Social Medicine, Vol. , No. , 2006.
Claudio Schuftan, Ho Chi Minh City
schuftan@gmail.com
We here present a historical piece way ahead of its time. It comes to us from South America, and its protagonist is the freshly appointed (youngest ever) minister of health in the pre-WWII Chile.
A left-of-center government had come to power in 1938 and Salvador Allende (1), a militant of the Socialist Party and a physician himself, was nominated for the position.
He approached the challenge by embarking on a ground-breaking socio-political analysis of the medical reality of his country that had come out scathed from the global recession of the early 1930s, because, in his words, “the Chilean economy had become a ‘slave’ of global events”. The social costs of the recession – as Chile lost lucrative world copper and nitrate markets – had been devastating for the poor (2). Allende understood how all this impacted on health and that is why he embarked in this analytical piece at the start of his mandate as a minister.
The result of his inquiry is the serene yet passionate socio-medical report whose opening section is here presented. It is noted that how he undertook the task of writing this report is also an important lesson for us in 2006: The report, clearly outlines the ‘crude reality’ (his words) of the true conditions of health and hygiene of the country which he gathered by extensively traveling through it. He thus documented in all its magnitude the state of misery that the people had been living under; he tells us how he learned first hand the urgent and acute problems which needed to be tackled emphasizing to us that the state of national health has consequences for everyone. Allende further made it a point through his report to show his citizens the bare facts.
Allende was clearly ahead of his time, because he saw Chile’s alarming socio-medical reality being an outcome of a hierarchy of causes ultimately brought about by structural determinants. And not only was he vocal about them, but also clear, unambiguous and absolute about the ultimate remedies needed to improve the situation sustainably.
In his report, Allende makes a number of observations and advances predictions – that are truly global and not only of national relevance to Chile of the 1940s. These observations/predictions (irrespective whether they were fully original or not) turned out to be almost prophetical. Taken together, they convey a frustrating sense of deja-vu.
Consider that in just short of ten pages Allende speaks:
· of ‘free competition’ (our current free market) being the culprit of many of the social evils affecting Chile’s proletariat and peasantry at the time;
· of the need of overcoming exploitation and ignorance to foster a healthy and educated people;
· of the cultural colonialism that impeded social progress in Chile of the late 1930s;
· of the fact that ‘progress’ had bypassed the great majority of Chileans – those who created most of the wealth of the nation;
· 5 of the fact that foreign companies (who received favorable tax breaks) served the interests of economic imperialism and not those of the country;
· of agriculture exploiting man more than the soil;
· of an economy that forces Chile to become a consumer of goods manufactured by large industrial countries (thus making the country dependent); and
· of international Capitalism only being interested in profits through production “to satisfy market demands and no more”… with its enterprises not being concerned about the fact that the working population lived in deplorable conditions;
…and do remember that this is said in 1939!
Allende then goes on to say and note:
· that the first obligation for action for governments (note he speaks in plural here!) is to defend themselves from the economic imperialism that roams the world;
· that, therefore, the good will of statesmen has its limits in the relations that the laws of the world economy impose on dependent countries;
· that the working class has been kept ignorant of the bare facts the report uncovers thus preventing them to recognize that they need to get organized to conquer the right to their own well-being, health and culture by breaking the trend of history and installing a government able to deliver the fruits of progress – which have always been the patrimony of a minority;
· that medical measures only produce benefits if they are accompanied by economic and financial resolutions;
· that it is not possible to provide good health to malnourished people working under merciless exploitation;
· that it is no consolation for Chile that other countries suffer similar ills;
· that Chile’s socioeconomic structure must undergo fundamental modifications to guarantee citizens conditions of welfare, i.e., that the solution to the socio-medical problems foremost require solutions to the economic problems affecting the proletariat;
· that the state must intervene in establishing appropriate norms and regulations to guarantee the above needed changes; and
· that there is thus an ‘imperative necessity’ to use all means to deal with the dangers that threaten the health of the poor.
If this all is not highly current in 2006, then the author wonders what is…
Under his proposed plan of action, Allende is perhaps one of the first to call for investments in ‘human capital’. He sees the latter as the fundamental base of economic prosperity, as the basis of all wealth and thus the maximum responsibility of the modern state. He reckons that human capital has been abandoned to its own fate with no social security systems in place.
He then describes the ‘social pathology’ of the country that neither the employers nor society are moved to change and remedy. He does not stop short of identifying what we today call social determinants of health, i.e., malnutrition, the lack of shelter and sanitation, illiteracy and other such which he correctly places at the center of the social reality of Chile in the late 1930s.
Towards the end, he keenly notes that we cannot waste any more time – a cruel reality when looked at from a 2006 perspective – without putting into action a ‘massive project’ aimed at intensifying health prevention, literacy campaigns and the tackling of the socio-medical determinants of health he so ably depicts in the report.
In the closing line – and perhaps with premonition – Allende tells us that Chile in 1939 was ‘in pursuit of its rights’; little did he foresee that, by the end of the century, the UN would make human rights (the right to health included) the center piece of its development outlook for the coming century.
How much impact the report had in Chile and in the rest of Latin America is difficult to assess. But looking with hindsight, it must have played a role in the annals of social medicine in the continent as a whole. Proof of it is that the School of Public Health of the University of Chile – that followed the tradition of this 1939 report – thereafter became the alma-mater of a full generation of ‘salubristas’ in Latin America.
As the reader can see, these are the things that many of us are still talking and writing about 65 years later. Allende’s thinking is contemporary, because the issues he identified have not been yet resolved. One cannot but sadly note that the world ignored Allende’s advice as much in 1939 as it does today in 2006. The forces that benefit from the current structures that result in preventable deaths, preventable ill-health and malnutrition are still well entrenched and firmly in command. Two generations of our peers seem to have lost Allende’s vision and denunciatory courage and got sucked-in into dreaming that technical solutions in public health would right the wrongs.
The lesson learned here is that we have to become keenly aware of how the prevailing system pushes us to device pat solutions (such as improving the management and efficiency of health programs, or throwing two-year projects at out major global health problems). This, as if Allende’s 1939 piece – and for that matter the 1978 Alma Ata Declaration – never existed. We have to become denouncers of this state of affairs and active protagonists in changing this so entrenched current attitude of our peers that ignores the social determinants of health with impunity. In 2006, nothing short of a(n) (updated) return to the principles of the Alma Ata Declaration will do. The People’s Health Movement is a network doing just that; check them out and join the movement; visit www.phmovement.org.
As for Allende, he never changed his views. In all his long political career, Dr Allende remained a physician at heart. He himself endlessly built on the foundations laid by this report. As a senator, he went on to prepare legislation creating the Chilean National Health Service in 1952 – a first in the Americas. Then, as a President of the Republic in the early 1970s, Allende introduced further progressive health and nutrition reforms in which the author was proudly involved.
But the pendulum was to swing backwards: 17 years of military rule dramatically undid the gains in social medicine Chile had made in the preceding decades – gains that have only seen a partial recuperation in the last over ten years of democracy that have followed the fall of the infamous general Augusto Pinochet.
Claudio Schuftan, Section Editor, Social Medicine Journal
claudio@hcmc.netnam.vn
End notes:
(1): Born on July 26, 1908, in Valparaiso, Salvador Allende came from an upper-class Chilean family with a long history of political activism. His grandfather was one of the founders of the Chilean Radical Party in the 1860s. After graduating from secondary school at the age of 16, Allende enrolled in the Coraceros Cavalry Regiment and, after a tour of duty, entered medical school at the University of Chile. Medical school helped further radicalize him as he lived, in very humble circumstances, with a group of students attracted to the writings of Marx, Lenin, and Trotsky. Allende became a student activist and was arrested twice and expelled once during his medical school years. He graduated in 1932 but, because of his radical history, was turned away from the Valparaiso hospitals and had a difficult time finding work as a physician. Allende was forced to take work as a pathology assistant, performing autopsies on the cadavers of the poor. He eventually established a practice among public welfare patients in Valparaiso.
In 1933, Allende was one of the founders of the Chilean Socialist Party, which was based on Marxist principles but was intended to be specifically Chilean rather than broadly international in its orientation and parliamentary rather than revolutionary in its politics. In 1937, he was elected as a Socialist deputy to the Chilean National Congress (the lower house), where he introduced legislation on public health, social welfare, and the rights of women. Two years later, Allende was named minister of health, prevention, and social assistance in the Popular Front government, a position he held until 1942.
In 1939, he published La Realidad Médico-Social Chilena (The Chilean Socio-Medical Reality), the source from which the excerpt published here in translation is taken. He concluded the book with the Ministry of Health’s proposals for health improvement that emphasized social change rather than medical interventions.
In 1942, Allende became the leader of the Chilean Socialist Party and in 1945 he was elected to the Senate (the upper house of parliament). During the 1950s, he introduced the legislation that created the Chilean National Health Service, the first program in the Americas to guarantee universal health care. Allende would remain in the Senate until 1970, and for nearly a decade during his tenure served as vice president and president of the Senate. He ran for president on 4 occasions: in 1952, 1958, 1964, and 1970. In the latter year, as head of the Unidad Popular coalition, he won 36.3% of the popular vote in a 3-way race. The Chilean Congress then ratified him as president. Allende called for profound economic and social change focused on improving the condition of the poor and decreasing the role of private property and of foreign corporations. As president, he sponsored the decentralization of health care by empowering local health councils that worked with social service sectors to serve the impoverished masses. Chilean doctors often felt threatened by Allende’s health care policies, which focused on public rather than private care and thus meant less income for private physicians.
Other democratic nations, most notably the United States, found Allende’s brand of democracy intolerable and gave millions of dollars to his various opponents, including organized medicine. Foreign intervention, factional divisions within the Unidad Popular and the Socialist Party, political opposition from the Chilean right, and economic instability all contributed to undermining Allende’s presidency. On September 11, 1973, his government fell to a military coup led by General Augusto Pinochet. Allende was found dead that same day. While the Chilean government maintains that he committed suicide, many others claim that he was assassinated by Pinochet’s troops. (Taken from Tedeschi, S.K., ‘Salvador Allende, Physician, Socialist, Populist and President’, AJPH, 93:12, 2014-2015, Dec. 2003).
(2): In 1938, the economic recession resulted in a conjuncture that led to a coalition of left parties – the Popular Front – to ascend to the presidency of the republic under a (center-left) Radical Party president. As President Aguirre Cerda formed his cabinet, the Socialist Party was assigned the ministry of health: Dr Allende was the nominee. He and his team then prepared the, by now, historical document “Chile’s Medical-Social Reality” we feature in this issue of the SMJ. Whether this report was influenced by the thinking of Virchow (SMJ No. 1) is difficult to ascertain, because Allende, a Marxist, was a keen practitioner of historic materialism applied to the 20th century imperialism in the neo-colony.