating their different cultural models. It will assume the strategy ofprimary care of health, comprehensive and integral, as the fundamental nucleus of the health system, in keeping to the spirit of social justice".246

Observatorio Latinoamericano de Salud.procedures originated in traditional and naturalmedicine for the care of integral health, and integratingpopular knowledge of proven efficacy.As a methodology, the Program is developed infour scopes:1) Field work;2) Scientific activities;3) Educational activities;4) Communication.In this manner, self-managerial knowledge anddoings have been systematized, and absorbed by thefamilies of communities:1) Academic: alarm signs that indicate acute respiratoryproblems; homemade preparation of salts fororal rehydration; therapeutic gymnastics; profit frombeehive products; care of plants; organic cultures;elaboration of phyto-medicines and medicinal soaps;use of microdose.2) Local popular: recognition of plants for health andnutritional; homemade medicines; preparations withplants; nutritious preparations with carob powder.3) Of other medicines: digiti-puncture; massages; distalreflexology.We can share the achievements in these threeyears. Within 7 hospitals and health centers of the interiorof the Province and 5 health centers in the cityof Formosa,including the service providers of their programmaticareas, dispensations with diverse origins innatural and traditional medicine and multiplying workshopshave been accomplished; the latter have been undertakenby schools and neighboring groups as well.Two establishments have created a mini-structureof their own, which credits them the category of"Centers of Local Production".Scientific studies have also been completed, andan interesting activity with nursing students of the NationalUniversity of Formosa and professionals of theGeneral Medicine Residency.Throughout the activities with students of theintermediate level, we consider that one of the mostnotable results has been the approximation of adolescentsand older people of their family and community.The young ones, on investigating natural health careand nourishment, could value the older people’s wisdom.Moreover, they promoted and performed inconjunction to the older people massage practices,therapeutic gymnastics, and digiti-puncture.Experiences such as the ones mentioned aboveare examples of the participation, meeting, and interchangingspaces this program offers, whereby thecommunity gains a patent role.Reflections from the Viewpointof Popular WisdomBenefiting from popular wisdom has presentedus with a form of participation and with an attitudeof openness to dialogue all through these events ofgreat communitarian feeling. It has propelled us toput forward our reflections, questions, discussions,and to dare to effectuate proposals. Subsequently wepoint out some of them:1) A Change in the Cultural and Scientific Paradigm5 : It is a question of shifting from an anthropocentricparadigm imposed by the occidental culture of5. 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 Tramade la Vida,Anagrama, Barcelona, 1996).247

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAmodernity to a bio-centric paradigm focused onHealth and Life.This is what the discourse and form of practice of thepopular sectors described demonstrate.2) The Right to Health: Neoliberalism shamelesslyincorporates the "right to health" to be the "right ofthe consumer" and the "right of the individual consumer",knowing that this "client" is not able to elect tohave medical care, or medicines, or the apparatus, oreven access to the professional to attend to him/her inthe majority of cases.At best, the "right to health" has been reduced to the"right to receive medical care".In contrast, popular sectors "feel" health in an integralmanner, as has been well defined by peasant women ofNorthern Argentina:"If we want to talk about health, the first thing is to seethat the land is alive. If the land is alive, we will havehealthy plants and animals. And it will be possible forus, human beings, to be healthy."This leads us to the acknowledgement that the Rightto Health is greater than the right to receive care forour health problems.We would rather have this care materialize throughthe dispensation of more adequate and culturally acceptedprocedures, starting from knowledge derivedas much from conventional as from traditional, natural,and bioenergetics medicine.At the same time, we aspire that care is furnished witha commitment and a sense of humane warmth, involvedin the feeling and thinking of affected people, familiesand communities. Care, which is essentially a permanentand sustained accompaniment, is paramount.Even having in mind the innate necessity that this rightto receive care conveys, it is by no means the totalityof the Right to Health.The cultural perspective of integral health of peasantcommunities and of Originating Peoples guides us torestate the "Right to Health" as the Right to be and livein good health in a healthy world. It is about theRight to Life and of any form of life, not only humanbeings’ lives.3) Basic Necessities: Integral health, thus understoodas the health of ecosystems, is the convening andgathering topic of all these mobilizations.From this emerges the vision that the Basic Necessitiesfor human beings to live well, individually and collectively,amount to the "six A’s of Hope" ("seis A dela Esperanza"): Air, Shelter and Lodging,Water, Foods,Love, Art ("Aire, Abrigo y Albergue, Agua, Alimentos,Amor,Arte"). If these six components are made availableand allowed to themselves remain healthy in ourlocal ecosystem, we will undergo a state of health perceivedas "Alegremia": joy circulating in our bloodstream.It is a question of a dynamic vision of healthand 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 timeinasmuch as a change in the paradigm of the occidentalculture is achieved. From reductionism, which understandsillness as "a deviation" to this holistic andecosystemic vision of life, health is able to grow strongerand stronger.248

Observatorio Latinoamericano de Salud.4) Bio-centric policies: We support that formulatingpolicies is a major priority, and primarily executingthem centered in life and in any form of life. And werefer to policies regarding everything, not only health.All policies should operate consistent with the principlesof synergy towards concretizing the Right toHealth as a fundamental Human Right and an essentialcomponent of the Right to Life and of any living form,as already indicated. The Right to Health must becomprehended as the right to be and live in a HealthyEcosystem.We propose the formulation and execution of thesepolicies in the context of a participative and direct democracy,which consists in a revolutionary, quotidianand artisan construction of that Other Possible Worldalready beginning to show.We enthusiastically urge everyone to allow a life withinlove and happiness, in a world as portrayed by theDeclaration of Bangladesh 6 :"A world whereby healthy life for everyone is a reality;a world that respects, appreciates and celebratesevery life and every form of diversity; a world that permitsthe flourishing of talents and skills to enrich oneanother; a world in which voices of peoples guide thedecisions that affect our lives".5) Local Development: The interaction with peasantpopular sectors and Originating Peoples demonstratesit is possible and advantageous to impel andpromote development policies of communities focusedon ecosystem health, specifically taking into accountthe health of all its components. To facilitatethis, we suggest a Local Development with self-managerialemphasis, based on the development of solidarityspaces where knowledge and doings are shared, inorder to ensure liberty and surmount dependence.This signifies putting into practice the idea that "We allknow we do not depend" slogan of one of the meetingsof popular health in the South Cone."Health in the hands of the community is a concept ofliberty. Liberty is a value that makes us worthy as people,and dignity is an important component of ourhealth," in the words of peasant men and women duringa Popular Meeting of Health in the North of Argentinain 1997.[INCUPO, 1997]Local Development is founded on the following strategies:● Intercultural Dialogue and Theory and Practice ofPopular Education and Communication● Eco-literacy instruction 7 .●Research with emphasis and qualitative methodologyapplied to Primary Care of Health of theEcosystems● Trans-disciplinary Work 8 .The idea is to develop the self-managerial potentialitiesof families and the organized community, as muchin the personal-familiar scope as within the communitarianand 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 organizationalprinciples of ecological communities and using them to create sustainable human communities". The coincidence with the vision of the peasant leaderFrancisco "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 communityof human beings. There are no problems since within the forest there is no egoism, they are always working one for the other". Boletín Red de Redes,Nro. 9, junio 2004.8. The trans-disciplinary is a qualitative leap in relation to the interdisciplinary: accomplishing an apprehension of the plot of life of ecosystems with holistic vision.Max Neef, Manfred, Desarrollo a Escala Humana, Redes, Uruguay, 1993.249

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA6) Primary Care of Health of Ecosystems: Weput forward the Primary Care of Health of Ecosystemsas the adequate strategy to carry out these biocentricpolicies.It is about an eco-systemic thinking, which allows us tounderstand that people’s health and life is connectedto the health and life of every one of the componentsof the ecosystem: the land, the water, the flora, thefauna, the air, and, of course, the human species itself,with its social, political and economical relations.This thinking and feeling that we are all interrelatedleads us to a logic that compels the focus of policies,strategies and plans to be concentrated in the promotionof health, each time healthier for the enjoymentof life in happiness and love.We believe that it is necessary and indispensable forthe continuity of life that we live in an ecosystem ofharmonious political, social, economical and environmentalrelations. This is possible, since it is the livingstyle the Originating Peoples teach us. They have alwaysfelt themselves a part of Nature, not as neoliberalismoperating against it.The multiple experiences shared in hundreds ofworkshops (for instance, the World Assembly of Peoples’Health, the International Forums in Defense ofHealth, the World Social Forums, and several otherevents to protest and propose) reveal that this dreamis possible.These energies in defense of life, expressed by theOriginating Peoples ceaselessly, that feeling of beingpart-of are the ideas that lead us to a political proposalthat pervades all human activities: Primary Care ofHealth of Ecosystems.We refer to the ecosystem with the vision of the deepestecology, namely human beings with their social,political, and economical relations as another componentof the ecosystem.The Declaration of Bangladesh offers us a real plan ofaction on formulating concrete economical, social, political,environmental, and sanitary challenges.We propose permanent reflection on the problems ofPrimary Ecosystems Health Care; a program to articulatetransversally all governmental and organized communityactivities. Prior to each intervention, we necessarilyhave to ask to ourselves:"With what does this endeavor contribute to the health ofthe local ecosystem?"[Monsalvo, 2004]alta_alegremia@yahoo.com.ar250

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 delos Pobres, Lumen, Buenos Aires● BOLETÍN RED DE REDES (2004) Nro. 9, junio.● CAPRA, FRITJOF (1996). La Trama de la Vida,Anagrama, Barcelona.● INCUPO (1997). Saberes Vivos y Diversos,Taller la Salud Popular,Argentina.● MAX NEEF, MANFRED (1993). Desarrollo a Escala Humana, Redes,Uruguay.● MONSALVO JULIO (2003). Reflexiones sobre Salud Integral, ElMedico, Buenos Aires, enero.● MONSALVO, JULIO (2002). Protestas y Propuestas, Revista Raíces,Buenos Aires, noviembre.● MONSALVO, JULIO (2004). Ponencia en el Taller: Globalización yPolíticas de Salud, III Foro Internacional en Defensa de la Salud delos Pueblos, Mumbai, India, 12-13 de enero.● OMS, UNICEF (1978), La Declaración de Alma Ata,.● RAMONET, IGNACIO (2005). Medios en Crisis, Le Monde Diplomatique,"el Dipló", Buenos Aires, enero.● REVISTA RAÍCES (2004). Nros. 30 y 31, Buenos Aires, abril.251

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA27Work, Health and Self-Management:An Experience of Articulation betweenSelf-Managed Companies and PublicUniversity in ArgentinaJorge Kohen, Germán Canteros, Franco IngrassiaEmergence of Self-Managed Companies in ArgentinaA birth is not a casual fact. The successful auto-managed, communitarians,jointly responsible companies recuperated by the workers are a creativecollective expression in front of unemployment. Little by little they takethe shape of a new productive sector of the country.They are born as a consequence of a multiple and complex process thatconveys the rupture of the circuit signed by illusion, anguish, depression andisolation, 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 theend of the 90’s, the blocking of roads, which set off in Cutral Có and Tratagalgave origin to a new social actor in Argentina, the "piquetero" (street fighter)movement. This new social actor generated a qualitative leap, permitted thereestablishment of the ties of solidarity and the emergence of a new identityand, thus, constituted a sanitary act of first magnitude.This first step was deepened in the opening of the new century andpropelled a further qualitative leap in the struggle and in the development ofthe social movements that resist and confront the neoliberal model: the recuperationof the companies abandoned by the employers and the launchingof the cooperative production. The worker who manages production andhis/her work force by him/herself arrives on the scene.252

Observatorio Latinoamericano de Salud.This is still an open process, subjected to diversetechnical, productive, political, financial and organizationaldifficulties. It is starting from the possibility of collectiveapproach to these obstacles that self-managedcompanies have developed a set of connections withdistinct institutions and national and regional organizations.In this instance, the participation of the publicuniversity reencounters some of its foundational definitionsin the role of the space of production of knowledgeat the service of society and its movements. Humanresources and university forms of knowledge arereoriented and reformulated here, as of the practicalconnection with specific problems that stem from theexperience of productive self-management.The Context in WhichThese Experiences EmergeThe process of globalization of its economy andparticularly the processes of Regional Integration(MERCOSUR, NAFTA), in addition to the role of theInternational organizations as the new regulating anddetermining devices of the policies to be applied andthe importance given to the massive means of communicationand information have played a central role inthe new social, cultural and ideological configuration ofArgentina.Neoliberalism materializes by way of a contradictoryprocess of gestation of hegemony combinedwith coercion. This has had the effect of an increasein the levels of social conflict, which have constitutedthe determinants of the workers’ profiles of health/illness.One of the most dramatic emergent circumstanceshas been the phenomenon of unemployment throughoutall of Latin America. During the first semesterof 2004, the Latin-American average unemploymentreached a 10%, while in an equal period in 2003the number rose to 11.4%, arriving at the highest levelin the last 30 years 1 . Consistent with National Instituteof Surveys and Census data, in the last trimester of2004, levels of unemployment and underemploymentin Argentina hit 13.2% and 15.2%, respectively.The processand magnitude of unemployment and underemploymentcan be observed in Diagram 1, taken fromthe Clarín newspaper [Diario Clarin, 2002]If we include in this the analysis the historicalevolution of poverty and indigence, we will have a moreprecise picture of the process and of the social scenegenerated by the economical policies applied andthe context where the phenomenon of recuperatedcompanies is expressed. During the second semesterof 2003 (last data published by the National Instituteof Surveys and Census), the rate of Poverty reached47.8% and that of indigence 20.5%. It can be inferredfrom these numbers that income insufficiency continuesto be the chief problem of the Argentinean society.Nearly half of the population is below the PovertyLine, and a quarter of it, below the Indigence Line.(DiagramIn present Argentina, more than 18 millionpeople live in a situation of poverty. Among them,close to 8 millions have their existence further compromisedsince they are indigents and thus live in a stateof extreme vulnerability. This vulnerability is manifestedin modes of disaffiliation and social exclusion.This process described quantitatively starts off inArgentina with the coup in 1976 and deepens in the90’s, producing a major restructuring of the socialwork force. The fundamental characteristic of this restructuringis the fragmentation of the work force in atleast three preponderant sectors: stable work, precariouswork and non-work. In line with their localizationin one of these three sectors, workers are force1. Source: Panorama Laboral, OIT. 2004.253

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Observatorio Latinoamericano de Salud.into distinct labor conditions and health problems. Inthe case of the stable work sector, a weakened socialsecurity system, exposure to specific hazardous processes,ergonomic exigencies, increase in the workingrhythm, and work formally prescribed continuouslyout of phase with work actually completed are consequences.In the case of precarious work, the workersexperience lack of social protection, multi-exposure tohazardous processes, generalized exigencies, and theexcessive physical and psychological wear out, triggeredby mobility and intermittence. Finally, in the caseof the non-work sector, workers are submitted to difficultyin the access to the health system, diverse modesof social cultural disaffiliation, and generalized deteriorationof health. Moreover, it is possible to observethe intensification of infant work as a family previoussurvival strategy and, in a number of cases, tomovement towards illegality (Diagram 3).Work and Health: Some Points of Departureto Think AboutIn prior work we have stated that workers’health is decided among the conditions they meet inthe two moments of their vital cycle: ProductionConsumption and Wear out Reproduction.The determining factors of health are developedthrough a set of processes, which acquire a distinctprojection before health, according to the social conditioningfactor of each space and time, namely in linewith the social relations in which they develop. Theseconditions can be the construction of equity, maintenance,and perfection, or, in contrast, they can be elementsof inequity, privation and deterioration.In the same way, society creates processesthat acquire protective and beneficial (healthy) propertiesor destructive and deteriorating (unhealthy) properties.When a process grows to be beneficial, itturns into a propitious aid to defense and support. Intime, it moves in the direction of favoring human life,individual and/or collective, and is a protective or beneficialprocess; conversely, when that process growsto be an element which provokes privation or deteriorationof human life, individual and/or collective, it is adestructive process.A process can correspond to differentdimensions of the social reproduction, and canbecome protective or destructive according to thehistorical conditions in which the corresponding collectivitydevelops [Breilh, 2003]. Nonetheless, it is es-RESTRUCTURING OF THE WORK FORCESTABLE WORKweakened social securityexposure to specific hazardousprocessesergonomic over exigenciesprescribed work out of phasew/completed workPRECARIOUS WORKlack of social protectionmulti-exposure to hazardousprocessesgeneralized over exigenciesNON WORKdifficulties in the accessto the health systeminfant workpsychological deterioration255

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAsential to point out that both types of processes donot exist separately; it is rather the concrete developmentof the processes of social reproduction that makesthe preceding acquire protective or destructivecharacteristics, consistent with the types of mechanismsthey incite in the human genotypes and phenotypesof the group involved.Operability in one or the other sense can have,as well, a permanent character and not be modifieduntil the living style does not undergo a leading transformation,or can have a contingent or yet intermittentcharacter. The processes, in proportion to theirrelevance in the definition of the characteristics of lifeand the weight these have in the corresponding livingstyle, can trigger alterations of major and minor significancein the epidemiological development. For instance,the working process, which has a considerableimpact in the conformation of living style, generallybrings about deep negative changes in health when itacquires destructive characteristics. Opposite this, thatsame working process can incite important protectiveconsequences, even developing under destructive circumstances.This means that a process can simultaneously inciteevents of both types. To illustrate the contradictorycharacter of social life facing health take the followinghypothetical case, where a job, which may bebadly remunerated and possibly completed understressing conditions, physical postural overburden, andchronic exposition to toxic substances (destructive facets),at the same time can contribute to the organizationof time, to learning, to the construction of a meaningof life, to the attainment of a exchange value ofthe work force (protective facets).The facets are more visible in the epidemiologicalprofile depend on the living style and the logic thatoperates in the corresponding social formation. Thereis always that movement of protection / destruction.However, the fact of being expressed in one orother direction of a particular group at a particularmoment depends on the character or logic underwhich the social reproduction operates.Critical processes, in the words of Jaime Breilh[Breilh, 2003], are selected in line with their magnitudeof intervention and their capacity to incite significantand sustainable consequences in the living style.As in every contradiction, the fact that one orthe other pole may not be noticeable or empiricallyobservable does not imply it does not exist, but merelythat, at that specific moment of development, it isattenuated or dominated.Hence, the labor process is neither intrinsicallyand purely beneficial to health, nor exclusively hazardous.Its beneficial aspects and destructive facets coexistand operate in distinct manners in accordancewith the historical moment and its social group ofmembership. In the working centers, subjects facespecific conditions. The capacity to deal with them dependson the capacities and supports they count uponas a collective and the individual conditions of defenseand reserves with which they live.Consequently, when workers accumulate and intensifyin their labor process the destructive modes ofwork, such as forms of shortage and deformation ofconsumption derived from wages, family or culturalalienating patterns, and the absence or weakening oforganization, there is an increase in the power of wearingand prejudicial processes. This consequentlybrings the individuals and collective of workers nearthe illness pole.Opposite this, if working conditions are favorable,workers will follow more closely to the pole ofhealth than that of illness [Kohen, Canteros, 2000].Favorable conditions include the content and organizationof work that permits the development of creativityand freedom, a collective of workers that controland dominate the working rhythm, the establishmentof democratically organized production, and a256

Observatorio Latinoamericano de Salud.remuneration system that allows the access to goodsand services that guarantee the satisfaction of therange of existent human necessities at a precise andconcrete historical moment of society. At both moments,workers meet both protective and healthyprocesses.When workers realize their loss of formal jobs,their life as unemployed takes place in the family settingand consumption and social reproduction shortagesmultiply. In studies carried out in 1994 and 1995,related to labor fieldwork (Faculty of Psychology ofthe National University of Rosario), and in subsequentstudies, we established that, regarding one`s mentalhealth, the unemployed worker moves through the followingcircuit:Illusion – Anguish – DepressionFollowing this circuit generates a series of significantsubjective impacts:● Identity disturbances● Depression● Depreciations● Rupture of liaisons● Collapse of existential projectsIn conjunction with these aspects of the deteriorationof unemployed workers’ mental health, we believethat an expression of the wear suffered and theimprint left by labor conditions is contained in the category"labor remaining capacity". This, we have definedas the confrontation between the remaining skillsof the subject and the exigencies of the productiveprocess (historically and socially constructed) 2 . Whena worker is left unemployed, experiences a labor accidentor is expulsed from the working center on accountof an illness, he/she faces his/her life and establishestheir way of passing through life with the laborremaining capacity.Workers whom are exposed to a series of hazardousprocesses at work and the negative impact ontheir psychic configuration have to undertake restructuringsin the way they transit through life.This is manifestin the set of restrictions to assume a completelabor life and unfold their potentialities.Thus, it followsthat they must assume work from the new "normality"attained, with the freedom permitted by the capacitiesthey still possess.This gains major relevance in two senses. One ispronounced at the time of trying to be reinserted inthe working process. As a first issue, and once he/shehas obtained the job and has finally surpassed the longline of aspirants, the worker is put through the pre-occupationalexam and/or the occupational medical-psychologicaltests and this is where the social difficultiesbecome evident and the labor remaining capacities aresturdily expressed. This test illustrates explicitly howmuch capacity the worker has left and what percentageof incapacity the worker has. A large amount ofworkers are disqualified in this exam, prevented fromacceding to the jobs.Furthermore, the worker transits having restructuredhis/her living style. Namely, all the wear accumulatedat work restructures the worker’s normalityfrom the frame of restrictions. For this reason, weconceptualize the labor remaining capacity as anemergent where the historicity of labor courses remainsimprinted 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 deCiencias Médicas UNR Inédito; Rosario, 2004.257

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINATo Occupy, Resist and Produce:Towardsa Definition of the Self-Managed CompanyThe deepening of the economical crisis and theprocesses of deindustrialization prompted by the systematicapplication of neoliberal policies in Argentinalead to the newest of social phenomena: the recoveringby the workers of nearly 200 bankrupt and abandonedcompanies. The recuperated and self-managedcompanies are the creative expression in front ofunemployment and its devastating effects.The processes of recuperation and self-managementemerged spontaneously in distinct locations ofthe country. Subsequently, they have grouped themselvesaccording to diverse strategies and modes of organization:the National Movement of RecoveredCompanies, the National Federation of Cooperativesof Work in Reconverted Companies, and the NationalCommission of Solidarity with the Occupied Factories.The term self-managed company relates to theundertakings comprised in a model of organization inwhich the articulation and the economical activitiesare combined with property and/or accessibility to capitalgoods and work and with the democratic participationin management of its members. This modelpromotes the cooperation of the collective of workersin the productive and administrative activities.The productive self-management is the extension ofthe principle of participative democracy to the productivedominium. In this sense, it would be insufficientthat workers simply occupied or possessed acompany; it is necessary that they hold the technicaland economical knowledge which would allow themto make it function.Even if it is all about heterogeneous experiences,with different models of organization and distinct levelsof development, it is still possible to recognizecommon features:● The capital integrally distributed among the membersof the organization● Control of the power of decision and the managementof the companies by the workers● The right of workers to vote and be voted for anyposition, inclusively a directing position●The existence of democratic mechanisms of managementand definition in assemblies of issues such as:policies of remuneration, disciplinary, of human resources,forms of organization of production, anddestination of results and surplus● Integral development, which endeavors sustainability,economical equity and social responsibilitySome Characteristics ofSelf-Managed Companies in ArgentinaIn present Argentina, diverse types of self-managedcompanies exist, organized under different juridicalforms: cooperatives, anonymous societies, of limitedresponsibility and other commercial.Towards the end of 2004, more than 300 companieswere registered, which employed approximately32.000 workers, and a significant number were beingdisputed, among others the Gatic company, which employed5.000 workers from several provinces.Consistent with data from the study center VoxPopuli, 86% of the recovered companies are part ofthe industrial sector; 12,3%, of the services sector; and1,7%, of the area of primary production.In relation to the existing capacity of production,48% of the recovered companies are producing a volumethat oscillates between 10% and 29% of their maximumpotential, 36% produce between 30% and 59%of their capacities, and 16%, to 60% or more of theircapacities.258

Observatorio Latinoamericano de Salud.Regarding the levels of employment, the companiesthat retain the same amount of workers and theones that had to reduce their roster are equivalent:each sector represents 40,4% of the totality, while15,8% incorporated new workers starting from thedevelopment of the productive self-management.The two companies of Zanón and Pauny havedistinct models that constitute examples of feasibilityof this alternative mode. The first, located in the ArgentineanPatagonia, has recovered its leadership inthe pottery market and develops an interesting processof cooperation with the "mapuche" communitieswho participate in the elaboration of designs for thenew lines of production.Pauny, alternatively, assumed the position of leadingcompany in the production of tractors. Startingoff with the assignment of reconditioning a single tractor,it rapidly overtook to produce 45 tractors monthlyand, at present, this quantity has increased to 70. Itsworkers earn the wage established in the collectiveagreement of the sector and, moreover, they have alreadydistributed the first profits.From Non-Salaried Work toProductive Self-Management:Some QuestionsThe experiences of recovering and self-managementof companies in Argentina put forward an unheardof problem, one which challenges creativity andthe capacity of innovation of whom are involved.From our focus on specifically health and work, wewould like to propose a set of questions that functionas the motors of our practices of intervention and research.The first has to do with the general orientationof the processes of productive self-management: is itpossible to think of them as processes of fragmentaryre-composition of the industrial model previous toneoliberalism, or is it about the experiences of economicalinnovation that implicate productive dynamics,which transcend neoliberalism?Another question related to the first deals withthe organizational models that collective managementadopts: does the latter produce figures of stable leadershipof traditional nature or does it develop complexmulti-referential processes which, in a context ofconstant change, allow the company to respond in aflexible manner, reshaping its internal organization in linewith the turbulences of its environment?The third question is connected with the processof intellectualization of work that self-managementrequires: which type of devices favors the developmentof collective intelligence and the joint elaborationof strategies?The fourth question is directly linked to the managementof health and the working hazards: doesproductive self-management sponsor the developmentof a model of epidemiological monitoring self-appliedto health and working security, or does it support amodel of delegation of health care, as does the hegemonicmedical model?The fifth question refers to the modes of articulationamid distinct experiences of social economy: isit possible to combine the resolution of quotidian problemsthat every experience of this sort entails withthe constitution of a new strategic temporality inwhich the sharing of inventions locally produced, theimplementation of projects of cooperation among variousproductive units, and the design of policies ofcommon action in relation to the range of governmental,commercial and financial organizations is possible?The sixth question concerns the subjectivityproblem: which devices and by what means and operationsis the subjective figure produced (the self-managedworker or the freelance worker) and capable ofdeveloping the objective production in a recovered259

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAcompany? And, what practices obstruct this productionof subjectivity?The last question touches upon the relationsbetween the productive activity and the work force:to what extent and in what points does the reshapingof production according to the premise of self-managementaffects the processes of reproduction of thework force? How does it affect the family and socialrelations of the workers? What type of implicationsdo these alterations have in the collective processes ofhealth and illness?Incubator of Companies ofCommon Economy: From the Recovering ofCompanies to the Self-Management of Healthand the Security at WorkIn October of 2003, in the city of Rosario, convokedby the National Movement of Recovered Companies,the First National Encounter of RecoveredCompanies had effect. The majority of self-managedcompanies of the country participated in this event.As a conclusion to this encounter, the creationof the Incubator of Companies of Common Economywas resolved in the womb of the National Universityof Rosario. Its goal is to support, give attention to, andresponse to the different demands of the cooperativeworkers, or more specifically, to make production viableand expand it, to improve the insertion in the market,to deepen the processes of self-management anddemocratization of the organization of collectivework.The recovering process of the companies andthe self-management of production constitute a favorableelement to the development of the workers’health. With this view, an interdisciplinary crew composedof more than 30 professionals and coordinatedby the Health and Work Area of the Faculty of MedicalSciences embarked on the accomplishment ofcomplete studies in health and labor security.The intervention method tends to reinforce theprocess initiated by the workers of the recoveredcompanies themselves, who have begun to managetheir own working process.In this mode of self-management, they participatein the planning, organization and development ofthe whole productive process, controlling the timing,the rhythm and the use of the work force. Thus, theproducts are not someone else’s but their own.The methodology that we implement combinesparticipative research techniques, which articulate andconsolidate the knowledge of workers, the medicalpsychologicalevaluations, and the analysis of securityand industrial hygiene engineers.The instruments we apply are the following:● elaboration of occupational-clinical histories of eachworker (clinical exams, audiometries, electrocardiograms,thoracic x-rays, ophthalmology, and completeurine and blood analysis)● completion of instrumental measurements of noises,illumination and discharge to earth of the electricalequipment● analysis of the collective processes related to mentalhealth and organization of work (workshops inhomogeneous and heterogeneous groups, individualsemi-structured interviews, which tend to elaboratelife histories, application of queries, scales and inventories)● elaboration of collective surveys of healthy and hazardousprocesses derived from the distinct elementsof the working process● elaboration of occupational hazards maps260

Observatorio Latinoamericano de Salud.The workshops and group reflection betweenworkers and the interdisciplinary crew have producedpreeminent results of the experience we have undertaken.The technical support of the Faculty of Engineeringhas been an invaluable stimulus and aid to the viabilityand growth of companies.The returning of the results of the studies is anessential component of our Methodology, since it denotesan instance of collective re-appropriation by theworkers. It consists of results on their working andhealth conditions, and establishes the foundations toimplement and sustain a program of EpidemiologicalMonitoring of Health and Security at Work.It is important to underscore also that the methodologyutilized permits the study of the processesof health/illness from a structural, particular and singularperspective, through the diverse levels of analysis.The intervention strategy starts off from the recuperationof the workers’ knowledge. As indicatedclearly by Néstor, a worker from the glassworks CooperativeVITROFIN, more than 70 years old: "I askedthe ‘compañeros’ (colleagues) about what I could do,and they said, ‘to teach, Néstor, to teach, because 50years of experience are not bought in any supermarket’". This process regains the accumulated experienceof the collective of workers and reinserts it in thenew conditions as a strategy of the surmounting of theneoliberal model."This process marks a new model, an anticipatoryform of production. They are factories, which havereborn as the premature, before time, since theyare companies, in the word of the workers that themselvesthat function and are directed by freelance workers.And they have been born before time becausethey represent a form of production, which anticipatesthe substitution of the dominant capitalist model ofproduction. And that is the fundamental nature of whywe have to care for that incubator, born in the FirstNational Encounter of Recovered Companies. The futureof 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 Emancipadorae Interculturalidad. , Lugar Editorial, Buenos Aires. Febrero,p. 208- 209.● Concepto desarrollado por Jorge Kohen y Mariano Musi en Reflexionessobre Salud y Trabajo en la Carrera de Especializaciónen Medicina del Trabajo Facultad de Ciencias Médicas UNR Inédito;Rosario, 2004● DIARIO CLARIN (2002). Bs.As,Argentina.● DIARIO CLARÍN (2002). Bs.As.,Argentina, Diciembre.● KOHEN J., Canteros G (2000). La Salud y el Trabajo de los Judiciales;Raymur Ediciones, Rosario.● KOHEN J (2003). Discurso Clausura 1er. Encuentro Nacional EmpresasRecuperadas; Rosario Argentina, Octubre.● OIT (2004). Panorama Laboral.261

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA28Sports andHuman EmancipationPaulo Ricardo do Canto Capela, Edgard Matiello JúniorPresentationIn the Brazilian context, the field of knowledge known as Physical Educationhas been a privileged space to reflect and act upon the worldwidemercantilist appropriation of the sports phenomenon.Although idealized visions of sports predominate within our country -which unconditionally associate them with health and living quality; with aestheticalbeauty of "perfect" bodies; with an alternative to drugs in the treatmentof certain diseases; with criminal rehabilitation; or even as an integrativeelement of nations; in fact, they ought to be examined under a differentperspective.Theoretical and practical experiences undermine those simplisticidealized conceptions. The knowledge and historical experience aroundthe practice of sports have come about through tortuous ways of consensusand conflict; however, a collective resistance against the commercialization ofsports 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 initiativetowards a peoples’ alternative project of health and sports practice, is to statesome crucial reflections, which lead to a different perspective about therole 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, places262

Observatorio Latinoamericano de Salud.and contexts, with varying degrees of criticism, not alwaysimplying a definitive rupture with powers institutedin scientific societies, governmental organizations,and other academic and professional spaces.In this sense, the 1980s were paradigmatic. It wasa moment of great intellectual enthusiasm and mobilization,in which a critical mass of social debate existedthat started to question hegemonic practices and promoteda community driven project with the intentionof transforming authoritarian, unfair and inequablestructures that modeled our society. It was expressedthat a Physical Education project would require combatingliberal-bourgeois ideology and conservatism[Guiraldelli Júnior, 1991].The purpose was to find richformulas capable of mobilizing corporal work and movement,and to face the contradictions within the system.Thereference was the concrete human being, embeddedin its social context, and at the same time themotor and the victim of the current social and productivesystem.Derived from this intense and wide-ranging politicalprocess, three distinct movements emerged. Thefirst with the commitment to present Brazilian societywith more appropriate educational alternatives, representingan emerging trend of physical education studies,based on a dialectic conception of physical movement.Theaim has been to improve the existing theoreticalbackground about this field of human activity.On the other hand, there were also teachers, who inspite of their ideals about renewing this field of healthwere less rigorous in their propositions.A third trendcorresponds to professionals that favor dominant conceptionsand work for the commoditization of sports[Coletivo de Autores, 2001]. It is worth mentioning afourth tendency, which reveals a lack of understandingof the historic role of physical education linked to politicalawareness and lend themselves ingenuously toreinforce the application of conservative dominationinstruments [Freire, 1992].Concisely, Brazilian Physical Education sustainedby a new theoretical-methodological framework, rootedin critical readings of education and society, hasprovoked noticeable changes in the understanding ofsports in recent years. Of all better known contributions,those corresponding to the commitments of thepublic school system are the ones more significant tothe Peoples’ World Health Assembly.From our perspective, aside from the importantquestions that can be directed toward public schools,they still hold potential for the democratization ofknowledge and the socialization of new approaches tophysical education activities -among them sports- andother expressions of corporal culture. If properly conducted,physical education in school would renew itspublic and communitarian essence by ensuring qualityapproaches, which have been referenced historically,that link to the aspirations and numerous, complexand urgent needs of the working class.Thus, it is about a change of direction, whichconcurrently conveys a sense of change, demandingthat the school be thought of as a cultural transformationpole [Arenhart; Capela; Matiello Júnior et al.,2003], which expands its educational action beyond itsclassroom walls, allowing the construction of a sportsproject that radicalizes its proceedings in defense andgeneration of life and human liberation [Freire, 1970].A Critique of Sports from aLiberating PerspectiveSports, being one of the most fascinating humanexpressions, unfortunately, has been strangled by thetentacles of greedy entrepreneurs and corporations,and has been shaped by the logic of the InternationalOlympic Movement through mass media into the dominatingelement of Physical Education, especially inschools. To have an idea of the magnitude of this in-263

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAfluence, several professionals understand the disciplineof Physical Education as synonymous to sports, depreciatingthe opportunity to include any other kind ofhuman physical movement and activity and/or popularculture.Without overstating, this signifies a compromiseof integral education of human beings in an entiregeneration!Despite numerous advancements concerning pedagogicalpropositions for the innovation of sports invarious fields of professional activity, we have observedthat this new knowledge is still scantily disseminated,and consequently its not rooted, therefore favoring alimited conventional conception of sports. Gramsciand other thinkers believe that when sports in schoolare interpreted as a mere technical process, reproducinghigh-level-performance movement patterns (astheir codes, values, and ahistoric character), they canimpede, from the viewpoint of the dispossessed, theconstruction of a national-peoples program, Hence, toestablish this dialogue among our allies in Latin Americaand the World, we stress our critical position alongsidepredominant academic standpoints. Our renewedvision and discourse have already reached various importantworld and Brazilian Public Health forums.Wewill operate as Physical Education teachers who identifywith a concept that challenges the following realities:that sports operate predominantly as a symbolicexpression of capitalist values: the form of practice andspectacle of workers subject to "Spartan" and inhumaneworkdays; and the audience, who are submitted toan alienated approach that converts life into a spectacleby passive consumers of sports [Pires, 2002].Pedagogic Possibilities in the Teaching ofSports for Human LiberationThe capitalist mode of production has provokednegative transformations in schools, converting theminto social spaces where competition becomes compulsoryin all spheres of human life.Thus, games, whichhave been historically linked to leisure, fun, and thecelebration of life within several cultural contexts,now have turned into modern sports with predeterminedrules and pressure to surmount limits; playingmates having to be treated as adversaries; in brief, thelogic of playing with changes to the logic of playingagainst.From the perspective of Physical Education forhuman 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 currentlyassumes in education for consumption, the sportsproblematic may be understood as a media-createdphenomena of the "spectacle society" in which we live.Sports, considered as a corporal and movementexperience, may be approached from an attitude ofinclusion. From this standpoint the construction/reconstructionof sports content can be created jointlywith those people engaged in the development of rules,techniques, and tactics.This approach would transcendthe logic of exacerbated competition and facilitatethe recovery of the ludic and party nature of thesecultural forms of practice.As teachers, we realize that changing the practiceof sports is not an easy task, since it often impliesconfronting false and legitimate expectations fashionedby the cultural industry throughout the decades.In the construction of sports experiences, fromthe position of human liberation, competition, physicalconditioning exigency, technique and tactic teachingdo not disappear, however they are re-signified. Competitionis modified to not the obligatory anymore,but the necessary to be established with the subjectsin order that all can play [Kunz, 1996].264

Observatorio Latinoamericano de Salud.Physical conditioning will not be acquired anymoreby the present logic that subjects sports workersto the wearing processes of "working burden",imposing on them a high level of sacrifice and pain,starting from training planning prior to playing.As partof the teaching proposal, physical conditioning will beacquired in the playing-the-game experience itself andby being involved in the construction of cultural experiences.Technique does not possess a single definition; ithas served through the history of civilization as oneof humanity’s emancipating elements. Nevertheless,in modern sports the technical issue adopts restrictedmeanings: repetition, homogenization, specialization,and reproduction, taking into account maximumperformanceobjectives. Technique should be aimedtoward facilitating participants to experiment withnumerous possibilities in order to open multiple culturalexperiences 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). Thetalented may be oriented and stimulated to cooperatewith and be tolerant of those who have not yetachieved the same capacity within the game.Notes for a Project ofHuman Liberation through SportsThus far, we can assert that sports, as a hegemonicpractice modeled by the International OlympicMovement, are part of the expansion process of occidentalcapitalist modernity. It is rich businessmen/womenwho lead this Movement; this space has neverbeen open to the working class.Accordingly, this organizationis a large diffuser of the world-views of thosewho conduct and confer its corresponding moral andintellectual direction [GEIA, 2002].In order to believe that another world is possible,a propos sports practice in favor of the celebrationof life among peoples, and an inversion of prioritieswithin a capitalistic context, is mandatory. If wereview history, we will verify that an internationalworking organization already existed and accomplishedthree significant Olympic events, which werefounded on principles of class solidarity, which nonethelessdid not resist the postwar [GEIA, 2002]. Wethink we will be able to recover this idea and constructan International Cooperative Olympic Movementin the future.To conclude, we indicate a number of assumptionswith the intention of jointly developing the elementsof this proposal, starting from the potentiallydemocratic space of the public school. These are reflectionsinitially stimulated by the historic contributionof a German researcher who lived among us[Dieckert, 1984].● Sports may not be a mere adaptation to the InternationalOlympic Movement phenomenon. Didactictransformations are indispensable, which aim at newanthropologic, philosophic and scientific conceptions,with the goal of creating a new socialist project;● Sports are not limited to competition among excellentathletes; hence, it may be performed independentlyof genuine norms and rules of competitivesports; it may not be narrowly thought of as a masculinefield of practice with elitist values;● Theory and practice may configure studies and educationprocess for Physical Education teachers; it isnecessary to surmount the excessive education ofteachers toward high-level-performance sports,which educates more specialists in Olympic modalities,rather than actually teachers.265

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA● Schools can turn out to be important centers of disseminationof human liberation sports. To achievethis, they need to be transformed into spaces thatfoster these experiences, which do not require expensiveequipment and facilities. It is perfectly feasibleto perform high-quality and more stimulating humanliberation sports with simple and economicalequipment;● Following this logic, we consider that school spacesand equipment can constitute what we have announced,Movement Popular Culture Centers, availableto and co-produced by local communities.Finally, we underscore that the present paperaims more at the socialization of our experiences withcomrades who struggle in defense of life and humanfreedom, than the presentation of a finished proposal.Our reflections are derived from the educational legacyof Paulo Freire, a Brazilian whose vigorous worksof revolutionary dreams never had the pretense ofbeing completed.266

Observatorio Latinoamericano de Salud.REFERENCES● ARENHART, D.; CAPELA, P. R. C.; MATIELLO JUNIOR, E. et al(2003).A Prática de Ensino de Educação Física em escolas de assentamentosdo MST. In: I Pré-Conbrace Sul, 2003, Pato Branco,PR: Secretarias Estaduais do CBCE - PR-SC-RS & Fadep, CD-ROM.● BRACHT,VALTER (1992). Educação física e aprendizagem social.Porto Alegre: Magister.● COLETIVO DE AUTORES (1992). Metodologia do ensino deeducação física. São Paulo: Cortez.● COLETIVO DE AUTORES (2001). Carta de Carpina. Revista Brasileirade Ciências do Esporte, v.23, n.1, p.33-40, set.● DIECKERT, JÜRGEN (1984). O esporte de lazer: tarefa e chancepara todos. Rio de Janeiro:Ao Livro Técnico.● FREIRE, PAULO (1970).Hearder and Hearder.Pedagogy of the opressed. New York:● FREIRE, PAULO (1992). A importância do ato de ler: três artigosque se completam. São Paulo:Autores Associados.●GEIA (2004). Um outro mundo é possível. Disponível em:.Acesso em: 24 dez..● GUIRALDELLI JÚNIOR, PAULO (1991). Educação física progressista:a pedagogia crítico-social dos conteúdos e a educação físicabrasileira. São Paulo: Loyola.● HILDEBRANDT, REINER; LAGING, RALF (1986). Concepção deensino aberto em educação física. Rio de Janeiro:Ao Livro Técnico.● KUNZ, ELENOR (1994).Transformações didático-pedagógicas doesporte. Ijuí: Unijuí.● KUNZ, ELENOR (1996). O esporte na perspectiva do rendimento.In: GTA - GRUPO DE ESTUDOS AMPLIADOS DE EDUCA-ÇÃO FÍSICA. Diretrizes curriculares para a educação física noensino fundamental e na educação infantil da Rede Municipal deFlorianópolis, SC. Florianópolis: o Grupo, p.95-104.● PIRES, GIOVANI DE LORENZI (2002). Educação física e o discursomidiático: abordagem crítico-emancipatória. Ijuí: Unijuí.267

Authors byChapters

Observatorio Latinoamericano de Salud.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 circulatedwithin research organizations and Master’s programs worldwide; leads research and intervention projects criticalof neoliberal model; member of the editorial council of various magazines; Mater’s degree visiting professorat 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 ImplementationAnalysis of Public Policies, Civic Culture, Associativism, and Social Participation; in 1977, joined the FIO-CRUZ (Oswaldo Cruz Foundation), Health Department, Brazil; currently, regular researcher at the PublicHealth National School of the FIOCRUZ; has published numerous writings.3. Gerardo Merino, Ecuadorian, member of the Ecumenical Commission of Human Rights (CEDHU), has developedmultiple projects in the field of human rights and health. The present paper was realized with HugoNoboa Cruz’s collaboration, also collaborator at the mentioned organization, which is one of the organizationsgreatly fostering the defense of human rights in the region.4. Adolfo Maldonado, Spanish, medical doctor, tropical medicine specialist. Since 1987, he has worked in HealthPrimary Care for indigenous and peasant communities of Mexico, Guatemala and Ecuador. Since 2000, as amember of "Acción Ecológica" (Ecological Action), he has researched the impacts of petroleum activity on thehealth of population near these installations in Ecuadorian Northeast, and has studied the impacts of the PlanColombia 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 ofSocial Medicine and the subject of Violence and Health, about which he has published a number of books and269

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAmultiple articles. He has been visiting professor and researcher within Latin America and Europe; regional andnational adviser of the OPS (Pan-American Health Organization),ACNUR; member of the Colombian NationalMovement for Health and Security; currently, Coordinator of the Public Health Interfaculty Doctorate atthe National University of Colombia.6. Mariano Noriega, Mexican, doctor, Master of Social Medicine, professor of the Master’s degree in Sciencesin Workers’ Health program of the Autonomous Metropolitan University, Unity of Xochimilco, his main researchline 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 SocialMedicine, 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". agronomer7. Francisco Hidalgo, Ecuadorian, sociologist, Master of Social Sciences, researcher of the CEAS (Health Studiesand 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. Maríade 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, researchassistant. 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, genderin floriculture research. Alexis Handal, North American, PhD candidate in Epidemiology, University ofMichigan, pesticide and child development research. Paola Maldonado, Ecuadorian, geographer (engineer),researcher of EcoCiencia, Jorgelina Ferrero y Stella Morel,Argentineans, Master in Social Work Programstudents (University of Córdova), interns of EcoHealth Research Program (CEAS).8. Walter Varillas, Peruvian, sociologist, Master of Political Sciences; executive director of the Health,Work andEnvironment 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) 2002-2003.9. 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

Observatorio Latinoamericano de Salud.10. Miguel Eduardo Cárdenas, Colombian, Doctor of Law, scientific adviser of the Fridrich Ebert Stiftung inColombia (FESCOL); has published important writings on the social and social rights situation in Colombiaand Latin America. Luz Helena Sánchez, Colombian, doctor, Master of Public Health, researcher of the ColombianAssociation for Health (ASSALUD). Martha Bernal, Colombian, economist, researcher of the SchoolStudies Center for Development (CESDE).11. Group of Mothers from Córdoba, Argentinean, it is composed of the majority of mothers whose childrensuffer leukemia, malformations and cancer, due to radioactive contaminants present in their district; onlytwo of them are supposedly healthy. Sofía initiated the Group more than two years ago. Previously, it wasmade 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 PublicHealth (Escola Nacional de Saúde Pública/Fundação Oswaldo Cruz, 1997). His research field is the impactof 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, biologistgraduated 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 researcherat the Fundação Oswaldo Cruz and Fellow Researcher of the Mount Sinai School of Medicine and FogartyInternational Center/NIH. Josino Costa Moreira, Brazilian, has a BSc in Pharmacy (Universidade Federal deJuiz de Fora, 1967) and PhD in Analytical Chemistry (Loughborough University, 1991). Technologist of theFundação 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) andDSc in Economy (Université de Paris VIII, 1988). Professor of Agrarian Economy at the Institute of IndustrialEconomy of the Universidade Federal do Rio de Janeiro.13. Alex Zapatta, Ecuadorian, lawyer, specialist in legal water regulation and agrarian political economy, researcherof the CEAS (Health Studies and Advisement Center) and the Agrarian Research National System, coordinatorof the juridical area of the Hydrologic Resources National Forum of Ecuador, coauthor of books onthe agrarian theme and the struggle for democratization of hydrologic resources.14. Catalina Eibenschutz, Mexican, doctor, specialized in endocrinology in Cuba; candidate to PhD in SocialSciences at the Education Institute, University of London. She is founder member of the ALAMES (Latin AmericanAssociation of Social Medicine); professor researcher in Social Medicine at the Autonomous MetropolitanUniversity, Xochimilco, since 1976; has worked in Chiapas closely to the EZLN (Zapatist National LiberationArmy) since 1994. Presently, professor of the Master of Rural Development program, being her researchline 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 "SalvadorZubirán"; founder of the Ecology and Health Training Center for Peasants in Chiapas; director of the Defenseof the Right to Health; member of the IBFAN (International Network pro Infant Nourishment).271

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINA15. Charles L. Briggs, of the United States of America, PhD in anthropology, professor and director of the Iberianand Latin-American Studies Center of the University of California, San Diego; author with Richard Baumanof Voices of Modernity (2003); author of numerous publications in the field of critical anthropology inhealth; at the moment, fosters a fundamental research line on the historical role of communication media facinghegemony in the field of health. Clara Mantini-Briggs,Venezuelan, doctor, coordinator of the NationalPlan of Struggle Against Dengue of the Environmental Direction and Sanitary Inspection of the Health andSocial 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 DeltaAmacuro state (Venezuela).16. Arturo Campaña, Ecuadorian, doctor, ex-professor of medical psychology at the Central University ofEcuador, Master of Social Psychology (University of Leningrad); author of books and publications on conceptualand methodological innovation in the field of mental health; scientific director of the CEAS (Health Studiesand Advisement Center); researcher of the international health certification of the fair and ecological flowerprogram; 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 Departmentof the Resistance to Petroleum Network Oilwatch; coordinator of the Network for a Latin AmericaFree 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. Sheis member of the Scientists Independent Panel concerned with genetic engineering, the Advisement Councilof the magazine "Biodiversity, Supports and Culture", the Political Ecology Magazine, and the Directing Councilof the Tropical Forests World Movement.18. Miguel San Sebastián, (MD, PhD) Spanish, has worked for 12 years in health primary care with indigenouscommunities of the Amazonic region in Ecuador Currently, he teaches public health and epidemiology at thePublic Health International School of Umea, Sweden. Anna-Karin Hurtig, (MD, DrPH), Swedish doctor withten-year experience in health primary care in Sweden, Nepal and Ecuador; at present, teaches public healthand epidemiology at the Public Health International School of Umea, Sweden. Aníbal Tanguila, health promoterof 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 asat the level of the FCUNAE Federation. His community, Corazón del Oriente, has suffered for several yearsthe contamination produced by petroleum exploitation. Santiago Santi has frequently been health promoterof the Sandi Yura Association, and its leader, as well as his community’s and the FCUNAE Federation; hebelongs as well to the ethnic group Naporuna. In his community, El Edén, petroleum is also exploited. TheHealth Promoters Association "Sandi Yura" is an organization of indigenous health promoters of the Amazonicregion 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. Atpresent, it counts with 100 promoters distributed in 70 communities, who provide diverse health primarycare services to a population of 12.000 people.272

Observatorio Latinoamericano de Salud.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 inPublic Policies and Health (PhD), University of Johns Hopkins, EEUUA, 2002. Minister of Health of the BolivarianRepublic 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, HealthSecretary of the Government of the Federal District of Mexico. She was regular professor at the AutonomousMetropolitan University of Mexico from 1976 to 2001; one of the personages of the Latin-AmericanSocial 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 thescenario 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 Sciencesin La Habana. He is professor of merit at the Superior Institute of Medical Sciences of La Habana; researcherof merit at the Science,Technology and Environment Department; Order "Carlos J. Finlay" of the StateCouncil of the Cuban Republic; regular member of the Sciences Academy of Cuba; honor member of the CubanPublic 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 publishednumerous 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; haspublished various studies and books; honor medal at the OPS; Order "Carlos J. Finlay" of the State Councilof the Cuban Republic; Order of merit in Public Health of the Government of Ecuador; awarded annually bythe Sciences Academy of Cuba; Hero of Ecuadorian Health of XXth century; decoration Santa Ana de losRíos of Cuenca. Cándido López Pardo, Master of Public Health, Doctor of Health Sciences; regular professorat the University of La Habana; visiting professor at the Tropical Medicine Institute "Pedro Kourí" andthe National School of Public Health in Cuba; adviser of the OPS/OMS, PNUD and UNFPA; member of theScientific Council of the University of La Habana and the Economy Faculty of the Human Health and WellbeingStudies Center of the high studies center. He has published innumerable books and articles; awardedby 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; Masterof Administration of Health Services; ex-professor of the discipline of Preventive and Social Medicine atthe Medicine Faculty; Councilor of the Departmental Board of Montevideo (1990-1994). Between 1995 and2000, 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 the273

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINACardiovascular Health Honor Commission; epidemiologist adviser of the Interior Medical Federation; Doctorof 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 TransmissibleIllnesses Control of the Public Health Department.23. Mónica Fein,Argentinean, medical doctor, Secretary of Public Health, Municipality of Rosario,Argentina, sheheads the technical group that conducts an ambitious health system reform project that incorporates realcommunity 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 GeneralDirection of Health Services.24. Mario Esteban Hernández, Colombian, doctor, Master and Doctor of History; District Secretary ofHealth in charge. Lucía Azucena Forero, Colombian, public administrator specialized in Social Evaluation ofProjects; Master of Social Sciences; Specialization in the Area of Analysis, Programming and Evaluation of theDistrict Department of Health. Mauricio Torres, Colombian, doctor, public health specialist, adviser in thesubject of Social Participation of the District Department of Health; Coordinator of the Latin-American SocialMedicine Association.25. National Front for the Health of Ecuadorian Peoples (FNSP), organization of confluence of social, popularorganizations, NGO’s, local and national organizations, women and men of Ecuadorian peoples, it constitutesa democratic and participative reference of unity, action and struggle in defense of health as a fundamentalhuman right, which promotes structural transformations of society to reach this objective. It was officiallyformed 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 WorldMovement; works with peasant communities and Originating Peoples, promoting intercultural dialogue andhealth primary care of ecosystems. Presently, he coordinates the Communitarian Health Program from theDepartment of Human Development in Formosa province, which aims at valuing local self-managed knowledgesand forms of practice.27. Jorge Kohen,Argentinean, doctor, researcher of the Independent Research Council at the National Universityof Rosario; Director of the Health and Work Area at the Medical Sciences Faculty of the National Universityof Rosario; career Director of the specialization of occupational medicine (FCM UNR); adjunct professorof the Psychology Faculty. Germán Canteros, Argentinean, psychologist, professor at the MedicalSciences Faculty; member of the Professional Team ASyT of the Medical Sciences Faculty at the National Universityof 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 professorof the School of Psychology, Provincial University of Entre Ríos; member of the Work and Health ProfessionalTeam of the Medical Sciences Faculty at the National University of Rosario.274

Observatorio Latinoamericano de Salud.28. Paulo Capela y Edgard Matiello, Brazilians, researchers in the field of sport sciences, leaders in the transformationof the philosophy of physical education and sports, towards an emancipating form of education andpractice.They are members of the Nucleus of Pedagogical Studies in Physical Education (NEPEF), which congregatesinvestigators of the Federal University of Santa Catarina, with the purpose of developing alternativePhysical 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".275

INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINACataloging information:614.428B835Breilh, Jaime (CEAS Editor)Latin American Health Watch (Alternative Latin American HealthReport).- Jaime Breilh (CEAS Editor).-- Cuenca, Ecuador:Editorial Fernández, 2005.250 p. il. tabs.ISBN-9978-44-258-81. PUBLIC HEALTH 2. HEALTH RIGHTS3. NEOLIBERALISM 4. PEOPLE’S PARTICIPATION5. LATIN AMERICA 2. HEALTH COLLECTIVEI. tTiraje:276