FACULTY OF SOCIAL HEALTH AREA
, and Humanistic
COMMUNITY PUBLIC HEALTH LECTURE
PRESENT AND FUTURE OF PUBLIC HEALTH. A CRITICAL SOCIAL MEDICINE FROM
This paper takes up the one made by the author called The challenge of developing public health as opposed to private healthcare, presented at the Panel "Future of Public Health" under the Twenty-first Meeting Latin American Association of Schools of Public Health - ALAESP. Rio de Janeiro, August 20, 2006.
Mauricio Torres Tovar 2 Medical, Occupational Health specialist. General Coordinator of the Latin American Social Medicine (Alamo) and member of the National Movement for Health and Social Security of Colombia. Email: coordinadorgeneralalames@yahoo.es
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the future if we do not only survive this
Cornelius Castoriadis "(...) the counter-hegemony, able to effectively challenge the dominant hegemony, born of reality and daily experiences
Antonio Gramsci
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reflection on the present and future of public health is still a recurring theme. This is arguably symptomatic: when you ask so frequently about his future, has to do with a lack of clarity about its present, a matter that confirms what we have clearly recognized since the early 90's in the sense that there a public health crisis. In 1991
Carlyle Guerra in the framework of the consultative group meeting on development of the theory and practice of public health in the Americas in New Orleans raised referring to the health situation in the region: ... I think the explanation that covers over the fact that the poor or the general public through the domain of any information, whose dissemination are not responsible, has been able to develop survival strategies that allowed them to survive even under conditions of greater hardness and most marginalized. I mention this fact to come again on one of the highlights of the profound change that is necessary to introduce in practice, and because they say the theory of health, which is the importance of participation, decentralization, the democratization in the organization of sectoral actions and beyond the sector. It is logical that we have also review care models and practices that lead, I think we have been changing in the sense of going to the notion of health sector identified as an activity for increasingly concerned with international and cross. " 3Guerra de Macedo, Carlyle (1991). Framework. Consultative group meeting on development of the theory and practice of public health in the Americas. New Orleans, 21 to 24 October 2001.
Likewise, the exercise proposed by PAHO in the early 90 and reproduced in the text of the public health crisis expressly left the old public health techniques rooted in stale shook at the insult of inefficiency, the failure of his speech, to the disorganization of his defroster, with its lack of legitimacy, but at the time this crisis, opened the door to new possibilities. 4OPS (1992). The crisis of public health: exploring the debate. Scientific Publication No. 540. Washington DC.
And in 1993 within the framework of the Andean meeting on public health is clearly raised the fact that public health was at a crossroads and that the State's concern for the public's health began to disappear leaving little space for the gift detention, as proposed by some funding agencies at the time, while action curative and rehabilitative goods began to be attractive to the private sector. It was also said that neoliberalism there trying to disappear our object of investigation and action by public health and we disappear as potential subjects builders of our history, as was the option of continuing to exist as objects without history or ethics or disappear as subjects . Public Health 5Escuela-OPS (1993). Public Health. Science, policy and action. Proceedings of the I Andean meeting on development of the theory and practice in public health. Quito, September 1993.
I raised at these meetings and publications and ratified during the years later at other meetings (among them two American Conferences on Education in Public Health, Rio de Janeiro in 1994 and Mexico 1998) and other exercises of reflection between highlighting the OPS driven earlier this millennium with the initiative public health in the Americas, confirmed the status of public health crisis, problems in theoretical and conceptual issues, weaknesses in practice to meet the health needs of the population and the new situation in the context of reforms health clearly weakened the State's efforts and hand, deepened the crisis of public health action.
After 6 years of the new millennium could to dare to say that this situation is not resolved despite the efforts of multiple actors and the opportunities that have tried to see through the crisis. For this we could say that the public health situation is dramatic and we could not overcome the epistemological problems, or take a leap into the practices that enable effective responses to problems and public health needs, to which is added the threat of global hegemonic policies which have been weakening the state and its action on the villages, where public health has lost enormous ground.
Amidst this scenario by discuss the future course of public health is quite difficult, when the present is so fragile. In a sort of exegesis would say, as many others have said long ago that without changing epistemological public health that lead to theoretical, methodological and practice, coupled with a renewal of the State, and more importantly to a renewal of the action of organized society in their communities, the future of public health is, antinomy, the private healthcare is the responsibility of public health is an individual, private and market, where the issue of externalities will be addressed by the State decentralized but on a very limited field of action (probably vaccination, control of some epidemics and sanitation).
Helped by the voices and views of social medicine, I will look initially and very quick affairs in the history of public health to try to see the epistemological origins of this field of knowledge, secondly look at the challenges Current public health, and thirdly to outline some possible ways to overcome the crisis and to envision a future of public health other than that I mentioned.
HISTORICAL REFERENCE: DARE TO BROWSE OTHER BEARINGS
To look to the future we must necessarily see the past and in this case we want to see the past to recognize the basis upon which originated and developed the public health model.
The dominant from ancient Greece is the paradigm hygienist related to the moods and the miasma. The idea of \u200b\u200bpolluted air has its roots in classical antiquity, the words "on the air, waters and places" of Hippocrates speaks of "bad air" (hence the name malaria) to explain that the poor air quality produced diseases, like bad water and bad places. 6Quevedo, Emilio. José Celestino Mutis anta public hygiene: a prisoner peripheral oracle in a metropolitan paradigm contradictory. In: The humanism of Mutis, and be enforced. sf
Also, from the Middle Ages and the Renaissance, from the medieval conceptions of galenism humoralists is coming if that infectious diseases were caused by the miasma, mysterious matter unhealthy transmitting human to human or from animal to human. 7Ibíd.
In the eighteenth century several doctors raised the need to take into account social standpoint in dealing with the problems of medicine and hygiene. Johann Peter Frank highlighted in the former GDR who raised "hunger and disease are painted on the front of the whole working class "and proposed creating a system with a global health policy, and the work of Bernardino Ramazzini in Italy on diseases of workers, which earned him the title of father of occupational medicine.
In the nineteenth century, Thomas Sydenham proposes a theory of health based on their classification of disease into two types: acute and chronic diseases. The first caused by the miasma that attack parts of the body fluid and, second, following the scheme of life of human beings, ie the defect or excess of their daily habits. Consequently, hygiene is divided into two branches: public health, responsible the prophylaxis of acute and therefore the control of air and water to prevent the proliferation of the miasma, and personal hygiene, aimed at encouraging self-management people, avoiding excesses in their life patterns. This theory leads to establish permanent hygienic measures in relation to public health such as paving, drainage, sewage, ventilation of the spaces, to avoid overcrowding and disinfect. 8Ibíd. Sydenham
thus breaks the old paradigm, which showed their total inability to address the phenomenon of epidemics, opening two lines of work: clinical empiricism and epidemiological perspective, which will advance the further development of the anatomy, pathophysiology, microbiology and epidemiology, providing power to a new paradigm of modern medicine. 9Quevedo, and Emilio Cardenas, Hugo. Health-disease process. sf
It should be noted that in the construction process of thought there were other important developments, but failed to compete with the paradigm inaugurated by Sydenham, which was then deepened with developments such as those made by Edwin Chadwink in England in the century XIX who deepened the line of hygiene for addressing the epidemic and the subsequent developments in the twentieth century Leavell and Clark on the natural history of disease, levels prevention and the epidemiological triad.
These papers and theses proposed a social rather than hygienic look worth noting:
In the nineteenth century are the work of Solomon Neumann in ancient Germany, who argue that "the majority of diseases that disrupt the full enjoyment of life does not depend on natural conditions but also social conditions ", by Rudolph Virchow in Germany also old who was asked to study the typhus epidemic at that time lashed the region and argue that the epidemic had causes social and economic issues related to poverty and is required sanitary and social measures to prevent further outbreaks. Virchow's proposal consisted of a radical social reform, broadly understood "full and unrestricted democracy, education, freedom and prosperity" argument these that earned him the title of father of social medicine. 10Rosen George. Da Medical Police to Social Medicine. Rio de Janeiro: Editorial Graal, 1979.
Louisville's works in France who demonstrated with statistical data that the frequency of illness and mortality rates in Paris were related to the living conditions of the various social classes; William Farr in England who posed in an official statistical report that hunger was responsible for many deaths, further observed that the excess mortality among the miners was produced by their working conditions and nutritional status.
Already in the twentieth century highlights the contributions of Henry Sigerist who argue that medicine is the study and application of biology in a matrix that is both historical, social, political, economic and cultural development and gave an idea germ of understanding of health as a human right and duty of the State to argue that "the people have the right to health care and society has a responsibility to care for their members." Henrick Blum developments who argue that health is the result of a large number of environmental determinants, behavioral, heritage and health services.
In Latin America highlights the contributions of Juan Cesar Garcia of Argentina, in the analysis of human resource training in health, who argue that "the health-disease-care is the expression of a particular socio-economic and cultural training" and Brazil's Sergio Arouca who contributed in building the collective health thinking and had an outstanding political work in the defense of health, who argue that "the Brazilian health reform is not born of a simple management process, technocratic or bureaucratic. Born in the defense of values \u200b\u200bsuch as direct democracy, social control, universal rights, the humanization of care, with the view of the fact that citizens are not a customer, not a user, rather it is subject. Brazilian health reform is a civilizing project. "
This historical development can be noted that public health in the process of gestation had its epistemological basis in sanitation that articulated the advances in microbiology, epidemiology, pathophysiology and set the current field of public health as called Edmundo Granda Public Enfermología is more moving as the analysis of individual phenomena of the disease to the analysis of collective situations, without detachment of the phenomenon of the disease to pass to the life and common welfare. Edmundo 11Granda. Public Health and the Metaphors of Life. Journal of the National School of Public Health. 18 (2) :83-100, July-December 2001. Subject
historical
constitutes a key to transform the public health situation, because as you continue looking through the same lens as the paradigm / 12Según Thomas Kuhn, a scientific paradigm is a set of outputs that share two characteristics: first, defined for successive generations of scientists with a set of problems and legitimate methods, and on the other hand, are sufficiently incomplete to leave many problems to be solved by scientists redelimitado. So a paradigm is an accepted model (for normal science) that attempts to force nature to fit within pre-set by the accepted model. In Quevedo. Emilio. José Celestino Mutis anta public hygiene: an oracle peripheral prisoner in a metropolitan paradigm contradictory. Op cit. / The findings of fact by itself does not ensure the construction of new theories explaining reality; / 13Quevedo, Emilio. José Celestino Mutis anta public hygiene: an oracle peripheral prisoner in a metropolitan paradigm contradictory. Op cit. / Which confirms the point made by Kuhn "any part of the aim of normal science aims to provoke new kinds of phenomena, in fact, the phenomena that do not fit within the limits mentioned frequently not even see them. Nor do scientists normally tend to discover new theories and often are intolerant to other formulas. Normal scientific research is directed to the articulation of those phenomena and theories and provides the paradigm. " 14Kuhn, Thomas (1971). Structure of Scientific Revolutions. In: Quevedo, Emilio. José Celestino Mutis anta public hygiene: a prisoner in a peripheral oracle paradigm Metropolitan contradictory. Op cit.
In this sense, the story shows the clear need to change "what you see is that expand the scope of analysis and the" way of looking "ie use other analytical tools of an integral and universal. 15OPS (1992). The crisis of public health: exploring the debate. Op cit. Here
as there is a clear legacy of history, and we must understand that only if we dare to sail other routes that have been given to public health, we will overcome the crisis and crossroads. Suffice it then propose another possible course of navigation which we indicated Rudolph Virchow and Juan Cesar Garcia through thought and social medicine movement.
CURRENT CHALLENGES OF PUBLIC HEALTH CRISIS IN THE MIDDLE OF
The exercise developed by PAHO in the context of public health initiative in the Americas, was to define 11 core functions of public health and develop a self-assessment process in 41 countries in the region. This exercise showed all the features a performance profile low intermediate, with better performance in the role eleven referred to reducing the impact of emergencies and disasters, the second on public health surveillance and monitoring function on number one, health assessment and analysis. The worst performer was the new role that has to do with the quality of services, the role eight, human resources development and function of ten, on public health research. 16Feo, Oscar. Public health in the reform processes and essential functions of public health. Review National School of Public Health. Vol 22, Special Issue: Third International Congress of Public Health.
This exercise and many other evidences say that today has enormous public health challenges, but perhaps the biggest, has been proposed by Virchow and Garcia, is the convergence and coordination with the social sciences in a process of renewal of its subject, its approaches and methods, to secure a perspective that helps us better understand the health situation of our country and its transformation into a process of strengthening democratic and inclusive social alternatives. / Personal 17Comunicación Jairo Ernesto Luna, a member of Poplar core Colombia. / What reorient its claim construction field of knowledge for life and not for the disease, nor for the market, which requires use of theoretical tools, methodological / staff 18Comunicación Alejandrina Cabrera, coordinator of Mexico Poplar core /. and to think and act on health as a matter social and not just "mainstream" social science - one of them or all-to thinking about health. 19Testa, Mario (1992). Public Health: on the meaning and significance. In: PAHO (1992). The crisis of public health: exploring the debate. Op cit. Therefore
this great challenge to be taken should guide the production of knowledge (research), training (formal education) and political action technique century Public Health / Personal 20Comunicación Mario Hernandez, a member of the core ALAMES Colombia. / And a new ingredient referred to his relationship with social organizational processes, with emphasis on social movements in health, also contributing in the production of knowledge with them from the recognition of other than the scientific knowledge, training from the perspective of the rich tradition of popular education and action in building the public understanding that is not constructed solely from the sphere of the state.
In turn, another major challenge to public health through this in relation to major social policy changes driven by the so-called globalization, which have impacted on the configuration of nation states and which have substantially transformed the social policies and the role of Been there. In this context, there have been reforms of social security and health, which determined that the States delegated the responsibility for health to the individuals themselves and their families and have given a prominent role to private actors in providing these services , causing a huge fragmentation of health systems which have strengthened the personal care component to the disease and weakened the collective action component of promotion and prevention.
Now this same context of globalization puts many other challenges to public health product that generates and processes: the migration of both major segments of the population and human talent health, the possibility of very rapid transmission of epidemics, the new type of trade agreements between nations, changes in the world of work and new locales, among others.
This context then puts a huge public health challenge, which is to survive in scenarios ex weakening of the state with a worsening of health problems and socio-epidemiological polarization, due largely to the deepening of inequalities social health regression, given by the rebound of previously eradicated diseases and / or controlled, the aging population, the deterioration of mental health, the increase of various types of political and social violence, the further environmental degradation, increasing poverty and famine with it, increasing inequalities and social exclusion, the use of biotechnology in health issues, among other relevant issues . 21López, O, F Peña (2006). Health and society. Contributions of Latin American thought. In E de la Garza (coordinator), Latin American Treaty of sociology. Ed Anthropos, Barcelona. / Personal 22Comunicaciones and Esperanza Luz Stella Álvarez Echeverri associated kernel ALAMES Colombia.
With this background of challenges and clear recognition of the millennium that after so many adjustments and reforms the situation economic and social development of most countries seems to be worse, health conditions and services are very poor and most companies continue to express their inability to promote and protect their health as far as their historical circumstances require, / 23OPS . The Crisis of Public Health. Op cit. / There is a clear need for progress on the reconfiguration of the new public health to recognize and assess the gaps and previous successes and can leap epistemological reconceptualization enable them, set a new disciplinary field, that shifts the transmission of knowledge and a time to redefine their social practices. NADA
NEW, JUST DARE TO SAIL A DIFFERENT DIRECTION: CONTRIBUTE TO RESOLVE THE PROBLEMS OF LIFE, NOT THE MARKET
From the historical and the period of crisis has been going through the public health, many things have been raised some time ago, that is required to address health issues and not the disease, it is necessary a multidisciplinary, that action must be beyond the health services and to be cross-cutting, down a set essential functions to shift its focus, it is essential to the articulation with the social sciences, among other things. The truth is that progress in this direction, despite the alleged agreement, are scarce and of poor impact, which is evident in both the biomedical model is still present in the training and practice and even worse, has been strengthened by the neoliberal health perspective, it becomes a private good for individual consumption to health.
Here it is worth saying, in a reflection autocratic, since I represent a sector of critical thought and action of public health, despite the radical analysis and innovative theoretical and methodological proposals from the current field of medicine social development in Latin America, this has failed to significantly impact the public health field. Edmundo 24Granda (2004). Public Health Quo Vadis? Paper presented at the Second Civil Society Forum on Health. Lima, 9-11 August 2004.
What then is the way to the future of Public Health not Private Health? Certainly we must navigate by way of a new public health, picking the offers theoretical and methodological approaches we have, the many experiences of progress and setbacks. That is, public health has a future in so far as to renew, that would otherwise perish because their essence is even subordinate under his own approval as happened when he had no ethical qualms about joining the 90 reforms have been harmful to the life of the public health.
As a sort of navigation log to start this new course, among many other things are required:
• To set up new counter-public health (to use Gramsci's quote) that is able to effectively challenge the hegemonic public health it is necessary parirla from reality and daily life experiences, which demands a different contact with reality, with people, their needs and there should emerge new ways of knowing and acting in the field of practices public health.
• Reassemble the epistemological field and public health action, passing through to support it: 25Ibíd.
o Emphasis on health, life, welfare, without neglecting the disease, but overcoming the issue of product profitability of curative care;
or methods that integrate various forms of understanding and capable of accounting structures and social action and structures;
or promote social practices that integrate various stakeholders and authorities from the State, to individuals, their groups to social movements.
• Recognize that the actors are not only public health professionals have to do with her experiences there, which as in the case of southern Mexico and Guatemala have allowed health promoters to form a combination of traditional knowledge and scientific knowledge, they have had very positive impacts on the health of their communities. / 26Albizu, José Luís (2005). Effect Guatemala. A trip to the promoters and promoters of health throughout life. Guatemala City. / This in turn requires that off-the spotlights and training scenarios, leaving the university the exclusive domain of professionals and technicians, to move to a formal no where what matters is not the title if not the knowledge and skills to contribute effectively to improving community health.
Now this implies, in turn, accepting that ensure the right to health requires social actors and the military forces and the concrete, the new public health contribution to training in the preparation of technical cadres political unions, political parties, social movements, etc. / Personal 27Comunicación Mario Rovere, a member of the Advisory Council ALAMES. / Is required to educate, train many and many in all areas, from the places where life takes place every day, but it is also defining work processes, learning spaces, from the perspective of human rights from the perspective of promoting quality of life. We can not keep thinking and teaching from the disease, from risk we have to teach from and for life. Mary Urbanski personal 28Comunicación counselor ALAMES Advisory Council.
• Recognize that communities also have the capacity to build the public and against a backdrop of weakening of the state community in its legitimate autonomy condition can advance organizational forms reached with public health issues and from this new position to reinvent and redefine the state. This then implies that the new public health contribution to building the public sphere beyond the state, even more so today is in sharp weakening.
• Required field transformations staff training as expressed Edmundo Granda "The training of adequate sanitation for public enfermología was associated with an image of the public health policy and technical controller, while at present, claims, an individual performer - mediator, ie interpreter of the ways individual and social actors in their daily lives, build their knowledge, develop actions related to health promotion and care for their illness, and strategic mediating powers scientific, political and economic support raising levels of health and life. " Edmundo Granda 29 (2004). Public Health Quo Vadis? Op cit.
• Evaluate the alternatives that have been occurring over time and the product of the context and power relations in the international arena have not been developed in particular I refer to proposals for APS, the prospect of social determinants of health and the prospect of the right to health.
• Recognise explicitly and without shame that health is a matter of policy and therefore the new Public Health has to necessarily establish a projection and different relationship with the policies, structures and institutions in the field to achieve larger doses of democracy, efficiency and equity. / 30Ibíd. / The political is the vindication of the public and public health, public health as well indivisible, non-tradable and therefore universal, beyond the state and health as a fundamental human right. 31 Personal communication from Saul Franco, a member of the Advisory Council ALAMES.
• The new public health should guide health systems, which means that public health is the guiding health policies, including those related to the organization of care of diseases and forms of financing. This implies a frank confrontation with the false separation between private goods and public goods in health, as claimed by neoclassical economists and therefore the insurance should not be a separate field of public health, is just one way of organizing the financing of health services and must give the full discussion of whether remain an individual matter or a real social and fair mechanism for funding to achieve universality. 32 Personal communication from Mario Hernandez Colombia ALAMES member.
• Exit the crossroads of the monitoring and regulation to advance a vision articulated its action around the creation of conditions to improve quality of life and not only prevent disease, ie enroll in a promotional approach of quality of life. 33 De Negri, Armando (2004). Adoção of promotional strategy uma da qualidade e saúde life: das transetorialidade policy. In: Girotti Sperandio, AM O Process construção da rede potentially saudáveis \u200b\u200bmunicipalities. Campinas-São Paulo: IPES, Unicamp, PAHO / WHO.
• Strengthen the practice of participation of people from a perspective of citizenship, where people are positioned as the holder of the right to health, and not as a consumer user of health services that only calls for a contract with the service provider .
• Being consistent with this blog navigation pregratos should strengthen health and public health graduate from the training include a focus on rights, social determinants of health and equity.
• The future of the new public health should be seen also from the areas of regional integration. Given this movement now runs our continent can not but stop a bit to appreciate it for its potential to add stress, meet, met, to think our problems together and dare to think joint responses. 34 Personal communication from Mary Urbanski.
• The future of this new public health depends on the one hand, and belonging the agendas of society, especially the excluded and secondly, that the State assume the challenge of collective health as an ethical commitment to ensure response to health and social needs and for overcoming the profound health inequalities existing.
Here are some elements of this blog that is necessary to discuss, adjust, expand consensus about it. But certainly it is, that to assume this new blog must start from recognizing that we have been sailing for our course and that it is possible to sail clear that respond to the great needs and public health situations which today crosses the world and our country in particular.
