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Resisting the Imperial Order and Building an Alternative Future in Medicine and Public Health

Rebeca Jasso-Aguilar is instructor of sociology at the University of New Mexico. Howard Waitzkin is distinguished professor emeritus of sociology at the University of New Mexico and adjunct professor of Internal Medicine at the University of Illinois. This article grew from an ongoing collaboration that has included a doctoral dissertation (Jasso-Aguilar, How Common Citizens Transform Politics: The Cases of Mexico and Bolivia, Department of Sociology, University of New Mexico, 2012) and a recent book (Waitzkin, Medicine and Public Health at the End of Empire, Paradigm, 2011).

Although medicine and public health have played important roles in the growth and maintenance of the capitalist system, conditions during the twenty-first century have changed to such an extent that a vision of a world without an imperial order has become part of an imaginable future.1 Throughout the world, diverse struggles against the logic of capital and privatization illustrate the challenges of popular mobilization. In addition to these struggles, groups in several countries have moved to create alternative models of public health and health services. These efforts—especially in Latin America—have moved beyond the historical patterns fostered by capitalism and imperialism. (We have chosen not to address the Cuban case here, which is in many ways exceptional, and on which a great deal of previous work exists.2) All the struggles that we describe remain in a process of dialectic change and have continued to transform toward more favorable or less favorable conditions. However, the accounts show a common resistance to the logic of capital and a common goal of public health systems grounded in solidarity, not profitability.

Protagonists of struggles in Latin America have experienced the direct impacts of political and economic imperialism imposed by the United States over the course of nearly two centuries. Policies that fortified U.S. dominance throughout the Americas originated formally with the Monroe Doctrine in 1823. Subsequently, U.S. economic and political elites succeeded in imposing a neocolonial environment, in which multinational corporations based in the United States could extract raw materials and open up new markets for the entire Western Hemisphere. The military forces of the United States protected the expanding U.S. empire through a series of invasions and other interventions throughout the nineteenth and twentieth centuries.

Latin American countries achieved political independence at various points in the past two hundred years, but economic independence has proven more elusive. Between the 1940s and ’70s, Latin American countries attempted to establish their own economic thought and to follow their own economic paths. During this period, the region experimented with policies that favored state intervention to promote industrialization. Among other things, these policies allowed for the development and expansion of public services such as education and health care. While such policies did little to reduce poverty or inequality, they underscored the role of the state in national economic policy and its responsibility to provide a social safety net.

An ideological shift occurred in the 1980s, and Latin America became a laboratory for experimenting with the stringent economic policies that would become known as neoliberalism. Neoliberalism seeks to assert the superiority of the market over the state; it aims to reduce drastically the role of the state in the economy and to favor austerity, fiscal discipline, deregulation, privatization, and the dismantling of the welfare state.3 Neoliberal policies were first imposed under military rule in Chile and later were introduced by elected governments in other Latin American countries, beginning with Bolivia in 1985. These policies were packaged as the Washington Consensus and were implemented under the watchful eyes of the International Monetary Fund and the World Bank. Between 1980 and 2010, the policies of privatization, deregulation, and liberalization led to a massive transfer of resources from the public to the private sector, the systematic elimination of the safety net, and the worsening of existing social and economic inequalities.

Due to a long history of confronting imperialism, Latin America became an especially fertile ground for resistance against neoliberalism. As a result, Latin American countries that were left in economic ruins due to the diligent application of neoliberal policies have led the struggle in the past fifteen years. Social movements in the region have unseated governments, appropriated factories, expelled corporations, sought autonomy and self-determination, engaged in electoral struggles, and shared broad demands of social justice.4

In this article, we analyze a series of popular struggles in which we have participated during the past decade as researchers and activists. These struggles include resistance against the privatization of health services in El Salvador and the privatization of water in Bolivia. The article also includes efforts to expand public sector health services in Mexico. Such scenarios convey a picture very different from that of the historical relation between imperialism and health—a picture that shows a diminishing tolerance among the world’s peoples for the public health policies of imperialism and a growing demand for public health systems grounded in solidarity. These examples also reflect a larger phenomenon: the success of popular struggles to facilitate the participation of common citizens in social issues usually discussed and decided by political and economic elites. In practice this change has translated into demands to have a say in policies related to natural resources such as water and gas, as well as health services and medications. As one Bolivian participant put it, people have seized the right to decide on matters of the public sector.5

The Struggle Against Privatization of Health Services in El Salvador

One of the first outbreaks of sustained resistance to imperial policies in public health and medicine took place during the late 1990s in El Salvador. This struggle focused on privatization policies initiated by the World Bank, in collaboration with a right-wing political party in power at that time. Efforts to resist privatization of health services and the public health system in El Salvador emerged as a model for analogous social movements elsewhere in Latin America. The example of El Salvador also illustrated similar processes that were to occur in many other countries throughout the world during the early twenty-first century, as imperial policies were met with sustained resistance.

From 1998 to 1999, the health care sector in El Salvador fell into political turmoil, when conflict broke out over various issues. First, unionized workers from the Salvadoran Institute of Social Security (ISSS, Instituto Salvadoreño del Seguro Social) mobilized for a salary increase, after an agreement was reached with—but not honored by—ISSS authorities. Second, an unfavorable revision of the collective bargaining contract further strained the relationship between workers and the ISSS administration. And third, the administration began to contract private entities for delivery of services—food, laundry, cleaning, and so on—to the ISSS hospitals; this outsourcing was the first signal of privatization within the ISSS. In line with this trend, two major public hospitals under renovation remained closed for several months, waiting to outsource their services to private entities instead of being returned to the management of the ISSS.6

Such actions comprised part of a strategy, favored by the World Bank, to privatize public hospitals and clinics. Simultaneously, the government tried to gather public sympathy for the privatization of health care on the basis of alleged corruption and inefficiency in the ISSS—all the while avoiding the term “privatization.” Several conditions, however, called into question the credibility of such allegations. For instance, during the previous thirteen years, those directly responsible for the functioning of the ISSS had been appointed by the party in power, the Republican Nationalist Alliance (Alianza Republicana Nacionalista, ARENA); these appointments included hospital directors and ISSS officials. Many ARENA politicians who supported privatization held a financial stake in this effort. In addition, the health budget was underspent, creating an artificial shortage of medications and delays in services, elements that proponents of privatization used to build the case for “modernization” and “democratization” of the health care system.7

These issues led to partial and temporary strikes in San Salvador. Workers mobilized in the vicinity of public hospitals. Those belonging to the Union of Workers of the Salvadoran Institute of Social Security (Sindicato de Trabajadores del ISSS, STISSS) began a national strike—an indefinite, escalating strike. Negotiations between the ISSS administrative authorities and STISSS workers collapsed. This collapse, combined with a growing concern among doctors about the privatization of health care, provided the ground for an alliance between the STISSS workers and the doctors of the recently created Medical Union of Workers of the Salvadoran Institute of Social Security (Sindicato Médico de Trabajadores del ISSS, SIMETRISSS). The medical profession, with little or no history of unionization, joined the national strike. The alliance of STISSS and SIMETRISSS produced a document entitled: “Historical Agreement for the Betterment of the National Health System” (Acuerdo Histórico por el Mejoramiento del Sistema Nacional de Salud). This document contained several points, including a demand for ending privatization in the national health system.8

A government commitment not to privatize health services ended the conflict temporarily. But instead of honoring the commitment, the Ministry of Health and the ISSS authorities continued to outsource hospital services, leading to ongoing conflict. For three years, workers from STISSS and doctors from SIMETRISSS organized strikes and rallies that gradually drew the support from the larger civil society. Supporting organizations included teachers and blue-collar unions, students, feminist and environmentalist groups, bus drivers, market vendors, peasants, and coffee growers; the majority of them affiliated with the umbrella coalition Citizens Alliance Against Health Care Privatization.9

Strikes varied in length, and participants walked a fine line not to alienate the population at large. During strikes, doctors tended to acutely ill patients on the sidewalks, a strategic as much as a humanitarian action to gain the support of the general population. Another calculated action involved “handing the hospitals to the administrators” and walking out, a symbolic gesture to demonstrate that the hospitals could not run without doctors. The government responded with repression, using tear gas, rubber bullets, and water cannons against strikers; doctors were fired and replaced with new personnel.10

Unparalleled solidarity and organization led to Congressional approval of Decree 1024, where the state guaranteed public health and social security. Decree 1024 stipulated that health care would remain public, prevented any future outsourcing of health care services, and effectively voided any prior outsourcing that the government had authorized since the beginning of the conflict. President Francisco Flores threatened to veto the decree, but coordinated pressure from sympathetic legislators in Congress and mass collective action on the streets forced him to comply with it.11

This victory, however, was short lived. Flores‘s party, ARENA, formed a congressional alliance which produced enough votes to repeal Decree 1024. The conflict continued for six more months, with several more marches and demonstrations taking place in San Salvador. These were massive rallies where demonstrators dressed in white as a symbol of peace and as a sign of solidarity with doctors and nurses wearing white coats. The demonstrations drew from 25,000 to 200,000 participants in a city of about 800,000 people. Many doctors sold their homes, cars, and home appliances to obtain the financial means to continue the struggle.12

The conflict ended when the World Bank reversed a privatization clause in a loan earmarked for modernizing the public health system. Union leaders and government representatives reached an agreement to stop the privatization of the public health system. Members of STISSS and SIMETRISSS were reinstated with their previous salaries and seniority, although some doctors who were replaced during the strike had to relocate. The agreement also established a Follow-up Commission on Health Reform, which included medical professionals, government officials, and representatives of unions and civil society.13

Efforts to maintain and to expand public-sector health care have continued, especially after the election in 2009 of leftist Mauricio Funes as president, representing the political wing of the Farabundo Martí National Liberation Front (FMLN; the military wing had fought with ARENA during the long civil war in El Salvador during the 1980s and ’90s). Dr. María Isabel Rodríguez, a well-known leader of Latin American social medicine who lived in exile during much of the civil war, returned to direct public health and medical services as national Minister of Health. Funes markedly increased the government’s consultation with civil society in economic and social policies. In health care, this orientation translated into a five-year strategic plan, for which the Citizen’s Alliance Against Health Care Privatization was the main source. In this way, the Citizen’s Alliance provided expertise for an independent movement engaged in proactive, long-term actions. An independent National Health Forum also emerged, as members of civil society were invited to design and implement health care policies, and to hold the government accountable for its commitments. The Funes administration incorporated voices that previously were marginalized, such as nurses, who have taken part with other groups in a new National Labor Roundtable. In addition, Funes brought more women into his cabinet, and these women have used their positions to emphasize reproductive health.

Salvador Sánchez Cerén, a former guerrilla leader with the FMLN who won the election for president in 2014, has pledged to consolidate the advances in health care that were accomplished during the Funes presidency. The Ministry of Health has embarked on additional initiatives to strengthen the public sector in health services. Supporting these efforts from a constructively critical position, a coalition of health professionals has become active, inspired by the contributions to social medicine of Salvador Allende in Chile. The coalition has honored Allende through its name, the Dr. Salvador Allende Movement of Health Professionals. Although the coalition grew from the earlier struggles against neoliberal policies in El Salvador, younger health workers have taken leadership in the organization. They spearheaded the selection of San Salvador as the site of the November 2014 congress of the Latin American Social Medicine Association, which drew thousands of progressive health workers to advance the struggle against neoliberal policies and on behalf of alternative models that strengthen public services.

Resistance to Privatization of Water in Bolivia

Although clean water remains a fundamental goal of public health, the world’s declining supplies of fresh water have emerged as a new frontier for corporate profit. Major corporations trying to sell water as a commodity have sought to privatize public water sources. In this context, the long-term resistance against privatization of water in Bolivia shows how a previously marginalized population can organize to win a struggle against powerful corporate forces that seek to commodify a critical public health resource.

Water availability in the province of Cochabamba, Bolivia, historically has posed serious problems. Climate and environmental conditions make this province a prime agricultural area. Agricultural workers (regantes, or those in charge of irrigation) managed dwindling water resources through irrigation practices rooted in cultural traditions known as usos y costumbres (uses and customs). Accelerated urbanization increased the demand for drinking water and water for domestic uses. Newer policies depleted underground water resources and favored urban development at the expense of the rural population.14

In 1997, the World Bank promoted privatization of Cochabamba’s public water utility, based on a rationale of eliminating public subsidies, securing capital for water development, and attracting skilled management. In its characteristic fashion, the Bank pressured the Bolivian government by making international debt relief in the amount of $600 million contingent on the privatization of water.15 New legislation, Ley 2029, allowed a private corporation, Aguas del Tunari, to lease Cochabamba’s public water and sewer company (Servicio Municipal de Agua Potable y Alcantarillado, SEMAPA). The contract effectively awarded Aguas del Tunari monopoly control over water services for forty years. The terms of the contract also prevented the regantes from using water in their traditional ways and allowed the company to appropriate any and all water sources, including neighborhood wells and rain water. A few weeks after the contract was signed, water bills increased by an average of 200 percent, an action known as the tarifazo.

The Water War, a series of collective actions that took place during 2000, quickly ensued. The Coalition for the Defense of Water and Life (often called just the Coordinadora) emerged to coordinate the mobilization of farmers, factory workers, professional people, neighborhood associations, teachers, retirees, the unemployed, and university students. These efforts included roadblocks, strikes, mass demonstrations and public assemblies, and a referendum. An intensive parallel investigation discovered among other things that Aguas del Tunari was a “ghost consortium” of enterprises grouped together under the control of Bechtel, a large U.S.-based corporation; prominent Bolivian politicians maintained economic interests in this consortium. Making this information public allowed the Coordinadora to gather support.

During these contentious months several developments strengthened the popular mobilization to block the privatization of water. The citizens of Cochabamba refused to pay their water bills, which they burned in public in highly symbolic acts. On various occasions, the city was paralyzed by demonstrations, barricades, and strikes; economic activity was largely disrupted. The government responded with police and military actions, which led protestors to escalate their demands. A referendum organized in March showed an overwhelming rejection of the contract with Aguas del Tunari, revealing a deep concern over the privatization of water services and supplies. The government’s response dismissed this democratic exercise. As protestors’ demands escalated and mass mobilization intensified, the government took further repressive actions. It initiated a disinformation campaign, established martial law, and allowed the use of live ammunition in clashes with demonstrators. Protestors intensified mobilizations and city-wide blockades, bringing the city to a halt. At the height of the conflict, a seventeen-year-old youth died and other protestors suffered injuries from gunfire. The youth’s funeral drew tens of thousands of angry protestors. Later that day Aguas del Tunari announced that it was rescinding the contract and leaving Cochabamba.

SEMAPA remained a public company, and several policy changes occurred as a result of the struggle. The board of directors implemented community engagement and direct participation through the election of community representatives, who became accountable to social organizations and the population at large. These changes revealed a social reappropriation of SEMAPA—transformation into a public company under control social, meaning control exercised by the community. This effort of civil society to exercise control over public resources has produced mixed results over the ten years after the water struggle. Nevertheless, it was a step that weakened the hegemony of neoliberal ideology, challenged the common sense of privatization policies, and opened the door to new forms of citizens’ participation in political life.

The struggle to defeat privatization and to strengthen public water supplies comprised the first of a wave of mobilizations and uprisings that broke the trajectory of neoliberalism in Bolivia. Opposition to the commodification of water and the social reappropriation of SEMAPA signaled people’s commitment to new ways of doing politics. This new form of political participation characterized the social upheaval that swept Bolivia. During this period, citizens defeated a tax hike, challenged water policies in El Alto (a large suburb of Bolivia’s capital, La Paz), unseated neoliberal president Gonzalo Sánchez de Lozada, and, in what came to be known as the Gas War, demanded participation in the decision-making process regarding the nation’s gas resources. This chain of events made the defeat of neoliberalism seem possible. The Water War contributed substantially to this possibility, as it did to the election in 2005 and reelections in 2009 and 2014 of socialist Evo Morales, Bolivia’s first indigenous president.

Novel processes of democracy and participation have taken place during the Morales administration. At the request of the Coordinadora and other activists representing various social movements, Morales committed to creating a new cabinet position: Minister of Water. This cabinet post dealt with pressing problems that remained after the recent water struggles and also aimed to encourage popular participation in government. The Ministry of Water included a social-technical commission formed by social movements, social organizations, and academics with expertise in water issues. The commission’s charge was to discuss, reach consensus, and approve any projects, plans, and programs of the ministry. Again the commission was to exercise control social. The type of community control involved in the social reappropiation of SEMAPA evolved into a form of co-management between the government and civil society. The commission originally held rights of discussion and voting on any project, plan, or program proposed by the Ministry. However, this role was limited from the beginning, and it became gradually more constrained under the argument that decisions made by others could not take precedence over the decisions of the Minister. Although the commission eventually disappeared, it represented one of several exercises in community participation to exert control and demand accountability from the Bolivian government.

Social Medicine’s Coming to Power in Mexico City

Bold new health policies, linked to the election of a progressive government in Mexico City, illustrate what an alternative vision of the possible can accomplish under conditions of broad sociopolitical change. In the 2000 election, the left-oriented Party of the Democratic Revolution (Partido de la Revolución Democrática, the PRD) gained control of the government in Mexico City, which comprises the equivalent of a state, while the conservative Party of National Action (Partido de Acción Nacional, the PAN) won the presidential election. Thus, political life in Mexico during the first decade of the twenty-first century saw the strengthening of two very distinctive political and economic projects: an anti-neoliberal position in Mexico City, represented by Andrés Manuel López Obrador (known popularly as AMLO), and a neoliberal one at the federal level, embodied by President Vicente Fox. The two projects led to very different results.

As governor, AMLO initiated wide-ranging reforms of health and human services. To the post of secretary of health, López Obrador appointed Asa Cristina Laurell, a widely respected leader of Latin American social medicine.16 Laurell and colleagues began a series of ambitious health programs, modeled according to social medicine principles. They first focused on senior citizens and the uninsured population, with a goal of guaranteeing the constitutional right to health protection.

The fourth article of the Political Constitution of Mexico and the thirty-fifth article of the federal health legislation grant this right, as well as universal coverage and free health care through public institutions. However, because these documents do not clarify what entity has the obligation to provide health services, this right in practice often comes to be seen as merely “good intentions.” In contrast, an assumption underlying these documents is that public institutions should provide health protection. This assumption offers a legal justification to make the state—presumably the guardian of the public interest—the provider of this right.17 The Mexico City Government (MCG) made use of this legal justification to design and implement health and human services policies that targeted vulnerable groups, thus making “the right to health protection a reality.” Broad goals that guided the MCG’s approach to health policy were:

To democratize health care, reducing inequality in disease and death and removing economic, social, and cultural obstacles to access; to strengthen public institutions as the only socially just and economically sustainable option granting equal and universal access to health protection; to attain universal coverage; to broaden services for the uninsured population; to achieve equality in access to existing services; and to create solidarity through fiscal funding and the distribution of the costs of disease among the sick and the healthy.18

Health policies of the MCG derived from a concept of social rights. Leaders of the MCG saw the creation of social rights—those that the state is required to guarantee—as one of the Mexican Revolution’s most important gains.19

Two major programs initiated by the MCG aimed to improve public health and medical services. First, the Program of Food Support and Free Drugs for Senior Citizens created a social institution that granted all seniors a new social right. This program started in February 2001, and by October 2002 it had become virtually universal, covering 98 percent of Mexico City residents aged seventy years or more. Citizens received a monthly stipend amounting to the cost of food for one person (the equivalent of $70) and free health care at the city government health facilities.20

A second initiative, the Program of Free Health Care and Drugs, focused on uninsured residents of Mexico City. By December 2002, about 350,000 among the 875,000 eligible families had enrolled. Later, by the end of 2005, 854,000 family units had registered in the program, which effectively amounted to universal coverage of the target population. The health care program provided all personal and public health services; MCG health facilities offered primary and hospital care for individuals and families.21

Financing these programs proved possible due to the MCG’s commitment to curb administrative waste and corruption. An austerity program beginning in 2000 implemented a 15 percent pay cut for top government officials and eliminated superfluous expenses. The austerity measures yielded savings of $200 million in 2001 and $300 million in 2002. Simultaneously, the government undertook crackdowns against tax evasion and financial corruption. These savings allowed the government to increase the health budget by 67 percent, meaning that 12.5 percent of the Mexico City budget went for public health and health services.22

Such community-oriented initiatives achieved wide admiration and contributed to the PRD’s electoral successes. While in 2000 the PRD victory in Mexico City had been tight, by April 2003 the approval rate for AMLO reached an unprecedented 80–85 percent. The PRD swept the 2003 midterm election and took control of the Mexico City legislature. AMLO’s austere and efficient administration, with zero tolerance for corruption and emphasis on social programs for the most vulnerable population, earned him the support of Mexico City’s population in his 2006 national presidential bid. It also earned him the wrath of forces that supported the neoliberal status quo, including Mexico’s political and financial elites who controlled the country’s major media. Weeks after the election, the national electoral commission awarded the presidency to the PAN candidate, Felipe Calderón, even after widespread social mobilization to challenge the election due to extensive evidence of fraud.23

The lopezobradorista movement that emerged to challenge the election continued despite its failure to reverse the results. This movement led to the formation of the “Legitimate Government of Mexico.” In this parallel, unofficial government, AMLO served as President and appointed a cabinet with intellectuals, social scientists, and politicians of leftist and anti-neoliberal ideology. Cristina Laurell once again became the Minister of Health. The parallel government kept the social medicine vision alive as a viable policy alternative. According to Laurell, the Legitimate Government was “not a shadow government understood as a reaction to official actions of the other government,” it was “much more proactive,” with the capacity “to elaborate and discuss original proposals using as a starting point another idea of what we want our nation to be.”24

In contrast, Popular Insurance (Seguro Popular), a federal health coverage program proposed and partly implemented by Vicente Fox’s administration between 2003 and 2006, expanded during the Calderón administration between 2006 and 2012. This insurance program comprised a service package with limited coverage, cost-sharing by families, and gradual enrollment of the uninsured population. Limited coverage disrupted the provision of comprehensive care. Cost-sharing amounted to 6 percent of family income, a financial burden for poor families. Services not included had to be purchased through private insurance. The latter signaled a further push toward the privatization of health care, which was in line with Fox’s and Calderón’s neoliberal agendas.

The different ways in which Fox and Calderón on the one hand and AMLO on the other treated public health and health services policies illustrated two discrepant visions of development. In 2006 the Mexican presidential election became so contested because it was a referendum on these different projects with the potential to create very different countries. As Laurell notes:

In 2006 what was at play was not just the election of a candidate, the future of the country was at stake. We lost the opportunity to rebuild our country and to make it less unequal, of building a nation for everyone, in which social rights are guaranteed and built, that is what we lost with this electoral fraud. What we are trying to do with the Legitimate Government and with the mobilization of citizens is to keep the hope alive.25

The lopezobradorista movement transformed itself into a social movement against neoliberalism and for the social, political, and economic transformation of the country. This movement deterred Calderón’s efforts to privatize energy during 2008 and during 2009 gained several seats in Congress, where they represented the only opposition to the neoliberal project. They questioned budgets and reforms, defended the movement’s positions, and presented counterproposals.

As the movement continued to organize and promote an alternative national project, AMLO ran for president again in 2012. The 2012 presidential election was a replay of the 2006 struggle between two very different projects. One project attempted to maintain the neoliberal hegemony; it was embodied in the candidate of the Revolutionary Institutional Party (Partido Revolucionario Institucional, the PRI), Enrique Peña Nieto, and supported by the PAN, the corporate and business class, and the church hierarchy. The other project represented a counter-hegemonic effort supported by the lopezobradorista movement, the PRD, and smaller progressive parties, and it posed a substantial challenge to the status quo. Corruption and fraud plagued this election also, through practices such as the use of cash and gift cards in exchange for people’s votes in favor of the PRI candidate.

Neoliberal reforms and repression of social movements have become trademarks of Peña Nieto’s government. His administration began with a labor reform that further eroded workers’ rights and security, and throughout 2013 he pursued regressive reforms in education, energy, and fiscal policy. Yet the counter-hegemonic movement in Mexico continues, as the leadership (including AMLO, Laurell, and many others) and their constituencies continue the struggle in health and other arenas, for instance in the more recent and so far successful efforts to form a new political party of the left. This dialectical process will continue to play itself out in Mexico during coming years.

Sociomedical Activism Toward a New Order

The struggles considered here confirm certain core principles of public health: the right to health care, the right to water and other components of a safe environment, and the reduction of illness-generating conditions such as inequality and related social determinants of poor health and early death. Affordable access to health care and clean water supplies provided by the state, for instance, have become the focus of activism throughout the world. Such struggles reinforce the principle of the right to organize at the grassroots and to have communities’ voices heard and counted in policy decisions. Activism that seeks alternatives to neoliberalism and privatization encourages participation by diverse populations, an emphasis on solidarity, and a rejection of traditional political forms.

The challenge is to develop strategies for activism that can extend these “counter-hegemonic” spaces to broader social change. A goal of the social movements that we have described is not simply to win but also to encourage public debate and raise the level of political consciousness. This new consciousness rejects the logic of capital and fosters a vision of medicine and public health constructed around principles of justice rather than commodification and profitability. No other path will resolve our most fundamental aspirations for healing.


  1. Howard Waitzkin and Rebeca Jasso-Aguilar, “Imperialism’s Health Component,” Monthly Review 67, no. 3 (July-August 2015): 114–29.
  2. Howard Waitzkin, Medicine and Public Health at the End of Empire (Boulder, CO: Paradigm Publishers, 2011), chapter 4.
  3. Susanne Soederberg, “From Neoliberalism to Social Liberalism: Situating the National Solidarity Program within Mexico’s Passive Revolution,” Latin American Perspectives 28 (2001): 104–23; Héctor Guillén Romo, La Contrarrevolución Neoliberal en México (México, DF: Ediciones Era, 1997), 13.
  4. The work of Samir Amin has influenced our own, for instance, “Popular Movements Toward Socialism,” Monthly Review 66, no. 2 (June 2014): 1–32.
  5. Observations in the sections on El Salvador, Bolivia, and Mexico derive from the participatory field work of Rebeca Jasso-Aguilar and the sources cited below.
  6. STISS (Sindicato de Trabajadores del Instituto Salvadoreño del Seguro Social, the Union of Workers of the Salvadoran Institute of Social Security), internal document detailing the chronology of the movement (San Salvador, El Salvador: STISS, 2002), in author’s possession; Leslie Schuld, “El Salvador: Who Will Have the Hospitals?” NACLA Report on the Americas 36 (2003): 42–45.
  7. Leslie Schuld, “El Salvador.”
  8. SIMETRISSS, “Historical Agreement for the Betterment of the National Health System,” Working Paper (San Salvador, El Salvador: SIMETRISSS, 2002).
  9. Lisa Kowalchuck, “Mobilizing Resistance to Privatization: Communication Strategies of Salvadoran Health-Care Activists,” Social Movement Studies 10 (2011): 151–73.
  10. STISS, internal document.
  11. SIMETRISS, “Historical Agreement for the Betterment of the National Health System.”
  12. Ibid.
  13. Leslie Schuld, “El Salvador: Anti-privatization Victory,” NACLA Report on the Americas 37 (2003): 1; Kowalchuck, “Mobilizing Reresistance to Privatization.”
  14. Alberto García Orellana, Fernando García Yapur, and Luz Quiton Heras, La Guerra del Agua, Abril de 2000: La Crisis de la Política en Bolivia (La Paz, Bolivia: Fundación PIEB, 2003); William Assíes, “David versus Goliath en Cochabamba: Los Derechos del Agua, el Neoliberalismo, y la Renovación de la Protesta Social en Bolivia,” Tinkazos 4 (2001): 106–31.
  15. Jim Shultz, “La Guerra del Agua y sus Secuelas,” in Jim Shultz and Melissa Crane Draper, eds., Desafiando la Globalización: Historias de la Experiencia Boliviana (La Paz, Bolivia: Plural Editores, 2008), 17–51.
  16. Howard Waitzkin, Celia Iriart, Alfredo Estrada, and Silvia Lamadrid, “Social Medicine in Latin America: Productivity and Dangers Facing the Major National Groups,” Lancet 358 (2001): 315–23; Howard Waitzkin, Celia Iriart, Alfredo Estrada, and Silvia Lamadrid, “Social Medicine Then and Now: Lessons from Latin America,” American Journal of Public Health 91 (2001): 1592–601.
  17. Asa Cristina Laurell, “Interview with Dr. Asa Cristina Laurell,” Social Medicine 2 (2007): 46–55; Asa Cristina Laurell, “Health Reform in Mexico City, 2000–2006,” Social Medicine 3 (2008): 145–57.
  18. Asa Cristina Laurell, “What Does Latin American Social Medicine Do When It Governs? The Case of the Mexico City Government,” American Journal of Public Health 93 (2003): 2028–31.
  19. Ibid.
  20. Ibid.
  21. Laurell, “Health Reform in Mexico City, 2000–2006.”
  22. Ibid.
  23. Héctor Díaz-Polanco, La Cocina del Diablo: El Fraude de 2006 y los Intelectuales (México, DF: Editorial Planeta Mexicana, 2012).
  24. Laurell, “Interview with Dr. Asa Cristina Laurell.”
  25. Ibid.
2015, Volume 67, Issue 03 (July-August)
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