COMMENTARY
Latin American Social Medicine and Global Social Medicine A fundamental change in the theory underlying public health and medicine is needed. Latin American social medicine (LASM), originating in a region of the world that has been subjected to colonial and postcolonial influence, will be part of this change. To the extent that the social production of disease among people in other regions is a consequence of various largescale forms of domination, LASM offers a relevant analysis, models of resistance, and exemplars of social medicine in practice. I draw upon LASM to examine the social production of disease in the Marshall Islands and Iraq. I suggest a basis for a global social medicine in the shared experience of suffering and describe implications for public health theory and practice. (Am J Public Health. 2003;93:1994–1996)
| Seiji Yamada, MD, MPH
IN THIS ARTICLE, I DRAW UPON Latin American social medicine (LASM) to examine situations in other parts of the world. I outline the contribution that LASM makes to global social medicine and identify reasons why it is necessary to learn about LASM. In the way that Foucault’s The Birth of the Clinic1 outlines the change from classificatory medicine to anatomoclinical medicine in the late 18th century, I believe that we are going to see changes in the fundamental theory of medicine—toward social medicine and toward an integration of public health and medicine—with a role for LASM.
ORIGINS OF LASM First and foremost, LASM offers to the rest of the world a form of social medicine forged under conditions of domination. In Latin America, colonial domination initiated by Spain and Portugal was followed by neocolonial domination by the United States. As noted by Howard Zinn: [L]ook at American policy in Latin America. What could be uglier or more violent than what the U.S. has done for over a century in Latin America? From the early dispatch of Marines to Haiti and the Dominican Republic to taking over Panama and the domination of Cuba to the dictatorships in Guatemala and elsewhere in Latin America . . . the deaths of hundreds of thousands of people as the result of what can only be described as American imperialism.2
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As Debora Tajer explains, LASM examines relations “between central and peripheral countries, as determinants of health conditions in the latter.”3(p2024) The emphasis placed on large-scale social forces is a common theme in LASM. In their recent review, Waitzkin and colleagues described the way in which social medicine can be distinguished from traditional public health: “much work in social medicine envisions populations, as well as social institutions, as totalities, whose characteristics transcend those of individuals. Social medicine therefore defines problems and seeks solutions with social rather than individual units of analysis.”4(p1594) Salvador Allende, physician, socialist, and a founder of LASM, decided that he could best serve its cause through political activity. He noted in a speech that he gave in 1971 as president of Chile: The experience of Chile and of so many other countries demonstrates the enormous limitations of the capitalist structure in satisfying the needs of the masses, whatever the extent of their internal development. In the case of Latin America its inadequacies are multiplied by the distorted features of a global system of production and exchange in which we have been given, and continue to suffer, the subordinate roles that [have] allowed us to be exploited to an intolerable degree.5(p130)
Allende was a victim of regime change in the military coup of September 11, 1973–Chile’s version of 9/11, and a reminder
of the vulnerability of our hopes for a better world.
THE CURRENT SITUATION Outright colonialism has been supplanted by more subtle forms of domination, with a prominent role played by international financial institutions.6 The resulting political and economic landscape determines patterns of health and disease among the people of Latin America. Asa Cristina Laurell has documented the social impact of structural adjustment policies adopted in Mexico in 1983. Reversing a trend in reduction of poverty that began in the 1960s, the percentage of poor households increased from 48.5% in 1981 to 78.0% in 1996.7 This rise in poverty and consequent poor health was followed by neoliberal “reform” of the health care system toward marketdriven insurance for workers covered by mandatory social security and a diminished set of services for the uninsured.8 Transnational insurance corporations have thus entered an insurance market that was previously the responsibility of public institutions.9 It is in the context of such national reforms that Laurell and her colleagues in the Mexico City government are instituting policies that restore health as a social right and a responsibility of government. Saul Franco points to the inequality of Colombian society as a structural element contributing
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to the violence so prevalent in that country. Justice and security is a social good that has been heavily privatized as paramilitary organizations step in where the government has lost control. Historically a country with one of the most unequal distributions of wealth in Latin America, drug dealers have now acquired vast tracts of land in Colombia.10 As an indicator of the role that the United States plays in such developments, Colombia is now the recipient of more US military aid than any country other than Israel or Egypt.11
APPLYING LASM TO THE MARSHALL ISLANDS Franco proposes the use of “explanatory contexts” as a theoretical tool in the study of violence in Colombia. He defines an explanatory context as “the specific combination of cultural, economic, social-political and legal conditions that make a phenomenon historically possible and rationally understandable.”12(pxxxx) In this vein, I briefly outline here an explanatory context for the epidemics of infectious and chronic diseases among the people of the Marshall Islands, where I have worked. Having defeated Japan during the Pacific war, the United States took control over Micronesia as a trust territory. Among perhaps its most egregious acts was the testing of nuclear weapons in the Marshall Islands from 1946 to 1957, leading to ecological destruction, displacement of residents of the area, and radiationrelated diseases. Today, the Marshall Islands still serve as a site for nuclear weapons development. Kwajalein atoll is the major testing site for the US Ballistic Missile Defense System; missiles
are launched from Kwajalein to intercept ballistic missiles launched from California. The largest island in Kwajalein atoll, Kwajalein Island, serves as the base for these operations. The Marshallese people are not allowed to live on Kwajalein Island, though they work there. They live in plywood and corrugated tin shacks on a much smaller island called Ebeye, where water is scarce and the sewage often backs up. A dependence on imported food of low nutritional value has led to malnutrition among children and an epidemic of weight gain and diabetes among adults.13 A cholera epidemic with 400 cases and 6 deaths occurred on Ebeye in December 2000. No cases occurred on the Kwajalein Island military base, only 3 mi (4.8 km) away. Thus, as a consequence of being subjected to the sort of military, political, social, and economic domination that the United States has imposed on Latin America, we see that the people of the Marshall Islands have paid with what little lands they have, their culture, and their bodies.
GLOBAL IMPLICATIONS The modes of domination that Latin America has suffered are now generalized to the world. The weapons developed in the Marshall Islands are used as a means to obtain acquiescence with US behavior in the world. The militarization of space, the essence of the Ballistic Missile Defense Program, aims to ensure the absolute military superiority of the United States, allowing it to act with impunity around the globe.14 US military planning clearly outlines the potential use of nuclear weapons,15 constituting a threat to the existence of
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the worldwide ecosystem and humanity as a whole.16 As noted by Franco, violence is not a random event. Most recently, we have seen the military technology developed in the Pacific Islands, with the attendant production of disease among the residents of the islands, put to use against the people of Iraq.
Again, LASM points the way for a critique of and resistance to the current situation: the awarding of reconstruction contracts to US multinational firms and the privatization of the oil industry. We must be vigilant for any future schemes to privatize health services or health insurance.
THE FUNDAMENTAL CONNECTION
GLOBAL SOCIAL MEDICINE AND IRAQ Having been invaded twice, having suffered under comprehensive economic sanctions in the interim, and being occupied now by the United States, the people of Iraq may wonder whether they do not live in a Latin American country. In turn, in the months before the recent war, the people of Latin America (along with the rest of the world) sympathized with the people of Iraq, and they showed their support by demonstrating against the impending event. There is a contentious debate about how many excess deaths occurred among Iraqis in the 2 wars and the period of sanctions. Even more contentious is the question of who is responsible for these deaths. Moreover, how were these deaths related to the destruction of the infrastructure, shortages of essential goods, lack of purchasing power, sanctions, or the responses of the government of Iraq? LASM might provide an explanatory framework for such issues. In regard to the military occupation of Iraq, Eduardo Galeano asked whether the democracy that is promised will be similar to that of Latin American countries occupied by the United States: Haiti under the Duvaliers, the Dominican Republic under Trujillo, Nicaragua under Somoza.17
In the end, how does LASM resonate for other people around the world? What is the fundamental emotional connection? I think about the character of Kip, the Sikh sapper, in Michael Ondaatje’s novel The English Patient.18 Its climax is the dropping of the bomb on Hiroshima. Kip, who has been defusing bombs for the British forces, realizes that—for those who run the show—the lives of “little yellow people” do not matter. Wittgenstein asks, in the Blue Book, whether it is “conceivable that one person should have pain in another person’s body.”19(p49) As Veena Das noted in her discussion of the mass rapes that occurred at the time of the partition between India and Pakistan, “I am in pain” is not an indicative statement.20 The person who utters it is not thereby conveying some internal state. Rather, by uttering it, he or she is “doing” a thing, namely, demanding some sort of action to relieve the pain. Perhaps a starting point for a global form of social medicine is for its practitioners to note, “I am in pain, for I have pain in the bodies of others.” Through the study of LASM, we learn of the suffering of the people in Latin America. Tajer notes that LASM defends health as a human right and a public good3; as suggested by Paul Farmer, we need
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to work on including “all humans under the rubric ‘human.’ ”21(p202) Such a perspective points the way for a social medicine that incorporates social engagement and political work toward justice and health. On the medical side, witnessing and documentation of such suffering is an apposite task as well for social medicine. And, of course, when we are fortunate, we can alleviate the suffering of the sick.22
PUBLIC HEALTH IMPLICATIONS The implications for public health practice are that we must explicitly recognize this social suffering and work to reverse those large-scale social forces that cause death and disease. And just as the analysis must take place at a social level, public health practice and medical practice must take place at a social level. In the end, social medicine seeks to encompass what is now considered to be under the rubric of both “public health” and “medicine.” Thus, we are glad to see the government of Brazil guarantee antiretroviral treatment for its people,23 and to see the government of Mexico City deliver health care to its people. Just the initial direct appropriation by the US Congress for the war on Iraq was $79 billion; more is needed for occupation and to facilitate the corporate takeover. How many premature deaths from disease could be prevented with such resources? Global social medicine advocates that resources be redirected away from death and destruction. Global social medicine seeks a world in which we are not subservient to corporate
globalization but, rather, to care for our fellow human beings.
About the Author The author is with the Hawai’i/Pacific Basin Area Health Education Center, Office of Medical Education, and Division of Ecology and Health, John A. Burns School of Medicine, University of Hawaii at Manoa. Requests for reprints should be sent to Seiji Yamada, MD, MPH, Hawai’i/Pacific Basin Area Health Education Center, University of Hawaii, John A. Burns School of Medicine, 1960 East West Rd, Biomed T-105, Honolulu, HI 96822 (e-mail:
[email protected]). This article was accepted June 29, 2003.
Acknowledgments
10. Franco S. International dimensions of Colombian violence. Int J Health Serv. 2000;30:163–185. 11. Bush allows US military aid to flow to Colombia. October 7, 2003. Agence France Presse. 12. Franco S. A social-medical approach to Colombian violence. Am J Public Health. 2003;93:xxx–xxx. 13. Yamada S, Palafox N. On the biopsychosocial model: political economic perspectives on diabetes in the Marshall Islands. Fam Med. 2001;33: 348–350. 14. Keller W. Missile defense: the untold story. New York Times. December 29, 2001:A33. 15. Gordon MR. U.S. nuclear plan sees new targets and new weapons. New York Times. March 10, 2002:A1.
I would like to thank Luis Avilés, Nancy Krieger, and 2 anonymous reviewers for their helpful comments on earlier versions of this article.
16. Chomsky N. September 11th and its aftermath: where is the world heading? Available at: http://www.hinduonnet.com/fline/fl1824/nc.htm. Accessed September 27, 2003.
References
17. Galeano E. The war. La Jornada. Available at: http://www.zmag.org/ content/showarticle.cfm?SectionID= 15&ItemID=3308. Accessed September 27, 2003.
1. Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. New York, NY: Pantheon Books; 1973. 2. Barsamian D. Can the system be fixed? An interview with Howard Zinn. Available at: http://www.zmag.org/ ZMagSite/Nov2002/Zinn1102.htm. Accessed September 27, 2003. 3. Tajer D. Social history of Latin American social medicine: overview, update, and present challenges. Am J Public Health. 2003;93:xxx–xxx. 4. Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health. 2001;91:1592–1601. 5. Allende S. Latin America emerges from underdevelopment [speech presented at the 14th annual session of the United Nations Economic Commission for Latin America]. In: Allende S. Chile’s Road to Socialism. Baltimore, Md: Penguin Books; 1973:130. 6. Kim JY, Millen JV, Irwin A, Gershman J. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Maine: Common Courage Press; 2000. 7. Laurell AC. Health reform in Mexico: the promotion of inequality. Int J Health Serv 2001;31:291–321.
18. Ondaatje M. The English Patient. New York, NY: Vintage Books; 1993. 19. Wittgenstein L. The Blue and Brown Books. New York, NY: Harper & Row; 1958:49. 20. Das V. Language and body: transactions in the construction of pain. In: Kleinman A, Das V, Lock M, eds. Social Suffering. Berkeley, Calif: University of California Press; 1997:70. 21. Farmer P. Pathologies of Power. Berkeley, Calif: University of California Press; 2003:202. 22. Farmer P. On suffering and structural violence. In: Kleinman A, Das V, Lock M, eds. Social Suffering. Berkeley, Calif: University of California Press; 1997:272. 23. Overcoming the obstacles: extending AIDS care and treatment to poor communities worldwide, lessons from the Brazilian AIDS program. Available at: http://www.pih.org/calendar/011013aids/ 011013aids_proceedings.pdf. Accessed September 27, 2003.
8. Laurell AC. What does Latin American social medicine do when it governs? Am J Public Health. 2003; 93:xxx–xxx. 9. Stocker K, Waitzkin H, Iriart C. The exportation of managed care to Latin America. N Engl J Med. 1999; 340:1131–1136.
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