Archive for the 'Latin American Social Medicine' Category
Add a comment July 17th, 2008 by bronxdoc
We have just published Volume 3, Number 2 of Social Medicine. The full table of contents in available on line. Here is some information about the articles:
Earlier this year we invited Asa Cristina Laurell, a prominent Mexican public health activist to prepare a special issue on progressive health reforms in Latin America. Dr. Laurell was the head of the Mexico City Health Department from 2000-2006 and - had the Mexican elections not been stolen by the right - she would currently be Mexico’s Minister of Health. She contributed a paper describing the Health Department’s experience with providing free medicines and medical care to people who did not qualify for coverage under Mexico’s employment-based Social Security System. Other papers examine Brazil’s Unified Health System, the SUS, which is one of the world’s largest public health systems; the Venezuelan attempts to provide free health to the all citizens with assistance from the Cubans; Uruguay’s moves to a public-private system that will guarantee the right to health; and finally Bogota’s experience with providing poor communities with access to health care through the Health at Home program.
American readers may be particularly interested in the article by Razel Remen and Lillian Holloway, two US students studying medicine at the ELAM school in Havana Cuba.
We publish two articles of original research. A Hong Kong team reports on public attitudes during the SARS epidemic in 2003, while Dr. Paula Acevedo presents data on reproductive patterns among Latin American immigrants in Spain.
Sadly, we publish the last article written by Edmundo Granda, one of the founders of ALAMES, the Latin American Social Medicine Association. He passed away in April of this year. He approved the final galleys of the Spanish version of his paper via blackberry from the hospital on the week he died. His paper considers the historical trajectory of ALAMES and where Latin American Social Medicine may be heading.
Finally, Dr. Lanny Smith interviews Chilean activist Victor Toro, a political refugee from Pinochet’s Chile, who is now facing deportation from the US, his home of nearly 2 decades. Ironically, he has been a immigrant rights activist (and patient of Dr. Smith) in the Bronx, New York, for most of these years. His account of becoming ill in an ICE detention facility mirrors the concerns discussed in our July 10th posting about Dr. Homer Venters.
Posted by Matt Anderson
Add a comment May 18th, 2008 by bronxdoc
[This post was originally published in January of 2006]
The Cuban Health System
In early December the editors of the Social Medicine Portal visited Cuba. This month we bring back some notes concerning Cuban health and health care.
Cuba’s health system is unique in the world. Built on a strong foundation in primary care, Cuba provides comprehensive health care to all residents of the island. Given extremely limited resources Cuba has amassed an impressive set of accomplishments in public health. The special position of Cuba is well seen in a graphic international comparison of deaths in children less than five prepared by the Karlolinska Institute.
Most health care is delivered by family physicians. Family doctors are responsible for a defined community and they typically live above (or near) the small consultorios located in the neighborhood they serve. The family physician we visited cared for some 800 people in the five blocks surrounding her consultorio. During the mornings she saw patients in the clinic; in the afternoon she did home visits.
For more complex problems, patients visit one of approximately 400 polyclinics distributed throughout the island. A polyclinic is similar to the outpatient department of a small hospital. Some emergency room functions (including administering Cuban-produced streptokinase) occur here, but primarily this is a place for specialist consultation, diagnostic procedures such as ultrasound and more sophisticated therapeutics (physical therapy, acupuncture).
Consultorios and polyclinics are considered to be primary care in Cuba. In the secondary care tier are the municipal and regional hospitals. Both WHO and PAHO provide health profiles on Cuba that are full of statistics. For a more political portrait, see Aviva Chomsky’s “The Threat of a Good Example: Health and Revolution in Cuba.”
As US clinicians, we are accustomed to the never-ending paperwork associated with figuring out what health services different patients are or are not entitled to; this exists because we have a two-tiered market-driven health care system. It was almost exhilarating to see a system in which such barriers to care did not exist and there was an overall health system. But is it was sobering to realize the enormous burdens under which Cubans work. Food is rationed (in a very thoughtful way), housing is in very short supply (particularly in Havana), many people wear used clothing from overseas and transportation is limited. Adding to these burdens is the embargo imposed by the US government. (see below).
The official Cuban website for health information is Infomed, a sophisticated site full of information. Unfortunately Infomed is available only in Spanish. Infomed provides links to the major Cuban health publications, including the Revista Cubana de Salud Pública. We were fortunate to meet its editor, Dr. Francisco Rojas Ochoa, a 2005 recipient of a PAHO Public Health Award. He shared with us a copy of their recent book “Salud para todos: Si es posible”, an explanation of how Cuba was able to achieve the goals of health for all through the development of a primary care system. English readers may wish to consult the website of MEDICC (Medical Education Cooperation with Cuba, see below) for more detailed information on the Cuban Health System.
Amongst the medical centers we visited was the Instituto Pedro Kourí (IPK) an internationally recognized center for research into tropical diseases. Science recently profiled an IPK researcher, Dra. María C. Guzmán for her work on dengue hemorrhagic fever and the development of a dengue vaccine. IPK hosts an international course on tropical diseases; US citizens, due to the travel embargo, can no longer participate in this course.
International Solidarity
For several decades Cuba has sent physicians throughout the world as a form of solidarity. MEDICC Review now devotes a column towards the activities of these internacionalistas. As we learned during our trip many healthworkers have been sent to Venezuela to participate in that country’s Barrio Adentro health program.
One of the most visible expressions of this international solidarity is the Latin American Medical School or ELAM. ELAM was set up to train generalist physicians with a primary care orientation. It provides scholarships to students from the Americas and Africa; in August of this year some 10,000 students from 27 countries were enrolled in ELAM. MEDICC has published interviews with a number of them. Interestingly enough, there no less than 348 US medical students studying on full scholarship at ELAM. How US students ended up in Cuba is the subject of a fascinating short article by Fitzhugh Mullan in the December 2004 New England Journal of Medicine (“Affirmative Action, Cuban Style”).
Cuba & the US: The bad…
The US government embargo against Cuba has essentially frozen all relationships between the two neighboring countries. There is an extensive literature regarding the negative health impact of this embargo, see for instance “The Impact of the U.S. Embargo on Health Care in Cuba: A Clinician’s Perspective” by Javier H. Campos, MD, or the detailed report on the impact of trade sanctions on Cuba, Haiti and Iraq by Richard Garfield. The gel in Cuba-US relations is fed by the enormous misunderstanding among North Americans of Cuban realities (see Alfredo Prieto González’ “The Image of Cuba in the U.S. Mass Media” and Jane Franklin’s “Looking For Terrorists In Cuba’s Health System”).
And it is not possible to discuss health in Cuba without mentioning the disgraceful conduct of the US military-including medical personnel-at Guantanamo Naval Base located in southwestern Cuba. See “Doctors and Torture” by Robert Jay Lifton as well as “Doctors and Interrogators at Guantanamo Bay” by M. Gregg Bloche and Jonathan H. Marks; both of these articles were published in the New England Journal of Medicine.
Cuba and the US: …and the Good
A non-governmental organization, MEDICC (Medical Education Cooperation with Cuba) was founded in 1997 as a bridge between U.S. and Cuban clinicians, faculty, students and researchers. For many years MEDICC sent US medical students to learn within the Cuban medical system. MEDICC’s activities have been sharply curtailed by the recent tightening of the embargo; educational trips to Cuba are now prohibited. MEDICC is currently concentrating on its excellent online journal MEDICC Review.
Project Infomed, run by the US-Cuba InfoMed Project maintains an excellent page of links to Cuba resources. Medical Students for Cuba, at the University of Michigan Medical School, was set up to provide humanitarian and medical supplies to Cuba.
-Matt Anderson and Lanny Smith
Add a comment May 13th, 2008 by bronxdoc
[This was originally posted in July of 2006]
The 2006 Jonathan Mann Award for Health and Human Rights was given to Juan Manuel Canales, a Mexican physician who has worked in the war zones of rural El Salvador and Chiapas, Mexico. This month the Social Medicine Portal highlights the work of this remarkable doctor who has spent over 25 years working alongside Central American and Mexican peasants and indigenous people in their struggle for a better life.
For Juan Manuel, the regular trip to one of the most isolated communities where he works starts before dawn. It begins with a two-hour ride in the foggy darkness. By the time he reaches the place where he has to start walking, the sun has come out and the fog is gone. The mostly uphill walk through pine forest and coffee fields takes another two hours, much of it on narrow footpaths.
Juan Manuel, supported by Doctors for Global Health (DGH), works with indigenous Mayan communities surrounding Altamirano, a rural community in Chiapas, Mexico, many of which are small and geographically isolated. Most of these farmers are supporters of the Zapatista movement, and consider themselves to be “in resistance.” The main component of his work entails training health promoters from these remote indigenous communities and helping them carry out projects in their villages, such as vaccination campaigns, to address the broad health needs of their communities. He also works with volunteer doctors and public health students to introduce them to Liberation Medicine, a model of rights-based, community development work.
Juan Manuel has devoted his life and career to helping oppressed peasant and indigenous communities demand their right to health care by establishing community medicine and public health programs. His understanding of and commitment to human rights and humanitarian law led to his belief that health care is a right, that the Geneva Conventions should protect civilians’ right to medical treatment in the midst armed conflict, and that a rights-based approach is an important tool for indigenous communities to protect themselves.
Championing this cause took no small amount of courage El Salvador in 1980s, where rightwing death squads roamed freely throughout the country and community-based health care was considered a subversive activity. (The support of the US for repression in El Salvador during the war has been well documented by the National Security Archive.)
Juan Manuel lived and worked in areas of heavy conflict, where the population was continually forced to flee bombings and incursions by the Salvadoran army. The violence eventually caught up with him, leaving him with loss of vision in his left eye and an injury to his leg that resulting in a permanent limp. (See photographs of the war in El Salvador taken by renowned war photographer John Hoagland.)
After the El Salvador civil war ended with the 1992 Peace Accords, Juan Manuel stayed in one of the most devastated communities — Santa Marta. He worked closely with the Pan American Health Organization and other groups to aid returning refugees and establish mental health programs for traumatized communities. It was there that he first began to use community radio as a public health tool. He worked extensively with health promoters and midwives to develop simple radio dramas that were humorous, but effective and engaging to teach about human rights and health.
In 1999 Juan Manuel turned his attention to the politically oppressed but fiercely independent populations of indigenous Mayans in Chiapas, Mexico, who are struggling for self-determination and respect for their human rights. (Read some of the history of this struggle, and stay up to date on the latest developments). There Juan Manuel continues to put into practice his belief in the interconnectedness of health and human rights on a daily basis, helping to construct a basic community health system that respects the needs of the indigenous population without imposing the priorities of outside health professionals.
Juan Manuel was honored at the annual Global Health Council awards banquet on June 1, 2006 in Washington, DC. You can read his powerful acceptance speech on the DGH website.
The Jonathan Mann Award was established in 1999 to honor Dr. Jonathan Mann and highlight the vital link between health and human rights. Sponsored by the Association Francois-Xavier Bagnoud, Doctors of the World, John Snow, Inc. and the Global Health Council, the award is bestowed annually to a leading practitioner in health and human rights.
Despite his untimely death in a 1998 plane crash, Jonathan Mann is considered by many to be one of the most important figures in the 20th century fight against global poverty, illness and social injustice. History will especially remember Dr. Mann for bringing to the world’s attention the basic notion that improved health cannot be achieved without basic human rights, and that these rights are meaningless without adequate health. Juan Manuel embodies Dr. Mann’s principles in his daily work. He exhorts us to “invertir en cabeza,” loosely translated, “invest in the mind,” as he trains the future leaders of indigenous communities.
- To read more about Juan Manuel and his work, read the DGH Reporter article “DGH Profile: Juan Manuel Canales”. If you would like to make a donation to help continue to make Juan Manuel’s work possible, you can do so through Doctors for Global Health.
Add a comment May 11th, 2008 by bronxdoc
A conference entitled Medical Education for the 21st Century: Teaching for Health Equity will take place in Havana from November 30 - December 3, 2008. Among the groups participating in this conference are PAHO, ALAMES, the Global Health Education Consortium (GHEC), MEDICC and the Cuban Ministry of Public Health. The deadline for submission of abstracts, which can be done on-line, is June 30th.
US citizens are subject to severe restrictions on travel to Cuba (see a discussion at the following link). Arrangements must be made through Marazul Travel Service. The Marazul website offers specific information on travel restrictions including guidance from the Office of Foreign Assets Control (OFAC) of the US Treasury Department.
it is important to remember that these restrictions are an real and important infringement on the free flow of people and ideas between Cuba and the United States. As the ACLU has pointed out: “There is no reason why Americans shouldn’t be able to practice their constitutional right to travel freely to Cuba.”
Add a comment May 5th, 2008 by bronxdoc
[This posting was originally published in November of 2004]
A new invitation to appreciate Ernesto “Che” Guevara-physician, writer and revolutionary-has appeared with The Motorcycle Diaries, directed by Walter Salles. The movie adapts Che’s journal notes during his 1952 “concientización” journey as a 23 year old medical student through Argentina, Chile, Peru, Colombia and Venezuela accompanied by his biochemist friend, the 29-year old Alberto Granado. In a New York Times Op-Ed piece, Che’s daughter, Aleida, herself a Cuban pediatrician, says this about her father’s diaries:
“His awareness grows that what poor people need is not so much his scientific knowledge as a doctor, but rather his strength and persistence in trying to bring about the social change that would enable them to recover the dignity that had been taken from them and trampled on for centuries. With his thirst for knowledge and his great capacity to love, he shows us how reality, if properly interpreted, can permeate a human being to the point of changing his or her way of thinking. I was only 6 when my father died, 37 years ago today, so I have few memories. I got to know my father only as I grew up. My mother, Aleida March, loved him very deeply, and shared his ideals, which she passed on to her children. What I remember most is my father’s great capacity for love.” (October 9, 2004)
If you love the people of Latin America; if the Andes, the Atacama and the Amazon inspire you; if you want to perceive a medical student who has is not afraid to speak his mind and act to healing, in a way that changes others around him (getting a whole community to accept the humanity of the lepers in their midst, literally, for instance); you will appreciate The Motorcycle Diaries. You may want to read the book for yourself-a quick and good read, in Spanish or in English translation. And, you might then want to learn more about the rest of Che Guevara’s life.
There are several large biographies. I recommend three and mention another with reservation. Both Che, Ernesto Guevara, A Legend in Our Century, by Pierre Kalfon (674 pages, translation from the French) and Che Guevara: A Revolutionary Life, by Jon Lee Anderson (831 pages, in excellent English) are well-written, fair and informative. A third, Ernesto Guevara, also known as Che, by Paco Ignacio Taibo II (852 pages, translated from the Spanish), is also very good-but the unbridled admiration of the author gives a one-sided portrait of the man. Finally, La Vida en Rojo: Una Biografia del Che Guevara, published later in English with the title Compañero, by Jorge G. Casteneda (560 pages), is also well-researched. Yet it is written with obvious and bitter Che-envy and could better have the title Let’s Trash Che.
Che, the man and the life he led, are not simple. The young Che thought Gandhi’s non-violent tactics were effective, and he writes of Gandhi with admiration. Later Che came to feel active opposition, including armed struggle, as a necessary step to confront structural violence and oppression. He came to this conclusion by fire, so to speak. On another trip through the Americas, this one including Bolivia, Ecuador, Panama, Costa Rica, Nicaragua, El Salvador, Guatemala, Mexico and Cuba-and onto the rest of his life-Che experienced first hand the United States Government view of what to do about a people who have a different agenda than corporate wealth and US Government control.
In 1954 President Arbenz of Guatemala, elected in free and fair elections, perceiving that the people in his country were starving, and that one landowner-US-based United Fruit Company-routinely left millions of acres fallow (about half their vast holding), put forward a very modest Agrarian Reform proposal. The United Fruit head lawyer, John Dulles, was alarmed. He discussed things with the head of the US CIA, conveniently Allen Dulles, his brother. (Flown into Dulles Airport in DC lately?) A coup was quickly arranged. Arbenz-who refused to give arms to his supporters-was easily removed, and a military dictatorship begun that would last into the 1990s and be responsible for an estimated 200,000 murders of Indigenous Guatemalans.
Che was there during the coup, and the unfortunate lesson he learned in Guatemala was alas crystal clear. The only voice the US Government would listen to when itself engaged in and supporting violent oppression is the voice of violence itself. (A partial list of dictators supported by the US Government during that and subsequent times: the Somozas in Nicaragua; Stroessner in Paraguay-who made his country welcome to Nazi war criminals; Marcos in the Philippines; various military juntas in Argentina, Brazil, and Uruguay; Papa Doc then Baby Doc in Haiti; Batista in Cuba; and these are just the ones practically everybody knows about. Pinochet came later, put into place by the US Government in a coup that killed public health physician and the democratically elected President of Chile, Salvador Allende, on 11 September 1973. Pinochet immediately, again with CIA assistance, rounded up ten thousand Chileans and international volunteers, putting them into the Santiago soccer stadium and killing them, see the moving movie Missing for what happened to the son of a US Congressman then.) Alas that Che had evidence then on which to base his preventive-violence perspective. What conclusion would he draw from looking at the world today?
Che led a life of actively making a difference, of exchanging a privileged potential for work with the poorest of the poor in changing their own lives toward becoming more just and human. He was among the architects of the Cuban Health System, where infant mortality and other health statistics are similar and sometimes better than those of the United States, certainly neighborhood by neighborhood, at a fraction of the expense. The sacrifice toward social justice is the main reason I personally find Che such an inspiration. Che’s leadership continues to spark the imagination and convictions of persons around the world. Some persons lament the “commercialization” of Che, whether the t-shirt worn by someone who does not know about his life, or other aspects. But I think of these things-whether a t-shirt image or a well-made movie-as being subtle introductions to the spirit of Che, to the positive, inspiring aspects of his life, which endure. As Eduardo Galeano, Uruguayan, said:
“A large part Che Guevara’s strength, I think, of this mysterious energy that goes so much further than his death and his errors, comes from something very simple: he was a rare kind of person who said what he thought and did what he said.” From “Celebration of the marriage of words and action,” El Libro de los Abrazos (The Book of Hugs)
Wherever we are living today, whether in the United States or another country, if we have eyes to see we know that most people in the world do not currently have lives of human dignity and social justice. Realizing this, opening ourselves to the cognitive dissonance that living and knowing can produce, what-if anything-will we actually do?
And, so, as Che said in a letter to his children, on his departure to the Congo, I leave you with his invitation:
“Above all, try always to be able to feel deeply any injustice committed against any person in any part of the world. It is the most important quality of a revolutionary.”
- Lanny Smith, MD, November 2004
There are many Che-related websites. The text of this speech “On revolutionary medicine” can be found at the Che Guevara Internet Archive. The Wikipedia entry on Che is a bit dry but has many links, including CIA documents on his death and the first chapter in Jon Anderson’s book. You might also want to visit the Biography Project. One of the largest Che sites is www.che-lives.com. For those interested in medical solidarity with Cuba we recommend visiting Infomed and MEDICC, Medical Education Cooperation with Cuba.
Add a comment May 4th, 2008 by bronxdoc
In the 1930’s Salvador Allende, a public health physician, served as Chilean Minister of Health. He produced an analysis of the social origins of disease and suffering in Chile, La Realidad Medico-Social Chileña, arguing that the solution to health problems lay not simply in improved medical care but also in better sanitation, housing, nutrition and working conditions. Echoing Virchow, Allende wrote: “[I]t is not possible to provide health and knowledge to a malnourished people, dressed in rags and working under merciless exploitation.”
These ideas were eventually embodied in the political program of the democratically-elected Unidad Popular government in Chile. Allende served as President of the Unidad Popular government from 1971 until his government was overthrown in a US-sponsored military coup on September 11, 197. Allende died in the coup which broke Chile’s long tradition of democratic government and initiated a long period of military dictatorship under General Augosto Pinochet.
Allende’s most famous document on Social Medicine is La Realidad Médico-Social Chilena (Chile’s Medical Social Reality which was published in 1939. Selections of this document were in 2006 in Volume 2, No 3 of of Social Medicine (English) and Medicina Social (Spanish) along with an introduction by Claudio Schuftan; the Spanish site also contains the original health platform from one of Allende’s presidential campaigns. The original version of La Realidad Medico-Social Chileña can be found (with a bit of searching) at the very rich Archivo-Chile.
For more information on Allende in Spanish consult the Salvador Allende archives run by the Partido Socialista. Salvador Allende: Chile’s Voice of Democracy offers English translation of some of Allende’s writiings and speeches.
To read documents related to US involvement in the 1973 coup (”the Latin American 9/11″) visit the National Security Archive website. Wikipedia offers a more general view of this “watershed event in the history of Chile and the Cold War.”
Add a comment May 1st, 2008 by bronxdoc
The University of New Mexico has developed a unique database of publications pertaining to Latin American Social Medicine. In collaboration with the University Health Sciences Center (Centro Universitario de Ciencias de la Salud - CUCS) of the University of Guadalajara (Universidad de Guadalajara) (Mexico) they are cataloging key texts (books, chapters, articles) that relate to Latin American Social Medicine. They index texts originally published in Spanish, English and Portuguese. Structured abstracts are then prepared in all three languages and made available on their website.
A search through the website for “Juan Garcia” brought up six of the key articles written by Juan César García, one of the principal thinkers in LASM, each with an English abstract. The database is currently the only English-language resource that will allow access to these materials so easily.
We have just published Volume 3, Number 2 of Social Medicine. The full table of contents in available on line. Here is some information about the articles:
