Barrio Adentro (MBA; ‘‘Inside the Objectives
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RESEARCH AND PRACTICE Confronting Health Disparities: Latin American Social Medicine in Venezuela Charles L. Briggs, PhD, and Clara Mantini-Briggs, MD, MPH Misio´n Barrio Adentro (MBA; ‘‘Inside the Objectives. We explored the emergence and effectiveness of Venezuela’s Neighborhood Mission’’) in Venezuela is one of Misio´ n Barrio Adentro, ‘‘Inside the Neighborhood Mission,’’ a program designed the most striking examples of Latin American to improve access to health care among underserved residents of the country, social medicine (LASM). With its origins in hoping to draw lessons to apply to future attempts to address acute health 19th-century European social medicine, par- disparities. ticularly the work of Rudolf Virchow, LASM Methods. We conducted our study in 3 capital-region neighborhoods, 2 small took root in Chile in the early 20th century and cities, and 2 rural areas, combining systematic observations with interviews of had become well established there by the 221 residents, 41 health professionals, and 28 government officials. We surveyed 1930s. LASM, which had also taken root in 177 female and 91 male heads of household. Argentina and Ecuador by that time, became Results. Interviews suggested that Misio´ n Barrio Adentro emerged from prominent in other areas of Latin America in creative interactions between policymakers, clinicians, community workers, and residents, adopting flexible, problem-solving strategies. In addition, data the 1960s and 1970s.1 LASM scholars and indicated that egalitarian physician–patient relationships and the direct involve- practitioners endorse collective rather than indi- ment of local health committees overcame distrust and generated popular vidual approaches to health care, stress the im- support for the program. Media and opposition antagonism complicated phy- portance of political–economic and social deter- sicians’ lives and clinical practices but heightened the program’s visibility. minants of health, and promote holistic Conclusions. Top-down and bottom-up efforts are less effective than ‘‘hori- approaches to health–disease–health care pro- zontal’’ collaborations between professionals and residents in underserved com- cesses.2 A related perspective that scrutinizes munities. Direct, local involvement can generate creative and dynamic efforts to epidemiological categories and measures—‘‘criti- address acute health disparities in these areas. (Am J Public Health. 2009;99: cal epidemiology’’3—stresses attention to the fac- 549–555. doi:10.2105/AJPH.2007.129130) tors that produce health inequities rather than descriptions and analyses of observed dispar- and 1980s, national health policies of the government enacted LASM-oriented policies ities.4 1990s decreased state investment in health based on equity and justice in health—deemed For example, rather than observing that care in favor of the private sector; growing to be a social right—and decentralized health rates of infant mortality are higher in a partic- social inequality negatively affected the ability institutions, integrating health services with ular minority group and analyzing individual of the poor to pay for services.8 In 2000, Asa local governments and fostering neighborhood risk factors, LASM and critical epidemiology Cristina Laurell,9 a leading critic of market-ori- participation.10 As an example of local-level scholars would document race- and class-based ented health policies, became secretary of health policies, LASM has been the dominant model in differences in access to health care, sanitary for Mexico City mayor Andre´s Manuel Lo´pez the Argentinean city of Rosario since 1995. In infrastructures, employment, and political rep- Obrador’s Party of the Democratic Revolution that city, local teams have worked with residents resentation and how they might produce government. At the same time that market-ori- ‘‘to guarantee that all decisions are made as higher levels of morbidity and mortality. These ented policies dominated nationally in Mexico, closely as possible to the level of the people scholars promote practices and policies that Obrador’spartyprioritizedhealthindeveloping directly affected.’’11(p233) treat health as a social and human right and strong social welfare institutions and providing We studied how access to health care was extend universal and equal health care access, free health care for the city’s 8.5 million inhab- extended to millions of formerly underserved oppose the privatization of health and its itants. The party defined health as a social right Venezuelans through the various programs transformation into a free-market commodity, and increased the health budget by 67% in its and policies instituted during the ‘‘Bolivarian and advocate strengthening the state’s role in first year in office.7 revolution’’ (named for Simo´n Bolı´var, who led guaranteeing access to health services.5 A Similarly, in Uruguay, from the 1990s to Venezuela’s war of independence), initiated by number of researchers and policymakers have 2005, metropolitan and national governments the left-leaning government of President Hugo reported on their efforts to convert LASM prin- adopted health policies based on LASM and Cha´vez Frı´as in 1999. In Venezuela, the public ciples into practice in administering municipal free-market principles, respectively. When health gains achieved in previous decades had and national public health systems.6,7 Broad Front leader and oncologist Tabare´ eroded during the 1980s and 1990s, as was In Mexico, although substantial gains in Va´zquez, mayor of Montevideo from 1990 evident in the falling percentage of the gross health services were made during the 1970s to 1995, became president in 2005, his domestic product spent on health and the March 2009, Vol 99, No. 3 | American Journal of Public Health Briggs and Mantini-Briggs | Peer Reviewed | Research and Practice | 549 RESEARCH AND PRACTICE decaying health infrastructure. When the ma- collaborated with community workers to sur- assumed active roles in fostering prevention, jority of health expenditures were transferred vey barrio residents on their perceptions of enhancing health infrastructures, and procur- to the private sector, the poor, whose economic problems in the areas of housing, health care, ing resources. position had weakened, faced large fees for education, food security, and employment. By December 2003, Plan Barrio Adentro many health services and medications.12,13 By Residents identified health care as their was so popular that Cha´vez transformed it into the late 1990s, class-based health disparities greatest concern and detailed institutional, a national plan based on the same basic fea- were enormous and much of the population transportation, and security barriers to obtain- tures, and the program was renamed Mission effectively lacked access to health care. ing medical treatment, especially during night- Barrio Adentro.19 MBA inaugurated a network The health policies of Cha´vez’s government time hours.18 Community leaders, residents, and of ‘‘missions,’’ broad social programs focusing on shaped the 1999 Bolivarian constitution, which IED workers were equal participants in these such issues as education, culture, homelessness, declared that ‘‘health is a fundamental social discussions, and they collaborated on a proposal housing, and food security.21 As of December right [and an] obligation of the State’’ and that to recruit physicians who would live in poor 2006, MBA included 23789 Cuban doctors, the public health system must be ‘‘decentral- neighborhoods and provide free health care and dental specialists, optometrists, nurses, and other ized and participatory ...guided by the prin- to involve residents directly in any changes personnel22 and more than 6500 sites where ciples of free-cost, universal availability, inter- instituted. patients were seen. By July 2007, 2804 primary sectoriality, equity, social integration, and IED presented the information gathered to care stations23 were being staffed by physicians, solidarity.’’14 Cha´vez initially appointed Gilberto Freddy Bernal, mayor of the Libertador community health workers, and health pro- Rodrı´guez Ochoa as health minister in 1999; Municipality, who issued a call for physicians moters. Sports professionals created dance and Marı´a Lourdes Urbaneja, past president of the to live and work in poor neighborhoods. Fifty exercise classes for the elderly, and physicians Latin American Social Medicine Association, Venezuelan physicians responded, but they provided more than 100 types of free medica- took over the post in 2001. declined to live in barrios (30 left immediately tions. According to our interviews and observa- Both Ochoa and Urbaneja attempted to upon learning that they would be required to tions, mental health issues have not been prior- translate LASM principles into policies and live in barrios; the remaining 20 participated itized. practices.15 Nevertheless, these policies and but were assigned to provide secondary care A second phase, initiated in 2004, included practices were largely ineffectual in transforming and thus were not required to live in barrios).19 319 integrated diagnostic centers, 430 inte- the Ministry of Health and providing adequate Recalling Cuban doctors who provided emer- grated rehabilitation centers, and 15 high- health care for the 50% of Venezuelans living in gency care after the tragic mudslides of1999 and technology centers as of 2007.23 Some facilities poverty.16 The Venezuelan Medical Federation remained as health care providers