IJE Advance Access originally published online on April 28, 2005
International Journal of Epidemiology 2005 34(4):739-741; doi:10.1093/ije/dyh176
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Commentary |
Commentary: Salvador Allende and the birth of Latin American social medicine
Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico, 87131, USA
E-mail: waitzkin{at}unm.edu
Succeeding generations have forgotten and then rediscovered the conditions of society that generate illness and mortality. Now, when disease-producing features of the workplace and environment threaten the survival of humanity and other life forms, it is not surprising that such problems receive attention. But there is a long history of research and analysis that has been neglected, despite its relevance to our current condition.
Salvador Allende, late president of Chile and a pathologist, helped establish the field of Latin American social medicine with his path-breaking epidemiological work, accomplished during the 1930s. Although social medicine has become a widely respected field of research, teaching, and clinical practice in Latin America, the accomplishments of this field remain little known in the English-speaking world. This gap in knowledge derives partly from the fact that important publications remain untranslated from Spanish or Portuguese into English. In addition, the lack of impact reflects a frequently erroneous assumption that the intellectual and scientific productivity of the ‘Third World’ manifests a less-rigorous and relevant approach to the important questions of our age. (Further information about Latin American social medicine appears in recent publications1–6 and a website: http://hsc.unm.edu/lasm.7)
Adherents of Rudolf Virchow's vision about the social determinants of mortality and morbidity immigrated to Latin America near the turn of the 20th century. Virchow's followers helped establish departments of pathology in medical schools and initiated courses in social medicine. For instance, a prominent German pathologist, Max Westenhofer, who directed for many years the Department of Pathology at the Medical School of the University of Chile, influenced a generation of students, including Allende, a medical student activist and future president of Chile. Allende's experiences as a physician and pathologist shaped much of his later career in politics. Acknowledging debts to Virchow and others who studied the social roots of illness in Europe, Allende set forth an explanatory model of medical problems in the context of underdevelopment.
While the roots of Chilean social medicine date back to the mid-19th century, the most sustained activities began after the nationwide strikes of 1918. During that year, saltpetre workers in the northern desert encouraged work stoppages in other industries, with the goal of improving wages, benefits, and working conditions. Luis Emilio Recabarren, a charismatic organizer among the saltpetre workers, emphasized malnutrition, infectious diseases, and premature mortality. During the next three decades, Recabarren and his political allies agitated for economic reforms as the only viable route to improvements in patterns of illness and mortality that affected the poor. During the 1920s and 1930s, social medicine flourished in Chile, partly as a response to demands of the labour movement.
Writing in 1939 as Minister of Health for a newly elected popular front government, Allende (working with his team at the Ministry) presented an analysis of the relationships among social structure, disease, and suffering in his classic book, La Realidad Médico-Social Chilena (The Chilean Medico-Social Reality).8 (Excerpts appear elsewhere in this issue of the International Journal of Epidemiology.9) La Realidad conceptualized illness as a disturbance of the individual fostered by deprived social conditions. Breaking new ground in Latin America at the time, Allende described the ‘living conditions of the working classes’ that generated illness. Allende emphasized the social conditions of underdevelopment, international dependency, and the effects of foreign debt and the work process. Describing issues that had not been studied previously, he analysed illegal abortion, the responsiveness of tuberculosis to economic advances rather than treatment innovations, housing density in the causation of infectious diseases, and differences between generic and brand name pricing in the pharmaceutical industry.
The introduction of La Realidad explored the dilemmas of reformism and argued that incremental reforms within the health-care system would remain ineffective unless accompanied by broad structural changes in the society. Allende emphasized capitalist imperialism, particularly the multinational corporations that extracted profit from Chilean natural resources and inexpensive labour. He claimed that to improve the health care system, a popular government must end capitalist exploitation.
Medical problems that Allende considered included maternal and infant mortality, tuberculosis, venereal diseases, other communicable diseases, emotional disturbances, and occupational illnesses. He observed that maternal and infant mortality rates generally were much lower in developed than in underdeveloped countries. After reviewing the major causes of death, he concluded that malnutrition and poor sanitation, both rooted in the contradictions of underdevelopment, were major explanations for this excess mortality. In the same section Allende gave one of the first analyses of illegal abortion. He noted that a large proportion of deaths in gynaecological hospitals, about 30%, derived from abortions and their complications. Pointing out the high incidence of abortion complications among working-class women, he attributed this problem to economic deprivations of class structure.
Allende designated tuberculosis as a ‘social disease’ because its incidence differed so greatly among social classes. Writing before the antibiotic era, Allende reached conclusions similar to those of modern epidemiology—i.e. major decline in tuberculosis followed economic advances rather than therapeutic medical interventions. From statistics of the early 20th century, he noted that tuberculosis had decreased consistently in the economically developed countries of Western Europe and the US. On the other hand, in economically underdeveloped countries like Chile, little progress against the disease had occurred. Within the context of underdevelopment, tuberculosis exerted its most severe impact on the working class.
Addiction was another problem that troubled Allende deeply. He maintained a concern with addiction throughout his career; one priority of his health policies as President of Chile was a large-scale alcoholism programme. In La Realidad, Allende analysed the social and psychological problems that motivated people to use addicting drugs. Rooted in social misery, alcoholism exerted a profound effect on health, an impact which Allende documented for a variety of illnesses, including gastrointestinal diseases, cirrhosis, delirium tremens, sexual dysfunction, birth defects, and tuberculosis. He also traced some of the more subtle societal outcomes of alcoholism; for example, he offered an early analysis of the role of alcohol in deaths from accidents.
The Ministry of Health's proposals that concluded La Realidad took a unique direction by advocating social rather than medical solutions to health problems. Rather than seeing improved health-care services as a means toward a more productive labour force, Allende valued the health of the population as an end in itself and advocated social changes that went far beyond the medical realm. In considering reform and its dilemmas, he reviewed the social origins of illness and the social structural remedies that were necessary.
Allende refused to discuss specific health problems apart from macro-level political and economic issues. The country's productivity suffered because of workers' illness and early death, according to Allende, yet improving the health of workers was impossible without fundamental structural changes in the society. These changes would include ‘an equitable distribution of the product of labour,’ state regulation of ‘production, distribution, and price of articles of food and clothing,’ a national housing programme, and special attention to occupational health problems. The links between medicine and broader social reality were inescapable: ‘All this means that the solution of the medico-social problems of the country would require precisely the solution of the economic problems that affect the proletarian classes.’10
He then proposed specific reforms that he viewed as preconditions for an effective health system. These reforms called for profound changes in existing structures of power and finance. First of all, he suggested modifications of wages, which if enacted would have led to a major redistribution of wealth. Regarding nutrition, he developed a plan to improve milk supplies, fishing, and refrigeration, and suggested land reform provisions to enhance agricultural productivity. Recognizing the need for better housing, Allende proposed a concerted national effort in publicly supported construction as well as rent control in the private sector.
Since the major social origins of illness were low wages, malnutrition, and poor housing, the first responsibility of the public health system, according to Allende, was to improve these conditions. Allende did not emphasize programmes of research or treatment for specific diseases; instead, he assumed that the greatest advances toward lowering morbidity and mortality would follow fundamental changes in social structure. This orientation also pervaded his proposed ‘medico-social programme.’ In this programme he suggested innovations including the re-organization of the Ministry of Health, planning activities, control of pharmaceutical production and prices, occupational safety and health policies, measures supporting preventive medicine, and sanitation programmes.
Allende's analytical position in social medicine lay behind much of his political work until his death in 1973 during the military coup d'état. As an elected senator in the early 1950s, Allende introduced the legislation that created the Chilean national health service, the first national programme in the Americas that guaranteed universal access to services. He linked this reform to other efforts that aimed to achieve more equitable income distribution, job security, improved housing and nutrition, and a less-dominant role for multinational corporations within Chile. Similarly, as a senator during the 1960s and elected president between 1970 and 1973, Allende sought reforms in the national health service and other institutions that would have achieved structural changes throughout the society. Due to his advocacy of a unified health service in the public sector, the Chilean national medical association (Colegio Médico) feared the effects of Allende's policies on private practice and therefore frequently opposed him, especially before the coup of 1973.
Many years later, the insight that the social origins of illness demand social solutions is not particularly surprising. Like Engels and Virchow before him, Allende saw major origins of illness in the structure of society. This vision implied that medical intervention without political activism would remain ineffectual and, in a deep sense, misguided.
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3 Waitzkin H. At the Front Lines of Medicine: How the Health Care System Alienates Doctors and Mistreats Patients ... And What We Can Do About It. Lanham, MD, and London: Rowman and Littlefield, 2001, ch. 3.
4 Krieger N. Latin American social medicine: the quest for social justice and public health. Am J Public Health 2003;93:1989–91.
5 Laurell C. What does Latin American social medicine do when it governs? The case of Mexico City. Am J Public Health 2003;93:2028–31.
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8 Allende S. La Realidad Médico-Social Chilena. Santiago, Chile: Ministerio de Salubridad, 1939.
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10 Allende S. La Realidad Médico-Social Chilena. Santiago, Chile: Ministerio de Salubridad; 1939, p. 198.
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