Health in Latin America Research Paper

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Despite overall improvements in health, the persistence of inequality in health outcomes for the poorest segments of most societies and inequitable access to healthcare resources has provided rich territory for social scientists working in Latin America. Health studies inevitably attract cross-disciplinary researchers, given the multiple roles that ill health and disease play within society. In addition to parent disciplines, several hybrids of the social sciences have focused on health, including medical anthropology, social demography, political economy, medical history, medical ecology, social epidemiology, and medical geography. This research paper examines the state and trends within social science research in Latin America over the past few decades, selecting the most common research themes tackled by these disciplines. The importance of the early 1990s for health and social science is captured by two dates. First, the quincentennial year of 1992 symbolized and energized the study of the contact between European and indigenous, New World populations, and the health ramifications and depopulation that followed. Second, a major outbreak of cholera, beginning in the early 1990s, which crossed the South American continent from east to west, shook the confidence of public health officials and scientists alike in disease control measures. Other themes include globalization, changing trade relations and complex migration flows between and within countries, rapid agrarian transitions, deteriorating environments, urbanization, and the changes in health delivery systems. At the micro level, medical anthropologists and sociologists have examined traditional health systems including folk medicine, healers, and the cultural contexts for multiple illnesses and treatments. These studies have helped enrich another bio-behavioral focus of study: ethnobotany and its counterpart ethno-pharmacopoeia. Between these macro and micro approaches lie sub-national or community studies where themes of privatization, decentralization, sustainability, and the role of civil society organizations are investigated in the light of (mainly deteriorating) public healthcare delivery systems.

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1. Definition Of Health

‘Health studies’ incorporate the analysis of health status as an outcome, where health is defined as ‘a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.’ Health status is also used in many social science studies as a determinant, for example, where poor health is seen as a push factor for migration to cities. But health studies also include the study of the organization of healthcare services, whether they are formal public or private services modeled on Western biomedical systems, or more informal, also private, traditional health services.

2. Contact Studies

Much research dating from the 1930s (Cook 1937) has investigated the depopulation of the New World following the European contact. The general consensus is that, by the late 1700s, levels had declined to 10 percent of the original population (Whitmore 1992). Critics of the reconstructed figures argue that the estimates are inflated for the pre-Colombian population (e.g., Henige 1998, Rosenblat 1992). The causes of depopulation are also disputed, though most agree that the primary cause was the introduction of Old World diseases to which the native populations had little resistance. Recent studies of the genetic constitution of these vulnerable populations suggest that high homogeneity meant that their low resistance to new pathogens was also equally homogeneous and can probably account for high mortality rates from smallpox, chickenpox, measles, influenza, and other infectious diseases.

The notion of a ‘health revenge’ by the New World in the form of syphilis has also been a fertile field of study in biosocial science. Medical geographers have traced the path of syphilis as it entered an apparently susceptible population (in Europe from the Caribbean and/or Meso-America) where the pathogen is hypothesized to have converted itself from a relatively harmless skin disease into a virulent sexually transmitted infection. The latest studies (using genetic markers) suggest that the infectious agent for syphilis existed on both sides of the Atlantic, but for reasons that are still unexplained the transfer of the New World version into Europe produced a more dangerous pathogen.

The term ‘Colombian Exchange’ has been commonly used since first popularized by Crosby (1972), to symbolize the biological, cultural, and sociopolitical consequences of the contact. For example, the impact of a changed diet has been examined by historical demographers and anthropologists in relation to survival, health, and nutrition. The changed diet came about through altered trade relations, the export of food items such as corn, potato, and tomato into Europe, and the import to Latin America of wheat, soya, sugar, rice, and many other foods, and massive ecological disruption in the New World as a result of pig importation (Settipane 1995).

3. Ethnomedicine

The idea of ‘exchange’ and the consequences for the health of native populations has also affected the way ethnomedicine has been documented and interpreted by anthropologists. Ethnomedicine has provided rich research areas including: the study of healers and the cured, the incorporation of Mediterranean medicine into healing traditions, the role of traditional African medicine and practices, patient–provider relationships, community-level integration between Western medicine and traditional healing systems, and studies of ethnobotany and ethno-pharmacopoeia. One contested area has been humoral medicine (e.g., Foster 1994, Tedlock 1987), a medical system based on concepts of fluid, temperature, and temperament balance. Humoral medicine encompasses the diagnostic methodology of defining illnesses as either hot or cold (or hotter or colder—i.e., a continuum), and thence prescribing hot or cold herbal or other treatments to (counter) balance the condition.

One ongoing controversial aspect has centered on the historical and cultural origins of humoral medicine. Did this classification originate from the contact period as Greco–Hellenic–Arab notions reflected in Spanish medicine were adopted by indigenous cultures (Foster 1994)? Was this development a coincidence, and the hot cold categorization of illness and cures simply an easy generalization that is found in an enormous array of different cultures around the world (Leatherman 1998)? The notion of syncretism is generally understood to describe the coalescence or joining together of traditions from different cultures. As applied to the contemporary debate over ethnomedicine’s origins, we can define it as meaning the adoption of traditions from one culture to another where the form remains the same, but the meaning and interpretation of the tradition changes.

Research has also been conducted around whether or not particular cures work, or whether they may actually, in some cases, do more harm than good (Greenway 1998). This has required extensive documentation and evaluation of folk medicines in a variety of settings. The Andean nations, Guatemala, Mexico, and Brazil have been the sites of most research. A few analysts have compared treatments using traditional medicine to equivalent treatments in biomedicine for certain illnesses (e.g, Bastien 1998). But much remains to be done in this field of comparative medical efficacy.

Some of these challenges in ethnomedical research center on the problems of scale and unit of analysis (Lock and Scheper-Hughes 1990). Ethnographic research, using interpretist frameworks, treats the health outcome as integral to understanding the meaning behind the particular treatments. Others rely on a more positivist framework, requiring ‘objective’ standards by which to judge the outcome of treatments (see Greenway 1998, Briceno’Leon et al. 1998). Put another way: social science has met a major challenge as it tries to answer questions of biomedical efficacy, since biomedical is only one form of efficacy, and the meaning of the use of particular herbs often extends beyond the mechanistic understanding of ‘fixing’ a single sick body part.

Controversy also centers on how to understand the medical pluralism that is almost ubiquitous in most societies, and specifically how traditional medicine should be integrated into biomedical health systems (Bastien 1992, Leatherman 1998). Arguments focus on the meaning of ‘integration,’ as well as the continuing debate of efficacy and safety of both modern and older pharmaceutical regimes in contexts where, apart from a few urban settings, drug distribution and control is largely unregulated. Some researchers and practitioners even see the pressure to include folk medicine into modern health systems as a way of justifying the limited introduction of modern healthcare in the remoter rural areas (Foster 1994). Meanwhile, Cuban health officials, in reaction to economic shocks from the US embargo and the removal of the Soviet-era subsidies in the early 1990s, and from the incentive to treat chronic illnesses with a wider range of treatments, have developed one of the most complete examples (in the Americas) of traditional medicine being officially incorporated within the biomedical system (Feinsilver 1993).

4. Macro Forces And Healthcare

Health and political economists have examined policy debates that encompass the relationships between the state, economic development, the health systems, and health and nutrition outcomes (Ugalde 1985, PAHO 1998). Debate revolves around two interrelated questions: first, what is the nature of the relationship between inequality (persistent and increasing poverty among the lower income groups), health, and economic growth? Second, what is the nature of the relationship between political participation, health, and economic growth (Frenk 1989, WHO 2000), and what is the role of the state in healthcare? Since Weil and Scarpaci’s (1992) analysis of the health in Latin America in the ‘lost decade’ (the 1980s), two streams of research have emerged. One stream has followed health services research paradigms examining payment mechanisms in different contexts, the fiscal instability of social security systems, and problems associated with health providers and health delivery systems.

A second school challenges the so-called ‘Americanization’ of healthcare systems. Of particular concern has been the impact of wide-scale privatization, the role of corporations in the delivery of healthcare, and the increase in health maintenance organizations. An array of reforming systems is being studied across the continent—from the municipalization with universal care in Cali, Colombia, to the competition with choice in Argentina. Costa Rica and Cuba stand out as examples of primary care models that can be regarded as classic system-level initiatives in health delivery. The critical examination of this ‘Americanization’ is an interesting twist on research that a few years ago was calling for more Westernization of health services (Waitzkin 1998, Stocker et al. 1999).

5. Health Transitions

Great efforts have gone into trying to explain why there is so much heterogeneity among Latin American populations, and why inequalities of health have been exacerbated over the past 50 years—years of increasing economic, if not social, development (Weil and Scarpaci 1992, PAHO 1998). A useful framework for describing the recent demographic experience is the demographic transition framework. Most Latin American nations have followed a common pathway moving from high to low mortality and fertility rates. For example, overall in the last 15 years of the twentieth life expectancy rose from about 66 to 72 years, with a range of between 78 to 55 between the best and worst national performers. These shifts have changed the population structure from a typically wide-based pyramid, with a majority of its population below 15 years), to a more evenly distributed population structure. Concurrent with (or as a consequence of ) the demographic is an epidemiological transition, where the common diseases of a population change from acute infectious to chronic illnesses such as coronary heart disease, diabetes, and cancer—the so-called life-style diseases. Deaths from these diseases outnumbered deaths from infectious diseases by 10 to 1 in 2000. This was a doubling of the ratio since 1985. These transitions, collectively known as the health transition, might make a modern-day cynic conclude that for many, life in much of Latin America is still nasty and brutish, but for a multitude of reasons, it is no longer all that short.

6. Conclusions: Continuity And Change

In general terms, there is a recognition among social and medical scientists of the need to substantially broaden the frame of analysis for health, development, and environmental change to include psychosocial and biocultural dimensions. But despite calls for this more inclusive approach, there is little follow-through yet. In terms of specific health problems, much more research is needed to reflect the changes within Latin societies; for example there have been few studies involving occupational health or chronic illnesses such as cardiovascular disease, diabetes, and cancer. Dependency problems associated with changing lifestyles such as alcohol, tobacco, and other drug addictions, or their consequences such as depression and other mental health challenges are beginning to attract some research (Good 1997). The consequences of natural disasters have also begun to attract attention in social epidemiological studies, but this has not yet been reflected in further interest within other social sciences.

Special populations such as children, adolescents, and poor women have energized a broad range of studies: from specific studies of family planning access and use, to integrated studies of reproductive health and development, to vulnerability to tuberculosis and AIDS. Many of these sub-population studies can trace their origins to the mainstreaming of feminist theory, to development studies that implicate women’s low status in many societies, and to the empowerment of indigenous populations and indigenous movement in general and the study of marginalized groups such as street children. The most recent developments in this trend is the study of the violation of human rights in the context of health. In the case of adolescent health studies, much recent work stems from the perception of adolescents being increasingly vulnerable to sexually transmitted infections. Social science may yet play a significant role in improving our understanding of the social networks of these children, and help policy makers provide better protective environments for them.

Other new themes include the application of ecological concepts to the study of complex relationships between humans, their landscapes and the pathogens and vectors that cause disease. An investigation of the relationship between ecology and disease was incorporated into social science research (especially in geography) beginning in the 1960s, but the variables were generally limited to the impact of altitude on health and the weight height adaptations to different ecological zones. There has always been an interest in the ways in which human behavior and human health may vary by place, but the field of disease ecology sets out to investigate the synergistic relationship between a specific disease (both pathogen and vector), a given ecology and the human factors and behaviors that affect that environment. Disease ecologists and human behavioral scientists are beginning to collaborate, incorporating multi-level frameworks (from micro to community level) to enhance our understanding of specific disease and human environments for diseases such as chagas, dengue fever and DHF, malaria, and other infectious parasitic and vector-borne diseases. Human adaptation of the landscape, particularly in the form of urbanization and widespread monocropping, has provoked changes in disease patterns that can only be understood from a perspective that integrates various disciplines, and moves outside that traditional realm of treating the patient in order to control disease.

Although it is too early to tell how long-lasting a tradition this may be, it would seem that the AIDS epidemic has succeeded in overcoming some of the more rigid boundaries between disciplines (Farmer et al. 1996). There are signs that as the social and biomedical fields begin to recognize each other’s contributions, social epidemiologists, psychologists, infectious disease clinicians, and medical anthropologists have begun to collaborate to advance our still very basic understanding of the interactions between social, political, and cultural structural constraints and the power of individuals.


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