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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.12 Rio de Janeiro Dec. 2019  Epub Nov 25, 2019

https://doi.org/10.1590/1413-812320182412.25152019 

ARTICLE

Health on the move: social movements and popular health in La Plata, Argentina

1Comisión de Investigaciones Científicas de la Provincia de Buenos Aires (CIC). Calle 526 entre 10 e 11, B1900. La Plata Buenos Aires Argentina. sol12lgr@gmail.com


Abstract

This article investigates the popular participation in health in neighborhoods of the periphery of La Plata (Argentina) in a context of emptying of social policies according to the neo-liberal regulations that govern with increasing force in the country and in the continent. In this framework of economic crisis that especially affects public health, social movements are organized to defend, while resisting daily impoverishment and building popular and collective health alternatives. The work, sustained in an ethnographic investigation, aims to reconstruct the ways in which the subjects reconfigure the ways of thinking about health and political participation in the daily life of the territories through different tactics and strategies of care and community-political construction.

Key words Popular Health; Participation; Agency; Crisis

Resumen

El presente artículo indaga sobre la participación popular en salud en barrios de la periferia de La Plata (Argentina) en un contexto de vaciamiento de las políticas sociales de acuerdo a las normativas neoliberales que rigen con fuerza creciente en el país y en el continente. En este marco de crisis económica que afecta particularmente a la salud pública, los movimientos sociales se organizan para defenderla, al mismo tiempo que resisten el empobrecimiento cotidiano y construyen alternativas de salud popular y colectiva. El trabajo, sostenido en una investigación etnográfica, se propone reconstruir los modos en que los sujetos reconfiguran los modos de pensar la salud y la participación política en la vida cotidiana de los territorios a través de distintas tácticas y estrategias de cuidado y construcción político-comunitarias.

Palabras clave Salud Popular; Participación; Agencia, Crisis

Introduction

Health constitutes a field of social and political dispute in which different discourses converge both to build and to install certain senses and to define the forms of intervention and regulation through public policies. An initial question to introduce our perspective is in the way we define it, as a complex, historically and culturally constructed concept that involves biological processes as well as social, political and moral ones. Although traditionally it has been defined from a biological, ahistorical and located within the medical discipline, today other dimensions and fields of knowledge are affecting, assuming that the biological is present but that each cultural configuration has created and disputed senses and values on what healthy means. In this sense, critical medical anthropology has distinguished three dimensions that converge in the health of people and communities: those of the disease – the biological disease –, the illness – the experience of suffering – and sickness – the social, economic and political processes1-3.

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not just the absence of conditions or diseases”. On the other hand, anthropological studies teach us that concepts are defined by a specific historical framework that exposes them in context and relates them to other signifiers and meanings4. From this perspective, the categories that order social life are always ethnographic, in the sense that they are constructed situationally in social interactions. Health is a category in dispute in which multiple discourses converge to influence the orientation of public policies and the practical resolution of daily life in relation to the processes of health, disease, and care.

The Social Movement in which we register our inquiry is a civil society organization that emerged in the 2001 crisis in Argentina. The studies on social movements (MS) have a vast bibliography from which we recover the concept proposed by Manzano from the anthropology of politics and power. For Manzano5, the notion of MS implies forms of social mobilization that challenge the framework of action established by “conventional politics”; that is, they develop outside the institutionalized political and social action spaces in liberal democracies. In this sense, the author points out the potential for reflection on movements to stress the notions of politics as a differentiated, institutionalized domain and as an arena of professionals; and, at the same time, the separation between State and Civil Society.

In turn, Manzano5 recognizes the heterogeneity of the MS that have proliferated since the sixties, identifying feminist movements, environmentalists, picketers and action processes that meet articulated in multiple demands. One of them is the right to health, which has been consolidated since the mid-twentieth century within the so-called “social issue”. In the 1990s, in Argentina, changes in the accumulation model were radicalized, generating an increase in unemployment and poverty, the dismantling of the State and the deterioration of the vital conditions of the people, which led to the crisis in 20016. Grimberg gives an account of the way in which, in this context, health enters the agenda of problems at the hands of the MS picketers. The politicization of the conflict in health can be seen in strategies such as collective censuses, roadblocks, taking over of hospitals, soup kitchens and assemblies7. These first political events of mobilization around the right to health and life are fundamental to think about the current politicization of health as a mobilizing axis of the protest in the neighborhoods, since they constitute a milestone in the historical memory of the popular organization.

In this article, the ways in which collective health is built in the daily life of neighborhoods of popular sectors will be addressed based on the analysis of the resistance practices of a Social Movement (MLJ) registered in the Confederation of Popular Economy Workers (CTEP). First, the methodology used will be detailed. Next, we will replace some distinctive features of the health system in Argentina and then reconstruct, in the following sections, the different organizational modalities developed by the MLJ actors to resist, fight and conquer rights in the neighborhoods. In the first place, we will cover the role of health promoters formed by MLJ itself “to build popular health in the neighborhoods” and the women’s political agency that assumes that role with their neighbors and cooperative partners. Second, we will analyze the participation of this movement in an organization called “Movement for the Right to Health” (MDS), a confluence of actors organized against Universal Health Coverage (CUS). Finally, we will analyze the self-managed health project of the Mutual Senderos, “the Mutual of Workers of the Popular Economy”.

Method

For the present investigation, we used a qualitative methodology with an ethnographic approach to interpret the perspectives of women who live and work in neighborhoods of the outskirts of La Plata and participate in the MLJ, what Geertz calls “the actor’s perspective”8. For this article, the data collected in one of the studied neighborhoods was emphasized, to achieve greater depth in its description. In the 2016-2017 period, we made observations in training workshops in health promotion, health workshops with neighbors, cooperative workdays, mobilizations, street cuts, and meetings. At the same time, we established informal conversations and interviews in the field with 10 women between 25 and 40 years old. Finally, the selection of the corpus was made from the first contact with key informants and the “snowball” technique to be able to multiply the conversations. The names of the interviewed actors were modified to protect their identity, respecting the ethical requirements in the work with the interlocutors.

Health in Argentina

The Argentine health system is made up of three sectors: the public sector that is financed through general income and is governed by the principles of universality and equity of care; the medical insurance sector, which is a mandatory health protection system for workers in a dependency relationship; and the private sector whose benefits are paid through the contracting of prepaid systems or through payments directly from the users.

La Plata belongs to the Sanitary Region XI of the Province of Buenos Aires. The relationship between center and periphery in a geometrically planned modern city9, constitutes an asymmetry of power in which what is left outside the urban area, in turn is left out, or unevenly integrated, of access to basic services such as health, education, transportation, and the environment, among other rights. The neighborhood in which we emphasized for this article, called “Futuro”, does not have its own Sanitary Unit. To access interventions in the official health system, it is necessary to travel long distances. The bus enters only during rush hour, that is, at the entrance and exit of the school, since the paving is irregular for traffic, as well as ambulances, which sometimes do not enter or delay attention to these spaces for being considered “dangerous”.

The public health system, in recent years, has reduced its capacity for attention due to irregularity in the execution of the budget, the lack of circulation of necessary supplies such as medicine and contraceptive methods and the dismantling of basic programs for the guarantee of Right to a healthy life. According to a report by the Fundación Soberanía Sanitaria (Sovereignty Health Foundation), current economic policies pushed large sectors into poverty and worsened the living conditions of the population as a whole. The increase in the price of medicine, prepaid and the inclusion of bonuses and co-payments in medical insurance companies, negatively impacted the health of the population by increasing out-of-pocket expenses and creating access barriers10. The report indicates that the loss of salary purchasing power and the increase in prices make it difficult to access food of sufficient quality and quantity, which impacts on the health indicators of the population, favoring the development of overweight, obesity and malnutrition.

Given these reconfigurations in living conditions, the right to health has weakened, sharpening the need for participation in the defense of rights. Next, we will address the tactics and strategies carried out by the MLJ to overcome the injustices related to health and build new ways of thinking and living health in the neighborhoods.

The health promoters

We understand that the practices described hereafter must be inscribed in a reflection on power and agency. To begin, we return to Certeau’s notion of tactics11, who believes that tactics are the resource of the weak to counter the strategy of the strong. The tactic acts from the imposition of an external force, against which it opposes resistance. In turn, we maintain, together with Ortner that “the agency is a necessary element to understand how people act (or try) in the world even when they are the object of specific wishes or intentions within a matrix of subjectivity, thoughts and meanings (culturally instituted)”12. According to Sewell13 “however uneven the distribution of resources may be, to some extent human and non-human resources are controlled by all members of society, regardless of how dispossessed or oppressed they are”. For Ortner12, to the extent that we understand that the subjects “have an agency”, we will examine their construction as a type of empowerment and as a basis for the realization of different “projects” in a world where domination and inequality prevail. We will see in this section, one of the tactics developed by the actors who have a leading role in the MLJ and the resistance in the neighborhoods: the creation of the figure of the promoter of popular health.

Given the state of the economic situation and the multiple barriers to access to the health system, in 2016, the MLJ created a specific area to address health in the territories. Before the creation of this space, the Movement had established itself as a mediator and a manager in the matter of the health of the workers of the popular economy under its administration. The office (headquarters of the Movement) receives daily telephone calls, visits and inquiries from cooperatives to get doctor’s appointments, as well as resorting to the organization’s referents to solve emergencies. Following this growing demand and the irregularities of an increasingly underfunded health system, it was decided, as a first measure of the area, to train a group of cooperatives from different neighborhoods of the city to become Health Promoters, such as “the first step so that the woman can go out and contribute to the prevention and health care of all the neighbors, in the neighborhoods where access to health services does not reach or is more difficult to access” (Reference of the health area). The health promoters receive their payment as consideration for the various welfare plans managed by the MLJ. One of the ways of building popular health consists of the creativity for the use of resources, so that what is given by Social Development then rethought in the terms and needs of its own territorial project.

The figure of the health promoter as such begins to be thought, above all, at the end of the 20th century, when the world-wide conception of health and the regulation of its exercise was re-oriented generating profound changes in health policies. This movement, which was transversal to all of Latin America, can be summarized in the Conferences held under the auspices of WHO: the Declaration of Alma-Ata (Russia, 1978) and the Ottawa Charter for Health Promotion (Canada, 1986). Within that framework, it is established that health is a fundamental human right and is defined as a state of complete physical, mental and social well-being and not just the absence of disease; while promoting individual and collective participation in health care.

The health promoters of the neighborhood who find themselves in a space of intersections are called to link the health system with the territory. The MLJ incorporated into its strategies the figure of the Health Promoter in a framework of relationships and particular meanings, which although it takes up central elements of the international guidelines, appropriates them in different ways. The promoters trained in the framework of MS, in addition to the guidelines suggested by international and national organizations, have the role of assuming a position of health struggle for their neighborhoods and promoting the organization and awareness that “each conquest is the result of fighting on the streets and on the roads”. A day of fighting in a road cut or camp in front of the Ministry of Health of the Municipality is also a day of work. At the same time that the cleaning of streams, ditches and streets and the conversations with the neighbors about the importance of health care and the link with the access roads to the health of the MLJ are a fundamental part of their role.

In this way, the promoters organized in the MLJ not only link their partners with the Health System but also organize with them to resist and demand responsibility for it in the face of the health crisis. Within this framework, women develop resistance and cunning tactics to build healthy lifestyles. For example, when the promoters suggest to their cooperative members to appear in the Primary Health Center “as informed as possible”, and if their requests for consultation are rejected, request a “certificate of negativity”, since “there they bail out”. In these workshops, in turn, they negotiate and stress the expectations of the health system that establishes recommendations “far from life in the neighborhoods”. It was in the framework of a workshop on “Hypertension and respiratory problems” that the item “gym assistance” and “consumption of fruits and vegetables” of the brochures prepared enabled a debate on the difficulties of adapting their living conditions to healthy practices suggested by the government; since the cost of this type of food is high and the neighborhood does not have gyms or parks for body recreation. The need to fight for everything that is missing is introduced in this mismatching situation.

In these photographs of the relationships that women establish between themselves and with health institutions, it is possible to observe the politicity of their experiences and their feelings concerning health. The construction of health in the neighborhood occurs in the space of relations of domination, resistance, struggle, and conflict. Health, in this context, constitutes one of the (transversal) axes of the struggle for better living conditions mobilized by the organization.

Some everyday scenes of transformation in health

Eyeglasses

It is six in the afternoon and school time begins. The teacher asked in the previous class for students to investigate a series of historical events linked to the struggle of women. María had “The First Meeting of Women in 1986”. She wrote in her notebook some notes and reads them aloud. When she looks down to read what is written, she puts on her glasses and her classmates pay particular attention to that object: “What beautiful glasses!”, “Where did you get them?” Maria thanks them and thanks the health promoter in particular who made the connection. The glasses are obtained through the MLJ and a University program called Visual Health. That same afternoon, the group organized with the health promoter to put together a list of those who needed to wear glasses in the next few days. When asked the question, many wondered for the first time if they saw well. Several months later, when the Mutual Senderos had deepened their affiliation in La Plata, the cooperative members were able to access one pair of glasses per year. For most of them those were the first pair of glasses they had ever had in their life. This acquisition was a significant change in their daily lives because it allowed them to perform their tasks more effectively, read on the board, look at the posters on the street with precision and help their children with their homework.

Affiliation

In June 2017, a group of students and cooperative members of the MLJ was invited to the provincial library to participate in the reading of stories and poetry. On the return trip, in a climate of intimacy under the excitement of the walk to the center among friends, Adela tells us that she is pregnant. She says she thinks they are going to be twins because her belly is very big and she already had twins. She is six months pregnant and still has not had an ultrasound. The teacher tells her that she needs to get medical insurance, so she can get an appointment with a doctor quickly. Valeria puts her in touch with María, who is the health promoter of the neighborhood. When she asks if she has medical insurance, Adela tells her that she “was lazy”. Her friends reproach her that she had played soccer throughout most of her pregnancy. Then they get started to make the affiliation during the week. Then they all laugh remembering that one of the tasks that the teacher asked them to do was to write the activities they do during the day and Rosana humorously says that Adela did not tell everything she did during the day. This is one of the cases in which the reliable figure of the health promoter shortened some of the most common health barriers in the neighborhood. Adela had not had good experiences in her previous ten pregnancies and births, she was mistreated and had to overcome difficult situations. One of the concerns of her eleventh pregnancy was that doctors would let her get a tubal ligation because when she requested it during her previous pregnancy, she was told she was too young. With the confidence of being accompanied by the promoter and the information she was given on her sexual and reproductive rights, together, they managed to make her pregnancy a process of decisions and autonomy.

The popular translation

It is Saturday morning and at the headquarters of the MLJ a meeting of “Gender and Native Languages” is starting. The activity is carried out in a small house where other activities such as primary and secondary school, the soup kitchen and the group of weavers work. It is a house of about 7 by 3 meters, with a small cement patio with a clay oven from which you can access an orchard. The original idea of the meeting was from Felicia, a Bolivian member of the cooperative who speaks Quechua as her first language. Felicia’s concern is that “to reach the women of the neighborhood” you have to know how to speak their language because “there are things that are better said in your mother tongue”. During the morning I would realize that she was talking fundamentally about painful experiences that are better expressed in your native language. This idea also arose in different instances of conversation in relation to medical care since “violence during childbirth is a problem that this neighborhood has”, as one of the workshop coordinators said. To which Felicia added that “Women are mistreated and we cannot communicate well”. The room is decorated with red and white signs that say the word “woman” in different languages. Soon the workshop begins with 20 women sitting in a circle and an introductory role-play takes place. The day was long and had different moments. For this article, we are interested in recalling one of them. One of the activities proposed by the coordinators was to recreate the doctor-patient relationship in a consultation at the Hospital. The actresses of the activity were Felicia and Noelia. Felicia in a white coat was the doctor and Noelia, the patient. In the role-play, the patient arrives with a strong stomach ache and the doctor kindly answers her in Quechua making signs and gestures to guide mutual understanding. She suggests taking medicinal herbs and sometimes speaks Spanish. In the analysis of the scene, the women gathered made a comparison with how they are treated by doctors and the way in which language becomes a barrier when it is added to abuse. Then the debate shifted to strategies to overcome this problem and the need for health promoters who know the languages spoken in the neighborhood.

In all these snapshots of daily life, it is possible to notice how the health training of the promoters is articulated with the conversations of daily life, the activities of the meeting and the advice that constitute the reproduction of society in the neighborhood entrenchment, those that, dismissed from certain perspectives of the social as mere reproduction are, as we saw, relations that favor the guarantee of the right to health in the urban periphery.

Fight against the CUS and the economic crisis

As we initially pointed out, one of the fundamental aspects to study health is the way in which it is defined by actors located in specific configurations. Mariana, one of the leaders of the MLJ and the health area defined it as follows:

The idea of popular health started a long time ago when we realized that health is something much broader than being sick, that health has to do with the living conditions of each one of us and not just with the instance of getting sick. So there we begin to develop this broader idea of health and begin to look for definitions of health that are a little broader, more comprehensive, than “being sick.” That led us to find what is called the “Popular Health” that has as a characteristic that states that health is something collective, that it is not a process of individual illness of a person, but is a collective social construction.

In addition to the previous practices described, MJL women who studied to be health promoters participate in a Provincial Forum of the Movement for the Right to Health (MDS). This space of political confluence gathers “people, institutions or organizations that maintain in their practices the defense of health as a right” through assemblies and interventions in the public space to pressure the authorities and make visible the crisis of the health system. It was formed in 2017 by health unions, social and political organizations and universities to fight against the CUS. Among health professionals, medical students of the University and social workers, the health promoters were “the only ‘representatives of the territory’” (in this way they were presented by those who led the meeting). When they were questioned to share their perception of what they “saw in the day-to-day neighborhoods” and to think about ways to spread the campaign against the CUS, one of the promoters pointed out the difficulty of preventing about the worsening public health conditions when currently its operation is precarious: “How do we tell the comrades of the neighborhoods to say no to the CUS if what we have now is not right?”

The CUS is, according to the MDS, “a policy that stratifies the population according to contribution capacity and defines better benefits for those who have payment possibilities”. According to its organizers, “the MDS forms a new experience in defense of the right to health in times of democracy in the Argentine Republic. It draws on the battle of workers and users in defense of their rights and the public system in the conceptual renewal of the process of care that expresses collective health”.

The right to health is presented by the MDS and in conjunction with the notion of struggle and conquest of rights of the MJL Health Area as a legitimizing notion of protest. Following Manzano14 who retakes Thompson15, this mobilization around health appeals to norms and customs generated in previous modalities of relations between the subaltern groups and the State. In particular, they refer to the memory of the creation of the Ministry of Health (now reduced to the Secretariat) and the health policies of the Welfare State. Thompson reversed the approach of the spasmodic view of popular history to ask about the legitimizing notions in which the livelihoods were rooted and emphasized that these notions anchored in the defense of traditional rights and customs, and appealed to social norms and expectations. In the definition of health as a right and the defense of public health, memory and mobilization processes are registered that are able to legitimize the organization against the current health situation and build new ways of thinking and living health.

According to Mariana, one of the leaders of the Health Area “For those of us who believe that health is a right, passing the Ministry to a Secretariat is suggesting that they are cutting it, that is, there will be less money to guarantee that right, and also that they are installing this idea that it will be a health service and not a right (Interview with Mariana).

The defense for public health constitutes an articulating node of dissimilar and shared experiences among multiple actors (doctors, nurses, social workers, politicians, health promoters, neighbors). This articulation is not necessary, but contingent and unstable, and meets constant definitions and re-definitions between disputes and negotiations. Both CUS and the reduction of the Ministry to the Secretariat under the orbit of the Ministry of Development constituted an interpellation for diverse actors identified in the legitimizing notion of the right to health.

The Mutual S enderos

Although the defense of public health is one of the fundamental pillars of the Health Area and the MLJ as a whole, they say “it is necessary to generate strategies to survive the day-to-day lives of neighborhoods today” (Promoter). At the same time, the Social Economy organizations developed a strategy to guarantee access to health during the absence of the State. It was in this framework that the CTEP in 2013 created the Mutual Association of Health Trails and in recent years the MLJ began to articulate with said medical insurance to improve the quality of life of its workers. This Mutual Association, since 2013, has a Family and Community Health Plan based on disease care and prevention, health promotion and education. In La Plata, it began with a practice constituted by a general practitioner outside the city and in July 2018 the Mutual Society’s own offices were inaugurated. The Health Center has the services of Pediatrics, Clinic, Gynecology, Obstetrics, and Dentistry. In turn, the booklet has sanatoriums, pharmacies, specialists and offices for the care of the members.

The unionized workers in the CTEP are mostly “cartoneros”, street vendors, traders, domestic and care workers, seamstresses, glass cleaners and “trapitos”, workers of recovered factories and workers of cooperatives dedicated to neighborhood improvement tasks (gutter cord, “ditching” and drains) or habitat care (stream cleaning, waste collection)16.

The Mutual Senderos bases its raison d’être on the workers of the popular economy. In their declaration of identity, they define the recipients of the Health Plan as “the postponed of our society”, “those who invented a farm and defended it to death”, “those who fight day by day for our land against indiscriminate progress”, and “those who have no labor rights”.

The coordinator of the Health space of the MLJ in the framework of the inauguration of the office of La Plata said that the founding fact constituted “an achievement of all men and women, that we have to inform in all the neighborhoods of this new place to serve us” and that “the opening of this new headquarters should give us a push to get our own ambulances to be able to make the transfers from the neighborhoods that we often need”. Since then, one of the fundamental roles of health promoters was the affiliation of their cooperative partners, while facilitating the link with the health system opened by the creation of the mutual.

In the context of this inauguration, one of the CTEP union leaders defined his position on public health and on the creation of a mutual society within the medical insurance sector, the mandatory protection system for women workers in a dependency relationship:

I never agreed that the workers organize the medical insurance plans because for me that had to be done by the State. The objective reality is that the State does not solve it. If the State does not solve it, we have to solve it. That is why the idea of starting a mutual society and taking care of health came up and with the small amount they can pay for the self-employed tax fee (...) trying to provide health (Intervention of Mario, union leader of the CTEP).

In turn, and in line with the definition of the MLJ Health Area, defined health in an integral way closely linked to the struggle and collective organization:

But our strategy goes far beyond solving the problems of a society that makes us sick, because we have in general the vision that health is when we go to the doctor, they attend to us, tell us the studies that we have to do and give us some medicine to cure us, or when they operate on us. Well, all that is disease, it is not health. Health is what we do collectively every day in the neighborhoods.

In these scenes, we notice the different battle entrenchments in which the popular sectors build health, both to defend public health and to resist in the “meanwhile”. Because while some may wait, “for neighborhoods, action and the struggle for everyday rights cannot be delayed” (Promoter).

Final thoughts

The sanitary doctor Floreal Ferrara focused on developing a comprehensive conception of public health linked to the notions of “conflict and struggle” and opposed to the conception sustained by international organizations based on the idea of “well-being” and “adaptation”. In this context, he proposed thinking of the state of health as a state in which “one is with a vital optimum, willing and holding any conflict that arises, then health is to overcome conflicts”17. This definition is very close to that elaborated by the subjects of our corpus, when conceiving that access to health is not something given or natural to the daily life of neighborhoods, but a right to conquer.

Throughout this article, we set out to investigate the modes of organization of the popular sectors to resist and build health in a context of crisis that particularly affects the health system. The strength of the claim in defense of public health refers to the constitution of a historical report of the Welfare State in which health in Argentina was conquered as an inalienable human right. At the same time, we saw that the sense of health is a historically and culturally situated category and that in our particular context of inquiry it is deeply articulated with the notion of struggle, since, according to a promoter “without struggle there is no health”.

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Received: January 29, 2019; Accepted: July 12, 2019; Published: August 28, 2019

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