Abstract

The article revisits nodal notions in the health field such as participation and community. These categories need to be revalued and understood in the light of modern public policies and the processes of construction of “the common”. In the territories daily life collective practices construct health-illness-assistance-care processes in social reproduction and also in the resistances to the social general hegemonic models, as well as those related to the health care services. These experiences and knowledge are axes for health practices focussed on territorial autonomy processes. Guided by those, professionals can turn to develop other practices outside of the classic, hegemonic and rigid care designs.

Keywords:
Community Participation; Collective Health; Social Psychology; Social Networks

Introduction

The notion of participation has been central to the theoretical-practical foundations of collective health, of community health, enriched by contributions from sociology, community social psychology (Montero, 2006aMONTERO, M. Hacer para transformar. Paidós: Buenos Aires , 2006a.) and community work in general (Chena et al., 2018CHENA, M. et al. Conceptos claves en el trabajo comunitario. Anuario de Investigaciones, Buenos Aires, v. 3, n. 3, p. 107-121, 2018.). Participation implies genuine processes to the needs and characteristics of the communities that increase the social connection and possibly well-being. For this reason, it is a pillar of the work as long as it attends to a subject who is a product and producer of the history, and as the axis and source of knowledge (Wiesenfeld, 2014WIESENFELD, E. La psicología social comunitaria en América Latina: ¿consolidación o crisis? Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 6-18, 2014. ). However, its use has come to obscure or blur its meaning.

Certain processes of institutionalization install the risk of crystallizing the meaning of participation linked to an utility to improve governance so as not to endanger the dominant socioeconomic system. In this framework, we agree with Fernanda Soliz (2016SOLIZ, F. Salud colectiva y ecología política: la basura en Ecuador. Quito: Uasb, 2016., p. 78) who states “it is urgent to put under debate what is meant by participation” when discussing the modalities of territorial approach in health processes.

Likewise, this review is intertwined with other key categories of community health such as community and the common. Different theoretical traditions in the social sciences have adopted these concepts so much that it has crossed over into public policy and they are in daily vocabulary. However, many of the disciplines related to health that have been taking these concepts for a long time have not recovered the conceptual review of their implications. Therefore, we seek to investigate connections between the notions of community and participation in order to contribute by considering the everyday life of multiple processes that make up the production of the common as ways of participation in territories of health work. This proposal would allow us to clarify the challenges arising from the tensions between community work, everyday life in the communities and institutional health practices. The role of the State questions the forms, scopes and actors involved in the decisions influencing territorial work. The different sections of this article can be read across the tensions, limits and possibilities of the activities of community health workers in governmental institutional settings.

Revisiting the community

Discussions on the notion of community are abundant, so we focus on the question of community linked to health in the territories. Knowing that neoliberal logics appropriate terms to make them fragile, this review seeks to recover the political meanings of social transformation in the studied terms.

Historically, communities have been delimited as the object of intervention based on an institutional program that mainly targets the popular sectors. This method offers a universal reference of work but it could generate distortions of local realities according to standards of life that do not reflect historical and territorial particularities.

By delimiting the subject “community”, actors are often made invisible, histories and projects are ignored. Moreover, the frequent definition of community as being defective is a common phenomenon in many institutions, and this deprives it of its identifying characteristics and transforms it into an object of decontextualized interventions.

Germán Rozas (2018ROZAS, G. Decolonialidad desde la psicología social comunitaria. Santiago de Chile: Universidad Austral de Chile, 2018., p. 81) formulates the problem of the “heterodesignation” of a community as follows:

This way of thinking invisibilizes the processes of oppression implied in these definitions, often masking the communities’ responsible for their living conditions and existence.

The ambiguous use of the term “community” makes necessary to review these references, since it is usually associated with psychosocial processes (empowerment, participation, etc.); with various populations in institutional frameworks with which community psychosocial work or research was conducted (schools, clubs, cultural groups, etc.); and with topics or groups studied related to social aspects, such as public policies, culture, development, youth, etc. (Wiesenfeld, 2014WIESENFELD, E. La psicología social comunitaria en América Latina: ¿consolidación o crisis? Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 6-18, 2014. ).

Montero (2004MONTERO, M. Introducción a la psicología comunitaria. Paidós: Buenos Aires, 2004.), reviewing this term, starts from a conceptualization that assumes common relationships in terms of doing, knowing and feeling. These relationships take place in a social environment in which certain interests and needs have historically and culturally developed; an environment determined by circumstances that affect groups of people who recognize themselves as participants, have common objectives, develop forms of social identity due to this shared history and build a sense of community.

Geographic delimitation is one of the difficulties encountered when defining community (Montero, 2004MONTERO, M. Introducción a la psicología comunitaria. Paidós: Buenos Aires, 2004.). This criterion has often been used to understand the community, since it is linked to forms of territorial organization based on historical constructions or on georeferenced and public policies of urbanization that have intervened in their identification. In addition, the sharing of an everyday geographic space may be attached to an increase in frequent interactions and the sharing of history, identity processes, needs and objectives linked to the territory. However, in today’s societies this is also affected by territorial segregation, social fragmentation, stigmatization, individualistic constructions and the increase of insecurity discourses that limit meeting spaces and, therefore, bonds.

The sense of community is presented as a “hard core” of the concept of community, it allows designating an intersubjective component of the community beyond its geographical references (Montenegro-Martínez, 2004MONTENEGRO-MARTÍNEZ, M. Comunidad y bienestar social. In: MUSITU OCHOA, G. et al. (Coord.). Introducción a la psicología comunitaria. Barcelona: Editora UCO, 2004. p. 43-72.; Rodríguez; Montenegro, 2016RODRÍGUEZ, A.; MONTENEGRO, M. Retos contemporáneos para la psicología comunitaria: reflexiones sobre la noción de comunidad. Revista Interamericana de Psicología , San Luis, v. 50, n. 1, p. 14-22, 2016. ). Based on the linkages, a “we” is generated in contrast to an “other” defined in terms of people who are not part of the community. The sense of community refers to:

Although the term “community” tends to acquire a tone of idealization and romanticism, it is necessary to assume it as complex, with the existence of multiple tensions. At the same time, it allow us to think of relationships from everyday situations and of the effects that are created there, the common also refers to the difference and tensions that arise (Rodríguez; Montenegro, 2016RODRÍGUEZ, A.; MONTENEGRO, M. Retos contemporáneos para la psicología comunitaria: reflexiones sobre la noción de comunidad. Revista Interamericana de Psicología , San Luis, v. 50, n. 1, p. 14-22, 2016. ).

Communities are integrated by persons who are so because of therelationships among others and communities are relationships between people (Guareschi, 2019GUARESCHI, P. Introducción al misterio de la comunidad. In: SAFORCADA, E.; CASTELLÁ-SARRIERA, J. Enfoques conceptuales y técnicos en psicología comunitaria. Buenos Aires: Nuevos Tiempos, 2019. p. 15-22.). This appears as a challenge because the focus is often centered on individuals, as isolated subjectivities, extrapolating the characterization of the community as well as generalizing collectives as a homogeneous whole without recognizing the differences that coexist in the group.

Notwithstanding these references, the definitions of community that underpin the territorial works are often not mentioned, and by using it in a general way, the political character of the concept is weakened (Rodríguez; Montenegro, 2016RODRÍGUEZ, A.; MONTENEGRO, M. Retos contemporáneos para la psicología comunitaria: reflexiones sobre la noción de comunidad. Revista Interamericana de Psicología , San Luis, v. 50, n. 1, p. 14-22, 2016. ).

The perspective of social transformation that is intended to be constructed and sustained in community work is a key dimension of the conceptual framework of collective and community health. To achieve this, we need to rethink community attending to its political power that unfolds in daily activities which are linked to life reproduction in a collective way.

The particular dimensions of everyday life focus on the link between the general processes of lifestyles and those of social reproduction in the objective conditions of existence (Castellanos, 1990CASTELLANOS, P. L. Sobre el concepto de salud enfermedad: descripción y explicación de la situación de salud. Boletín Epidemiológico, Washington, DC, v. 10, n. 4, p. 1-7, 1990. Disponível em: <Disponível em: https://bit.ly/3dbCygf >. Acesso em: 13 abr. 2021.
https://bit.ly/3dbCygf... ). In these, the community - through problems, needs and resources build links in everyday life that configures relationships that make up a network through which meanings, discourses, narratives and common ways of doing things circulate, within the ways that the broad social context makes possible. The common has conflicts, tensions and disputes, as well as mutual recognitions that are articulated in everyday life.

How can this network of relationships be addressed, emphasizing the political character of the community? What political ties can be considered beyond institutional references and citizenship?

These are relevant questions considering that historically the State has been the main referent and scenario of “political” disputes. The issue refers to a fundamental split in the modern project that produces the public-private separation. Thus, activities related to the support of everyday life were relegated to the private sphere and deprived of politicization. Rethinking the community implies recognizing the political power that unfolds in daily activities linked to life reproduction in a collective way. This review is supported by the contributions of some feminist authors who think about the forms acquired by the community and the relationships between the production of the common, affective ties and ways by which the community is organized.

Silvia Federici (2014, apud Navarro; Linsalata, 2014NAVARRO, M. L.; LINSALATA, L. Crisis y reproducción social, claves para repensar lo común: entrevista a Silvia Federici. Revista del Osal, Ciudad de México, v. 15, n. 35, p. 15-26, 2014. Disponível em: <Disponível em: https://bit.ly/3s6CVNa >. Acesso em: 13 abr. 2021.
https://bit.ly/3s6CVNa... ) argues that community does not exist without the production of the common, and there is no production of the common without community. The common is a social relationship rather than a property attribute; it is also produced and related to the ability to decide collectively according to material, symbolic and affective constructions. It is a central notion of the term community network, which designates the collective forms in which useful work for human life reproduction is expressed and carried out. It also emphasizes the links centered on the common and the purpose that animates them: the pluriform reproduction of life (Gutiérrez-Aguilar, 2011GUTIÉRREZ-AGUILAR, R. Los ritmos del Pachakuti: cómo conocemos las luchas de emancipación y su relación con la política de la autonomía. Destacados, Ciudad de México, n. 37, p. 19-32, 2011.). The community framework refers to a

The production capacity of the commons involves the reproduction of human and non-human life and it appears as:

We emphasize the common as a fundamental issue of political horizons not centered on the state, as public and universal (Gutiérrez-Aguilar, 2011GUTIÉRREZ-AGUILAR, R. Pistas reflexivas para orientarnos en una turbulenta época de peligro. En Gutiérrez, R. (Ed.) Palabras para tejernos, resistir y transformar en la época que estamos viviendo. México: Pez en el Árbol Ediciones, p. 31-55, 2011. ). This does not suggest that states cease to operate in one way or another in the dynamics of these communitarian political horizons. Although the unfolding of the community political horizon is not centered on the state, they are linked. The common linked to the territory, shape up in articulations with institutional and capital logics that intimidate the dynamics that threaten the instituted and hegemonic.

In the networks and links present in the historical evolution of the territories, meanings and ways of doing things in common are configured. They are linked to the ways of sustaining life and dispute or accommodate to the hegemonic logics.

Capitalism today tends not only to the extractivism of common goods and bodies, but also to the weakening and fragmentation of community relations. The ways of capitalist accumulation affect the modes of social regulation that impact on daily practices, subjectivities and links, complicating the logics of interventions or community accompaniment. If we focus on the chain of daily precariousness in the continuum of work, family, consumption, education, social plans, plus daily management to sustain oneself in the precariousness of all vital aspects, evidence the challenges involved in building together and, at the same time, how relationships are necessary to sustain life.

Barttolotta, Gago and Sarrais-Alier (2017BARTTOLOTTA, L.; GAGO, I.; SARRAIS-ALIER, G. La gorra coronada: diario del macrismo. Buenos Aires: Tinta Limón, 2017.) call these aspects of our time “totalitarian precariousness”. This term designates those circuits of mistrust, fear, susceptibility in everyday bonds that are the latent violence of our time. These sensitive and susceptible coexistences make up the complexity of everyday life, in which the agenda and its complications can deconstruct what is put together with great effort in order to reproduce life and maintain it.

Inter-subjective relationships that occur in the communities appear as primary links related to affection, solidarity, but also with disputes that gradually build relationships in everyday life. Also, in territories there are secondary connections that refer to functional and bureaucratic relationships (Guareschi, 2019GUARESCHI, P. Introducción al misterio de la comunidad. In: SAFORCADA, E.; CASTELLÁ-SARRIERA, J. Enfoques conceptuales y técnicos en psicología comunitaria. Buenos Aires: Nuevos Tiempos, 2019. p. 15-22.). In the latter, a certain dilemma arises around the relationship between institutions, the market and community or institutional practices, power disputes and community work.

The community is “a social space where organized collective actions can be developed towards social transformation and, therefore, constitutes an empirical space for research and action” (Montenegro-Martínez, 2004MONTENEGRO-MARTÍNEZ, M. Comunidad y bienestar social. In: MUSITU OCHOA, G. et al. (Coord.). Introducción a la psicología comunitaria. Barcelona: Editora UCO, 2004. p. 43-72., p. 44), so it is central for praxis in health. However, in territorial work it is done with a group of people, although we allude to communities as a homogeneous whole, suggesting that this variable number of participants exhausts this collective. In this action, we invisibilized members of the community who do not participate, silent or dissident voices of these actions. “This exclusion distorts the community reality, by annulling the diversity that shelters and anonymizes a part of its members” (Wiesenfeld, 1997 apud Wiesenfeld, 2014WIESENFELD, E. La psicología social comunitaria en América Latina: ¿consolidación o crisis? Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 6-18, 2014. , p. 11).

This situation invites us to discuss who is involved and in what way in the configuration of what we call communities, since not all the people living in the work territories participate in the same way. Do the institutional approaches show an inclusive and democratic process? What motivates those who withdraw or are not as visible as the leaders or key informants?

In synthesis, beyond an external definition of community, it seems important to us to resort to an expression that emphasizes the centrality of the common when thinking about practices. To this end, the notion of community network suggested by Gutiérrez-Aguilar allows us to emphasize the materiality of the multiple relationships that are built in the territories around sustenance and life reproduction . This implies organizational forms that are configured around the defense of collective decision-making capacities. The tendency to practices that consider the common would help to recognize the territorialities, knowledge, priorities, meanings and needs of community processes. Thus, it enables people to consider diverse and multiple instances of participation.

Participation as a standard of community practices: How is it built and why is it stimulated?

From the current perspectives of social health, specifically the ones related with psychology, participation has been considered a pillar of work when thinking about relationships with the community (Montenegro; Rodríguez; Pujol, 2014MONTENEGRO, M.; RODRÍGUEZ, A.; PUJOL, J. La psicología social comunitaria ante los cambios en la sociedad contemporánea: de la reificación de lo común a la articulación de las diferencias. Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 32-43, 2014. ), and even as an ontological characteristic, as an axis and source of knowledge (Wiesenfeld, 2014WIESENFELD, E. La psicología social comunitaria en América Latina: ¿consolidación o crisis? Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 6-18, 2014. ). In community work, one of the main characteristics is the participation of the community in decisions about the relevance of the problems, the ways on how to proceed with them, the knowledge and experiences considered valuable, etc.

Some debates on participation incur in analyses like those mentioned in relation to community, since it has also undergone processes of institutionalization that have limited its meaning. With the increase in its enunciation has come its depoliticization by linking it to formal instruments to improve governance. It is important, then, to discuss what we consider participation, who is involved in community health work and in which ways.

The health field has made numerous efforts to modify the biomedical mercantilist work ways, among which we can mention primary health care (PHC), which included social participation as the axis of integral health care practices. Then, health promotion (HP) was introduced as a strategy within international organizations at the time when capitalist logics blurred PHC as a strategy for health work with communities, turning it into or sustaining it with the same ‘medicalizing’ and ‘mercantilizing’ values from which it was intended to be separated.

PHC and HP have been defined by different actors (institutions, international organizations, etc.) to respond to equally diverse purposes (control, governance, technification, medicalization, but also problematization, community organization, etc.) not all of them achieving the revolutionary character of their origins. Several authors (Chapela, 2008CHAPELA, M. C. ¿Qué promoción de la salud ha fracasado? In: CHAPELA, M. C.; CÁRDENAS ELIZALDE, R. Aspectos políticos y prácticas públicas de la salud en México: seguridad social servicios, promoción de la salud. México: Universidad Autónoma Metropolitana, 2008. p. 91-108.; Fals-Borda, 1987FALS-BORDA, O. La participación comunitaria: observaciones críticas sobre una política gubernamental. Bogotá: Análisis Político, 1987.; Montero, 2006bMONTERO, M. Teoría y práctica de la psicología comunitaria. Buenos Aires: Paidós , 2006b.) recognize that in the modalities and strategies of work, the logics of power and participation vary constantly and are disputed in order to make possible different ways of emancipation. The greatest obstacles are found when sustaining verticalist, state-centered, control and academic logics of power. In these articulations, the possibility of constructions that safeguard the particularities of each context of intervention is put into tension.

Citizen participation is often the term used to designate people as protagonists that signify, give content, decide and achieve futures to express favorable changes for the health of bodies and the environment. Fals-Borda (1987FALS-BORDA, O. La participación comunitaria: observaciones críticas sobre una política gubernamental. Bogotá: Análisis Político, 1987.) pointed out that the association of the concept with citizenship limits participation to civic relations with the State when it should be broader and more experiential.

Historically, at the base of the concept of citizen is the notion of modern individual, which creates a dividing line to designate as citizens a certain model of people and not others, based on a calculated and utilitarian reason. Thus, the individual is configured without historical or social references, and is supposed to be sufficiently rational to choose individually or cooperatively the best options for growth, progress, development, healing, etc. Individual appears, then, proper to meet the demands of the market (Heler, 2000HELER, M. Individuos: persistencia de una idea moderna. Buenos Aires: Biblos, 2000.).

Citizenship models prioritize definitions based on hegemonic systems of power with their institutions and organizations. By proposing participation processes based on citizenship logics, these are restricted to hegemonic criteria of cultural and economic validation that can be sustained through various organizations and institutions.

Capitalism, as a dynamic system in continuous mutation, generates participations that prioritize practices of subjection rather than emancipatory ones. In fact,

Thus, it becomes a technocratic and bureaucratic (if not political-partisan) requirement that serves more to the interests of the intervention rather than those of the community and, therefore, leads to process of invisibility, formalization and state capture of spontaneous and informal forms of participation and to the weakening of their transformative potential (Montenegro; Rodríguez; Pujol, 2014MONTENEGRO, M.; RODRÍGUEZ, A.; PUJOL, J. La psicología social comunitaria ante los cambios en la sociedad contemporánea: de la reificación de lo común a la articulación de las diferencias. Psicoperspectivas, Viña del Mar, v. 13, n. 2, p. 32-43, 2014. ). When it is thought that someone does not participate, based on criteria that limit participation to logics that are closed in form, space and time, are made invisible their spaces and multiple qualities of interaction and contribution to the community networks that are built every day in their territorial interactions.

Claudia Bang (2011BANG, C. Debates y controversias sobre el concepto de participación comunitaria en salud: una revisión histórica. Eä Journal, Buenos Aires, v. 2, n. 3, p. 1-23, 2011. Disponível em: <Disponível em: https://bit.ly/3wQihEA >. Acceso em: 13 abr. 2021.
https://bit.ly/3wQihEA... ) considers the community reality in which participatory actions are put into play involves a complex network of microscopic and capillary power that characterizes it. This network has not been the subject of much reflection and discussion from the community health perspective and has often been made invisible in the formal statements that deal with the conceptualization of community participation.

Power is always relational, so it can refer to fluid capacities of doing things, with heterarchical, dispersed ways, which are produced and inhabit multiple ways of organizing and regulating relationships, time and space. However, it can also suggest crystallized forms of these flows, which, as a hierarchical imposition of trajectories or projects, organize social relations according to the deployment of capital and are often articulated with state-centered normatization.

When the common of communities is linked to institutional practices in terms of openness and horizontality, the processes of participation incur in connection movements that can enable dialogues, agreements, revisions even in the same community networks and including the tensions that inhabit them. However, when institutional characteristics, objectives and needs are prioritized over community needs, they affect the modes of production and social reproduction. The state-centric institutional purposes deploy modes instituted from colonial knowledge that are usually covered by universalist logics that annul or make invisible the particularities of the communities.

These notions, schematically opposed, appear linked repeatedly around the dispute of meanings, resources, activities, institutions, etc. Logics of subordination, imposition, exposure, subsumption and exclusion are also actualized in the everyday life of people and communities, that is, the modalities of participation of the same community have diverse links related to capitalist logics. Thus, we conceive participations as forms of community social relations that exceed the institutional view and that, although they are part of collective decision-making capacities, they also imply contradictions. They focus on instances of resistance, construction of autonomy or alternatives that become dynamic as others with respect to modern-colonial capitalist institutional forms and the inequities they reproduce in cultural and economic-political terms that legitimize or invalidate ways of acting, feeling, thinking, sensing, intuiting, etc.

To accentuate community relations, Barúa Caffarena (2014BARÚA CAFFARENA, A. Un aporte a la construcción de lo participativo en salud comunitaria: erótica social. Anales de la Facultad de Ciencias Médicas, Asunción, v. 47, n. 2, p. 71-84, 2014. Disponível em: <Disponível em: https://bit.ly/3ddH5Ph >. Acesso em: 10 mar. 2019.
https://bit.ly/3ddH5Ph... , p. 75) proposes to think participations that he calls autonomous and points out:

Political activity, as the regulation of coexistence, implies considering a certain collective capacity to shape the world and social relationships, even to shape the space-time inhabit. Social emancipation, in this context, is a discontinuous and changing set of collective actions of autonomy. It is not the point of arrival or the conclusion of a cumulative process, but a tendency to inaugurate a different space-time in the economic, social and political spheres, in opposition and escape from the order that capital and the State imparted.

Proposing participation as a present component in life reproduction activities, which can be linked to the community organization of everyday life, can open a bridge to think about participation as a form of a politics of autonomy. For Gutiérrez-Aguilar (2011GUTIÉRREZ-AGUILAR, R. Pistas reflexivas para orientarnos en una turbulenta época de peligro. En Gutiérrez, R. (Ed.) Palabras para tejernos, resistir y transformar en la época que estamos viviendo. México: Pez en el Árbol Ediciones, p. 31-55, 2011. , p. 29), this policy is “always concrete and particular, although it can be expansive or self-centered, depending on the needs of those who set it in motion and at in which moment they do so”. The politics of autonomy is concrete and particular because, in principle, it speaks in the first plural person: we.

Alba Carosio (2020CAROSIO, A. La emancipación desde los feminismos latinoamericanos y caribeños. Cuadernos del Pensamiento Crítico Latinoamericano, Buenos Aires, n. 72, p. 1-4, 2020. Disponível em: <Disponível em: https://bit.ly/3wRXlx9 >. Acesso em: 13 abr. 2021.
https://bit.ly/3wRXlx9... ) suggest that for these processes it is urgent to prioritize links, generate community and a community that cares, with practices based on the ideal of co-responsible interdependence between state-communities and sexes. She proposes that the knowledge and practices of care and connection should be guides in the management of public policies and the basis of the model to act with others. Thus, emancipatory participation should uphold principles of non-violence, co-responsibility, generate the exercise of contextualization and reflection to address its politicization. Thinking about participation invites us to question ourselves about the possibilities of disputing time and space in our work as health professionals in terms of care.

Recognition of the common and of the diversity: challenges in practice

The community is the fundamental field of action for community health practices, which makes it necessary to question the characteristics of the subject that public policies contribute to build. The tensions that this requirement revives between community, State and market deserve a framework that situates how we think about the question of the State.

The Nation-states in Latin America emerge as an expansion and consolidation of nineteenth-century capitalism and, therefore, are configured subordinate to capital on a global scale. Thus, they emerge as culturally and economically backward. This structural weakness has used the State for capitalist development and the production of a collective identity, so it has been a central organizer of societies (Thwaites Rey; Ouviña, 2012THWAITES REY, M.; OUVIÑA, H. Repensar al Estado desde su especificidad periférica: configuraciones y metamorfosis de la estatalidad. Ciencias Sociales, Buenos Aires, n. 82, p. 12-18, 2012. Disponível em: <Disponível em: https://bit.ly/3mRzg53 >. Acesso em: 13 abr. 2021.
https://bit.ly/3mRzg53... ). The states participate as a control and social reproduction mechanism within the framework of global capitalism, although they can be understood as a space of contradictory social relations insofar as they support capitalist mechanisms and control devices; at the same time, rights must be made effective and they must promote the welfare of society.

The State in its practices and discourses, as a unified and rationalized administrative entity that holds its sovereign authority in a homogeneous manner, defines what is inside and outside from the forms of administrative rationality, political order and the authority it holds. Under this perspective, public policies are aimed at controlling what is in disorder, in this case there are the margins the most affected by the deployment of the State, and it will do so in a violent manner (Das; Poole, 2004DAS, V.; POOLE, D. (Ed.). Anthropology in the margins of the State. Santa Fe: SAR Press, 2004.).

Probably the diverse reality of Latin American societies invites us to locate the productive capacity of these “margins”. It introduces with emphasis a question about how the practices and politics of life in these “margins” are related, modulated and mutually influenced by the practices of regulation and discipline by the State. It therefore becomes necessary to “rethink the boundaries between the center and the periphery, the public and the private, the legal and the illegal, which also penetrate the heart of the most fruitful European liberal states” (Das; Poole, 2004DAS, V.; POOLE, D. (Ed.). Anthropology in the margins of the State. Santa Fe: SAR Press, 2004., p. 6).

In this sense, we can reflect about the role of State or third sector workers in health policies and how to make participatory processes centered on community rhythm and forms compatible with those closer to the official demands or those of the market.

This challenges us to recognize our own normativity in order not to delegitimize or make invisible collective productions that occur in the territories beyond our presences. Some professional-institutional difficulties in generating changes in the ways of linking with the communities may be observed in: the predominance of bureaucratic, linear-causal, individualizing logics (in spite of sometimes acquiring the name of community); professionals as central figures with mainly supporting roles; “scientific” knowledge validated and valued over “popular” knowledge; temporal-spatial logics that prioritize the convenience of the professionals rather than those of the communities; among others. These elements are challenges to modify relationships; recognizing them may imply steps towards other practices.

In addition to considering the obstacles that typical capitalist modern institutions exert on alternative work, it is important to pay attention to the situated practices that overflow the institutional. We note that in these processes there may be indications that show us how to build from/with the existing networks, without attempting to force others to adapt to universalist policies, focused on population groups identified as problematic, which suggest changes to adapt to a model of progress and social change externally determined.

In collective and community health, the challenge for community intervention and accompaniment is to value and recognize the existing networks, with their tensions and diversities, for life reproduction and its sustainability, beyond those recognized by the system. Thus, perhaps, in this reconstruction of the common we will also find ourselves being part of it, learning, sharing, dialoguing. These interactions challenge us to respect diversity and the different epistemologies that will dialogue in the search for the construction of horizontal links. In this context, community participation represents a challenge for the professional roles that are poorly trained in academia and, therefore, scarcely prepared to attend to processes that are part of the everyday life of community networks, such as the link, the dialogic, the affective, the playful celebrant, the group, the intercultural (Barúa Caffarena, 2014BARÚA CAFFARENA, A. Un aporte a la construcción de lo participativo en salud comunitaria: erótica social. Anales de la Facultad de Ciencias Médicas, Asunción, v. 47, n. 2, p. 71-84, 2014. Disponível em: <Disponível em: https://bit.ly/3ddH5Ph >. Acesso em: 10 mar. 2019.
https://bit.ly/3ddH5Ph... ).

It is possible to redefine work with the territories if we consider their decisive importance in the orientation of our work. Different workspaces are restricted to bureaucratic logics, of the same health system or of other institutions, which often restrict creative possibilities. This generates tensions at least between militancy, commitment and convictions, labor precariousness, overload of tasks and repetitive work time and control. Merhy (2006MERHY, E. Salud: cartografía del trabajo vivo. Buenos Aires: Paidós, 2006.) proposes that relational technologies, which allow the worker to listen, communicate, understand, establish links, and care for the user, which are called “soft technologies”, are those that provide spaces of autonomy to act in health in the ways that people consider in accordance with their values and/or interests. The reinvention of health practices is thus linked to the performative capacity of those who ascribe to the horizon of community work to become co-authors of them.

Merhy, Feuerwerker and Burg Ceccim (2006MERHY, E.; FEUERWERKER, L.; BURG CECCIM, R. Educación permanente en salud: una estrategia para intervenir en la micropolítica del trabajo en salud. Salud Colectiva, Buenos Aires, v. 2, n. 2, p. 147-160, 2006. , p. 159) state:

For participatory work horizons aimed at building collective autonomy, territorial approaches should be guided by the communities as a transforming quality per se. Seixas et al. (2016SEIXAS, C. et al. La integralidad desde la perspectiva del cuidado en salud: una experiencia del Sistema Único de Salud en Brasil. Salud Colectiva, Buenos Aires, v. 12, n. 1, p. 113-123, 2016. ) point out that in the encounters in which are shared sensations of listening, accompaniment and care, there is the capacity to receive diverse knowledges in the exercise of recognizing otherness and producing with others. In these encounters, processes of mutual interference and the possibility of joint construction can occur.

Although it is not possible to prescribe recipes in this regard, thinking in terms of accompaniment seems to give us some clues. The non-prescription as a practical guide implies the need to generate agreements with the communities, often knowing that some organized people or sharing common interests will be the ones to manage some processes. Not only to focus on historical leaderships to think about the collective, but also, to make constructions from the different articulations that emerge in the communities facing multiple situations. It is in the way and in the possibilities in which we are with others that we can work.

Accompaniment is a practice that comes from feminism; it is the first aid movement that gives us clues about this modality of joint approach. Accompanying is understood mainly in subjective terms, based on processes of recognition of the particularities of the people with whom we interact, exchanging knowledge, experiences and feelings. In other words, the task refers to meeting with what people bring, recognizing the richness of their experiences and knowledge of their realities, their contexts, possibilities and obstacles. It implies understanding that accompaniments are not limited instances in time, but often involve long-term processes in which something is done collectively, to which each one contributes from their knowledge and challenges in an interaction of mutual recognition and affectation.

The community accompaniment that we propose takes the sorority bases of feminism (in terms of recognizing common interests) in order to provide mutual support and understanding, and at the same time, addressing the differences presented by those who participate, as tensions inherent to social practices. The aim is to open up to deep changes in the collectivization of the subjectivities of those who participate and share spaces by working together, with the transmission of valuable and new experiences to be shared (Martínez de la Escalera, 2018MARTÍNEZ DE LA ESCALERA, A. M. El acompañamiento otro y la experiencia feminista. Animal Político, Ciudad de México, 2018. Disponível em: <Disponível em: https://bit.ly/3uHB2s0 >. Acesso em: 13 abr. 2021.
https://bit.ly/3uHB2s0... ). This approach would tend to develop ways of working in community health according to each context, exchanging points of view and differences in order to learn together and solve situations that are felt as important. Those following the aim of building healthier processes of dignified life with greater community wellbeing and with the expansion of rights related to gender, class, ethnic and generational aspects, in connection with the territories and nature as an integral part of life.

Final considerations

This itinerary proposes the need to review the meanings, needs and structures of the community, in articulation with the tensions and disputes that can be observed in the linkages and in State structures. According to Rodríguez and Montenegro (2016RODRÍGUEZ, A.; MONTENEGRO, M. Retos contemporáneos para la psicología comunitaria: reflexiones sobre la noción de comunidad. Revista Interamericana de Psicología , San Luis, v. 50, n. 1, p. 14-22, 2016. , p. 16), “in the treatment of difference and the possibility of meeting, lies the political and ethical component of what we understand as community”. These aspects, proper of collective characteristics, are frequently left aside in intervention/accompaniment processes. Especially because many of these respond to definitions given by public policies, which in order to maintain governance recruit professionals for homeostatic purposes.

Tensions, stigmatization and fragmentation are also part of communities' diversity and, in general, are important challenges to be addressed by health institutions with a communitarian perspective. They are the most complex points to be addressed, since they express a certain crisis of the social bond and the weakening of community support. Perhaps, the ways to address them may be found in the emergence of the meetings, in the interaction processes, or it may be the community’s proposal as long as ways are created to share these discomforts.

The challenge is even greater if we consider that most objectives of public policies in which professionals with communitarian perspective are inserted, are framed within neoliberal policies. Interventions from this type of public policies carried out in Argentinian health sector(Berroeta et al., 2019BERROETA, H. et al. Psicología comunitaria, programas sociales y neoliberalismo: la experiencia chilena. Revista Interamericana de Psicología, San Luis, v. 53, n. 2, p. 281-297, 2019.; Lapalma, 2009LAPALMA, A. Investigación participación ciudadana en salud en el Mercosur (2006-2008). Psicología y Psicopedagogía, Buenos Aires, n. 20, p. 1-19, 2009. Disponível em: <Disponível em: https://bit.ly/3sbhavL >. Acesso em: 13 abr. 2021.
https://bit.ly/3sbhavL... ) are not aimed at attacking social structures, but at helping people, so the transformation processes that are stated to be sought are hardly achievable. This dispute of meanings between the programmatic and ethical-political purposes of community and collective health orientations means that performative capacities often make the difference, regardless of the power disputes that this implies. This occurs despite the fact that participation is understood as a right or that the program titles include the terms participation or community in their logics (Lapalma, 2009LAPALMA, A. Investigación participación ciudadana en salud en el Mercosur (2006-2008). Psicología y Psicopedagogía, Buenos Aires, n. 20, p. 1-19, 2009. Disponível em: <Disponível em: https://bit.ly/3sbhavL >. Acesso em: 13 abr. 2021.
https://bit.ly/3sbhavL... ). This requires other proposals in the health spaces in order to create different realities to what community and participatory logics refer to.

The political horizon of community and collective health has been strengthened by contributions from feminist social movements, native peoples, workers and the unemployed, and developments in critical theories. They have shed light on marginalized or silenced issues about different oppressions that are sustained in domains of power, discourse and difference (Zaldúa; Sopransi; Veloso, 2005ZALDÚA, G.; SOPRANSI, M. B.; VELOSO, V. La praxis psicosocial comunitaria en salud, los movimientos sociales y la participación. Anuario de Investigaciones de la Facultad de Psicología, Buenos Aires, v. 12, p. 115-122, 2005. Disponível em: <Disponível em: https://bit.ly/3sfZU8q >. Acesso em: 13 abr. 2021.
https://bit.ly/3sfZU8q... ). Therefore, sharing networks also means getting involved with the subjective circuits of oppression in order to try to be part of resistance processes.

The recognition of community networks is presented as a warning against their technocratization. These networks imply the need to work together with the communities as collaborators, as peers who share territory for different reasons, and knowing that this role modification will also lead to subjective modifications as well and will raise questions about professional roles and practices. In other words, these would be a way of searching for social transformation in which the understanding of integral health processes of populations is built in a common effort with health workers. Thus, it challenges the collective capacity to have an impact on the public issue with workers accompaniment, making pressure on the governance processes.

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