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Social Medicine and Collective Health

Social Medicine and the Coming Transformation
Oscar Feo Istúriz is a professor at the University of Carabobo and the Bolívar-Marx Institute of Advanced Studies, both in Venezuela. He was also coordinator of the health commission in the National Constituent Assembly. He is a long-term leader of the Latin American Association of Social Medicine and an active researcher in the working group on “International Health and Health Sovereignty” of the Latin American Council of Social Sciences.
Howard Waitzkin, Alina Pérez, and Matthew Anderson, Social Medicine and the Coming Transformation (New York: Routledge, 2021), 308 pages, $26.95, paperback.

Social medicine is well-known in Latin America and elsewhere in the Global South, where such ideas and the strategies necessary to advance them are widely engaged. In fact, social medicine has flourished over the last century and a half in these regions of the world. Unfortunately, in the United States, social medicine is generally marginalized or repressed, limiting public mobilization and knowledge on this front. Fortunately, Howard Waitzkin has worked tirelessly to change this situation. His recent book, Social Medicine and the Coming Transformation, written with Alina Pérez and Matthew Anderson, is sure to become a fundamental part of social medicine’s bibliography. It was first published in English in 2021, at the height of the COVID-19 pandemic, and then in Spanish in 2023. Social Medicine and the Coming Transformation presents how clearly pandemics demonstrate the social determination of health and illness. Yet, the work’s scope reaches far beyond pandemics to encompass the most crucial societal barriers to health. It also describes a transformative path ahead, leading beyond the sickening social conditions imposed by the global capitalist system.

Social Medicine and the Coming Transformation begins by pointing out the social nature of population health and disease. Waitzkin, Pérez, and Anderson offer concrete examples of how social structure and living and working conditions have greater relevance in the genesis of a population’s diseases than biological factors or medical care itself. They clearly highlight that achieving good health in society necessitates changing the distribution of social wealth and power and the reduction of inequalities. In other words, it involves a revolutionary transformation of society.

Waitzkin, Pérez, and Anderson point out that in Latin America, especially Brazil, social medicine takes the name of collective health, generating an alternative to traditional public health, which, in many countries, has become subservient to the market and capital. The fundamental object of institutionalized medicine and public health has ceased to be health. These fields generally dedicate themselves to disease and individual risk factors. They have failed to consider how collective ways of life and processes in communities protect and affect health. The Brazilian health reform movement of the 1970s and ’80s was simultaneously a fight both against the military dictatorship that plagued Brazil and an effort to construct a unique and universal health system. Whatever successes emerged in both struggles undoubtedly came from intense popular mobilization for democracy and the right to health. Sergio Arouca and other courageous leaders played important roles in this memorable fight. Today, the Brazilian Association of Collective Health and the Brazilian Center for Health Studies continue this legacy to fight for good health for everyone.

Frederick Engels, Rudolf Virchow, and Salvador Allende were all forerunners of the social medicine movement. Engels presented an in-depth analysis of workers’ experiences in textile factories and their living conditions in The Condition of the Working Class in England. In doing this, he is one of the precursors of social medicine and occupational health. Virchow, the undisputed father of social medicine worldwide, was the first to point out clearly the social nature of health and medicine. Waitzkin, Pérez, and Anderson highlight the importance of Virchow’s conflict with a young Robert Koch regarding the causality of tuberculosis. When Virchow was president of the Berlin Medical Academy, Koch pointed out the relationship between that disease and the microorganism that would later bear his name. However, Virchow emphasized that the microorganism was not enough to cause the disease. Instead, it was necessary to recognize that specific social conditions had to exist that went far beyond the germ. Virchow was applying a distinction in the philosophy of science between necessary and sufficient cause. In this case, the microbe alone was insufficient to cause the disease of tuberculosis without the contribution of social conditions like poverty, inadequate housing, malnutrition, and poor sanitation. Finally, Allende, who was eventually elected president of Chile, was a pioneer of social medicine. Barely 30 years old, Allende was serving as Chile’s Minister of Health when he wrote The Chilean Social Medical Reality, which became a foundational text presenting ideas about the social determination of health. A central axis of Allende’s monograph involved the need to analyze health-disease from its social determinants, as well as the transformative nature of social medicine in practice.

Following this rich presentation, Waitzkin, Pérez, and Anderson discuss the situation of social medicine in the United States, including its challenges. Their history of how social medicine was born hand in hand with workers’ struggles is fascinating, especially regarding Lowell, Massachusetts, a former textile-producing city that today is home to a renowned center dedicated to workers’ health. They highlight how husband-and-wife collaborators Abraham Jacobi and Mary Putnam pointed out in the nineteenth century that the fundamental mission of medicine is to promote profound social changes and become an instrument of transformation.

Within the United States, the market has long governed health care. The persecution of socialism, promoted by McCarthyism, was essential to opening the field of health to big capital. It is quite clear that health insurance policies and what is now called “universal health coverage” are simply market strategies to consolidate the field of health as a space for extraordinary profits flowing to the medical, industrial, financial, and insurance complex.

A particularly important part of Social Medicine and the Coming Transformation is the discussion of imperialism and health. Philanthropic foundations, as part of philanthrocapitalism, play a fundamental role in the construction of health care systems throughout the Global South in order to eliminate conditions that have served as obstacles to the profits of big capital. For example, the Rockefeller Foundation promoted the creation of a Ministry of Health in Venezuela in the 1930s to fight against malaria, as the disease was hindering oil exploitation—the basis of John D. Rockefeller’s world empire. Neither charity nor justice was the main motivation, only exploitation and profit.

Social Medicine and the Coming Transformation also shows how social medicine practitioners and knowledge emerge from the United States. In this contradictory situation, there is some hope that policies and actions may be developed in the Global North for a better world and future. Nevertheless, the authors emphasize that a strong movement for social medicine and collective health is necessary within the United States.

Social transformation requires addressing inequalities. The authors focus on three axes of inequalities in health: social class and classism, race/ethnicity and racism, and gender and sexism. Their key contribution involves recognizing that each axis of inequality determines illness and death mainly through discrimination and oppression, rather than class, race, and gender considered as demographic variables. To these three axes, I would add social territory, those spaces where health and illness emerge differently for different human groups. We need an intersectional vision of social medicine and collective health that includes class/classism, race-ethnicity/racism, gender/sexism, and territory in order to find the roots of health and disease and, above all, to generate transformative proposals.

Social Medicine and the Coming Transformation also includes an interesting discussion regarding social medicine in Latin America. The authors feature important work by Juan César García, María Isabel Rodríguez, and Asa Cristina Laurell, all leaders in this field. García, an Argentine doctor and sociologist with a strong Marxist influence, is considered the father of Latin American social medicine. A central current of his critical thought emphasizes political commitment, pointing out that the purpose is not only to analyze and understand health, but also to transform it. At 101 years old, Rodríguez, from El Salvador, continues to be lucid and robust as an expression of knowledge and the fight for the right to health after serving as a rector of the University of El Salvador and Minister of Health. Laurell, a Swedish-Mexican doctor, who is a critical leader in health management, is one of the fundamental figures of social medicine and collective health.

There are numerous examples of how public health has ceased to fulfill its function and how an alternative social medicine-collective health is required, given that it is a strong approach capable of promoting the changes that our society needs. This is exactly why the Latin American Social Medicine Association incorporated collective health into its name, now calling itself the Latin American Association of Social Medicine and Collective Health. In addition to the fight for the right to health care, this organization incorporates the need for a new framework of decolonization, the emancipation of nature, and the construction of health sovereignty.

Importantly, Social Medicine and the Coming Transformation addresses the key issues of capitalism, imperialism, and health in relation to collective health. At the same time, it raises the need to transcend care for disease, favoring a new paradigm of comprehensive care for health and life. In this old dilemma, we talk about health, but tie ourselves permanently to disease and its individual clinical features. One of the fundamental challenges of social medicine/collective health is to overcome this reductionist fixed gaze on disease and the risk factors of individual lifestyles. Instead, we are moving to a richer understanding of collective ways of life and processes that in the community protect or harm health. This approach does not view medical institutions as the center of health. Instead, it recognizes social territory as its axis, where health, rather than disease, is socially determined, and collective ways of life are expressed.

Social Medicine and the Coming Transformation will become part of the canon in social medicine. The book is particularly useful given its focus on the United States, as well as Latin America, and other regions of the Global South. Its publication in both English and Spanish helps create bridges for discussion between the progressive sectors of the United States and those in Latin America, which without a doubt must unite efforts in a common fight. We will build this future together.

In closing, it is important to note that Jaime Breilh’s Critical Epidemiology and the People’s Health (Oxford University Press, 2020) is also mandatory reading, as it helps establish the foundations for a new way of doing and understanding epidemiology from a Latin American perspective via the concept of “critical epidemiology.” Together, Social Medicine and the Coming Transformation and Critical Epidemiology offer revolutionary and transformative perspectives on understanding and doing health.

2024, Volume 75, Number 08 (January 2024)
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