Social inequities and contemporary struggles for collective health in Latin America

ABSTRACT

As part of a planned series from Global Public Health aimed at exploring both the epistemological and political differences in diverse public health approaches across different geographic and cultural regions, this special issue assembles papers that consider the legacy of the Latin American Social Medicine and Collective Health (LASM-CH) movements, as well as additional examples of contemporary social action for collective health from the region. In this introduction, we review the historical roots of LASM-CH and the movement’s primary contributions to research, activism and policy-making over the latter-half of the twentieth century. We also introduce the special issue’s contents. Spanning 19 papers, the articles in this special issue offer critical insight into efforts to create more equitable, participatory health regimes in the context of significant social and political change that many of the countries in the region have experienced in recent decades. We argue that as global health worldwide has been pushed to adopt increasingly conservative agendas, recognition of and attention to the legacies of Latin America’s epistemological innovations and social movement action in the domain of public health are especially warranted.

KEYWORDS:

• Social medicine
• collective health
• social movements
• global health
• Latin America

Introduction

The field of global health has evolved significantly since the beginning of the twenty-first century with the rebranding of ‘international health’ to ‘global health’ (Birn, Pillay, & Holtz, 2017; Cueto, 2015). While this shift recognised and aimed to create new flows of health-related knowledge, resources and interconnected platforms for health governance (Brown, Cueto, & Fee, 2006), its impact has also had a homogenising effect on understandings of varied approaches to health. Paralleling criticism of globalisation more broadly (Labonte, Schrecker, Packer, & Runnels, 2009; Navarro, 1998), the field of global health has been leveraged primarily by actors from the global North (Beaglehole & Bonita, 2010; Macfarlane, Jacobs, & Kaaya, 2008), prioritising understandings of health problems and solutions from a northern perspective (Adams, Behague, Caduff, Löwy, & Ortega, 2019; Birn, 2011; Brown & Bell, 2008; Lakoff, 2010; Ollila, 2005; Ottersen et al., 2014). Indeed, roughly two decades after the rebranding to ‘global health’, little attention is paid to country or regional diversity regarding frameworks of public health and how these approaches fit under the umbrella of ‘global health’. Certainly, frequent failure to recognise, teach, and meaningfully incorporate southern perspectives is not a condition in which the field arbitrarily finds itself. Instead, this reflects fundamental distributive injustices inherent to late global capitalism that have led to the political and financial empowerment of particular actors within the apparatus of global health, including the World Bank, International Monetary Fund, influential philanthropists, and corporations, in addition to multilaterals and state actors (Birn, 2014; Laurell, 2008; Mitchell & Sparke, 2016; Waitzkin & Jasso-Aguilar, 2015b). In response, this special issue is part of a planned series from Global Public Health aimed at encouraging recognition of epistemological and political alternatives reflected in public health approaches outside the global North. While Global Public Health itself is situated within flows of global North and English language scholarship, this series is committed to thinking broadly and deeply about public health traditions and approaches often unrecognised.

To contribute to greater recognition of epistemological diversity in how public health is understood and practiced, this collection of articles emphasises the legacy and applications of a distinct approach to public health that falls under the rubric of what we are designating as LASM-CH – Latin American Social Medicine and Collective Health (the latter an alternative terminology used especially [though not exclusively] in Brazil). LASM-CH is best understood as a rich and diverse intellectual current, shaped by both academics and activists and driven by key research centres, graduate programmes, and academic networks established in the region (Birman, 2005; Breilh, 2013; Granda Ugalde, 2008; Laurell, 1989; Paim & Almeida Filho, 1998; Tajer, 2003; Waitzkin, Iriart, Estrada, & Lamadrid, 2001). In particular moments, the LASM-CH movement has significantly influenced health policy reforms in Latin America, especially through the ascendance of actors who ascribe to the tradition to policymaking positions at the level of municipal, state, and regional governance (Briggs & Mantini-Briggs, 2009; Laurell, 2003; Tajer, 2003; Waitzkin, 2005). Broadly speaking, however, the LASM-CH movement has remained counter-hegemonic in the arenas of health policy and research alike (Almeida Filho, 1989, 2000; Breilh, 2003, 2008). Although it is not the only approach to public health in the region, and it co-exists in different ways with more conservative and technocratic perspectives in many countries, the LASM-CH movement has been the source of critical, innovative scholarship and policy alternatives from which the broader field of global health has and should continue to benefit (see also Adams et al., 2019; Holmes, Greene, & Stonington, 2014). Below we highlight the LASM-CH movement, as well as additional key approaches from the region at the nexus of activism, policy and health equity that have been influenced by or expanded on the LASM-CH legacy – particularly in the areas of human rights activism and recent popular opposition to neoliberal governance – in order to advance understanding of twenty-first century health politics in the region and the lessons they offer.

The LASM-CH approach

Many accounts of the LASM-CH movement’s history tie its intellectual roots to nineteenth century European social medicine and, in particular, to the scholarship of German pathologist and social scientist Rudolph Virchow, who viewed the material conditions of everyday life – especially those linked to class structure – as key causes of illness and early death and the state as having a key role in the protection of health (Tajer, 2003; Waitzkin, 2006; Waitzkin et al., 2001). Students and followers of Virchow’s vision immigrated to Latin America, where social medicine perspectives increasingly gained footing, interacting with the importance of Marxist perspectives in Latin American social theory, and shaping a unique intellectual trajectory in response to the region’s particular political conditions (Waitzkin et al., 2001).

By the 1930s social medicine had a stronghold in Chile and significantly influenced medical student Salvador Allende, who first as Minister of Health, later as Senator and ultimately as President would oversee the founding of Chile’s first national health service – the first in the Americas to guarantee universal access to health services (Waitzkin, 2005). Over the course of his political career, Allende would also promote a range of additional reforms to achieve a more equitable income distribution and improve social conditions broadly, efforts that eventually inspired to a violent coup d’état in which he was killed in 1973 (Waitzkin et al., 2001). Other early key figures whose politics either reflected or resonated deeply with social medicine perspectives include (but are by no means limited to) anarchist physician Juan Lazarte who was active in the 1930s–1950s as a leader of one of Argentina's medical unions; Peruvian hygiene expert Carlos Paz Soldán; Josúe De Castro of Brazil, who wrote ‘The Geography of Hunger’ (1952), analyzing of the structural roots of malnutrition and hunger; Ernesto (‘Che’) Guevara who would help lead the Cuban revolution in 1959; and physician and sociologist Juan César García who would serve as research coordinator within the Pan American Health Organization (PAHO) from 1966 to 1984 (Cueto & Palmer, 2015; Waitzkin et al., 2001).

Social medicine perspectives coalesced most visibly as a social movement in Latin America in reaction to authoritarian regimes that held power in the region through the 1970s and into the 1980s. Drawing on Marxist perspectives – the hegemonic theoretical current in Latin American social sciences at the time (Laurell, 1989) – and also particularly Engels’ report on the condition of the working class in England, which was widely circulated among them, scholars, student activists, and political dissidents came together in nodes to critique of the prevailing capitalist social order fortified under these regimes and the associated decline in living and health conditions. Their organising and attempts to promote reform were at times met with violent consequences, as Allende and his followers earlier experienced in Chile (Tajer, 2003; Waitzkin et al., 2001). But despite instances of repression, this period spurred the founding of key organisations that united social medicine proponents in the region – particularly under the umbrellas of the Centro Brasileiro de Estudos de Saúde (CEBES) in 1976, the Associação Brasileira de Saúde Coletiva (ABRASCO) formed in 1979 (both in Rio de Janeiro), and the Latin American Social Medicine Association (ALAMES) founded in Ouro Preto, Brazil, in 1984. As re-democratisation swept the region understanding of health as a social right and one intimately connected to the full exercise of democracy was well-established across these groups (Cueto & Palmer, 2015). In Brazil, for example, activists in the sanitary reform movement and proponents of Collective Health in many ways spearheaded this moment of re-democratisation and the articulation of a new social contract broadly. They also developed a comprehensive plan for participatory health reform that would be written into the 1988 constitution and provide the architecture for the Brazilian Unified Health System or Sistema Único de Saúde (de Camargo, 2009; Paim, Travassos, Almeida, Bahia, & Macinko, 2011; Vieira-da-Silva & Pinell, 2014; Weyland, 1995).

Moreover, across these networks and centres – as well as key graduate programmes in social medicine and collective health being consolidated across the region – an anti-hegemonic approach to epidemiology itself emerged. This approach stood (and remains) in contrast to more conservative or mainstream public health approaches throughout the region and beyond and in opposition the principles underpinning decades of initiatives spearheaded by actors like the Rockefeller Foundation – initiatives that often involved vertical programming focused, especially, on enhancing the productivity of labour linked to US-based multinational corporations with presence in the region (Birn & Solórzano, 1999; Cueto, 1994). In this sense, early on, LASM-CH proponents recognised the science of epidemiology as an epistemological battleground and a direct expression of relations of power in society (Barreto, 2004; Breilh, 2003, 2008; Breilh & Granda, 1989). As Elis Borde and Mario Hernández have detailed in this issue, LASM-CH proponents have produced extensive critiques of mainstream epidemiological approaches, in particular regarding limitations to mainstream conceptualizations of causality and validity (Almeida Filho, 1989, 2000) and to risk-factor logic (Ayres, 1997; Breilh, 2003; Castiel, 1999; Castiel, Rodrigues Guilam, & Ferreira, 2010). Accordingly, Tajer (2003) has written, ‘thus began a new and distinctive methodological tradition in the field: the critical and ideological analysis of what is usually presented as purely technical knowledge’ (p. 2023).

Beyond these critiques, the LASM-CH movement has offered numerous proposals for re-approaching both epidemiology and public health practice more broadly. Classic tenets of the movement include: the integration of social science theory into health analyses (in particular Marxist perspectives, but also contributions from Foucault, Gramsci, Bourdieu, Althusser, Giddens, and Habermas, among others) and special attention to the impact of capitalist development on health; epidemiological analysis conducted through the lens of collectives (e.g. social class) rather than on groups of individuals; a commitment to praxis or the union of theory and practice so that academic analysis is also, at once, a political intervention; and an analytic focus on the dialectic relationship between health, disease, and care, rather than on static health outcomes (Franco, Nunes, Breilh, & Laurell, 1991; Granados Cosme & Delgado Sánchez, 2006; Granda Ugalde, 2008; Irwin & Scali, 2007; Tajer, 2003; Waitzkin et al., 2001).

Latin America as a laboratory for neoliberal reform

The LASM-CH movement’s consolidation in the 1970s and 80s coincided with – and, in important ways, directly contributed to – an upwelling of support for health equity as a broad social goal and access to primary care services as articulated in the 1978 Alma-Ata declaration issued at the World Health Organization’s International Conference on Primary Health Care. There now exists a well-developed historical literature on medicine and public health in Latin America that helps to situate the LASM-CH movement’s contributions from this watershed moment in international health politics to the present (Birn et al., 2017; Birn & Necochea López, 2011; Cueto & Palmer, 2015; Palmer, 2010; Waitzkin & Jasso-Aguilar, 2015a). This begins with the resistance that arose almost immediately to Alma-Ata’s articulation of its progressive (if not radical) Primary Health Care goals (Thomas & Weber, 2004). The Alma-Ata declaration contained three central themes cross-cutting its focus on comprehensive preventive services – it opposed expensive technology irrelevant to the needs of the poor, in favour of ‘appropriate technology’; it opposed overspecialisation and medical elitism, in favour of community participation and intersectoral institutional engagement in meeting health goals; and, finally, it positioned health as an instrument for development, rather than its outcome (Cueto & Palmer, 2015). In opposition to these goals, a more conservative approach under the label of ‘selective primary health care’ was rapidly articulated under the purview of institutions including the World Bank, the Rockefeller Foundation, and UNICEF, as well as the influence of the for-profit sector. Proponents of ‘selective primary health care’ would advocate for a more limited understanding of primary health care centred, especially, on preventing childhood diseases through growth monitoring, oral rehydration techniques, breast-feeding, and immunisation (or GOBI).

As Cueto and Palmer (2015) have noted, ‘though it did not provide the main impetus for the official push codified at Alma Ata, Latin America would become one of the great battlegrounds of its implementation’ (p. 209). Indeed, although early progress toward establishing holistic primary health in settings like Costa Rica and Cuba had fuelled Alma-Ata’s goals and values, over the course of the 1980s the conservative ‘selective’ approach to primary health care would become far more amenable to health policy makers in Latin America. This, as economic crisis swept the region in the wake of the Latin American debt crisis and given the clear preference at the time among international agencies like UNICEF for more focused, short-term, and technical interventions. The repression of comprehensive primary health care, however, was just a start.

Through the 1980s and into the 1990s, the World Bank (with the International Monetary Fund, the Interamerican Development Bank, and the U.S. Government) would increasingly assume the reins of international health policy making, promoting the Washington Consensus throughout the region and converting Latin America into a living laboratory of neoliberal macroeconomic reform (Laurell, 2000). This era of structural adjustment would entail the reduction and privatisation of state social services and safety-nets, the expansive opening of national economies to foreign trade and investment, the deregulation of finance capital, and the overall promotion of the market and its logic over a state-based social contract. In the domain of health this would mean the contraction and decentralisation of health care services and programmes, increasing precariousness of health professionals’ terms of labour, emphasis on management efficiency, and growing prominence of private insurance and other forms of public-private partnerships in the sector (Cueto & Palmer, 2015; Pfeiffer & Chapman, 2010; Schrecker, 2016).

Pushing beyond neoliberal public health

In response, LASM-CH proponents have taken as a central task the ‘demystification of the processes of neoliberal health system reform’ (Tajer, 2003, p. 2025) through the production of systematic evidence about its deleterious impact on the right to health. This work counts important points of intersection with research on the social determinants of health that fuelled WHO-level interest in this area as of the early 2000s. However, LASM-CH approaches to the social determinants of health should not be equated with discourse linked solely to the WHO Commission on the Social Determinants of Health launched in 2005. LASM-CH scholarship stands to offer more, particularly with regard to identifying and radically addressing the fundamental relations of power that drive social determinants of health, as various scholars from the region have articulated (Borde, Hernández-Álvarez, & Porto, 2015; Buss & Pellegrini Filho, 2007; CEBES, 2010; Eibenschutz, Tamez González, & González Guzmán, 2011; Gonzalez Guzman, 2009; Spiegel, Breilh, & Yassi, 2015). We return to this point further below.

Offering a further framework through which to oppose neoliberalism’s impact on health, the LASM-CH central tenet of health as a universal, human right increasingly has taken a central role in state-level and regional health policy through the 1990s and into the twenty-first century (Meier & Ayala, 2014). This is perhaps not surprising in light of the important role that Latin American thinkers and activists have historically had in advocating for human rights considerations in international relations (Sikkink, 2015). But this was reinforced in significant ways over the course of the 1990s in relation to the emerging field of health and human rights (Stolkiner, 2010; Yamin & Frisancho, 2015). During this period, several Latin American countries were key sites for the development of participatory, rights-based approaches to reproductive health, playing key roles in and around the 1994 International Conference on Population and Development in Cairo (Shepard, 2006) and the Fourth World Conference on Women in Beijing in 1995 (Alvarez, 1999). Heavily influenced by LASM-CH approaches, policy-making in the region related to HIV and AIDS was also at the forefront of pioneering rights-based approaches to the global epidemic (Berkman, Garcia, Muñoz-Laboy, Paiva, & Parker, 2005; Cueto, 2001, 2019; Parker, 2009; Smallman, 2007). Rights-based policy-making related to mental health also underpinned a restructuring of psychiatric care throughout the Americas (Meier & Ayala, 2014). In addition, Latin American policymakers and activists have played an especially important role in questioning intellectual property rights and trade regimes that have limited access to medicines (Loyola, 2008; Vieira & Di Giano, 2019), and in promoting flexibilities such as the Doha Declaration on TRIPS and Public Health (Amorim, 2017a, 2017b).

Broad opposition to neoliberal governance culminated in the region over the early 2000s with the rise of leftist governments and constitutional reforms, comprising Latin America’s populist ‘pink tide’. These shifts ushered in a wave of health sector reforms across the region – most prominently in Venezuela, Uruguay, Bolivia, Ecuador, and Nicaragua. Such reforms were also visible in Mexico City, where LASM leader, physician, and sociologist Asa Cristina Laurell put LASM-CH principals into action as the city’s Secretary of Health between 2000 and 2006 and in 2019 ascended to national leadership in the public health sector with the election of president Andrés Manuel López Obrador. Around the region, these reforms have explicitly recognised health as a socio-political endeavour, involved efforts to democratise health policymaking, and most importantly included steps to re-centre health as a state-guaranteed social right (Hartmann, 2016; Laurell, 2008). In Ecuador, Bolivia and Nicaragua, specifically, these ‘post-neoliberal’ strategies have been marked by fragile but hopeful attempts to redistribute capital surplus to social policies, to institute interculturality, to strengthen civil-society relations, and to articulate health-related objectives through the concept of ‘living well’ (i.e. Buen Vivir), even as states have struggled to overcome economic continuities from their neoliberal pasts and largely remained mired by market-oriented extractivism and varying degrees of fiscal restraint (Grugel & Riggirozzi, 2012; Hartmann, 2016; Rojas, 2017).

As we discuss below, during this period – and now especially as the region’s ‘pink tide’ recedes and more conservative forces return to power in many countries across the region – LASM-CH researchers have taken up the work of evaluating these reforms to understand what lessons we might draw from them (Birn, Nervi, & Siqueira, 2016; Breilh, 2011). On the international stage as the field of global health has struggled to recover from the 2007/2008 global financial crisis (Navarro & Muntaner, 2014), interest in the social determinants of health and human rights has similarly experienced a retreat in favour of ‘cost-effectiveness’, continued reliance on public-private partnerships, and public health interventions evermore narrowly targeting groups deemed to be at highest risk. Indeed, investments and political momentum in the field of global health are now moving away from action on the fundamental social processes that determine health, wellbeing and disease (Bekker et al., 2018; Benatar, Gill, & Bakker, 2011; Marmot & Bell, 2009; Schrecker, 2012; Schrecker & Bambra, 2015). In this context, Latin America and in particular the LASM-CH movement offers not only rich epistemological alternatives, but also systematic evidence and lessons drawn from attempts to move beyond neoliberal health policymaking and establish more just, equitable, and inclusive approaches.

Into the twenty-first century: LASM-CH legacies and contemporary health social movements

What is the on-going legacy LASM-CH in the twenty-first century? This special issue brings together a collection of papers that respond to this question by addressing three cross-cutting themes: First, articles in this special issue examine the ways in which LASM-CH perspectives have remained an element of international cooperation and solidarity in the health arena in the region, and beyond, into the twenty-first century. Second, articles examine recent efforts toward major health system reforms carried out during what some scholars have termed the region’s ‘post-neoliberal era’ (Hartmann, 2016). These articles foreground how LASM-CH perspectives have been incorporated and restyled in the midst of these reforms. Third, we include articles that examine cases of contemporary health social movements in the region, pointing to elements of the LASM-CH legacy within them and also to a range of other factors more broadly structuring collective action for health at present. These case studies bring forth aspects of the landscape of health politics in twenty-first century Latin America that have posed both opportunities for and challenges to struggles for improved health equity.

Networks of international cooperation, solidarity, and knowledge

Although the influence of the LASM-CH tradition is often overlooked on the international stage, its impact on transnational circuits of intellectual and political exchange – within and beyond the region – is longstanding (Birn, 2006). Indeed, scholars in this issue, tracing the historic and contemporary trajectories of the LASM-CH approach, offer new understanding of the multidirectional and multi-level exchanges through which this tradition developed and disseminated.

In the first article included in this special issue, Eric Carter (2018) addresses the origins of social medicine’s unique articulation in Latin America. While, as noted above, the ideals of social medicine are frequently believed to have migrated to Latin America from Europe – originating first among pioneers like Virchow, then travelling through academic circles, and later gaining institutional ground via the interwar efforts of international organisations – Carter argues that these were not simply one-way channels through which the ideals of social medicine were imported into the region. Instead, he shows that formal meetings sponsored by organisations including the League of Nations (LN) and the International Labour Organization (ILO) were ‘sites of contestation over the causes of health inequalities, the universality of liberal welfare state policy models, and the role of science in policy’ (p. 2). Carter writes that in the context of such venues ‘Latin American experts seldom took their cues from European social medicine, and offered their own integrative and politically sophisticated analysis of social and structural causes of local public health crises’ (p. 4). Indeed, he argues, in the 1930s and 1940s LASM perspectives avidly coalescing in the region clearly transcended the technocratic recommendations and less politically radical approaches to social medicine promoted by the Geneva-based institutions, in such policy domains as nutrition and social security.

In decades following those on which Carter focuses in this issue, repression of left-leaning health activists in the region would take place at the hands of the authoritarian regimes that came to power across Latin America during the Cold War era. In response, networks of cross-border solidarity and intellectual exchange would paradoxically increasingly solidify. Indeed, LASM-CH proponents not only built strong networks of solidarity across national borders through academic and civil society alliances, but they also formed key partnerships across and between activist networks. As Rafael de la Dehesa (2018) describes in his contribution to this issue, by the early 1970s LASM-CH and feminist groups in Brazil (and to a more limited extent in Mexico) formed key alliances through which to confront the global reproductive regime. Given the ‘inscription of family planning within larger projects of economic development and geopolitical oppositions’ (p. 3) the issue served as a ‘bridge’ between social medicine advocates and feminist collectives.

Networks of solidarity and knowledge exchange in which LASM perspectives were disseminated through the region also formed beyond the level of civil society, marking official foreign policy, as well, as Anne-Emanuelle Birn and Carles Muntaner (2018) clarify in their contribution to the issue. Focusing especially on Cuba as a key champion of official regional cooperation in the health sector, Birn and Muntaner note that this example of inter-state cooperation is often ‘deliberately overlooked by most mainstream (Northern) observers’ (p. 8), but has represented an important alternative to U.S.-dominated and conservative international cooperative efforts like the Pan-American Sanitary Bureau and initiatives of the International Health Division (IHD) of the Rockefeller Foundation.

Tracing the legacy of this south-south cooperation into the twenty-first century, María Belén Herrero, Jorgelina Loza, and Marcela Beatriz Belardo (2019), in their contribution to the special issue, describe the on-going impact of LASM-CH perspectives in the context of the Union of South American Countries (UNASUR). Founded in 2008 with the rise of leftist and progressive governments in many countries of the region (which vowed to restore the role of the state and counteract the effects of neoliberal policies on social welfare), this new project of regional integration has focused on health, its political determinants, and its implications for human rights. Drawing significantly on the intellectual resources available through the region’s ALAMES network, the UNASUR Health Council has promoted ‘movement toward horizontal cooperation and technical support, away from what its leaders view as an out-dated vertical model of donor and recipients’ (p. 8–9). Although currently threatened with the rise of conservative leaders in the region, UNASUR member countries over the last decade have negotiated as a block to defend their interests ‘in multilateral spaces, in front of the market and other international and transnational organizations’ (p.8).

On the global stage of international cooperation in the context of WHO policy and programming, although the social determinants of health (SDH) approach has gained important ground, in this issue Elis Borde and Mario Hernández (2019) clarify that it is critical to recognise that the LASM-CH perspectives remain peripheral to these international efforts. Specifically, they argue the work and advances of the WHO’s Commission on Social Determinants of Health (SDH) should not be understood to fully encompass or subsume more the radical and potentially more transformative LASM-CH perspectives. Indeed, they argue, the SDH approach falls far short of LASM-CH perspectives especially with regard to a ‘comprehensive analysis of society, of power relations in society and the processes in which these determinants develop and are reproduced’ (p. 6). Absent, as well, is ‘discussion on political struggle, oppression and exploitation, that is, social processes that generate and substantiate unequal power relations in capitalist development models, let alone alternatives to capitalist development’ (p. 6). In this sense, Borde and Hernández argue, LASM-CH perspectives remain a source of under-recognised alternative and notably progressive vision for how we may move forward globally toward a systematic reduction of health inequities, even as LASM-CH perspectives and concepts are continually being revised, advanced, and strengthened by researchers in the region (see Martinez-Parra, Abadía-Barrero, Murata, Méndez Ramírez, & Méndez Gómez-Humaran, 2018).

National health system reforms

At the national level, Brazil represents a particularly notable stage on which the perspectives shared by the LASM and CH movements coalesced and gained broad recognition in the context of political transformation and associated health system reform. In the 1970s, amid collective action for democratisation in the face of military dictatorship and an upwelling of protest against the deteriorating social conditions brought about with Brazil’s neoliberal ‘economic miracle’, the collective health or saúde coletiva movement emerged as an ideological approach to health as a social right (Cueto & Palmer, 2015). As noted above, by the late 1980s, the movement’s representatives or sanitaristas had gained sufficient political strength to incorporate into Brazil’s new constitution the framing for a universal, decentralised and participatory Unified Health System (SUS), a national project that continues to evolve today. In their contribution to this issue, Mahmood & Muntaner (2018) analyse the sanitaristas’ efforts to integrate into the architecture of the SUS institutional spaces that would permit community participation and control over public policy – spaces that sanitaristas viewed as key to fostering an alternative social order to economic neoliberalism, under which private interests most often monopolised the ear of government. As Mahmood & Muntaner describe, this was achieved through the SUS, most notably, with the creation of Health Councils, where civil society would have the opportunity to formally engage in health policymaking at national, state, and municipal levels. In parallel with the construction of the SUS, in this issue Feldenheimer da Silva et al. (2018) detail the extraordinary achievements made toward integrating civil society into food and nutrition security (FNS) policy-making in Brazil. However, in parallel with challenges faced by the SUS, these authors note that with time it has become clear that ‘while Brazil stands out as a reference in social participation and control in relation to FNS actions, the established participatory bodies have not been sufficient to avoid the deleterious political influence of agribusiness and big food companies’ (p. 7).

Mahmood & Muntaner (2018), in their contribution to the issue, also describe similar attempts to democratise decision-making in health in Venezeula’s Barrio Adentro programme established in 2003. Here they offer important insight into the health reform efforts initiated under the wave of leftist, anti-neoliberal governments that began to take power in Latin America at the turn of the millennium. Other contributors to this issue examine more recent examples of the region’s ‘pink tide’ – most notably Ecuador, Bolivia, and Nicaragua – and efforts through state-led initiatives to engineer progressive, anti-neoliberal health sector reforms. These reforms to an extent incorporate LASM-CH values, even while maintaining ties to previous neoliberal models of health governance (see also Hartmann, 2016). Authors analysing these reforms in this issue point to the complexities involved under these ‘post-neoliberal’ regimes in establishing a new social contract that would account for broader dimensions of well-being in development goals, better address the social production of disease and strengthen state-society relations through civil society engagement.

For example, in this issue Friederic and Burke (2018) write that ‘under President Rafael Correa’s administration (2007–2017), the Ecuadorean Ministry of Health has established a state-centred, populist health care regime that incorporates elements of Latin American social medicine into a post-neoliberal platform’ in a ‘backlash against nearly two decades of neoliberal policies that aimed to radically marketise society, minimise the welfare and regulatory arms of the state, and convert basic social services into commodities’ (p. 2) in Ecuador. However, through analysis focused on the particular community of Las Colinas in rural northwest Ecuador, the authors argue that Correa’s National Plan for Good Living (Buen Vivir) and its state-centred healthcare reforms, have in this case paradoxically weakened existing community organising for collective health. In another of the issue’s articles, Spiegel et al. (2018) examine a community-arts based intervention carried out in Ecuador under Rafael Correa’s National Plan for Good Living (Buen Vivir), critically assessing its potential to support collective well-being in marginalised communities of urban Ecuador. Finally, Hartmann (2018) analyses in this issue the comparable ‘Live Beautiful, Live Well’ (‘Vivir Bonito, Vivir Bien’) initiative implemented in Nicaragua beginning in 2013 under President Daniel Ortega. Hartmann points to the ways in which environmental public health messaging disseminated through this government programme, only narrowly, if at all, escapes classic neoliberal invocations of individual responsibility for health and well-being, even while the campaign is veiled in rhetoric championing solidarity, shared responsibility, and recognition of cultural plurality. For these authors, contemporary efforts that engage social medicine in Latin America invoke LASM-CH perspectives, but do not constitute their broad adoption in the context of national reforms. Instead, LASM-CH ideals remain aspirational, indeed often radical, especially in comparison to more mainstream approaches to public health.

Case studies in contemporary social action for health

The final group of articles in this special issue is dedicated to case studies of contemporary social action for health taking place across the region. Here we open the issue to scholars analysing action beyond the lens of LASM-CH perspectives. As a counter-hegemonic intellectual current in the region, proponents of LASM-CH perspectives have in many contexts and moments joined forces, worked parallel to or been complemented by other approaches to mobilisation for health as a social right. Here we draw out themes that emerge across these cases in order to contextualise the legacy of LASM-CH perspectives within a broader field of health politics in the region.

First, while LASM-CH proponents in some contexts historically subordinated identity-based struggles to a broader class-based or general social struggle (as noted by de la Dehesa, 2018), the entanglement of identity, citizenship and health has powerfully propelled key social movements in Latin America as elsewhere, particularly in the context of the struggle against HIV, as several contributions to the collection demonstrate. In this issue Laura Murray, Deanna Kerrigan, and Vera Silva Paiva (2018), for example, track the mobilisation of sex workers in Brazil who time and again have provocatively affirmed their rights as ‘putas’, defending prostitution both as work and as a sexual right. Sex workers in this context have fought for HIV policy and programming that explicitly acknowledges the link between HIV vulnerability and key structural factors including stigma, gender inequalities, and the criminalisation of sex work. In their contribution to the issue, Salazar et al. (2019) argue that the HIV-research industry in Peru has provided a context in which emergent transgender women’s activism has taken shape. But this contribution to the issue and that of Castellanos (2019), which analyses LGBT activism in the Dominican Republic taking place amidst international funding for HIV prevention, both foreground an important cautionary: social action agendas carried out under the heavy shadow of international aid and research dollars has, in some cases, succumbed to a narrower public-health focus rather than assiduously pursing demands for political recognition and broader social rights.

Identity-linked struggles for health citizenship of course have not been limited to the domain of HIV. In their contribution to the issue, addressing a classic domain of LASM research and political action, Mauricio Torres-Tovar and Jairo Ernesto Luna-García (2019) describe the formation of associations of sick and disabled workers in Colombia. These have coalesced as a consequence of changes related to neoliberal labour, health and social security reforms of the early 1990s, which contributed to the erosion of working conditions and occupational health protections. Arising in response to a distinct set of political conditions, in this issue Ardila-Gómez et al. (2018) analyse the similar expansion of users’ participation in the arena of mental health policymaking with the proliferation of user’s associations in Argentina. These associations – though not to be confused with a social movement in and of themselves – have multiplied in the wake of national legislation mandating that psychiatric reform in Argentina follow a rights-based approach and engage users in participatory decision-making, which in turn took its cue from the United Nations Convention on the Rights of People with Disabilities.

Indeed, as several contributions to the special issue indicate, in Latin America, as elsewhere, leaders of contemporary social action initiatives for health are successfully leveraging international human rights treaties to advance their agendas. Most prominently in our collection, Hepzibah Muñoz Martínez and Ann Pederson (2018) offer insight into how civil society organisations in Argentina creatively mobilised the United Nations Convention on the Elimination of all Forms of Discrimination Against Women in order to win tobacco control legislation in the late 2000s. Arguing that marketing practices of tobacco predatorily targeted women, especially economically marginalised women, activists were able to leverage gender-based anti-discrimination protections to garner a public health win.

Another trend evident in the region in the context of social action over issues from violence to obesity, our collection points to activist coalitions’ increasing reliance on health metrics and indicators as instruments to support struggles for health equity. Oscar Maldonado (2018), in his contribution, offers a cautionary narrative with regard to the use of ‘scientized’, quantitative data as the basis for health equity claims. He describes how feminist scholars and women’s organisations mobilising in Colombia for the decriminalisation of abortion came to rely heavily on arguments grounded in global health logic and metrics (accounting for the burden of unsafe abortion in terms or women’s mortality and morbidity) in order to re-frame debate away from issues of morality or gender-based rights. Although this move was key to the Colombian Constitutional Court’s decision to decriminalise abortion, Maldonado explains that anti-abortion groups are now in turn mobilising quantitative evidence. Where statistics regarding the public health burden of unsafe abortion at first seemed to carry an illusion of ‘objectivity’, opponents have successfully cast doubt around the production and validity of these epidemiological facts, imperilling the infrastructure on which abortion decriminalisation was established.

Finally, our collection concludes with observations from Amy Moran-Thomas (2019) on Belize – an often-overlooked part of the region where, she writes, basic healthcare access has not historically been framed as a right of citizens. Moran-Thomas reminds us that while the legacy of health social movements may be exceptionally strong in Latin America, there are many patients whose experiences remain at the margins and who are still struggling to gain a collective voice in contexts of persistent neglect, if not abandonment. Describing the first rights-based patient activism in the history of Belizean national medicine, which emerged among patients seeking access to dialysis, Moran-Thomas points to measured, tenuous, but nonetheless hopeful signs that ‘future visions of rights’ could find footing even in where their legacies are absent.

Conclusion

In the process of editing this special issue, we sought to bring together a wide array of scholars, working within the LASM-CH movement or studying advances in social action for collective health across multidisciplinary perspectives – history, epidemiology, anthropology, geography, and health policy. We were pleased by the response from Latin American authors, who constitute the majority of contributors to this collection. Indeed, contributing scholars are located across top institutions in the region, including the Universidad Andina Simón Bolívar, Universidad Nacional de Colombia, the Universidad Autónoma Metropolitana-Unidad Xochimilco, the Universidade do Estado do Rio de Janeiro, and FLASCO Argentina, to name a few. While this collection advances scholarship exploring the often under-recognised epistemological and political differences in public health across global regions, here we only brush the surface of the dynamic currents of LASM-CH-influenced research and other strands of health activism on-going in the region. We encourage readers to look to core LASM-CH institutions for additional resources, including ALAMES (alames.org), CEBES (cebes.org.br) and ABRASCO (abrasco.org.br). At a time when global health worldwide has been pushed to adopt increasingly conservative agendas in the wake of an extended global financial crisis, the rise of radical right populist politics, and the rupture of liberal democratic regimes, attention to legacies of Latin America’s epistemological innovations and social movement action are especially warranted.

Acknowledgements

This special issue has benefitted enormously from the involvement of contributing authors, many of whom also served as peer-reviewers on multiple papers for this issue. We are particularly grateful to Marcos Cueto and Anne-Emanuelle Birn for their support in helping us shape the vision for this special issue and for supporting us in the dissemination of the call for papers. Additionally, we owe Eric Carter, Kenneth Camargo Jr., and César Torres Cruz a very special thank you for their close review of the introduction and their important suggestions for improvement which led us to, again, acknowledge the importance of collective health mobilisation in Latin America, not only historically but its contemporary application and re-articulations.

Disclosure statement

No potential conflict of interest was reported by the authors.