A theoretical reflection on public health from a standpoint of social justice, which does not overlook the individual, is presented. Based on a conceptualization of social justice, human rights and health in the framework of an epistemological analysis, a particular perspective on social justice and its implications for public health praxis, using a public health program as an example, is revealed. Some routes are identified in order to orient and put into practice the actions developed in public health programs. This requires a different way of understanding the scenarios and interchanges among people in the field of clinical practice. It is understood that these fields can also be seen as a suitable opportunity for the establishment of individuals and individualities committed to the political struggle for human rights, equity in health and recognition of a life worthy of human dignity.
Public health; Social justice; Individual; Children
Social justice is a standard that has been upheld in public health practice by many health-care professionals, from Wirchow to people such as Héctor Abad Gómez, who lost his life in the struggle for human rights in Medellín. Furthermore, according to Venkatapuram11. Venkatapuram S. Health justice. An argument from the capabilities approach. Cambridge: PolityPress; 2011., all areas of public health assume social justice, even if that is not made explicit. The problem identified by Venkatapuram consists of the lack of theoretical development of the notion of health justice in the discipline of public health. According to him, this situation has serious consequences for public health praxis because the failure to consider social justice can lead to a proliferation of orientations and actions that perpetuate conditions of injustice.
The object of this study is to promote thinking about social justice in the area of public health to contribute both to the theoretical development of the discipline and to the preparation of proposals for action consistent with building a more just society as a necessary condition for advancing the health of both individuals and groups. To do this, I will defend the following theses:
. Theorizing public health from the perspective of social justice means understanding health as life beyond that of the individual human being and, in the case of human life, as "intersected" by human flourishing.
. Public health and the social justice mainstream have rendered the concrete subject invisible to the degree that public health and social justice are based on dichotomous visions of reality, assume an uprooted subject, and are located in rational frameworks unaware of feelings. This situation has an impact on the development of a public health praxis that is committed to social justice and health understood as life and human flourishing.
. To limit thinking on social justice, human rights, and equity to the field of public policies, health systems, and the role of the State constitutes a reductionism of public health; thus, defining what is public about public health is a part of the struggle for social justice.
. Assuming a public health praxis based on a theoretical proposition of social justice that does not render the concrete subject invisible, and a consequent conception of health based on life and human flourishing means a profound change in what we consider as the goal of public health, our criteria for setting priorities, and how to take action.
The argument that I will present is composed of three major categories of analysis. The first is an epistemological reflection that addresses the topics of reality, reason, and especially, the relationship between subject and society. The second analyzes some components of justice, ethics, and morality. The third reflects on the concept of health. Finally, I will take the growth and development monitoring program in children as an example to analyze the consequences of assuming a justice perspective that does not render the subject invisible with regard to public health praxis.
According to Rawls, social justice refers to the way in which great social institutions distribute fundamental rights and responsibilities, and determine the division of the advantages stemming from social cooperation; institutions favor certain initial positions over others22. Rawls J. Liberalismo político. México: Fondo de Cultura Económica; 1995., which generates deep inequalities and "affects humans in their initial opportunities in life"22. Rawls J. Liberalismo político. México: Fondo de Cultura Económica; 1995.. Marxists prioritize considering how the conditions of production are distributed from a structural perspective that analyzes property and control over the means of production, that is, the hierarchy of power and exploitation33. Tornblom K, Vermunt R. Distributive and procedural justice: research and social applications. Burlington: Ashgate; 2007..
The social justice discussion depends on recognizing the oppression that some human groups and subjects impose upon "others" who are subordinated by conditions of, inter alia, social class, race, ethnicity, gender, sexual preferences, knowledge, and social position.
It is important to emphasize a particularly important manner in which domination is exercised: symbolic control. According to Bourdieu and Passeron44. Bourdieu P, Passeron JC. La reproducción. Elementos para una teoría del sistema de enseñanza. 3ª ed. México: Fontamara; 1998., dominant groups impose their way of seeing the world (subjectivities, meanings, and legitimate values, that is, their culture) to maintain social order. Symbolic control is performed not only through the use of mass media but also through formal and informal education, such as that provided in the health sector - the latter legitimated by biomedical scientific discourse that regards popular knowledge as a series of cultural beliefs and ties.
We need to draw on Foucault's55. Foucault M. Power/knowledge. Selected interviews and other writings. 1972-1977. Nueva York: PantheonBooks; 1980. approach to power to understand it as networks of relationships that are organized, hierarchized, and coordinated beyond the repressive and legal level, linked to ways of knowing, disciplinary techniques, and economic relationships that also involve processes of resistance. This concept of power is required to analyze the relations that take place at the clinic, in public health programs, and in research in the health field.
It is also true that the manner in which a more just and equitable society is understood varies depending on historical, sociocultural, economic, and political conditions. What we understand as just is related to our values and therefore is a moral matter. I understand morality as a series of self-imposed, binding norms and values in the form of obligations or prohibitions, which deserve general recognition and call on the community of acting subjects. I understand ethics as thinking about morality, that is, the analysis of the conditions under which norms and moral values are both imperative and binding66. Pieper AM. Ética y Moral. Barcelona: Crítica; 1991..
Thus, justice has been a topic of constant debate. Below, I present some theoretical elements from the debate about justice that are needed for the discussion that I hope to conduct.
I will begin with Rawls' critique of utilitarianism and of radical liberals such as Nozick and Hayec. Maximization of well being at the cost of some persons and groups constitutes a form of instrumentalizing them and thus would contradict the Kantian concept of dignity. In response, the American philosopher proposes access to a sufficient level of primary goods - rights, liberties, income, and the social basis of self-respect
- for all people, to guarantee the opportunities required for each person to implement his or her life plan. This constitutes a proposal for distributive justice based on just procedures that would characterize a fair and well-ordered society.
Sen, in asking "what kind of equality?", critiques Rawls for basing justice on an equality of goods because there are people who do not have the same ability to convert goods into a good life77. Sen A. ¿Igualdad de qué? Conferencia pronunciada en la Universidad de Stanford, 22 de mayo de 1979. [Internet]; 2014 [consultado 2014 feb 10]. Disponible en: http://www.fder.edu.uy/contenido/rrll/contenido/licenciatura /documentos/76456536453545354634783.pdf
http://www.fder.edu.uy/contenido/rrll/co... . Disabled individuals may need more assistance and support to fulfill their necessities and aspirations. This concept is related to the maxim popularized by Marx8 8. Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010."from each according to his abilities, to each according to his needs". The focus should not be on goods but instead on persons, on the particular subject99. Nussbaum M. Creating capabilities: the human development approach. Cambridge: Belknap Press (Harvard University Press); 2011. , 1010. Max-Neef M, Elizalde A, Hopenhayn M. Desarrollo a escala humana. Una opción para el futuro. Uppsala: Fundación Dag Hammarskjold; 1986., and should guarantee equality of abilities, understood as opportunities or freedoms that require development, not only of certain skills or human functions, but also of goods.
Nussbaum proposes ten basic capabilities based on what a life with human dignity would mean1010. Max-Neef M, Elizalde A, Hopenhayn M. Desarrollo a escala humana. Una opción para el futuro. Uppsala: Fundación Dag Hammarskjold; 1986., which together amount to a basic fundamental human right to human development.
This list of capabilities is commensurate with the proposal for human development presented by Max Neef et al.1111. Honeth A. Reconocimiento y menosprecio. Sobre la fundamentación normativa de una teoría social. Buenos Aires: Katz; 2010., from a human-needs perspective1010. Max-Neef M, Elizalde A, Hopenhayn M. Desarrollo a escala humana. Una opción para el futuro. Uppsala: Fundación Dag Hammarskjold; 1986.. Along this line, Honneth argues that justice is not a matter of goods distribution but instead the recognition of dignity for all1212. Marx K. Glosas marginales al programa del partido obrero alemán. [Internet]; 2014 [consultado 2014 ene 16]. Disponible en: https://www.marxists.org/espanol /m-e/1870s/gotha/gotha.htm
https://www.marxists.org/espanol /m-e/18... . Symbolic struggles for legitimacy and struggles for distribution are essentially struggles for recognition.
Critiques of mainstream theories of justice: the invisible subject
According to Benhabib, mainstream theories of justice have caused the concrete subject to become invisible1313. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992.. The Kantian vision of a universalist justice is based on an ahistorical subject without sociocultural roots, a universal subject: a subject who is adult, white, male, healthy, and autonomous. The veil of ignorance, the theoretical experiment upon which the impartial justice of Rawls is based, assumes a subject who is without gender, social class, race, age, health status, abilities, aspirations, and subjectivities. It is a subject like me, deracinated, who loses his identity: it is the generalized other of which Mead speaks1313. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992..
In contrast to this generalized other, it is necessary to recognize a concrete other, who has a concrete history, identity, and affective-emotional makeup. This subject is different from me and has specific needs, motivations, and abilities. I recognize the other in confirming both his humanity and his individuality, and thus, I recognize his alterity in moral experience, which requires the construction of a shared vision1313. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992..
In reflecting on the Holocaust, Levinas, who is cited by Bárcena and Mélich, criticizes these universal moralities that forget an other with a face: the other to whom I relate and with whom I construct relationships mediated by feelings and not only by reason1414. Bárcena F, Mélich J. La educación como acontecimiento ético. Natalidad, narración y hospitalidad. Barcelona: Paidós; 2000.. This corresponds to a concept of the human being as dependent and fragile, that is, heteronomous. According to Levinas1414. Bárcena F, Mélich J. La educación como acontecimiento ético. Natalidad, narración y hospitalidad. Barcelona: Paidós; 2000., autonomy as an ideal that guides human morality is only possible precisely due to the heteronomous condition of the human being.
In Kantian universalist morality, moral judgment is rational and unconditioned, and it does not consider either consequences or interests. In addition, it of course does not account for feelings. This morality fits well within a contractualist concept of the State that assumes a rational and calculating human being.
These moralities are strongly criticized by feminism, which reasserts moral judgments conditioned by caring relationships and which considers the results of moral action, as suggested by Gilligan1515. Gilligan C. La moral y la teoría. Psicología del desarrollo femenino. Mexico: Fondo de Cultura Económica; 1985.. This is a morality of care for the other, like that which guides child rearing, or care for nature, of which I am part and which is incumbent upon me beyond my own benefit or fulfillment of duty.
Benhabib thus demonstrates a problem within these universalist morals: dualistic reasoning that separates justice from the good life as antagonists; the public sphere of justice (historical) from the private sphere of the home, the family, care, and intimacy (ahistorical); the law from reasons underlying natural inclinations; the brilliance of knowledge from the obscurity of the emotions; autonomy from child rearing; independence from the bond; and the sovereignty of the self from relationships with others1313. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992.. These moralities exclude from public life the relationship with the cosmos, the intimate domestic family circle, child rearing, relations of kinship and friendship, love, and sex.
Overcoming this dualistic reasoning requires, according to Benhabib, assuming universalism as a regulative ideal that does not deny our materialized and rooted identity1313. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992.. The "general good" would thus be an organizing ideal and not a point of departure. This is a reasoning crisscrossed by conflicts and tensions to the degree that one recognizes the impossibility of obtaining ideal consensus. Furthermore, one will always need to confront the disjuncture between the social validity of norms and normative institutional arrangements as seen from a local perspective and its hypothetical validity with respect to criteria of justice, equity, or impartiality from a universal perspective.
This idea thus corresponds to a process of moral and political struggle that assumes a justice supported by morality rather than legality as the basis for defending human rights. This justice subverts the duality between the ethics of justice and law with an ethics of care and responsibility. It is configured in the framework of a morality of interaction based on a debate that exposes all of its supporting assumptions to criticism. From a critical perspective, this justice recognizes that politics cannot be neutral and avoid moral constraints; in this series of ideas, the conceptions of being, reason, society, ethics, and politics are inseparable. Finally, Benhabib notes that determining that which is in the public sphere is always a struggle for justice.13 13. Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992.
Human rights: a moral topic transcending legal implications. In this vein, Tugendhat proposes considering human rights, at their source, as moral rights. According to him, rights are derived from subjects' needs, interests, and aspirations for living a life with dignity.1616. Tugendhat E. Lecciones de Ética. Barcelona: Gedisa; 1997. Subjects can demand rights because we grant them, because we see in the other a subject with rights, and because we recognize these rights due to their condition of being human. In agreement with Tugendhat, Sen sees moral rights as the parents of legal rights because the struggle for their defense is constitutive of their incorporation into laws and constitutions.88. Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010. However, law is also the sphere in which some individual freedoms should be limited, precisely to protect rights.
The human rights debate is broad and complex. A critical point of conflict relates to the tension between universalist and communitarian perspectives on the scope of human rights guarantees: should only civil and political rights be guaranteed or should economic, social, and cultural rights also be protected? Likewise, one observes radical positions that see human rights as bourgeois or sociocultural impositions for exercising hegemonies and protecting the advantages of the powerful. From this broad debate, I will only consider a few points that are pertinent for my argument.
Many thinkers identify serious limitations on views that consider only civil and political rights to be matters of justice. The argument that one should only guarantee those rights that the State can provide for all, is disputed by Sen because no State guarantees civil and political rights to all of its citizens88. Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010..
Tugendhat notes that guaranteeing only first-generation rights amounts to preserving the advantages of the privileged; furthermore, it would be impossible to guarantee first-generation rights without assuring those of the second generation, which are necessary for developing the abilities required for people to participate as citizens1616. Tugendhat E. Lecciones de Ética. Barcelona: Gedisa; 1997.. In this sense, Tugendhat notes, the distinction between the rights of one generation and another is irrelevant. Finally, Nussbaum proposes that all States should construct public policies using the achievement of ten basic capabilities for all persons as a point of reference99. Nussbaum M. Creating capabilities: the human development approach. Cambridge: Belknap Press (Harvard University Press); 2011..
Fields understands rights as a social practice beyond their legal legitimation:1717. Fields AB. Human rights theory: criteria, boundaries, and complexities. International Review of Qualitative Research 2009; 2(3):407-418. he begins by conceiving of the human being as a being with the potential for development through which he or she must satisfy his or her needs, interests, and aspirations. However, society is composed of human groups and subjects that dominate others through an exercise of power that frustrates the development of individuals, human groups, and even entire societies. These excluded groups struggle against domination for recognition and the possibility of their own development, which ultimately leads to a formal legitimation under constitutions and legal frameworks. Human rights are historical because they are relational social practices.
Throughout history, changes have come about in what are considered to be violations of aspirations and the potential for development, such that different human groups question the legitimacy of established cultural, social, and economic practices, such as ethnic movements, feminists, LGBT (lesbians, gays, bisexuals, and the transgendered), and others.
Which concept of health?
In the field of public health, the concept of a right to health is often seen as restricted to access to health services. However, this view is considered to be reductionist because the right to health includes other rights, such as the right to quality education, to dignified work, to shelter, to potable water, and to proper nutrition, among other things. Thus, the following question arises: What is the meaning of "health"?
Below, I will present a concept of health resulting from a reflection on justice. I begin with the critique made by Sen88. Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010. of the utilitarian concept of well being, which can be extrapolated to the idea of health as well being11. Venkatapuram S. Health justice. An argument from the capabilities approach. Cambridge: PolityPress; 2011.. A critique is made of the homogenization that results from taking a single criterion, well being, for conceptualizing health, along with the idea of maximizing well being at the cost of certain subjects and human groups. Furthermore, however, one must overcome a subjectivist perspective because subjects and human groups under conditions of extreme deprivation may lower their aspirations to those of a life with dramatic limitations that limit the development of a life with dignity and still be satisfied in the end. Thus, making comparisons based on each person's idea of well being would not be an effective parameter. This constitutes one more reason for liberal thinkers to support an approach based on capabilities. Targeting policies based on the neoliberal development model that seek to compensate individuals and human groups that have been relegated by the market competition, corresponds to the utilitarian theory of justice, which attempts to maximize well being at the expense of neglected individuals and groups.
Venkatapuram assuming the capabilities approach, criticize Sen's muddled conception of health as capability. Venkatapuram sees Nussbaum's as a more accurate position because she establishes health as one of the ten basic capabilities. Even so, here Venkatapuram finds Nussbaum's concept of health as one that is tied to the biomedical perspective. For this Indian epidemiologist and philosopher, health would extend to all ten of the capabilities proposed by Nussbaum, with the understanding that health is equal to a life with digniyt. Thus, the right to health would be the right to the set of rights implied by the ten basic capabilities proposed by Nussbaum.
Venkatapuram labels this meta-capability as the "capability to be healthy". Given that Nussbaum's focus on capabilities is also termed human development, one could equate health with human development, although Venkatapuram does not frame it in this way11. Venkatapuram S. Health justice. An argument from the capabilities approach. Cambridge: PolityPress; 2011.. In the Latin American public health field, Saúl Franco, Edmundo Granda, Jaime Breilh, Gastón de Sousa Campos, and many others have proposed health as life and even as something beyond human life. From an ethical perspective, health has been proposed within a framework of defense of human rights beyond mere access to health services. For example, Jaime Breilh speaks of an ethics of life and health, based on the four "Ss" of a healthy life: sustainability, sovereignty, solidarity, and health/ holistic biosecurity1818. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):13-27..
An epistemological reflection that is also ontological and political
The pragmatic proposal by Sen, that of not waiting for change in social institutions to act on specific injustices and placing the individual prominently, which doesn't mean a lack of awareness of social factors, is criticized by Venkatapuram because of the individualist emphasis he sees in Sen's works, which distances them from a structural analysis of the debate. These critiques are shared by Latin American thinkers, including Jaime Breilh1818. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):13-27.. To counteract this shortcoming on Sen's work, Venkatapuram builds an argument employing the causal view used in epidemiology. He establishes a hierarchical causal chain for health that would be determined by interactive influence of changing biological endowments and necessities within the internal arena, the social and physical conditions in the external arena, and individual behaviors. Social conditions
- that is, conditions at the supraindividual level
- are the "causes of causes" because they provides a broader explanation for the determinants of health and their asymmetrical social distribution. This view is in line with the concept of subsumption used in the theory of the social determination of health11. Venkatapuram S. Health justice. An argument from the capabilities approach. Cambridge: PolityPress; 2011..
Venkatapuram's causal and hierarchical conception, in line with the structural and intermediate determinants proposed by the World Health Organization (WHO), has two problems that have been identified by some theorists of alternative trends in Latin American public health: the limitations of using a causal perspective for understanding health, and second, living the subject in the background, in light of the priority given to the social structural arena. Both problems are components of a dualist worldview that seeks to reduce the world to dichotomous packages: cause/effect, subject /society, human being/ nature, mind/body, and biology/culture, among others.
A causal and deterministic view of justice is problematic in accounting for matters of freedom and human flourishing. This problem is part of the ontological and epistemological debates that extend to concepts of the world, of science, and of the human being. They involve tensions between monistic and pluralistic views of the world on the one hand and between determinist and non-determinist positions on the other hand1919. Peñaranda F, Rendón C. Determinismo-indeterminismo y el debate de los determinantes-determinación social de la salud. Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):47-56..
In the field of public health, the problems associated with a causal, determinist, and dualist view of the world were identified at the end of the 1970s by Jaime Breilh, who proposed his idea of determination as an alternative, based on the works of Mario Bunje, who was influenced by Hegelian philosophy. Hegel sought to reconcile the human being who had been separated from nature, for what he sought to return to a monist concept of the universe employing a dialectic perspective in which opposites were experienced and reconfigured as a whole1919. Peñaranda F, Rendón C. Determinismo-indeterminismo y el debate de los determinantes-determinación social de la salud. Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):47-56..
Without plumbing the depths of Hegelian philosophy, below I will emphasize three concepts needed to advance the defense of the proposed theses1919. Peñaranda F, Rendón C. Determinismo-indeterminismo y el debate de los determinantes-determinación social de la salud. Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):47-56..
. The idea of determination has various related meanings. On the one hand, it refers to a being's way of being and becoming as a potentiality that develops through a dialectical process. On the other hand, it refers to the constituents of a being that are expressed in its process of becoming.
. Within the dialectic as negation and mediation, identity requires otherness. One ceases to be in order to be the other: one is in the other. Each fact opposed to another is mediated by this other, where "mediated" means that one is traversed by the other, which one carries within oneself.
. Causality constitutes only one of the determinants in the dialectical development process of the self. The dualistic perspective of cause-effect disappears within a dialectical opposition.
Several Latin American health professionals have critiqued hegemonic public health trends related to the invisibilization of the subject. In particular, the dualistic view of Cartesian reasoning has led to proposing a sharp difference between public health as the health of populations and clinical health as the health of individuals. Even more, Carvalho note how this duality in some Latin American social medicine and collective health proposals, responding to the emphasis of hegemonic public health practice given to a micro and biological perspective, have turned toward a deterministic and structuralist view in which the subject becomes a product of forces located in the social superstructure2020. Carvalho S. Saúde coletiva e promoção da saúde. Sujeito e mudança. São Paulo: Hucitec; 2005..
Costa and Costa, cited by Carvalho2020. Carvalho S. Saúde coletiva e promoção da saúde. Sujeito e mudança. São Paulo: Hucitec; 2005., add that because of the confrontation with clinical discourse, these positions end up making a "tabula rasa" of individuality and singularity2020. Carvalho S. Saúde coletiva e promoção da saúde. Sujeito e mudança. São Paulo: Hucitec; 2005.. For this reason, Breilh emphatically states as follows: "From a dialectical perspective, there is no ontological primacy either for the individual or for society"1818. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):13-27.. In addition, Granda suggests that "an alternative public health goes from rescuing the subject and having its foundation on a perspective of health from a point of view of life"2121. Granda E. ¿Quo vadis salud pública? In: E Granda. La salud y la vida. Quito: Ministerio de Salud; 2013. Vol. 3. p. 41-63..
Consequences for praxis
Below, I will explain the social justice perspective that I assume as the result of specific moral and epistemological positions, to then use a specific example to propose how this perspective affects the way public health and its field of action is conceived. In the following section, I expound my view of social justice as a route for action.
I understand social justice as a historical process related to guaranteeing social-cultural and individual conditions that allow all subjects to lead a life with dignity in which they are assured opportunities to develop their potential, which in turn requires the realization of their needs, aspirations, and interests. I understand human flourishing as a holistic process, one that is synergistic, interactive, and iterative, which cannot be addressed in parts. I conceive of a dialectical world beyond a dualistic vision of reality and from which the subject in his or her singularity is recovered without ignoring the intervention of the structural and the social determination.
Following Sen, I assume equity as the equality of opportunities to be and do that which subjects and collectives have reason to value88. Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010.. Capabilities, then, are the realization of the opportunity required by the subject to construct and execute his or her life plan. Thus, the struggle for human rights, understood as the struggle for dignity and recognition, is the struggle to guarantee the goods and conditions of a sociocultural nature that assure this opportunity, an opportunity that responds to the singularity of a subject who is also sociohistorical. In this way, I understand equity in the framework of a conception of justice based on respect for the difference among subjects and collectives, with diversity in their needs to and abilities for converting goods into a good life2222. Siqueira R, Schramm FR. A saúde entre a iniquidade e a justicia: controbuições da igualdade complexa de Amartya Sen. Cien Saude Colet 2005; 10(1):129-142..
Reflecting on equity implies recognizing that the model of development based on capitalism has promoted forces and relations based on individualism, consumption, domination, and exploitation that have severely affected opportunities for subjects, collectives, and entire societies to flourish. They have also threatened the sustainability of life beyond the human being and the degradation of the physical environment.
This model of development, together with the reigning international order, has created an enormous socioeconomic gap between rich and poor, which constitutes a terrible injustice. A perspective of equity that begins by recognizing that we live in a finite world, that we are a part of nature in complete interdependence with other human beings and the socio-economic, biotic, and physical environment based on a dialectical and human-dignity perspective, requires a concept of justice based on the redistribution of wealth and goods, the limitation of private property, and progress toward the construction of just social institutions and procedures, all of which must recognize a global justice setting that demands a new supranational order.
However, transforming an unjust society is consubstantial with the development of the ability of the individual and the collective subjects to construct themselves and to construct society. It requires, thus, the strengthening of the capability to participate, understood as the skill and the socio-political conditions for this construction. Participation and struggles for individual and collective rights will be framed within the tension arising between individual freedom and collective interests, a tension that will always be mediated by power relations and by struggles for the recognition of dignity.
How does one apply these principles for social justice, human rights, and equity to the field of public health? I begin by exploring reflections on the concept of health as life, based on human flourishing within an iterative, synergistic, and interactive process, along with structural social transformation and the sustainability of nature.
Following de Sousa Campos, I affirm that health is a dialectical co-construction in which two contradictory poles participate, precisely because each one is mediated and traversed by the other2323. Sousa Campos G. Método paideia: análisis y cogestión de colectivos. Buenos Aires: Lugar; 2009.. One pole belongs to the immanence of the subject and is composed of his or her biological and subjective determinations, which are in turn configured by the tension between "desire" (from the psychoanalytical perspective) and interest. The other pole corresponds to the universal pole that transcends the subject and is configured through social necessities, institutions and organizations, the economic, cultural, and social context, and finally, the environment.
The contradiction of these two poles creates a singular synthesis that de Sousa Campos describes in the following way:2323. Sousa Campos G. Método paideia: análisis y cogestión de colectivos. Buenos Aires: Lugar; 2009. "[...] the subject intervenes in the world through politics, management, work and daily activities [...] [to] understand himself and the world of life [...] subjects interact with other subjects, constituting spaces for dialog - collective spaces - in which there are multiple results depending on the ability and power of each person".
For de Sousa Campos, this synthetic moment is educational and therapeutic to the extent that23 23. Sousa Campos G. Método paideia: análisis y cogestión de colectivos. Buenos Aires: Lugar; 2009."[...] people manage to develop a greater ability for reflection, and consequently, acquire a greater ability to intervene on the structural factors that condition them, whether these are external factors (such as culture, organization and the family) or internal to the subject (personality and character). It would be like an education taking place throughout the course of life, a permanent form of therapy, a constant concern for the construction of [...] persons while they go to school, work, do politics, or use some health service".
I conclude by presenting the consequences for public health praxis of using a social justice perspective such as the one presented here. I am interested in analyzing the microspace mediated by the face-to-face relationship in which the dialectic expression between clinical and public health is made real. I will use one of the so-called health promotion and disease-prevention programs as an example: the Program for Detecting Changes in Growth and Development in Children under Ten, presenting the results of research by our group over the past ten years.
This program - generally valued by those involved, the human health teams, and parenting adults - is also criticized because in spite of the important results that it has achieved, they also see its serious limitations related to resolving their needs, concerns, and interests. One explanation for these findings relates to the fragmentation, instrumentalization, and invisibilization of the concrete subject.
This is a result of the biomedical orientation of the program, which medicalizes child rearing, bypassing the ontological, social, cultural, and historical dimensions of caring for the lives of boys and girls by parenting adults for the following reasons: parenting adults are made into instruments for attending to the children; the program is centered on children's diseases and not on their health and that of their parenting adults; and traditional education is based on symbolic control of the biomedical discourse and behavioral change leading to an imposition of culture and dependence on medical power. This is a daily experience that is very limited in its ability to promote health that is conceived as human flourishing and progress toward social transformation.
A new direction in the program based on a concept of health as life and as a dialectical coconstruction of individual synthesis could be performed by aiming not at problems (deseases) in growth and development but on child rearing understood as an ontological, social, cultural, and historical process with two key functions: caring for children's lives and for their education. Given that child rearing requires the human flourishing children and parenting adults, it demands a holistic approach that overcomes its fragmentation and instrumentalization, requiring a transdisciplinary approach from which to address various types of interests, needs, and aspirations.
Thus, a liberating and problematizing education, such as the one proposed by Freire, is suggested, one based on collective reflection that gives participants, human health teams, and parenting adults a broader and more critical understanding of child rearing to strengthen their ability to take action2424. Peñaranda F. Las fuerzas sociales y el escenario comunicativo en la educación para la salud: el caso del programa de crecimiento y desarrollo. Cien Saude Colet 2011; 16(10):4023-4031.. This is an education oriented toward the development of abilities and the strengthening of students and educator autonomy and considers them as concrete subjects2525. Freire P. Pedagogía del oprimido. México: Siglo XXI; 1975..
Thus, sessions in the program must be recognized as public spaces in which the anxieties, problems, interests, and aspirations of the participants are transacted. In this sense, it is a space for sharing perspectives and positions within the framework of a process of debate and deliberation, in an enviornment of knowledge dialogue to establish collective agreements, both inside and outside of the sessions. Thus, group sessions are proposed to facilitate social mobilization and the construction of social networks.
Nevertheless, a justice perspective requires accounting for the conditions of injustice in which many families conduct child rearing. Thus, the program would go beyond the sessions within the broader framework of an organizing and participatory process that boosts collective mobilization. It is in the community setting where acts of solidarity, collective management, inter-institutional coordination, and political mobilization are produced through the struggle to resolve day-to-day problems, to defend human rights, and to transform the conditions of life.
It is evident that a health system, such as the Colombian system, which operates under market conditions, would be unsuitable for a social justice approach conceived in the terms proposed here. Likewise, one must consider health education as a fundamental right and not as a strategy or tool, which has been the traditional way of understanding it in the health sector. One must recognize the transcendence of matters such as child rearing for public health, for its importance to each subject, for society as a whole, and particularly, for addressing health as life.
Thus, from so-called programs of health promotion and prevention, one can also boost the political struggle that address both the State and civil society. It is important to recognize that in intersubjective relationships in a clinical setting, subjects and subjectivities committed to the struggle for human rights, health equity, and a life with dignity are also constructed.
- 1Venkatapuram S. Health justice. An argument from the capabilities approach. Cambridge: PolityPress; 2011.
- 2Rawls J. Liberalismo político. México: Fondo de Cultura Económica; 1995.
- 3Tornblom K, Vermunt R. Distributive and procedural justice: research and social applications. Burlington: Ashgate; 2007.
- 4Bourdieu P, Passeron JC. La reproducción. Elementos para una teoría del sistema de enseñanza. 3ª ed. México: Fontamara; 1998.
- 5Foucault M. Power/knowledge. Selected interviews and other writings. 1972-1977. Nueva York: PantheonBooks; 1980.
- 6Pieper AM. Ética y Moral. Barcelona: Crítica; 1991.
- 7Sen A. ¿Igualdad de qué? Conferencia pronunciada en la Universidad de Stanford, 22 de mayo de 1979. [Internet]; 2014 [consultado 2014 feb 10]. Disponible en: http://www.fder.edu.uy/contenido/rrll/contenido/licenciatura /documentos/76456536453545354634783.pdf
» http://www.fder.edu.uy/contenido/rrll/contenido/licenciatura /documentos/76456536453545354634783.pdf
- 8Sen A. La idea de la justicia. Bogotá: Santillana Ediciones Generales S.A.; 2010.
- 9Nussbaum M. Creating capabilities: the human development approach. Cambridge: Belknap Press (Harvard University Press); 2011.
- 10Max-Neef M, Elizalde A, Hopenhayn M. Desarrollo a escala humana. Una opción para el futuro. Uppsala: Fundación Dag Hammarskjold; 1986.
- 11Honeth A. Reconocimiento y menosprecio. Sobre la fundamentación normativa de una teoría social. Buenos Aires: Katz; 2010.
- 12Marx K. Glosas marginales al programa del partido obrero alemán. [Internet]; 2014 [consultado 2014 ene 16]. Disponible en: https://www.marxists.org/espanol /m-e/1870s/gotha/gotha.htm
» https://www.marxists.org/espanol /m-e/1870s/gotha/gotha.htm
- 13Benhabib S. El ser y el otro en la ética contemporánea. Feminismo, comunitarismo y posmodernismo. Barcelona: Gedisa; 1992.
- 14Bárcena F, Mélich J. La educación como acontecimiento ético. Natalidad, narración y hospitalidad. Barcelona: Paidós; 2000.
- 15Gilligan C. La moral y la teoría. Psicología del desarrollo femenino. Mexico: Fondo de Cultura Económica; 1985.
- 16Tugendhat E. Lecciones de Ética. Barcelona: Gedisa; 1997.
- 17Fields AB. Human rights theory: criteria, boundaries, and complexities. International Review of Qualitative Research 2009; 2(3):407-418.
- 18Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):13-27.
- 19Peñaranda F, Rendón C. Determinismo-indeterminismo y el debate de los determinantes-determinación social de la salud. Rev. Fac. Nac. Salud Pública 2013; 31(Supl. 1):47-56.
- 20Carvalho S. Saúde coletiva e promoção da saúde. Sujeito e mudança. São Paulo: Hucitec; 2005.
- 21Granda E. ¿Quo vadis salud pública? In: E Granda. La salud y la vida. Quito: Ministerio de Salud; 2013. Vol. 3. p. 41-63.
- 22Siqueira R, Schramm FR. A saúde entre a iniquidade e a justicia: controbuições da igualdade complexa de Amartya Sen. Cien Saude Colet 2005; 10(1):129-142.
- 23Sousa Campos G. Método paideia: análisis y cogestión de colectivos. Buenos Aires: Lugar; 2009.
- 24Peñaranda F. Las fuerzas sociales y el escenario comunicativo en la educación para la salud: el caso del programa de crecimiento y desarrollo. Cien Saude Colet 2011; 16(10):4023-4031.
- 25Freire P. Pedagogía del oprimido. México: Siglo XXI; 1975.
- Publication in this collection
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