Keys to public health and the protection of life
Alain Basail Rodríguez[1]
I have been fortunate enough to have the friendship of many outstanding healthcare professionals. These past few days I haven't stopped thinking about them, and so these modest lines are a heartfelt and grateful tribute to each and every one of them for their work and teachings. I owe them this for years because they always drew my attention to the importance of public health in shaping society, and vice versa. Therefore, it is my moral obligation to express my gratitude for the wise and generous words of my dear friends Roberto Capote Mir (†), Rosa Margarita Durán García, Alied Bencomo Alerm, Juan Manuel Castro Albarrán, Carolina Tetelboin Henrion, Montserrat Bosch Heras, and Enrique Saforcada. Although what I will try to say here I learned from them, I accept the responsibility of venturing into unfamiliar territory, perhaps even getting myself into a complex situation.
A true epochal shift occurs when we, as individuals, take responsibility and have the opportunity to guide the course of events with some vision of where we are headed. Many of us believe that the current pandemic crisis represents a historical turning point, an epochal change. However, as my colleague and friend Rigoberto Solano Salinas would say, we have doubts about our ability to build upon, and I would add, to give meaning to these changes, given the exception or the perceived void. These are legitimate and human doubts that we must discuss publicly because the responsibility and the cost of the damage caused by natural phenomena and social disasters ultimately fall on the public sphere. To do so, we can turn to old and new paradigmatic ideas that, while offering solace, reconfigure social relations and allow for the emergence of new normalities or social realities. One of the many pieces of this broad and complex horizon of change is public health, or the collective care system that shapes the fabric of life we create for ourselves as a society.
Health, social, cultural, and environmental factors are deeply intertwined. Therefore, examining key aspects of health involves considering social connections, cultural mediations, and environmental conditions. I believe it is time to collectively review a series of epistemological shifts that will allow us to broaden our perspective on current problems or, at least, reframe the questions we ask about the state of public health. This will give rise to alternative answers that have been silenced for years by hegemonic discourses and practices, despite addressing the historical demands of various actors. Before outlining this review, I believe it is necessary to include some analytical insights from Latin American critical thought on health/illness/care/prevention.[2]
The current epidemic crisis has profoundly impacted public health systems, highlighting their limitations and the difficulties they were already facing. The pandemic reveals much more about the origins and structures responsible for what is happening and what could happen if we fail to recognize that we are witnessing changes in animal habitats, and consequently, in viruses, as well as the beginning of new pandemic cycles, and the emergence of forms of chronic illness linked to social determinants, lifestyles, and systems of life. The pandemic has collapsed the social logics that defined health and illness within service systems and healthcare infrastructure. It has exposed the precarious working conditions of healthcare workers. It has been a crisis of a healthcare model, of health services, and of their management, transferring costs to medical personnel, patients, their families, and communities at large. A resounding failure of the policies of the last 20 or 30 years and of the hegemonic conceptions that shaped them.[3] We must warn with all necessary forcefulness in the chronicles of these days about the announcement of the break with those past models.
The crisis in healthcare systems has been no surprise to anyone, though it has caused great concern. Criticism of the incompetence and weakness of public agencies in providing rapid, comprehensive, and effective responses has bordered on a profound institutional delegitimization that conflates the analysis of the social causes of the current situation with public alarm over the dramatic consequences of the lack of adequate resources. This is not about throwing everything overboard, but rather about rethinking the profound vulnerability of institutional structures from other perspectives that broaden and reverse, for example, the hegemony of biomedicine or "the curative care logic linked to a lucrative approach to disease."[4]
It's not so difficult to think things through more carefully and start, first, with the structural conditions of so-called emerging diseases—that is, the socioeconomic aspects. These compel us to consider the tremendous inequality that permeates the social structure, social vulnerability, poverty, malnutrition, hunger, chronic immune system problems, and the appalling social living conditions (problems with access to clean water, unsanitary conditions, overcrowding, pollution) that create favorable conditions for the reproductive cycles of viruses, bacteria, and other pathogenic microorganisms and their spread.
Emerging health problems are linked to living conditions and lifestyles in both urban and rural areas. Examples include diabetes and obesity, chronic kidney disease, mental health issues, violence, teenage pregnancy, accidents, and lung diseases. All of these illnesses are intertwined with the increasing precarity of life resulting from unemployment, labor flexibility and longer working hours, the precariousness of workers, a decline in quality of life, chronic poverty and even destitution, as well as cultural patterns based on excessive, unnecessary, and irresponsible consumption. Furthermore, the deterioration of living and productive conditions in rural areas due to the agribusiness boom in both animal husbandry and extensive agriculture, which intensively use pesticides, water, and destructive and dangerous technologies to increase productivity, further exacerbates these problems. Mining, whose extractive practices have serious consequences for nature, destroying ecosystems and severely impacting habitats and bionatural processes, as well as affecting populations who suffer damage to their skin, eyes, respiratory system, ears, skeletal and nervous systems, gastrointestinal problems, and premature births, and who witness the spread of viruses and new diseases. Not to mention the violence against women and all the social toxicities related to competitiveness, high-performance demands, violence, pressure, emotional blackmail, guilt, gossip, demotivation, fear, negative stimuli, and overwork or overload in work, family, digital, or social environments, which produce detrimental health effects such as stress, anxiety, emotional instability, low self-esteem, moodiness, unhappiness, frustration, distrust, and other social ills.
After briefly examining society's disrespectful pressure on nature, we can now look at society's ominous pressure on itself. Neoliberal policies emphasized competition and deregulation in the markets for the supply and sale of medical goods and services to relieve the state of "obscene social burdens," facilitate "stability," and improve the chances of creating "prosperity." However, these policies have failed and offered little social solace. For example, they emphasized the defunding of public health services, the underfunding of healthcare systems, and the precarization of infrastructure and labor conditions. They modified healthcare models by institutionalizing medical protocols universally. They restricted the scope of social programs to the poor, emphasizing targeted, discriminatory, minimal, and segmented care. They promoted the abandonment of citizen-centered social policy and disregarded universality. They deteriorated the quality of public services. They delegitimized public and social security institutions, made them precarious, and contributed to their loss of identity and social prestige. They fostered the transfer of resources to the private sector through concessions, sales, agreements, transfers, service purchases, tenders, and outsourcing—processes that were not always publicly transparent and used mechanisms that facilitated corrupt practices. All of us who have been ill know about the increased cost of medicines, private healthcare spending, and even the impoverishment of many families. Healthcare is one of the most lucrative businesses through "quality private services," insurance, and the pharmaceutical industry.
What we are experiencing today exposes the processes of healthcare system reshaping under neoliberalism. The dominant conceptions of health, medical services, and care stemmed from viewing the patient as a consumer of services, segmenting the patient/client by assigning a value to individuals, prioritizing the sale of services by profiting from need, and creating precarious working conditions and training healthcare workers according to the prevailing model. The landscape of abuses was shaped by budget cuts, reductions in services and their hours, limited coverage of certain medications, the lack of social security for young people, informal workers, women, and children, the privatization of services that were no longer being provided, and the promotion of various supplemental private insurance plans. Most healthcare reforms in Latin America favored stratification, fragmentation, and privatization of healthcare through packages tailored to different groups.
In short, neoliberal processes damaged comprehensive public systems and degraded the conditions that threaten healthy living. Today we know some things. We know that increasing healthcare spending to cover administrative costs, advertising, and other unnecessary expenses is useless. We know that the idea that private services are the answer to major public health problems is a myth. We are aware that the public-private partnership for resource transfer and the buying and selling of services must be rethought. We have experienced how medicalization itself generates other health problems. We watch in horror as a gigantic market for disease is created, our power to make decisions about our health is expropriated, and our lives are commodified.[5]
After everything we've been through, we shouldn't allow history to repeat itself. We definitely need a new normal in the field of health and illness, a completely new framework for maintaining a healthy society. These new ideas aren't so new; they're the result of years of careful development, alternative approaches, and counter-hegemonic struggles. Now, the need for reform is clearer than ever. If public policies and healthcare models are tied to a social matrix, we must consider what kinds of reforms we seek, what shifts in focus we make. It's become clear that in the midst of this health crisis, fighting to preserve human lives is paramount, but it's not just about the absence of disease, having hospital infrastructure, trained and fairly paid medical and paramedical personnel, medications, vaccines, and supplies. We must also fight to avoid getting sick, considering what collectively destroys us and degrades the health conditions of the entire population, because health, as a complex process of sustaining life, has multiple social and cultural dimensions.
We need to explore how we navigate and inhabit other experiences so that saving lives through disease prevention becomes society's collective priority. For example, some key insights into the necessary shifts in approach involve epistemological changes that move from the imperative to the adaptable, namely:
- From commodification to democratization.
- From individual rights to universal rights.
- From the dualization and parallelism of a public apparatus subordinated to the private, to the synchronization and subordination of the private to the public interest.
- From systems of individualized, insured or judicialized “participation”, to systems of social participation in health.
- From curing disease to preventing disease.
- From curative and care-based medicine that leads to medicalization to overcome crises, to preventive medicine that promotes health extensively in the social and community spheres.
- From the biomedical model focused on isolating individuals from disease, to the biopsychosocial, cultural and spiritual model that starts from the social processes of health and the cultural contextualization of the well-being of people and populations.
- From promoting disease to promoting health.
- From promoting individual self-care to promoting group, family, and community self-care processes.[6]
- From the negative epidemiological approach and vector control that fosters hypochondria, vulnerability and collective fear, to the positive epidemiological approach and promotion of strengtheners of will, defenses and collective values.[7]
- From the fragmented and individual, to the holistic, collective or community-based.
- From public health to community health.
In general, it is about decommodifying by removing public services from commercial circuits that are very lucrative for the pharmaceutical industry with its mechanisms of bribery and corruption of politicians, doctors and scientists to improve profitability.[8] The new approach should aim to guarantee a universal, high-quality, well-funded health system with high-level material and human resources; to recognize the universality of the social right to health and care for diverse health and illness needs under the same conditions; and to ensure equal access to health care for all, as well as the necessary equity to prioritize the most vulnerable and historically discriminated-against population based on class, ethnicity, gender, race, age, illness, or place of origin or residence.
Democratization in the field of health, as in all social fields, implies collective solutions, a deep connection with community-based social organizations that, under a more participatory and post-disciplinary model, integrate diverse perspectives, foster dialogue between multiple disciplinary viewpoints from all sciences, humanities, and arts with local knowledge, and enable collaboration around consensus-based agendas—not mandated ones—with strategic responses grounded in comprehensive health education programs and effective intercultural risk communication. It also requires alliances with well-paid, socially recognized healthcare workers who enjoy suitable working conditions. Even a redesign of epidemiological surveillance systems, moving beyond centralism, top-down approaches, and biostatistics in the age of Big Data, can be complemented by participatory monitoring that, supported by the dynamism of community agency, allows for the development and planning of long-term curative and preventive actions and a "Positive Health Management" approach.[9] It has been shown that verticalism, interventionism, or authoritarian discipline have limits and serious consequences, while the construction of cultural mediations based on collective agreements can allow for intersectoral attention, promote interculturality, and ensure the integration of holistic perspectives on life, as well as the provision of culturally relevant mechanisms to warn of and resolve problems or prevent conflicts in variegated cultural contexts where different cultural matrices coexist.[10]
Life is not a business, and it shouldn't be in a society that prioritizes the protection of all its forms and fights against the degradation of life itself. Capital, risks, fears, and stigmas cannot dictate which lives should be lived above the right to life itself. Knowledge and social organization must provide cultural, economic, and political sustainability to the changes in the paradigms of health and epidemiology. The radical nature of the changes in the culture of health will depend on everyone, but the reconstruction must begin as soon as possible and gradually move toward a public health system that reaffirms, in solidarity, the priority of life over any attempt to hijack, obstruct, or prevent it for economic and political interests. This is a matter of strategy for collective survival, of a new vision of care and social protection of life that is meaningful for all social actors as health agents, regardless of their differences and distinctions.
[1] Representative to the CLACSO Steering Committee for Mexico.
[2] Carolina Tetelboin Henrion and Asa Cristina Laurell (Coords.). For the universal right to health. A Latin American agenda for analysis and struggle. Buenos Aires: CLACSO / UAM, 2015.
[3] Oliva López-Arellano and Edgar C. Jarillo-Soto, “The neoliberal reform of a health system: evidence from the Mexican case.” CSP: Cadernos de Saúde Pública, vol. 33, no.14, 2017, pp. 1-13. doi: 10.1590/0102-311X00087416.
[4] Anabel Pomar, “No to normality: Coronavirus and health. Interview with Jaiem Breilh.” LavacaBuenos Aires, April 20, 2020.https://www.lavaca.org/mu146/no-a-la-normalidad-coronavirus-y-salud/>
[5] Juan Gérvas and Mercedes Pérez-Fernández. The expropriation of healthBarcelona: Lince editions, 2015. Another classic by these authors is Safe and sound (and free from unnecessary medical interventions)Barcelona: Lince editions, 2013.
[6] Eduardo L. Menéndez, “Marginalized and ignored but basic actions: Coronavirus and the self-care process.” ICHAN TECOLOTL. The House of the OwlMay 5, 2020.https://ichan.ciesas.edu.mx/acciones-marginadas-y-ninguneadas-pero-basicas-coronavirus-y-proceso-de-autoatencion/>
[7] Enrique Saforcada and Mariana Moreira Alves, “The Public Disease.” Health & Society, vol. 5, no. 1, 2014, pp. 022-037.
[8] Peter Gøtzsche. Deadly drugs and organized crime: How Big Pharma has corrupted the healthcare systemBarcelona: Lince editions, 2014.
[9] Enrique Saforcada, Martín de Lellis and Schelica Mozobancyk. Psychology and Public Health: New Contributions from the Perspective of the Human FactorBuenos Aires: Paidós, 2010. Enrique Saforcada, Jorge Castellá Sarriera and Jorge Alfaro. Community Health from the perspective of its protagonists: the communityBuenos Aires: Nuevos Tiempos, 2015. Martín de Lellis and Enrique Saforcada. Psychology and public health policiesBuenos Aires: Nuevos Tiempos, 2019.
[10] Enrique Eroza Solana and Mónica Carrasco Gómez, “Interculturality and health: reflections from experience.” LiminaR. Social and Humanistic Studies, vol. 18, no. 1, 2019, pp. 112-128.https://doi.org/10.29043/liminar.v18i1.725>
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