A socio-psychological perspective on community participation in health during the Unidad Popular government: Santiago de Chile,from 1970 to 1973

Introduction

In Latin America, community participation in health has conventionally been described and analysed from a non-historical perspective, frequently focused on isolated and depoliticised experiences of participation that have no long-term impact either on individuals or communities (Kerrigan et al., 2008; Llovet et al., 2011). Participatory approaches have been conceptualised within a biomedical background, oriented toward the expansion of health services to marginalised groups and the cultural adaptation of health systems to local contexts, providing more cost-efficient medical services (Filho and de Araújo, 2002; Torri, 2012), and, recently from a socio-psychological perspective, community participation has been directed at changing health-related behaviour through peer education programmes and community empowerment (Guareschi and Jovchelovitch, 2004; Ramella and de la Cruz, 2000). Although there are some exceptions (Quintal de Freitas, 2000; Wong-Un, 1998), this general perspective of analysis neglects the central role that disadvantaged communities have played in the construction of health institutions and social responses to public health challenges in our societies, alienating what is essentially a social product from its historical subject, that is, the organisation and mobilisation of urban workers, peasants and pobladores. ¹

The comprehension of health as a social product implies the existence of different social subjects that have consciously constructed and transformed health institutions within history, not as a gradual and consensual process, but as a reflection of antagonist interests among social classes (Molina, 2010; Navarro, 1974). From this position, some authors have emphasised how disadvantaged communities, through their struggles for improving their living conditions and demand for equitable public services, were largely responsible for the advancements in the financing and provision of health care in Latin American and African societies (Campbell et al., 2010; Illanes, 1993). This historical perspective contrasts with development discourses related to community participation, in which participation is ‘reduced to a series of methodological packages and techniques’, and sanitised from any transformative intention (Leal, 2007). Similarly, the dominance of the epidemiological transition theory in social and health sciences, a ‘conceptually weak’ model (Martínez and Leal, 2003), which assumes that economic growth and modernisation are accompanied by automatic improvements in health, conceals the notion that health achievements have often been the expression of radical mobilisation of disadvantaged communities (Avilés, 2001; De Kadt, 1982).

In this regard, community participation in health in Latin America can be comprehended as a specific dimension of a wider social movement related to the organisation of marginalised communities since the 19th century. Particularly in the case of Chile, the organisation and mobilisation of popular classes had a central role in the creation and development of Chilean health system and policies, in a context of poverty, high levels of infant and maternal mortality, malnourishment and epidemics (Navarro, 1974; Paluzzi, 2004; Waitzkin et al., 2001). Through the political and social claims of urban workers and pobladores, followed by the ambivalences of the oligarchic state expressed in repression and political concessions, disadvantaged communities achieved salary rises, the provision of basic education for the popular classes and the implementation of safer and more hygienic conditions in working places (Illanes, 1993; Molina, 2010). In addition, the creation of the National Health System in 1952 and its later institutional development until 1973 reflects the historical demands of disadvantaged and marginalised communities, confronted with the antagonist interests of dominant Chilean elites and the Chilean Medical Association; these latter aimed at the classist segregation of health systems and the privatisation of medical services (Illanes, 1993; Molina, 2010).

During the 1960s, community participation in health was expressed through the formation of Health Delegates and Health Militias, popular and autonomous organisation that took responsibility for the local health problems inside poor urban settlements. These organisations provided basic health care to their communities, developed local health education programmes, built policlinics and mobilised pobladores to put pressure on the government for the expansion of health services (Cofré, 2007; Fuentes, 2007; Paiva, 1989). With the arrival of the Unidad Popular government in 1970, a leftist political coalition headed by former president Salvador Allende, community participation in health achieved its greatest historical development, ending abruptly due to a military coup on 11 September 1973. The recognition of social participation and democratisation as central health policies of the government and the political and social maturation of organised communities were expressed through massive health campaigns and the creation of Local Health Councils and Health Joint Committees, consultant organisations representing community, labour associations and health workers in every policlinic and hospital in the country (Navarro, 1974; Weinstein, 1977).

Although historiography research related to public health brings forward the significance of community participation in health from 1970 to 1973 under the rule of the Unidad Popular government, these experiences have been described and analysed from an institutional perspective, as adjuvant to government policies, rather than being seen as a research focus in their own right (Illanes, 1993; Molina, 2010). However, studies of social movements in Chile, when detailing the organisational experiences of pobladores and urban workers, fail to directly address health-related activism and mobilisation during this period (Garcés, 2002; Pinto and Moulian, 2005). Therefore, through this article and from a socio-psychological perspective, I will attempt to explore and describe these experiences of community participation in health, highlighting the fact that disadvantaged communities have often played a much more active role in struggling for health than what is acknowledged in much of the Latin American ‘community participation’ literature and development discourses.

Methodology

The purpose of this qualitative research is to explore the experiences, meanings and representation of social actors involved in community participation in health in Santiago de Chile, from 1970 to 1973. It explores how these experiences were constructed focusing on disadvantaged communities and their processes of organisation and mobilisation. This study was approved by the Institute of Social Psychology Ethics Committee, London School of Economics, and informed consent was given and signed by all participants.

Results and Discussion

Informants provided an account of the expressions of community participation in health from 1970 to 1973 as multiple and dynamic, constituting critical responses to the health and political challenges that communities faced. Through the narratives of the participants, we can recognise three different moments in community participation that, although not well limited, are related to specific historical themes.

Initially, health responses through participation were mainly directed by the government, expressed in massive health campaigns, and the creation of Health Brigades in the settlements of Santiago de Chile. Health Brigades were relatively autonomous organisations, mostly constituted by young women who were trained by health workers, in a similar way to modern programmes of ‘peer education’, as the educational training of members of disadvantaged communities, in order to disseminate information of health-related problems (Campbell, 2003). These women were part of their communities, understood local health problems and they had the trust and respect of the rest of the population:

These women begin to constitute themselves in subjects, I mean they became as the community model and reference in health … I mean, the medical doctor lost prominence, I mean, people began to realise that Health Brigades were capable of resolving things, and people began to trust in them. They did this despite only being their ‘peers’, as it is named today … But the prominence they had, the capacity to convene people, it was not through imposition, but they were those who went from hovel to hovel. (Poblador 1)

During this fist moment, community participation in health was aimed to expand health-care coverage, to prevent diarrhoeas and bronchopneumonia in children, to educate pregnant women and to prevent alcoholism inside settlements:

We organised from the Ministry of Health and from the General Directorate of the National Health Service an emergency committee and an immediate campaign, through massive collective participation, to face the two biggest diseases that monopolised infant mortality in Chile at that time: bronchopneumonia … all respiratory diseases and their complications in winter, which were brutal, and the diarrhoeas in summer, and gastrointestinal diseases. (Health Government Official 3)

After these initial experiences, data analysis suggested a second moment in community participation in health, characterised by the development of more autonomous and wider in scope experiences of participation. In this time, health problems were not only conceptualised in relation to malnourishment, maternal mortality and any other disease, but their solution was also linked to the necessity of direct grassroots participation in health decisions. Prompted by the Health Brigades, and latter by the creation of the Local Health Councils in September 1971, the necessity of community participation was expressed through the questioning of former health institutions, and an emphasis on the need for local mobilisation for meeting the challenge of extending health-care services:

Then, people from the Health Brigades at the beginning, they did this work, the work of … let’s say, health treatments, wound healings … education I would say, training of people, promotion and prevention … eating healthy food and all of this. But over time, they evolved in a different way … with greater emphasis on health rights, to conditions of living. We [the pobladores] mobilised against the San Bernardo Hospital, we even occupied it, well … not really occupied it … for many days, and finally the Hospital agreed to hold a conversation with us, in our settlement, to reach a solution for our demands. (Poblador 2)

Which other problem did we have? That the Health Joint Committee was consultative, but it didn’t resolve anything. I mean, it could collect our concerns about all the irregularities regarding industrial health in our work, could even propose things, but it couldn’t solve anything. (Poblador 1)

Finally, and after the first general strike on October 1972, when track owners, merchants and professional organisations, including medical doctors, protested against the political and social reforms directed by the government, the analysis of our interviews highlighted a third moment in the development of community participation in health. This was characterised by a growing social movement, with comprehensive health definitions related to the radical democratisation of health services, to the understanding of the relationship between community health and wider socio-economic structures, and where community organisations assumed the defence of health of their own people. While doctors went on strikes against the government, the pobladores and other health workers maintained the functioning of policlinics and hospitals, and organised the defence of policlinics when these were objects of terrorist attacks from the extreme right wing groups opposed to the Unidad Popular government and its reforms:

What I saw was the problem of low wages, of workmen … sometimes there was money to eat, but not for medicines … sometimes there was no money to eat … and there were a lot of children with very low weight, malnourished. (Poblador 3)

Then the people assumed the defence of health centres, and these cordons when I arrived that day … year 72’, in the general strike, all our health centres in Santiago were surrounded by people with sticks … the Local Health Councils were forming cordons surrounding the policlinics to prevent terrorist attacks, to protect the entrance of the people that went to request attention, to ensure that health care services wouldn’t be hampered … in case that women or babies needed attention. And who attended the babies? Well, health assistants … medical students, and those four of five medical doctors that did not agree with the strike, because the other twenty five were on strike. (Health Government Official 3)

Finally, when the Military Coup in September 1973 was imminent, the pobladores organised themselves in health groups and with community first aids kit, preparing for what they thought would be a violent and brief period of resistance, that ultimately lasted for 17 years:

In 73’ … must have been in June, when things were already so bad, you understand? Then the people asked us in the Local Health Council: What should we do if things get worse? People surely will be maltreated. Well, some small things, I mean a first aid kit is required, you understand? For them to have some analgesics, mostly injectables, gauzes for wound healings, and those kinds of things. Then, communities made this effort, in the policlinic we gave them some indications, and they … even from the health offices, they gave us more medications than usual, so we could provide for … let’s say, to supplement this effort that communities were making to put together their own first aid kits. (Primary Health-Care Worker 3)

I say, it was not violence … it was defence, defence of life. Because we, when we made barricades [after the Military Coup], it wasn’t for violence, but it was to prevent the police from coming in and killing more of our people. It was a legitimate defence that we, as pobladores had to have, because we had to defend life, and if I was in a Health Brigade in this case, even more so, because I was not defending only my life, but also the lives of all the people. (Poblador 5)

From a socio-psychological perspective, we can recognise in the aforementioned experiences of community participation a pedagogical process, facilitated by the creation of Local Health Councils as social and political spaces for dialogue, in which Health Brigades and other organisations were able to articulate a common social identity, and to generate critical consciousness sustained on local social representations. Through the development of these radical responses to collective health challenges during the period from 1970 to 1973, pobladores constituted themselves into social subjects, actively transforming Chilean health institutions, and defying the unacceptable social and economic privileges of the dominant elites. Soon after the military coup in 1973, pobladores and health workers involved in these experiences of community participation in health were fiercely persecuted, Local Health Councils were prohibited and public health services were gradually dismantled.

Conclusion

In this article, I have provided a brief analysis of community participation in health in Santiago de Chile, from 1970 to 1973. These experiences are depicted as a pedagogical process, in which pobladores constituted themselves into social subjects, actively transforming Chilean health institutions and providing original and courageous responses to public health challenges in this period. These findings contrast with the timid and non-historical attempts to understand and implement participatory programmes in health in Latin America, often conceptualised as adjunct and depoliticised projects with no genuine intentions to change governmental health systems, much less to transform social structures of oppression. As Campbell et al. (2010) have pointed, this position ‘seldom result in significant sustainable or generalised social change’, arguing for the necessity of building ‘receptive social environments’ in which unequal power relations are challenged by radical social movements, as illustrated in the successful experiences of the Movimento dos Trabalhadores Rurais Sem Terra in Brazil, India’s Jan Swasthya Abhiyan and Treatment Action Campaign in South Africa. Community participation in health in Chile during the Unidad Popular government contributes to this critical understanding of participation, conceived as a dialectic and transformative action from historically disadvantaged communities, aimed to change our present day inequitable societies.