Abstract

In the following article we investigate health/illness problems from the experience of subjects who live in peri-urban neighborhoods in Paraná city (Entre Ríos, Argentina). Based on a collaborative ethnography during the years 2017-2018 - which included in-depth interviews, audiovisual recordings and action-research with residents of peri-urban neighborhoods of Paraná city, visits to Health Centers, interviews with professionals and administrative staff, as well as with some Organizations that work in health promotion and prevention of illnesses and/or grievances- the processes of social determination of health-illness-death in vulnerable territories are investigated. Based on a reconstruction, we fundamentally delve into the consequences and dynamics that the existence of an open-air dump embodies in the lives of those who inhabit the territory, which is the epicenter for addressing various sanitary situations. Deepening in the determinations involves a journey through socio-historical, political and cultural situations of this territory that make an impression on the corporalities and in the ways of understanding the processes of health / illness and experiencing them.

Key-words:
Determination; Vulnerability; Territory; Health/Illness Processes; Dump

Introduction

In the following article we investigate health problems based on the experience of subjects living in peri-urban neighborhoods of Paraná city (Entre Ríos, Argentina). These aspects are part of a rights perspective that requires thinking about health in the territory. This key implies integrality in health, as a field in dispute, crossed by historical, social, cultural, economic and political components that exceed both legal regulations and an approach to disease processes as objective instances, ahistorical, capable of being separated from the bodies that carry, suffer and coexist with them.

The construction of social problems from the perspective of territoriality involves mapping the singularity of spaces, which we circumscribe in this case in peri-urban neighborhoods of the capital city of the Province of Entre Ríos²2The province of Entre Ríos is located in the central-eastern area of the Argentine Republic, south of the American Continent. It is important due to its strategic geographic position, including an obligatory passage in the north-south axis of the Argentine Republic with Brazil and the east-west axis comprised by the Bioceanic Corridor linking Uruguay and Chile (Government of Entre Ríos, 2019). Paraná, its capital, has a population of approximately 340,000 inhabitants over an area of 1,974 km2 (INDEC, 2010)., Paraná, located on the left bank of the river that gives it its name in Argentina. San Agustín, Balvi, Las Flores, La Floresta, Antártida, San Martín are some of the neighborhoods that are part of the space addressed in this study, located in the periphery, southwest of this city. These neighborhoods are characterized by some of their inhabitants as “marginal” and “discriminated”, having various types of problems. They are characterized by a high level of poverty, precarious housing -many of them with sheet metal walls and tin roofssheet- without basic services such as sewer and drinking water; with dirt roads. In addition, these neighborhoods are adjacent to an open-air dump (Volcadero), which has its own dynamics and creates vulnerabilities in terms of health. It is the landfill for all the waste generated in the capital city and exists for approximately 100 years. In its origins, it was a place far from the city that soon became populated and acquired other dimensions. In light of the neoliberal and exclusionary policies of the 1990s, and in a context of impoverishment, exclusion and loss of employment in Argentina, the volcadero, as it is known, is the epicenter for many families who, excluded from formal employment, use it to generate some income or obtain items for their consumption.

From a collaborative ethnography (Lawless, 1993LAWLESS, E. Holy women, wholly women: sharing ministries of wholeness through life stories and reciprocal ethnography. Philadelphia: University of Pennsylvania Press, 1993.; Lassiter et al., 2004LASSITER, L. E.; GOODALL, H.; CAMPBELL, E.; JOHNSON, M. N. (Ed.). The other side of middletown: exploring Muncie’s African American community. Walnut Creek: AltaMira Press, 2004.; Lassiter, 2005LASSITER, L. E. The Chicago guide to collaborative ethnography. Chicago: Chicago University Press, 2005.; Rappaport; Rodriguez, 2007RAPPAPORT, J. RODRIGUEZ, M. E. Más allá de la escritura: la epistemología de la etnografía en colaboración. Revista Colombiana de Antropología, Bogotá, v. 43, p. 197-229, 2007.) during the period 2016-2019 -including in-depth interviews, audiovisual recordings and action-research with residents of peri-urban neighborhoods of Paraná city, visits to Health Centers, interviews with professionals and administrative staff³3We worked with 3 Health centers located within the study area, which are not mentioned in order to protect confidentiality, and which had internal workers and researchers who guaranteed collaborative work in the face of local interests and priorities., as well as with some Organizations that work in health promotion and prevention of illnesses and/or grievances such as the House of Care and Community Accompaniment (CAAC - Casa de Atención y Acompañamiento Comunitario)- the processes of social determination of health-illness-death are investigated.

The considerations produced are part of an extensive work from which we have been able to reconstruct some arguments in co-production with the inhabitants of these spaces, together with the research and intervention team⁴4The results published in this article are part of the book XXX currently under development, which concentrates the results of a series of articulated cancer research supported by XXX during 2016-2019. This is a major project involving a wide range of qualitative, quantitative and participative methods. For reasons of limited space, we do not discuss in depth here the strategies and methods developed, although this can be found in the publication mentioned in its various chapters. It is also worth mentioning that many of the subjects/participants in the research are co-authors and/or authors of chapters and have participated in the analysis of the data as well as in the different stages of the research carried out under the direction of Dr. Natalia Luxardo.. In methodological terms, in a first cycle of ethnographic work, key informants were identified, field records were kept, non-directed interviews and participant observations were conducted, which made it possible to hierarchize local priorities, identify emic categories and establish partnerships with organizations and networks within the communities (Luxardo, Sassetti, Bello, s/f). Together with the communities, various objectives were then established, reviewing common interests in academic objectives -of external researchers- and those of the place -internal researchers and those working in institutions such as grassroots organizations, health centers and community members-, an aspect also facilitated by the exchanges and presence in the CAAC grassroots organization. The collaborative work with the communities was established with two main social groups: informal workers in the open-air dump and people involved in the prevention of consumption problems in these neighborhoods.

Collaborative ethnography emphasizes the construction of knowledge, recognizing the processes of production, involving those who embody those experiences as an inherent part of it. It is thus a matter of emphasizing collaboration in the ethnographic process itself instead of hiding these relationships (Rappaport; Rodriguez, 2007RAPPAPORT, J. RODRIGUEZ, M. E. Más allá de la escritura: la epistemología de la etnografía en colaboración. Revista Colombiana de Antropología, Bogotá, v. 43, p. 197-229, 2007.), producing a round-trip that is reintegrated in the fieldwork process (Lassiter, 2005LASSITER, L. E. The Chicago guide to collaborative ethnography. Chicago: Chicago University Press, 2005.) and that exceeds its institution as “data”. We recovered stories from interviews⁵5The interviews had an Informed Consent, in which participation was endorsed, first commented orally and then submitted for signature. It included confidentiality clauses and personal privacy rights, ensuring that the names and personal data of the participants were not divulged. The ethical safeguards present in the “Guidelines for ethical behavior in the Social Sciences and Humanities” (Lineamientos para el comportamiento ético en las Ciencias Sociales y Humanidades) of the Ethics Committee of the National Council for Scientific and Technical Research were also considered (CONICET, 2006)., ethnographic records and from the microhistories. We thought side by side with the inhabitants of these spaces from an approach that is rooted in the discussions faced by exponents of Social Medicine and Collective Health. In this way, we seek to articulate the sociocultural processes with the dimensions of health/illness/attention/care by constructing a knowledge that involves and makes the inhabitants of the daily life of the territory being investigated participate.

We structure the article in three sections. In the first, we outline the theoretical-epistemological guidelines on how to read the notion of territory. In the second, we mapped some of the characteristics of the studied space, delving into the existence of an open-air dump, which characterizes and imprints its own dynamics in the studied territory. In the last one, we recovered the notion of urban sacrifice territory and determination, to describe the complexities and circuits of vulnerability that cross the life in the studied territory, deepening dynamics and paradoxes.

Some theoretical considerations about territory

The notion of territory, despite the different theoretical derivations, assumes a first difference with the conception linked to the physical-geographical space, which can be delimited and which is delimited, previously fixed, stable and self-defined. Historically, this understanding was associated with wars for the control of physical spaces, in order to identify and dispose natural and human resources (Borde; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017.). Along these lines, critical geography differentiates the notion of place from that of territory, understanding place as the geographic location of people in a given time (Spinelli, 2016SPINELLI, H. Volver a pensar en salud: programas y territorios. Salud Colectiva, Lánus, v. 12, n. 2, p. 149-171, 2016. DOI: 10.18294/sc.2016.976
https://doi.org/10.18294/sc.2016.976... ). Even so, within the discipline, the meanings also change and, within the geography of life, the place assumes a place close to the one we propose to develop from the notion of territory, since it involves a complex process of appropriation by identification, involving affective and symbolic aspects via the practical experience of the inhabitants of these spaces (López; Michelli, 2016LÓPEZ, S.; MICHELLI, V. (Coord.). Problematizando la salud. Aportes conceptuales y experiencias de trabajo en territorio desde la perspectiva de la medicina social / salud colectiva. La Plata: Universidad Nacional de La Plata, 2016.). As argued by these authors on which we are based, the territory implies a spatial experience, as a “knowing how to inhabit”, which recovers everyday life. A “place where subjective experience and the production and reproduction of social structures ‘meet’ in a complex dynamic” (López, Michelli, 2016LÓPEZ, S.; MICHELLI, V. (Coord.). Problematizando la salud. Aportes conceptuales y experiencias de trabajo en territorio desde la perspectiva de la medicina social / salud colectiva. La Plata: Universidad Nacional de La Plata, 2016., p. 50).

As a historical path, the territory involves conditions and livelihoods⁶6It is useful to recover the work of Polo Almeida (2016) that reconstructs historically the notion and systematizes its development in the field of Latin American Collective Health, differentiating, likewise, the Anglo-Saxon proposal of Political Ecology. of social groups, always linked to power relations, a “relational-symbolic space, in which capitals and fields that are created, recreated and can extend it act” (Spinelli, 2016SPINELLI, H. Volver a pensar en salud: programas y territorios. Salud Colectiva, Lánus, v. 12, n. 2, p. 149-171, 2016. DOI: 10.18294/sc.2016.976
https://doi.org/10.18294/sc.2016.976... , p. 160). In turn, it acts as a dense category to express, in the words of Porto-Gonçalvez, modes of appropriation -territorialization-, which enable the creation of conditions for the construction of identities -territorialities- tied to historical processes: “We are far from a space-substance, but rather in front of a relational triad of territory-territoriality-territorialization. Society is territorialized, territory being its condition of material existence” (Molina Jaramillo, 2018MOLINA JARAMILLO, A. N. Territorio, lugares y salud: redimensionar lo espacial en salud pública. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 1, p. 1-12, 2018. DOI: 10.1590/0102-311x00075117
https://doi.org/10.1590/0102-311x0007511... , p. 6). The territory condenses the structural plots from which possible modes of territorialization are produced, as labyrinthine plots proper of the social (Spinelli, 2016SPINELLI, H. Volver a pensar en salud: programas y territorios. Salud Colectiva, Lánus, v. 12, n. 2, p. 149-171, 2016. DOI: 10.18294/sc.2016.976
https://doi.org/10.18294/sc.2016.976... ).

The territory recovers processes of identification, of imagination about the world, as ways of conceiving and understanding the practices of the subjects in complex social networks, where not only rationalities are articulated, but also, inevitably, affective aspects with the experienced space, from where it is felt and understood, from where opportunities and possible transformations are also delimited. Thus, dynamism is an intrinsic characteristic, and its analysis can only be considered as a political construction involving decisions anchored in the interactions between the inhabitants of those spaces and between the ones we are trying to characterize as specific processes, a decision⁷7Following this line, it is possible to establish a closeness and familiarity with the notion of anthropological field. (Guber, 2005).. As Spinelli (2016SPINELLI, H. Volver a pensar en salud: programas y territorios. Salud Colectiva, Lánus, v. 12, n. 2, p. 149-171, 2016. DOI: 10.18294/sc.2016.976
https://doi.org/10.18294/sc.2016.976... ) refers, the territory is a human construction, unfinished, in permanent movement and transformation, which can be home or prison also for the subjects ⁸8For a more detailed analysis of these aspects from the perspective of public policies in Greater Buenos Aires, see Chiara (2012, 2016).. These territorial dynamics, outside of a romanticized view, accommodate it as a home, transited, occupied, signified, disputed, from which different processes of subjectivation, community ties, care practices and also resistance to different types of violations are built, both from singular and collective experiences. At the same time, it often operates as a prison -”marginalized” or “discriminated” territories, as some of its inhabitants refer to, or sacrifice zones, as we will mention- in which inequalities and different circuits of vulnerability are reproduced, as we will refer to in the following sections.

The territorial dimension occupies a central place not only to think about health policies that address inequalities and structural phenomena, but also in reverse terms, as referred by Chiara (2016CHIARA M. Territorio, políticas públicas y salud: hacia la construcción de un enfoque multidimensional para la investigación. Revista Gerencia y Políticas de Salud, Bogotá, v. 15, n. 30, p. 10-22, 2016. DOI: 10.11144/Javeriana.rgyps15-30.tpps
https://doi.org/10.11144/Javeriana.rgyps... ), to build territoriality in the face of the demands, needs and projects that the community delineates. This is why the livelihoods⁹9The distinction with lifestyle, associated to individual voluntary practices and decisions, is crucial to introduce the notion of livelihoods as a personal and collective praxis (Menéndez, 2009) with several implications for Public Health (Almeida Filho, 2000). and the sense of appropriation of the territories constitute central elements for the field of Social Medicine and Collective Health (Breilh, 2003BREILH, J. Epidemiología Crítica: ciencia emancipadora e interculturalidad. Buenos Aires: Lugar Editorial , 2003.; Breilh, 2013BREILH, J. La determinación social de la salud como herramienta de ruptura hacia la nueva salud pública (salud colectiva): epidemiología crítica latinoamericana - raíces, desarrollos recientes y ruptura metodológica. In: SEMINARIO INTERNACIONAL DE LA SALUD PÚBLICA, 8., 2013, Bogotá. Bogotá: Universidad Nacional de Colombia, 2013.; Almeida Filho, 2000ALMEIDA FILHO, N. La ciencia tímida: ensayos sobre deconstrucción de la Epidemiología. Buenos Aires: Lugar Editorial, 2000.; Laurell, 1994LAURELL, A. C. La salud: de derecho social a mercancía. In: LAURELL A. C. (Comp.). Nuevas tendencias y alternativas en el sector salud. Ciudad de México: Universidad Autónoma Metropolitana Unidad Xochimilco, 1994. p. 9-31.). Livelihoods integrate the collective into everyday life as ways of doing, but also of giving meaning, in order to sustain or transform practices. The livelihoods then cancels the individual-collective dichotomy, given that the subjects assume their movements in the frameworks of their own community, with its possibilities and traditions, a necessary key to understand the processes of health/illness/attention/care as the specific ways of living, suffering, falling ill, dying, caring. Territory, experience and significance are inherently linked, characterized by the dynamism produced by the movement of territorialization.

Features of the territory: problems, needs and “volcadero”

If thinking about territory implies a spatial experience, a knowing how to inhabit everyday life, collaborative ethnography was crucial to collectively construct the most important issues for its inhabitants and internal researchers. The most evident needs are part of the infrastructure of these neighborhoods, for example regarding the lack of sewers or the presence of “broken sewers” that overflow; they flow out with all the “dirt” because they are improperly made; they become clogged because garbage falls in. The permanence of these exposed causes accidents to children who play in the streets, exposing them to dangers that can be prevented. As said by a resident of Barrio Balvi, this situation is considered “inhumane”:

In addition, the inhabitants recognize the precarious conditions of the houses, many of which are built of metal sheets and other elements found in open-air dumps, such as boards and plastic sheeting. Access to basic services is also problematic. According to some community center workers in the neighborhood, between 80% and 90% are “hung up” on the public lighting system. The water supply, especially in summer, is scarce and is often “interrupted “, so that neighbors must anticipate to collect water in buckets. Access to gas, both for cooking and heating, is also a scarce resource. In most of the houses, the gas cylinder in the kitchen is the only gas installation and many times in winter what they do is...if they have gas, they light (...) inside the house a bucket or some container that allows them to heat the house a little bit (worker of CAAC, 2018). This situation entails dangers associated with having fire close to flammable products present in homes and the possibility of fires.

In socio-educational terms, illiteracy is a basic problem reported by some of the professionals working in Primary Care Centers and Neighborhood Organizations. Dropping out of school is part of the need for many young people to use that time to work, but also, in some cases, to generate income associated with substance use, mainly drugs and alcohol, which begins around the age of 11 or 12. Pregnancies are another reason why many adolescents leave educational institutions to care for their babies, a task delegated exclusively to women.

In terms of wages, many of the people living in the neighborhoods have the Supplementary Social Wage (SSC - Salario Social Complementario), which represents half of the minimum and mobile wage, to support themselves during the month, or they work in precarious jobs. One of the main sources of income, shared by the inhabitants of the territory, is part of the work in the volca or volcadero -from the native category-, the open-air dump shared by these peri-urban neighborhoods of Paraná city. As mentioned in the introduction, although it was initially located on the peripheries of the capital city, demographic expansion -accompanied by neoliberal policies, impoverishment, exclusion and loss of employment- promoted population growth in the nearby area, becoming the epicenter for many families who, excluded from formal employment, used and still use it to generate some income or to obtain items for consumption.

The volcadero is conceived as a work space for “classifiers” or for “operate”, where different generations are learning to “live off garbage”, which means spending long days of between 12 and 14 hours in order to have some income. The “classification” requires, on the one hand, separating garbage such as paper, plastics or metals to then sell these items and buy food. A cooperative of people who recycle and select from burning garbage is also recognized. This practice has become widespread, since it allows recovering metals from the waste in a faster way. On the other hand, there are those who are identified as “operators”, people who search through the garbage for products for direct, daily consumption, as an activity of extreme necessity in the absence of other alternatives. As one of the women who participates in the CAAC of the neighborhood says:

The volcadero is a space shared by people of many ages, seniors, youth, children and adolescents. Many of the school-age children go to the Community Center for a “cup of milk” as a kind of “break” or “recess” from work when they are older. It is also experienced as a game or help to their parents, when they are younger. In addition, some adults or young parents bring their children with them, as care tasks become more difficult:

The volcadero is a place of work for many people and families. But it is also used as a space of dispute between the people who live there. There are codes and organizational modes that allow us to see the territory as a space of power. Trucks are designated in discharges: “each garbage has its owner”.

It can be said that the volca or volcadero imprints its own dynamics in the territory studied: in the practices of who live there, in the organization, distribution and ways of generating resources, in the socio-educational decisions and opportunities, and in the ways in which the population cross, lives and signifies the processes of health/illness/attention/care.

Sacrificial urban territories: complexities, violence and dilemmas for health action

The approach anchored to the territory, within the field of health and public health, recovers the processes of social production and reproduction as the basis of the social determination of health-illness-death (Borde; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017.). Understanding the lifestyles and scenarios of the inhabitants of the analyzed neighborhoods is an irreplaceable basis for understanding inequalities and inequities, the different ways of getting sick, the ways of suffering and the possibilities of well-being (Breilh, 2010BREILH, J. Informe alternativo sobre la salud en América Latina. Quito: Global HealthWatch, 2010.). Thinking about health implies reorienting actions to the processes of social determination that reproduce some historical-territorial conditions: “That is to say, the territory socially and biologically produces life, which is inevitably linked to health” (Borde; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017., p. 271).

The Collective Health current problematizes unidirectional causalities to address the social determination of health as a complex and multidimensional field that forces us to consider the territory, in its productive and social relations, as part of a system of accumulation of power and culture, as part of a structural and historical order (Casallas-Murillo, 2017CASALLAS-MURILLO, A. L. La medicina social-salud colectiva latinoamericanas: una visión integradora frente a la salud publica tradicional. Revista Ciencias de la Salud, Bogotá, v. 15, n. 3, p. 397-408, 2017. DOI: 10.12804/revistas.urosario.edu.co/revsalud/a.6123
https://doi.org/10.12804/revistas.urosar... ). The social determination of inequalities in health/illness processes refers to the multiplicity of aspects that affect the ways in which people live, get sick, take care of themselves, die and also access care. These are social hierarchies that define the access and quality of health services, living conditions and habitats, access to education, problematic consumption, employment possibilities and conditions, the different forms of violence involved, among other determinations that have an impact and are “an intimate expression of historical-social-spatial processes in ‘socio-historical subjects who fall ill’ (Hernández; Quevedo, 1992)” (Borde; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017., p. 272). Determination thus argues with proposals that produce causal relationships between factors or dichotomous visions -such as individual/society- to assume history, contradictions, social processes: “More than ‘ex-position’ to external risks, subjects undergo processes of ‘im-position’ of life conditions (Hernández, 2008HERNÁNDEZ, M. Desigualdad, inequidad e injusticia en el debate actual en salud: posiciones e implicaciones. Ciudad de México: Asociación Latinoamericana De Medicina Social, 2008., p. 9). Health problems cannot be understood in terms of individuals, but as part of the same territorial dynamics. As Spinelli states, “The territory shows us that the epidermis is not the limit of the individual and that if we go beyond the skin of each subject we can transcend the risk factors to think in terms of interaction and social play, and discover the social vulnerabilities and the logics of power (macro and micro), as well as the power that underlies the territory” (2016, p. 159). The volcadero is a direct reference, not only because of the different professionals who work in the Health Centers of the neighborhoods or in the Community Centers, but also because of those who circulate it and spend long days there. The livelihoods systematize a set of problems that are linked to this inhabiting of the territory.

Respiratory diseases are identified as one of the main childhood illnesses, especially in winter, associated with the burning of garbage. The smoke, as reported by a social worker from the Anacleto Medina Health Center, produces a very strong smell, generating a lot of toxicity in the environment and haze. The “gases” and “rotting” are commonplace among people who are there daily. People who work at the volcadero also report illnesses and ailments resulting from exposure and inclement weather:

These conditions affect people who work with the garbage and also who live in the surrounding areas. Exposure to accidents is recurrent among workers, due to the handling of garbage and contact with cutting materials or other types of objects, as well as proximity to rotten products and toxic waste. The entrance and exit of trucks has its implications among the people waiting for the arrival of “new” materials, which recognizes power dynamics that assign “moments” and types of materials. One of the events that redefined the work itself was an accident involving a 16 year old teenager who fell asleep waiting for one of the trucks at the volcadero and was run over by it, resulting in a fractured pelvis. A very sad situation, as one of the workers recalls:

The adolescent’s event represents not only a mere accident, but an expression of a set of social problems that he embodies and that despite being recognized by those who inhabit these spaces, are presented as inevitable.

The arrival of trucks means, for many people and families, the possibility of eating that day. In addition to the municipal dump, there are also other private spaces where supermarkets dump their unmarketable merchandise. The area, therefore, is characterized by “volcaderos” of different origins: So people who do not have, who do not have enough and who do not... look for that food. Expired, mashed, damaged food (inhabitant of Balvi neighborhood).

The need to wait for trucks, find food supplies, exposure to cold and inclement weather show us, in a gloomy and shocking way, that prevention and health promotion are not alien to the conditions of vulnerability in which people live. When you are in crisis and there is no possibility of eating well, diseases appear, as emphasized by one of the people who actively participates in the Community Center next to the volcadero.

This territorial configuration, following Marcelo Firpo-Porto (2013)FIRPO-PORTO, M. Injustiça ambiental no campo e nas cidades: do agronegócio químico- dependente às zonas de sacrifício urbanas. In: FIRPO-PORTO, M.; PACHECO, T.; LEROY, J. P. Injustiça ambiental e saúde no Brasil: mapa de conflitos. Rio de Janeiro: Fiocruz, 2013. p. 133-174., expresses what can be referred to as an urban sacrifice territory. The peri-urban neighborhoods analyzed are configured as marginalized and exploited zones of a capitalist development model that spatially organizes different zones in the cities (Bordes; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017.). The sacrifice is visceral evidence of the structural violence against the inhabitants. These zones “are an expression of the unsustainability of this hegemonic model of city and development and are characterized by industrial pollution of the air, water and soil, but also refer to areas of social sacrifice where fundamental rights are denied and violence is exercised to adapt spaces to the needs of large enterprises and historically privileged social groups” (Borde; Torres-Tovar, 2017BORDE, E.; TORRES-TOVAR, M. El territorio como categoría fundamental para el campo de la salud pública. Saúde em Debate, Rio de Janeiro, v. 41, n. especial, p. 264-275, 2017., p. 268).

The daily life of the inhabitants of the territory exposes them to different forms of violence and situations that are part of vulnerability circuits. Health/illness processes are the result of a whole set of circumstances. Respiratory diseases and allergies cannot be disassociated from the continuous exposure to toxic smoke from the volcadero, but, at the same time, they are chronic conditions linked to livelihoods and housing conditions.

In this circle of vulnerability, the problems of addictions and violence are also identified by residents and health workers. Problematic substance use is linked to circuits of violence and mutual suspicion between groups. Cocaine, marijuana, adulterated cocaine and synthetic drugs are the most common substances. We should also mention the early consumption of alcohol by children and young people as one of the most worrying issues.

The people who work as professionals in the Health Centers, in the Community Centers, as well as the neighbors and regular workers of the volcadero, are aware that consumption problems cannot be separated from the conditions of vulnerability and structural violence that persist. The policies or lack of public policies, the loss of employment, the crises and the naturalization of an increasing percentage of people below the poverty threshold are fertile ground for those who find in consumption an “escape route”, a way to avoid the daily suffering and that is “gradually installing itself” with difficulties to be reversed.

Violence also affects relationships. In addition to structural violence, violence in relationships, gender violence and situations of abuse are also recognized. Violence is interrelated and is the result of a multiplicity of situations experienced:

Situations of “suspicion”, but also of violence associated with crime -in turn a product of territorial disputes, historical wounds and family controversies- tend to deepen in adolescence, when violence also paradoxically acts as a means of containment and generation of bonds in fragile contexts:

As the professionals recognize, the work is also a task in the face of prejudice, fear, impotence and pain, which inexorably requires an understanding about the territory in order to develop joint intervention strategies.

Concomitantly, the fragility of bonds, consumption problems, teenage pregnancies, raising babies and the need to generate resources or income for families have an impact on the socio-educational aspects of children, young people and adolescents: “They drop out of school early,” as the Social Worker at the Health Center said. Thus, it can be seen that socio-educational problems are closely linked to these vulnerability circuits: You ask teenagers everything, but... that teenager is collecting garbage or doing something else (inhabitant of Balvi neighborhood). In this wheel, the experiences of illness also operate as a conditioning factor for access to education:

Territories or sacrifice zones produce sick, dependent, fragile bodies, prone to generate and experience situations of violence, which feedback each other in a circle that reproduces and naturalizes inequalities and vulnerabilities. Structural conditions and life contexts marked by circles of vulnerability are inevitably involved in the modes of illness and death in the peri-urban neighborhoods studied. The territory is connected to health and life, since the processes of production and social reproduction, which are the basis of social determination, take place in it. In this sense, considering the contradictions and possible alternatives of groups and populations is a basic requirement to understand the processes of health/illness/attention/care from the knowledge and practices, from the livelihoods -as an incarnated experience anchored to the territories- of those who inhabit them.

In this case, we cannot ignore the fact that the volcadero condenses a series of social and sanitary problems. At the same time, in a context characterized by the lack of opportunities, by situations of poverty and indigence, the volcadero is a fundamental source of work for many people and families, who “manage” the garbage, who make of it a resource to live or to trade. Thinking about territory implies noticing these controversies and approaching health promotion with the inherent contradictions, with the possibilities and alternatives that are presented to the inhabitants of these sacrifice zones, encouraging not only constructive proposals, but also those capable of being appropriated and sustained by their inhabitants.

Conclusions

The territory, as we have mentioned, is more than a physical-spatial location, containing resources and population. We refer to situations of inequity and vulnerability as manifestations of structural violence that can be condensed under the heading of sacrifice zones. The consequences and displacements caused by the existence of an open-air dump, the associated working conditions, but also the housing and environmental conditions, as well as the problems associated with substance abuse, violence, fragile relationships and access to education, are part of a complex network.

Addressing the relationship between territory and health, from the perspective of Social Medicine and Collective Health, promotes the consideration of these structural, social, cultural, historical and political factors in order to understand how inequalities are transformed into inequities, principles of injustice that violate various rights and expose some groups to particular circumstances and sufferings. Thus, far from thinking about the social determination of health from cause-effect associations in relation to the health of the population, the analysis assumes the complexity embodied by the territory in the production of subjectivities. As we mentioned, from a territorial perspective, it is not only a matter of thinking about health policy from structural frameworks, but also anchored to the demands and needs in a process of territorialization that involves the livelihoods in their discomforts and associated problems.

The volcadero is the epicenter of various socio-health dilemmas, but it is also a source of resources for many of the people who “live” from it, a means of work and subsistence, which does not exclude rules, codes and categories of workers. This shows how the problems it embodies are far from being addressed from simplistic models, linked, for example, to the relocation or elimination of the dump.

Collaboratively mapping the territories was a way of addressing the complexities and identifying health problems with the inhabitants themselves, from their daily lives. On the other hand, it was understood that the territory embodies power relations, which are interconnected and cross practices and spatialities, for example, in the rules and codes of access to work in the dump or the ways in which young people, above all, circulate and are challenged by the problematic consumption of substances. As we have mentioned, these aspects are also part of power relations tied to conditions of vulnerability and structural violence, which delineate sacrifice zones and exclusion processes in which unemployment, poverty, lack of public policies participate in the processes of social determination of inequalities and, therefore, in the processes of health/illness/attention/care. As Sajama summarizes, people live, get sick and die depending on the conditions in which they work (production) and live (reproduction), dynamics linked to the territory. In this sense, the enforceability of rights can only be settled collectively from the possible, imagined, accepted, feasible, permitted, enabled, constructed and promoted conditions for the exercise of care, for the production of life and health.

Acknowledgments

This article was possible thanks to the dialogues and contributions of Leandro Alva, graduate in Nursing, and Teresita Calzia, graduate in Social Work. It is also a product of the generosity of Dr. Natalia Luxardo and her joint work for the production of these results. Finally, it is worth mentioning that the article is part of a larger collaborative research on social inequalities in health.

References

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