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História, Ciências, Saúde-Manguinhos

Print version ISSN 0104-5970On-line version ISSN 1678-4758

Hist. cienc. saude-Manguinhos vol.24 no.4 Rio de Janeiro Oct./Dec. 2017

http://dx.doi.org/10.1590/s0104-59702017000500002 

ANALYSIS

Cuadernos Médico Sociales from Rosario, Argentina, and other Latin American social medicine journals from the 1970s and 1980s

Hugo Spinelli1 

Juan Martín Librandi2 

Juan Pablo Zabala3 

1 Director, Instituto de Salud Colectiva/Universidad Nacional de Lanús.

2 Fellow, Instituto de Salud Colectiva/Universidad Nacional de Lanús.

3 Investigador adjunto, Consejo Nacional de Investigaciones Científicas y Técnicas/Universidad Nacional de Quilmes; Instituto de Salud Colectiva/Universidad Nacional de Lanús.


Abstract

In the 1970s and 1980s, a series of journals were founded to disseminate ideas from Latin American social medicine in various countries across the continent, during the early stage of a movement that would later become institutionalized in Brazil under the name “collective medicine.” In this article, we look at the principal characteristics of those endeavors: Revista Centroamericana de Ciencias de la Salud, Saúde em Debate, Salud Problema, Revista Latinoamericana de Salud and Cuadernos Médico Sociales. We focus in particular on Cuadernos Médico Sociales, published in Rosario, Argentina. We analyze the conditions under which this publication emerged, the editorial processes it followed, and the central role played by Carlos Bloch, its founder and managing editor.

Keywords: history; social medicine; public health; social sciences; journals.

Resumen

Entre 1970 y 1980, fueron creadas un conjunto de revistas con el objetivo de difundir las ideas de la medicina social latinoamericana en distintos países del continente, en una etapa temprana en la institucionalización de este movimiento que luego se afianzó en Brasil bajo el nombre de “salud colectiva”. En este trabajo recorremos las principales características de esos emprendimientos: la Revista Centroamericana de Ciencias de la Salud, Saúde em Debate, Salud Problema, Revista Latinoamericana de Salud y Cuadernos Médico Sociales. En particular, nos focalizamos en los Cuadernos Médico Sociales de Rosario, analizando las condiciones de su surgimiento y los procesos editoriales que marcaron esta publicación, donde fue central la figura de Carlos Bloch como editor e ideólogo de la revista.

Palabras clave: historia; medicina social; salud pública; ciencias sociales; revistas.

The Latin American social medicine movement began to coalesce in the mid-1960s, and in the following decades it became definitively institutionalized in the academic environment (especially in Brazil) under the name “collective medicine” (Nunes, 2016, 2013; Vieira da Silva, Pinell, 2014). In the period we analyze, from the 1970s to the mid-1980s, the field was still being established, and was therefore addressing a series of questions that were fundamental to defining its identity in political, theoretical and social terms. Some of the elements involved in this process include:

(a) A set of diagnoses - from different theoretical perspectives - focusing on the dire social conditions of healthcare and a critique of “traditional” public health, linked to a functionalist theoretical framework and a technocratic concept of state intervention (Testa, 1993; Granda, abr.-jun. 2004);

(b) The construction of institutional spaces for social medicine, whether within academia, labor unions or politics. In this sense, a key role was played not only by journals but also by postgraduate degrees, conferences and seminars on the topic;

(c) A set of actors who became well-known figures in the field in different countries around Latin America. They led to certain “traditions” or schools, subsequent generations of which continue to be reference points nowadays;

(d) The definition of what relevant issues or problems were to be discussed within the field.

In this article, we focus on analyzing a group of journals that played a role in this process. We discuss the conditions under which they were created, the institutional spaces within which they arose, and their principal editorial strategies as vehicles for the dissemination of ideas but also as political and institutional enterprises that constitute a fundamental space for understanding some of the issues outlined above.

In analytic terms, we start from the assumption that journals play a crucial reproductive role in any scientific field: they represent validation of knowledge produced; they provide a means for spreading that knowledge; they are the space where discussions and exchanges occur, and where the problematic conceptual limits of the field are ultimately set (Bourdieu, 2003; Latour, Woolgar, 1995). On the other hand, as new institutional creations, they bear witness to the process whereby a field is created and to the political stances taken within it, whilst also constituting spaces for the different actors to operate.

A field of knowledge is effectively institutionalized when it achieves a particular set of characteristics: when a range of arguments, methods and knowledge techniques render study of a given area a major topic and not merely an adjunct issue; when it can be taught by specialized professors; when there are opportunities for publication in specialized journals; when funding and other research resources can be requested from established institutions and there is verifiable demand for the results of that research; and lastly, when scientific societies and undergraduate or graduate degrees or other forms of disciplinary validation emerge (Blanco, 2006; Nunes, 2015). Therefore, we need to clarify that the Latin American social medicine movement was not, properly speaking, an institutionalized academic field in the period under discussion; that came years later (Nunes, 2016). However, it was a developing space within which multiple political, conceptual and institutional conflicts were taking place. Therefore, the main working hypothesis of our analysis is that journals reflect some particular features of this field in its early stages, as seen in the conditions that gave rise to the different projects, the editorial strategies followed, and the content of the articles published.

In this article we intend to analyze some of those conflicts in light of a set of editorial experiences in different countries and in different institutional contexts, which were all part of the same process on a regional level. To do so, we look at the experience of five journals, concentrating in particular on one of them, Cuadernos Médico Sociales (CMS), published in Rosario, Argentina. This allows us to analyze some of the characteristics of the process of institutionalization of the field, by tracing the shared lines of continuity from the 1940s on. We argue that Juan César García and the network of relationships he was able to build up are crucial to understanding the development of the field in subsequent decades.

We reconstruct the editorial activity relating to Latin American social medicine via five journals that were identified by leading figures in the field as the ones most closely identified with the movement.

We use a qualitative strategy based on bibliography searches, data analysis and secondary sources. That information was complemented by twelve in-depth, semi-structured interviews with various editors, members of editorial boards and people close to them: Víctor Aliprandi, Susana Belmartino, Claudio Bloch, Hector Buschiazzo, José Carlos Escudero, Asa Cristina Laurell, Eduardo Menéndez, Hugo Mercer, Zulema Quinteros, Jaime Sepúlveda, Ernesto Taboada and Octavio Zanarello. The interviews were conducted in person at the Rosario Medical Association (Asociación Médica de Rosario, referred to hereafter as AMR), the Institute for Collective Health at the National University at Lanús (Instituto de Salud Colectiva de la Universidad Nacional de Lanús) and online via Skype. All the interviewees were told the goal of the study and they granted permission for their names to be used. In the interviews, we sought to ascertain the speakers’ intellectual, political and personal history, to reconstruct the frameworks within which they worked and their perceptions of the editorial field and of social medicine at the time.

The epigenesis of Latin American social medicine and its publications

Juan Samaja (2004) - following Hegel - insisted on the need to question not only the function of existing structures but also their historical epigenesis, by which he meant the formative developments that led to them; in other words, the connections to later content, avoiding the trap of attending only to immediate results. Therefore, we frame the epigenesis of Latin American social medicine in relation to three points of reference that are part of a complex, non-linear process full of conflicts and contradictions. These advances and retreats are part of a sociohistoric dynamic that, when we look back, reveals the dynamics of institutionalization.

The first reference point comes in the work of Henry Sigerist (1891-1957) in the United States, from the early 1930s until the post-war period, at which point McCarthyism took hold and Sigerist returned to Europe in 1947. But prior to that, he focused on studying the history of medicine and healthcare systems (Nunes, 1992).

The second reference point we take is from Chile, from 1930-1940, when social medicine advanced considerably thanks to the figure of Salvador Allende (1939) and his work La realidad médico-social chilena (Socio-medical reality in Chile), which led to the creation of the National Health Service (Servicio Nacional de Salud) in 1952, just four years after the National Health Service (NHS) was founded in the United Kingdom. From then on, the School of Public Health (Escuela de Salud Pública) at the University of Chile (Universidad de Chile) became a guiding light for a whole generation of Latin American public health researchers who traveled to Chile to train. In terms of our analysis, the importance of the Chilean journal Cuadernos Médico Sociales needs to be emphasized, since it was the first periodical of social medicine in Latin America in the twentieth century and a crucial forerunner to the publications we analyze in this article. Montoya-Aguilar (2009) discusses the rise of the Chilean CMS as linked to the publication and dissemination of material from the professional training seminars for doctors that were supported by Salvador Allende, who was a former president of the College of Physicians (Colegio Médico).

The third reference point is the work of Juan César García (1932-1984), in particular from the mid-1960s until his death. He was important both for his contributions as an organic intellectual within the movement and for the role he played in his position at the Department of Human Resources at the Pan American Health Organization (Departamento de Recursos Humanos de la Organización Panamericana de Salud). He connected people and institutions, helping to spread ideas, publicize authors, and create post-graduate training programs in social medicine whose effects can still be seen today (Galeano, Trotta, Spinelli, 2011); he was also instrumental in helping to found and/or develop the journals analyzed in this article. García was a fundamental figure in the development of Latin American social medicine (Nunes, 2013).

Latin American journals of social medicine in the 1970s and 1980s

In the mid-1960s, social medicine underwent a resurgence in Latin America. In the different countries across the continent, it came together as a movement thanks to a group of actors who were heterogeneous in terms of training and occupation but united by the common denominator of being linked to leftist political movements (some were members of the communist party, while others were merely identified with Marxist approaches and/or belonged to parties with populist roots). This new perspective involved a revision of prior approaches to public health; it emphasized the role of the socio-economic structure in determining population health, openly critiqued economic development as a model for achieving social equality, and criticized the expansion of medicine as an industry (Nunes, 1991; Vieira da Silva, Pinell, 2014; García, 1977). Although this movement started emerging in the mid-1960s, it was in 1972, in the city of Cuenca (Ecuador), that it first became known as “social medicine,” reviving a concept that had arisen in the great revolutionary movements of Europe in 1848 and adding the descriptor “Latin American” to underline the local nature of the thinking involved (Almeida Filho, Paim, 1999), and to denounce the domination involved in the North-South relationship.

In the process of institutionalizing this movement, an important role was played by a group of journals that functioned as spaces for promoting new approaches (both original work by regional authors and work by internationally-known figures) and affirming a collective identity. In chronological order, the following publications emerged during this period: Revista Centroamericana de Ciencias de la Salud (Costa Rica); Saúde em Debate (Brazil), Salud Problema (Mexico), Cuadernos Médico Sociales (Argentina) and Revista Latinoamericana de Salud (Mexico). Chart 1 shows the main characteristics of the journals analyzed.

Table 1:Latin American social medicine journals in the 1970s and 1980s 

Journal title Date founded Number of issues a year Status Publisher Country Editorial team for first issue
Revista Centroamericana de Ciencias de la Salud 1975 Three Ceased publication in 1982 Confederación Universitaria Centroamericana Costa Rica Jaime Sepúlveda and Fabio Castillo
Saúde em Debate 1976 Three Active Centro Brasileiro de Estudos de Saúde Brazil Emerson Elias Merhy, Ana Maria Segall Correa, Dalmo Herrera Feitoza, David Capistrano Filho, Sandra Roncali Mafezolli, Aguinaldo Gonçalves and Mirian Ibañez
Cuadernos Médico Sociales 1978 Four/three Ceased publication in 2002 Asociación Médica de Rosario Argentina Editorial team not named
Salud Problema 1978 Two Active Universidad Autónoma Metropolitana Mexico Hugo Mercer, Asa Cristina Laurell, Catalina Eibenschutz, Pedro Crevenna, Clara Fassler, José Carlos Escudero and Emma Nápoles
Revista Latinoamericana de Salud 1982 Two Ceased publication in 1982 Editorial Nueva Imagen Mexico Asa Cristina Laurell, José Carlos Escudero, Catalina Eibenschutz, Ricardo Loewe, Eduardo Menéndez and Hugo Mercer

By analyzing the editorial teams on the five journals and the authors of articles they published (with or without pseudonyms), we can see how these journals incorporated, connected and made possible the exchange of ideas and research experiences that facilitated the construction of a collective identity in the 1970s and early 1980s; they show the process of scientific and scientific demarcation both of themes and theories that was taking place in the field. Indeed, the role these journals played in establishing the movement can be seen in the relationships between their academic advisory boards, where the reiteration of names shows both the strong links between these enterprises and also the emergence of leading figures in the field in subsequent decades. For example, Hernán Vargas and Rodrigo Gutiérrez, who were both members of the advisory board of the Revista Latinoamericana de Salud, also participated on the Revista Centroamericana. Also on the board of the Revista Latinoamericana de Salud were Sergio Arouca, Hesio Cordeiro, Hugo Behm Rosas, Vicente Navarro, Mario Testa, Giovanni Berlinguer, Jaime Breilh and Pedro Luis Castellanos, among others. Meanwhile, these same figures kept coming up as authors of a large proportion of the articles published in those journals. This is particularly true of Juan César García, who published at least one article in early issues of all of the journals (except for Salud Problema).

The group of journals analyzed thus constitutes a corpus that allows us to analyze the field. That said, we would like to clarify two things in order to put our research topic in perspective. Firstly, the process of institutionalizing social medicine was not limited to the editorial strategies analyzed here. We should also mention that many of the authors were involved in creating post-graduate degrees, as were some of the journals themselves. Notable among them were the MAs in social medicine offered by the University of the State of Rio de Janeiro (Universidade do Estado do Rio de Janeiro, Uerj) in Brazil, and by the Autonomous Metropolitan University-Xochimilco (Universidad Autónoma Metropolitana-Unidad Xochimilco, UAM-X) in Mexico. Both functioned as privileged spaces for training and developing social medicine networks in which Juan César García played a fundamental role as “talent seeker” and funder. Michel Foucault was invited to give talks within the MA program in Brazil. His lectures were published in the first issues of several of the journals analyzed here (Galeano, Trotta, Spinelli, 2011).

Secondly, while these journals were the main publications during the rise of the field, the spread of Latin American social medicine was not due solely to them, a fact which could apply to the emergence of any field of knowledge. On an international level, Everardo Nunes (1991) has identified certain journals that dealt with the relationship between health and the social sciences, such as Social Science and Medicine, created in 1967; the International Journal of Health Services (1971), under the directorship of Vicente Navarro; and the Italian journal Epidemiologia e Prevenzione, founded in 1976 by Giulio A. Maccacaro. On a regional level, moreover, there was the Revista de Administração Pública (Brazil); Revista Mexicana de Ciencias Políticas y Sociales (Mexico), Educación Médica y Salud (Pan American Health Organization) and Estudios Sociológicos (Mexico) (Nunes, 1991); we should also mention that Ciencia Nueva (Argentina), among others, published work on social medicine.

Revista Centroamericana de Ciencias de la Salud

This journal appeared from 1975-1982, and published a total of 23 issues in eight years. It was founded within the framework of the Central American University Confederation (Confederación Universitaria Centroamericana), serving as the official publication and a forum for debate for the various degree programs involved. The confederation was a body linking all the national universities of Central America in the Central American Health Sciences Program (Programa Centroamericano de Ciencias de la Salud), which included representatives from Honduras, Guatemala, Nicaragua, Costa Rica and Panama; the journal was published by the confederation.

Revista Centroamericana de Ciencias de la Salud was directed from the outset by the Chilean pediatrician and public health specialist Jaime Sepúlveda, who arrived in Costa Rica as an exile from Chile. The journal was in constant contact with the Central American Program for Post-Graduate Work in Social Sciences (Programa Centroamericano de Posgrado en Ciencias Sociales). One of the leading figures involved with the journal was Vargas Gutiérrez, the dean of medicine at the University of Costa Rica and a member of the communist party; he was one of Juan César García’s essential contacts in Costa Rica.

According to those interviewed, there was an influx of social scientists into the Latin American Social Sciences Faculty (Facultad Latinoamericana de Ciencias Sociales, Flacso) in Costa Rica. On the faculty there was Vinicio González, a dental surgeon who had studied sociology at Flacso in Chile, where he met García. González was a central contact for Sepúlveda in the early days of the publication.

As the various issues began appearing, Sepúlveda commented that he came into contact with various different colleagues such as Juan César García, Gustavo Molina - in exile in Medellín, Colombia - and figures from the UAM-X. The journal published Juan Samaja’s first work in the healthcare field, a series of articles entitled “Logic, biology and medical sociology” (“Lógica, biología y sociología médica”), a line of scholarship that culminated in his book Epistemología de la salud (The epistemology of health) (Samaja, 2004). Other figures relevant to this project were Luis Felipe Bekker, Hernán Vargas and Ricardo Zambrana.

A particular feature of this journal is that it published themed seminar issues on topics such as occupational health and workers’ living conditions, healthcare systems and working-class health insurance coverage, or the second Latin American Seminar on Social Sciences (Seminario Latinoamericano de Ciencia Sociales), held in Nicaragua under the Sandinista government. The importance of these seminars, according to Sepúlveda, is that they laid the groundwork for the conferences of the Latin American Social Medicine Association (Asociación Latinoamericana de Medicina Social, Alames), beginning with the Cuenca II (1983) meeting in Ecuador. The journal also pioneered the publication of articles on workplace health and environmental conditions. It closed down due to the international conflict in Nicaragua precipitated by the counter-revolutionary movement of the “Contras.”

Saúde em Debate

This journal was founded in 1976 to promote the activities, publications, courses and texts of the Brazilian Health Studies Center (Centro Brasileiro de Estudos de Saúde, Cebes). The goal was to develop a critical perspective outside the biomedical field that would address organizational aspects of the healthcare system. It was a crucial means for spreading ideas linked later to healthcare reform in Brazil, and it was strongly influenced by the spread of the bibliography proposed by García. Unlike the other journals, it devoted more space to graphic languages, including covers featuring satirical caricatures, whether of the state of healthcare or of personalities linked to the topic at the time (Sophia, 2013).

The militant nature of these publications can be seen in the following anecdote. When the first issue came out, David Capistrano, one of the leading public health specialists in Sao Paolo, walked over to the journal’s headquarters with the issue in his hand, and remarked to the woman accompanying him, “Rosa, do you know what this means? This journal is our first victory; it’s going to lead to big changes” (Bastos de Paula et al., 2009, p.152). According to José Rubem Bonfim, a member of the editorial team, David Capistrano was inspired by the German journal Die Medizinische Reform (Medical reform), founded in 1848 by Rudolf Virchow (Amarante, Rizzotto, Costa, 2015; Bastos de Paula et al., 2009). In 1986, David Capistrano was also one of the people behind the book series Saúde em debate from Hucitec press, which is still active and has now published over three hundred titles, including some by Henry Sigerist.

Salud Problema

This journal was founded in 1978, in the context of an MA in social medicine at the UAM-X. This university project was proposed by Ramón Villarreal Pérez, the first dean of the Xochimilco campus, with collaboration from Juan César García y José Roberto Ferreira. They all worked for the education section of the Pan American Health Organization (PAHO) on human resources training, directed by Villarreal, who wrote the prologue to La educación médica en la América Latina (Medical education in Latin America) (García, 1977).

In this initiative, both in the creation of the journal and the launching of the masters program itself, we can see the fundamental role of the support provided by García through the PAHO. In fact, as Hugo Mercer (1978, p.3) has pointed out in the first issue of Salud Problema, the journal

was created to meet the nation’s need for specialized personnel, as well as producing research studies. This need is not limited to Mexico but is widespread in Latin America. That is why an agreement was established between the PAHO/WHO, the Department for Health and Medical Care (Secretaría de Salubridad y Asistencia) and the UAM-Xochimilco to make it possible to bring in grant-funded scholars from different Latin American countries for the MA, and to send evaluators and academic support from the PAHO/WHO.

The above excerpt shows that the thinking behind the endeavor was to achieve widespread dissemination of the field and broaden academic space across Latin America. The MA in social medicine at the UAM-X offered a course every year specifically devoted to social medicine, which was taken by Susana Belmartino and Carlos Bloch (the editors of the Rosario Cuaderno Médico Sociales) in 1980. The publicity given to these courses in issues 12 and 13 of Revista Centroamericana de Ciencias de la Salud shows, once again, the relationships between post-graduate degrees and journals in the institutionalization of the field.

Revista Latinoamericana de Salud

The Revista Latinoamericana de Salud also came out of the MA in social medicine at UAM-Xochimilco in 1982. Its editorial team consisted of professors and coordinators of the MA. Unlike the other initiatives, this journal sent work to the private publisher Nueva Imagen, under Guillermo Schavelzon, who was interested in the project. The press was already publishing a collection entitled Salud e ideología (Health and ideology), coordinated by Eduardo Menéndez, who had brought out 13 titles.

While the experience was a positive one, according to those interviewed, only two issues appeared, since the press could not afford to continue publishing the journal during the economic crisis in Mexico. It is worth noting a remark made by Asa Cristina Laurell, who was interviewed on the editorial production process at the time: “Everything was very slow. Communication was by mail, and the postal service in Latin America wasn’t the greatest. Texts were typed out on typewriters, all of which made communication and exchanges with the authors very slow.”

Cuadernos Médico Sociales (Rosario)

Cuadernos Médico Sociales (CMS), published in Rosario, Argentina, was created in 1978 to publicize developments in Latin American social medicine, and it became a space for active debate about the state of the Argentine and Latin American healthcare systems. Thus, the journal made it possible for ideas and arguments to be circulated and discussed over various generations, and became an unquestionable reference point in different settings. CMS was part of a broader network aimed at integrating and unifying a critical approach to the health-disease process, and it provided a space for resistance that worked to articulate thinking that incorporated local, Latin American and international references in a brand-new synthesis.

We will analyze the case of the Rosario CMS in greater depth than the previous cases, in three respects: (a) the political context of the dictatorship that was going on throughout the development of the journal; (b) the institutional context in which it developed; (c) the editorial procedures for the journal. In each of these aspects, we identify the principal actors and reconstruct the strategies they pursued.

The political context: the military dictatorship and survival strategies

Analysis of the rise of the Rosario CMS needs to take into account a factor that fundamentally affected the journal’s development: the Argentine military dictatorship’s policy of political persecution from 1976-1983. The journal’s first issue appeared in April 1978, two years after the military seized power and set out to combat the alleged danger of working-class and/or leftist movements. The military regime began practicing state-sponsored terrorism within Argentina, and tens of thousands of people were persecuted, tortured, disappeared, or forced into exile. Within that context, just three months before the beginning of the FIFA World Cup held in Argentina - which gave human rights some international visibility as a way to fight state-sponsored crimes - with institutions such as the National Academy of Medicine (Academia Nacional de Medicina) supporting the military dictatorship (Spinelli, 2014), the social medicine movement could not find spaces to support its development. On the contrary, many leading figures had to go into exile in Latin America or Europe; others lost their jobs and were forced into internal exile.

This was the case for Carlos Bloch, the driving force behind CMS. During the military dictatorship, he was fired from his teaching and clinical positions at a provincial hospital. His son mentions that “the dictatorship turned him into a full-time public health expert” (Bloch, 2013). Forced by circumstances to leave his job, Bloch wielded his experience and personal contacts to move to the Center for Health and Social Studies (Centro de Estudios Sanitarios y Sociales, CESS) within the Rosario Medical Association (Asociación Médica de Rosario, AMR). There he founded CMS and was involved in various research projects on the history of the healthcare field in Argentina (Belmartino et al., 1988; Belmartino, Bloch, 1994) and the market for medical work in Rosario (Bloch, Torres de Quinteros, Belmartino, 1981).

The career of Susana Belmartino, another leading figure in the field and part of the research team at the CESS, also shows the political and institutional situation in the country and the nature of the CESS and CMS projects. In October 1975, she was threatened by the Argentina Anticommunist Alliance (Alianza Anticomunista Argentina, known as “Triple A”) along with thirty other educators, and forced to resign her job as head of practicums in the department of contemporary history at the National University of Rosario (Universidad Nacional de Rosario). In 1978, she was contacted by Silvia Sigal, Carlos Bloch’s wife, who had also been fired from the Faculty of Medicine (Facultad de Medicina), and invited to work on a project involving the history of the healthcare field (Belmartino, 2010). She was 40 years old when she joined the CESS, and she did her most well-known research there: “They treated me well; they listened to me, respected me, and that helped me make national and international contacts,” she acknowledged in her interview.

In that context of persecution and and loss of job opportunities, the AMR - thanks to its interests and its public visibility - provided a space that shielded the proponents of social medicine from potential reprisals. This was possible in part because of the AMR’s ambivalent position in the public sphere; while its directors were often physicians linked to leftist causes, in general they did not belong to groups espousing armed struggled. The other factor was that, as a physicians’ organization, the true interest of the AMR board lay in maintaining the power of the medical association; to keep that power, it could not be seen by the military as harboring revolutionary militants.

Thus, the AMR made possible one of the main publishing goals of social medicine and became a refuge for professional development for the editorial team at CMS. For Bloch, this team was equally involved in research activities and publishing the journal as it was to managing the association’s affairs. In Belmartino’s case, CMS helped her pursue an academic research career in healthcare history. Her CV lists over fifty scientific articles published in national and international journals (most often in CMS), as well as eleven books. The majority of these publications were the product of collaborations with CESS researchers, including a number of papers co-authored with Bloch, Troncoso and Quinteros, among others.

Despite this, when Belmartino applied to join the National Board for Scientific and Technical Research (Consejo Nacional de Investigaciones Científicas y Técnicas, Conicet), she was rejected, like the rest of the professional team at CMS, showing another of the limitations the dictatorship imposed on people’s careers.

The institutional context and possibilities for development: the Rosario Medical Association and the Center for Health and Social Studies

The Rosario Medical Association was founded in 1932 to defend the interests of medical professionals. However, it also carried out other types of activities, like creating the Center for Health and Social Studies (CESS), as described in number 13 of the association’s minutes for July 26, 1973. The founding agreement was signed by Osvaldo Madera, Eduardo Depaoli, Isidoro Palosky, Raúl Cárdenas, Ernesto Taboada, Carlos Alberto Toni and Silvia Sigal, and it states that:

The country cannot continue running the work of healthcare under rules and organizations from the previous century … the need for change in the current rather anachronistic healthcare structures obliges this Association to endeavor to promote a new kind of medical care that will contribute to improving health levels in the population (AMR, 1973, p.23).

The founding documents assign four goals for the CESS: (1) to carry out studies on topics identified as healthcare and socio-medical problems, the organization and funding of healthcare, and medical care and training; (2) to consult with the AMR’s governing body as an expert board; (3) to disseminate work on “social medicine and public health”; and (4) to publish a journal that would be a mouthpiece for the CESS (AMR, 1973, p.24). According to statements made by Bloch years later, the center arose in particular out of discussion over how to create a Comprehensive National Healthcare System (Sistema Nacional Integrado de Salud, SNIS) (Trabajo gremial…, 1993).

In March 1977, in the wake of political purges, Carlos Bloch was named director of the CESS (AMR, 1977). There he set out to launch publication of CMS and developed a whole strategy for connecting with other social medicine proponents, among them Juan César García. One of our interviewees stated that CMS emerged at least in part because the intellectual group based in the CESS felt they needed a different political strategy that would bring broader range of theoretical views to the discussion, since the traditional forms of struggle such as professional associations were hampered by the political situation. This involved great personal dedication on the part of Carlos Bloch. His son remembers him as working tirelessly, throwing himself into CESS meetings held at their home, which was full of files and books reflecting the political activities of the association as well as editorial activities. Bloch also showed receptivity to other disciplines, which earned him the nickname of “the entomologist” among his colleagues, since according to Belmartino, “he would go looking for bizarre specimens [meaning professionals from other areas and approaches] and bring them to the CESS.”

The AMR was able to provide support and funding for CMS because its resources had increased thanks to a spike in membership in the early 1970s; it went from 711 members in August 1972 to 1,141 in August 1974, an increase of 60% over two years (Asociación, 1974). This was a result of the importance of medical organizations in handling payment of doctors’ professional fees, within what Belmartino and Bloch (1994) called the “business pact” between the Medical Confederation of the Republic of Argentina (Confederación Médica de la República Argentina) and the General Confederation of Labor (Confederación General del Trabajo), which administered social security funds and the substantial profits to be derived from financial control of those resources.

Overall, Carlos Bloch succeeded in building a kind of institutional stability within the AMR that was not possible in other spaces, thanks to his devoted hard work and his political management skills within the association. In fact, interviewees considered him the brains behind the AMR, even though he was never its secretary general. His office was a meeting point for people. According to Belmartino, “Bloch had a lot of power within the association, and I think he handled it really well, because he never confronted anyone directly; he would try to work around a problem and move on.”

Within the AMR, political stability was based on a strategy of including the different factions within the association. Thus, after each election, the AMR appointed some members of the opposition lists to the board of directors, as in the case of Hermes Binner, a socialist, who later became the Secretary for Health and mayor of Rosario (1995-2003), governor of Santa Fe (2007-2001) and then a candidate for the presidency in 2011. This strategy has allowed the Lista Movement Association - of which Bloch was a cofounder - to stay in control of the AMR from the 1970s to the present. That stability created a productive work climate for CMS. Belmartino remembers the AMR as “a very generous association; an institution with a good work philosophy that sought to stay in power without abandoning its principles. The AMR was in total agreement with us at the beginning, when Osvaldo Madera - the secretary general - and Eduardo Dipaoli - a board member - came to talk with us ... it was later, when the board of directors became more mixed, that the criticism started.”

This support did not mean that the AMR openly identified with social medicine or listed CMS as central to its objectives. In fact, despite Bloch’s leading role in the AMR and the importance of CMS in Latin America, within the context of the association and its professional groups, CMS often went unnoticed. Belmartino says that at one point they organized informational meetings “and [people] hadn’t read what we were talking about.”

The AMR’s support did come into question when the association’s resources waned in the 1990s, after an overhaul in the handling of professional contracts. At that point, there was more criticism of the CESS’ board of directors, which led to financial difficulties keeping the journal in print and caused it to shut down in 1995, marking the end of the first stage of CMS in Rosario. Three years later, in 1998, thanks to a group of researchers who (according to Belmartino) came up with a method of organization and distribution that did not generate expenses for the AMR, CMS resumed publication until 2002, when the economic crisis throughout the country forced the journal to close down for good.

Clearly, one of the main factors behind CMS’ continuity and stability - in addition to the material support provided by the AMR - was its solid team of full-time professionals, who earned the same as a full-time position at the university. The creation of the CESS and CMS involved the collaboration and participation not only of Carlos Bloch, but also Osvaldo Madera, the AMR’s secretary general, Eduardo Dipaoli, a member of the board of directors, and María del Carmen Troncoso and Zulema Quinteros, research consultants at the PAHO. Some of the articles in CMS came from their research. Historian Susana Belmartino also published work with CMS a year later.

Editorial procedures

Editorial decisions involving content in CMS were made by Carlos Bloch, who developed a series of strategies for obtaining, publishing and publicizing material that covered different points of view. Bloch felt the journal’s primary goal was to promote social medicine theories among physicians, so the early issues contained few previously unpublished articles, and were mostly devoted to reprinting work by foreign authors who were not always well known. According to Belmartino, publication of the early articles was very influenced by the network of personal contacts with members of CESS, and was driven fundamentally by the AMR’s activity and also by consultants for the PAHO. García played a central role in obtaining these consultancy positions, which offered an opportunity to get to know leading figures in other countries. Bloch’s experience was key here, as was Troncoso’s, who had also worked at the PAHO and collaborated with Juan César García. Susana Belmartino mentions that “García was a big friend, and he was at the PAHO; I imagine he was the one who got us the funding for the first books.”

Thus, Bloch also contacted potential authors by letter - as in the case of Mario Testa - and invited them to submit articles. Belmartino says that Bloch also used the telephone a lot for networking and that in addition he “spent the day reading; his friends at the AMR called him a bookworm. He set up the AMR library and so among the clinical journals we were sent journals on social medicine.”

This strategy of dissemination meant that the journal did not initially follow criteria that are fundamental to present-day academic journals, such as originality and peer review. In the early years, the decision to publish was made by Bloch. It was he who read and selected the articles that came along (both original and previously published) and chose the ones he found interesting for publication in the journal. This sometimes involved an editing process, one more indication of the survival strategies necessary in times of repression. As Belmartino tells it, they needed to be careful not to trigger censorship and so, if there was a word that might irritate the military regime - concepts of a Marxist nature - it was changed before the text was published.

But undoubtedly, the extent to which the publishing venture could clash with political reality is mostly vividly revealed by the strategies for concealing the identity of some authors. The phrase “publish or perish” was coined in 1942 (Garfield, 1996), although it was popularized in recent decades to express the pressures within academia for researchers to publish. But in the context of this article, it could be reformulated as “publish and perish,” given the danger for both publishers and authors of putting one’s ideas in print. For this reason, people frequently published under pseudonyms. For example, Juan Cesar García published under the pseudonym Aureliano Mierr, in a reference to Aureliano Buendía, a central character in the García Márquez novel One hundred years of solitude. García used either that pen-name or “Brenda Starr” - an allusion to an adventurous reporter who featured in a cartoon strip at the time - to publish texts that were later republished under his true name in some of the journals analyzed here, and/or in book form. In the Rosario CMS, Mario Testa published under the pen-name Paulo Alexandre, a combination of the names of his two sons, and José Carlos Escudero published under the name Martín Sabelli, in homage to María Angélica Sabelli, a guerrilla fighter with the Revolutionary Armed Forces (Fuerzas Armadas Revolucionarias, FAR), who was executed at the Almirante Zar Naval Base in the Trelew massacre, and Martín in homage to Martín Fierro (a central character in an epic poem by the Argentine writer José Hernández). Carlos Bloch and Susana Belmartino also used pen-names to publish work on the military government’s healthcare policy: in the Revista Centroamericana de Ciencias de la Salud they appear as Carlos Alarcón and Susana Balmaceda, in a clear homage to tango (Balmaceda, Alarcón, 1979). This editorial practices, which would seem strange nowadays, point to the terror present in Latin America in those years.

Organization, editing and content

The printing costs and the skilled labor involved in publishing a journal (editing, proof-reading, layout, printing, and distribution) are usually the main obstacles to regular publication in editorial ventures. In the case of CMS, these challenges were handled differently in the journal’s two different stages (1978-1995 and 1998-2002). In the early years, production was managed by the CESS team, mainly Carlos Bloch and Victor Aliprandi, with financial support from the AMR for printing and distribution. The AMR actually had a press that printed the institution’s own journal, and it took over printing CMS. Under that scenario, the early issues looked more makeshift (the pages were stapled together and black and white cardstock covers were used). The signature blue cover was introduced in 1980, with issue 12. From then on, the journal’s resemblance to the Chilean Cuadernos Médico Sociales is not merely in name but also in terms of format and color, although this is not mentioned in the accounts of any of the interviewees.

Under this scenario, the journal managed mostly regular publication. Although it did not achieve the objective of appearing monthly, as initially envisaged (AMR, 1978), it fluctuated between three and four issues a year, except in 1978 and 1979 when it brought out six issues a year. This means that 332 articles were published during its first phase (1978-1995).

Figure 1: Covers of Cuadernos Médico Sociales from Chile and Cuadernos Médico Sociales from Rosario, Argentina 

The journal’s second phase, from 1988-2002, involved a change of strategy in terms of editing and distribution. After the AMR refused to continue meeting those costs, Susana Belmartino says that the journal was relaunched after “a group of researchers proposed to Carlos [Bloch] that we would handle distribution in a way that wouldn’t generate costs.” In practical terms, this meant that a press outside the AMR had to take over the editing, printing and binding. As a result, the journal underwent a qualitative technical improvement; a higher-quality paper and production process were used, and the frequency of publication changed. The journal shifted to publishing bi-annually until it closed in 2002, by which time it had published 65 articles.

Even with the limitations it faced, the journal did have various distribution channels: AMR associates, subscriptions or complementary copies donated to hospitals, healthcare centers or other places linked to public health, and to those active in different areas of social medicine. Distribution was by mail, since there was an agreement under which postage cost next to nothing. According to all our interviewees, this gave CMS significant visibility in various union-related settings and above all within the teaching of medicine, an area in which the “blue covers,” as they were known by some readers, came to be regularly consulted, discussed and referred to. Hugo Mercer acknowledges that CMS was a monumental journal, and that its articles were obligatory reference works for various sectors, including traditional physicians, for whom the contributions of Susana Belmartino, with her knowledge of history and her methodological rigor, were fundamental.

As for the content of the journal, Bloch’s editorial decisions turned the Rosario CMS into a space for the dissemination of ideas that reflected the multiple theoretical perspectives and themes within Latin American social medicine, at a period when the field was growing and redefining its goals and disciplinary and theoretical approaches.

Thus, it published articles from a Marxist perspective, but also other critiques of the healthcare system, including approaches such as symbolic interactionism or medical anthropology from the United States (Castro, 2011; Menéndez, 2009). This heterogeneity can also be observed in the national origins of the contributing authors, where representatives of European schools (especially French and Italians) mingled with Latin Americans and, to a lesser extent, with documents from the Pan American Health Organization (PAHO) and the World Health Organization (WHO).

Thus, in the early years, CMS published notable authors like Michel Foucault; public health experts and epidemiologists with international reputations such as Halfdan Mahler, Jean Clavreul, André Pierre Constandriopoulos, Mario Timio, Giovanni Berlinguer, Thomas Bodenheimer, and Milton Terris; and public health experts from Argentina and Latin America (whether exiled or not) such as Aldo Neri, Floreal Ferrara, Jorge Katz, Carlos Canitrot and Emiliano Galende, to whom we should add various members of the editorial teams on the other journals analyzed here, mentioned above.

In terms of content, the topics covered by the journal also reflect the main interests within the field of Latin American social medicine. Based on the articles published, one can, in fact, reconstruct a broad range of topics: the journal’s main themes were the origins of social medicine, the training of physicians, strategies for primary care, the role of social security and “social projects,” the different health insurance models, the evolution of the doctor-patient relationship, advances in the pharmaceutical industry and its corporate power, the development of medical technology, the critique of traditional psychiatric therapies, and occupational health. In addition, the CESS team contributed articles on the politics and history of the healthcare system in Argentina.

Final considerations

The journals analyzed here reflect some of the main characteristics of the field of Latin American social medicine at an early stage in its institutionalization. In particular, they show the hybrid characteristic of being at once a space for “thought” and for practice (Almeida Filho, Paim, 1999), in which healthcare policy intervention mattered as much, or more, than mere production of knowledge (which was subordinate, in any case, to capability for social intervention). So it is not useful to analyze these journals merely as academic enterprises, nor to analyze the strategies for creating this space according to the classic parameters for institutionalization in other scientific disciplines.

Given the period in history in which this process of institutionalization occurred, the journals analyzed performed at least two central functions: on the one hand, they helped circulate previously published work as part of a dissemination strategy but, above all, they served to delineate the boundaries of interests within the field and at the same time to help promote the production of original knowledge of Latin American social medicine, contributing to the consolidation of a group of authors and readers.

There were various common features among the experiences we have analyzed. Most importantly, we stress the strong influence of the political processes taking place as these journals grew up. In the first place, there was the repressive environment of military dictatorships in the region, which involved persecution and exile for the majority of the leading figures in the movement, who were for the most part either formally or informally linked to popular and/or leftist parties or movements. A related and more subjective type of result of the political situation was the growth of strong solidarity networks connecting the protagonists of this story, which led to the construction of work spaces in the different countries that allowed productive opportunities to arise. In the construction of these networks and the creation of these opportunities (whether thanks to PAHO resources or to crucial symbolic and political support), we should emphasize the importance of Juan César García.

As we have indicated, García is undoubtedly a crucial link between all these publishing ventures, directly and/or indirectly. The presence of articles by him in early issues of all the journals and his support in terms of connecting authors and editors is clear. He was the organizer of a network in which some nodes strengthened over time, while others disappeared. These networks made it possible, in the context of the Latin American dictatorships, to support numerous professionals, providing settings for specialists to meet, such as scientific conferences or professional institutions, and resources allowing them to subsist through consultancies at international organizations.

Another element these publishing ventures had in common was the difficulty of overcoming their dependence on personal efforts and becoming long-term institutional projects. The shortage of technological resources for publishing, the impossibility of professionalizing the process, funding uncertainty and distribution and marketing difficulties were challenging obstacles to overcome in the majority of cases. In general, the first issues of these journals were very rudimentary in publishing terms, but they managed to improve over time.

As social medicine became institutionalized and developed spaces for professional training and positions, the role of publications in the field began changing. The journals that survived modified their original approach, incorporating practices typical of scientific journals (double-blind peer review, indexing, and a requirement that work be original). This meant that the eminently political approach they followed at the outset was complemented by others that were more specialized, scientific and editorial.

The importance of these journals is that they succeeded in creating a framework for articulating a field of knowledge, inspiring other journals of social medicine and/or collective health. Nowadays, some of the journals analyzed, and others that came after them, have become indexed scientific journals that represent a significant proportion of the publications included, for example, in SciELO Public Health and the main international databases for scientific bibliography.

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Received: March 01, 2016; Accepted: October 01, 2016

Avenida 29 de Septiembre, 3901 B1826GLC - Lanús - Argentina hugospinelli09@gmail.com

Avenida 29 de Septiembre, 3901 B1826GLC - Lanús - Argentina juan@librandi.com.ar

Avenida 29 de Septiembre, 3901 B1826GLC - Lanús - Argentina jpzeta@unq.edu.ar

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