Healthy childhood, proximity and public policies

"A successful society is an inclusive society, without any kind of fences (physical or symbolic)," says Raul Mercer, a sanitarist. A conversation about health and childhood, published in the magazine Written 11 "Local Childhood and Education".

Niños sentados
Niñez saludables

To begin with, we would like to know what the specific role of a medical doctor is, especially in relation to childhood.

A health care practitioner is a health professional who is concerned about the population's health issues or problems from a demographic perspective. Unlike a medical clinic that works with the patient and his family, those who work in the field of Public Health, we do it with large populations.
When we talk about Public Health, we are not referring to the health of the state sector or the government or the official sector. On the contrary, when we speak of Public Health it is an equivalent to Poblacional Health. In other words, no person is excluded from being part of a population. This is in order to clarify the differences between the subsectors of care providers where there is a public sub-sector (which provides care in public hospitals and health centers), a social security sub-sector (corresponding to works social) and a private sub-sector (corresponding to prepaid medicine). In short, those who work in the field of Public Health, we develop activities collectively, we do not work alone, we do it based on an interdisciplinary and intersectoral approach, taking into account that health problems transcend the medical-care sector.
It is estimated that 10% of what we generate of health depends on the contribution of the medical care system, and 90% depends on other factors related to social policies, living conditions, access to education, the possibility of having a decent job. As we see, health goes beyond a sick person's bed or being hospitalized or not. It is much more.


How was your choice and what made you become a sanitarist?

As a medical student, I was fully convinced that physicians had an important social role in contributing to improving people's health and resolving health problems that affect the entire population. Over the years and as I became aware of the restricted field of the biomedical approach, I felt the need to transcend the boundaries or limits imposed by the profession to see what happens beyond the perimeter or the physical space where one works, a hospital or an inpatient unit. After working for many years as a pediatrician in the clinic, I decided to make a change in my professional life and have a training that allowed me to incorporate new lenses to analyze the context of health beyond the edges.
It was thus that I had an academic experience abroad where I could penetrate other disciplines such as epidemiology, medical anthropology, medical sociology, evaluation of technologies, health economics, in short, a series of research fields and inquiry aimed at enriching the field of analysis and understanding of the complexities associated with the health-disease process.
Back in my country I had to make a kind of professional reengineering and look for other fields of labor insertion linked, basically, to the management of health policies and programs. That is why, my professional development took place at the municipal level in Florencio Varela where, in addition to coordinating the maternal and child program, I had the opportunity to be director of the hospital.
Then, within the scope of the Ministry of Health of the Province of Buenos Aires, coordinating the Maternal and Child Program. I also had a transit through the Ministry of Health coordinating the technical teams of the maternal-child and adolescent area. Later I began a transition to the academic field working in different institutions such as CEDES (Center for State and Society Studies), CISAP (Center for Research in Population Health of Durand Hospital) and FLACSO (Latin American Faculty of Social Sciences).

The patient doctor relationship is fundamental in the concretion of health policies, how to achieve trust?

I could say, in general terms, that the relationship of trust that is established with the population that we attend is built over time. From this construction, a kind of virtuous circle is generated in terms of the expectations that the professionals have of their patients and their families, as well as of the families with respect to the ideal or the imaginary that they expect from the professional. We must see this phenomenon as a processof mutual learning and accompaniment that for the case of a pediatrician represents practically the fourth part of the life of a person (if we add the period of pediatrics attention, plus the arrival of a little brother, plus the subsequent bond). This implies understanding that in this life path one is part of the life of families.
All this makes health understood as a process under construction that demands years contrary to the imaginary of health as an issue associated with the emergency or the conjuncture. This process of learning is molded or adjusted considering both the scientific and ideological and spiritual aspects that make health practices, to recognize health as a right associated with autonomy, to the possibility of decidingfreely and informally what is best for one's body, to understand that health can not be assumed as a commodity.


What health plans have you most interested in at the national level?

What examples would you give of good health and primary care policies?Our history is shaped by very good intentions. There were also and there are very good health plans from the point of view of their goals. But we see, as counterpart, defects in the implementation processes. Many issues that are technically very well oriented in terms of their intentionality, when it comes to putting them into practice we find innumerable barriers. Once again, the short-term issues prevent the realization of initiatives that require an extended temporality. This happens with health programs, plans and policies. In all cases, this entails long-term investments that require years of continuous and sustained work. As a result of these obstacles, there is a deficiency in the mortar construction capacity, that is, a sense of political and programmatic coherence that supports these processes, beyond the political and administrative administrations of the day. We could give many examples. Argentina has a very rich history in Primary Health Care. During the Alma Ata Conference (1978), there was talk of "Health for All by the Year 2000". This statement, today has been truncated as a utopia since not all the population is guaranteed their health. Undoubtedly, the greatest pandemic that affects humanity today is exclusion, inequality and social injustice.
Another aggravating factor that accompanied the development of Primary Care was to think of it as a disgrace, as a second care for the poor. It is now scientifically proven that those countries that have achieved changes in the health system are startingthe strengthening of Primary Care, the gateway to the health system.
If one could imagine an integrated health system, it should have all the centers of attention enjoying the same capabilities and resources. The same ones that one can observe in establishments that attend to more affluent sectors of the society.
In this way, we would be guaranteeing access to the best resources and the quality care of the entire population regardless of their sub-sector provider where they attend.
Another clear example of good policy was vaccination policies, although this field has been transformed into a space of tensions. On the part of the families, the existence of groups that question and distrust of the benefits of the vaccines. On the part of the State, the lack of clear criteria on how to incorporate new vaccines in vaccination schedules. Sometimes vaccines are incorporated by market interests rather than by the fact that there is a scientific and epidemiological need to justify it. I want to clarify that it is not an exclusive phenomenon of Argentina. In short, we always see that the formulation of a health policy can coexist positive and negative aspects that require a permanent critical discussion.

Taking into account the local, the Centers of Primary Health Care are very important, what assessment do you deserve?

The Primary Health Care Center (CAPS), poorly called "peripheral center" (since it is a contradiction where the central can never be peripheral), is the reference area for the health care of the population in its own place of residence. The CAPS are distributed throughout the territory of our country. All provinces have installed capacity. This capacity, in turn, must be considered both from the point of view of its building infrastructure and its instrumental equipment and human resources. The health team is the sensitive nucleus, the heart that gives vitality to the CAPS.The CAPS, besides being the gateway to the health system, constitute the sensor that perceives the state of health of a neighborhood, a community, an immediate environment. When I say that health centers grew in disrepute is because there is also a false belief that hospitals are highly complex and health centers are of low complexity. This muletilla repeats itself historically without any handle. I wonder: where did this sort of groundless truth come from? I make this question because to assume the hospital as a center of high complexity, implies considering it as the guiding space of knowledge that directs the organization of the healthcare system. It is from what the hospital says, that the rest of the health system responds as if they were directives.
It is well known that working in a hospital generally gives more prestige and, supposedly, allows the professional to be confronted with more rare, more complex, more difficult diseases. From this logic, the hospital-centric model, based fundamentally on the use of technologies, marks the rules of the system. In the present circumstances, we are starting from a conceptual error, since the type of technologies that are used in a hospital, totally differ from those used in the CAPS. For this reason, I suggest breaking this paradigm of associating complexity with hospital care. From my perspective, the CAPS are places of high complexity because this implies recognizing the difficulties of working in and with the community, the neighborhood, social and interpersonal relationships, the role of institutions, interests at stake ...
On the other hand, trying to apply tools of social or population approach from a logic and hospital vision, is fallacious. If our toolbox is composed only of a hammer, we can not think that with a single tool we can solve the whole reality. The toolbox, in our case, will require much more than a hammer, requires other tools.
This box will allow the approach of the knowledge of society, the mapping of actors of social networks, understand the problems associated with existing health systems both formal and alternative, intercultural aspects of health, beliefs, worldviews ...
In this way we rethought the health center as a much more dynamic space that confronts in the day to day with the social dynamics that many times, from the hospital, are not registered.


How do you see health and childhood today?

We could question childhood as a space from which to think the development of a community, consider Tonucci's vision of seeing the world from the perspective of boys and girls. If you could close your eyes and imagine how childhood is, among the elements that characterize it, we could mention empathy, play, warmth, socialization, honesty, transparency, nonviolence. If we salvaged these values ??to translate them into service development, urban development models, local progress based on the rights of children, the reality would undoubtedly be totally different.
Many of the problems affecting adult society are rooted in the non-recognition of children in a society. Ensuring good living conditions for children is an element that promotes social capital, to be fairer, more inclusive societies with less incidence of problems will affect the adult population as non-communicable chronic diseases or those that affect old age as problems associated with early memory loss or premature aging.
From the perspective of health services and public health, health centers should be integrated with other institutions that work with children, such as educational and recreational facilities.
Take, for example, the right to play. Playing for a child is as important as any other creative, artistic or learning activity in mathematics. Gambling is not a form of energy discharge or a way to promote leisure so that boys and girls do not bother or are entertained.
The Convention on the Rights of the Child in Article 31 states that all children have the right to play. The question we should ask ourselves is whether all municipal and provincial governments have developed a game policy for children. Hence, when investigating tools and experiences of urban planning based on childhood, it should be based, first of all, on the knowledge of the needs and rights of children to achieve full development. This would also imply knowing how children develop from a population perspective.

Then what characteristics should a center or hospital have forprovide the best possible care?

I suggest at this point to separate the situation of health centers and hospitals. On the one hand, hospitals historically had greater resources allocated in health budgets. On the other hand, health centers should improve their conditions both in terms of comfort and the necessary resources to guarantee the permanence and stability of the health teams that work there, including the need to have a living wage. Local or provincial authorities should be well aware of the significance of investing in social capital and ensuring that their integrated health system works for the community.
I had the opportunity to visit Primary Care experiences in other countries, this is the case of Brazil. This country has the Unified Health System (SUS) where it is possible to perceive the degree of social insertion of health centers and how the community assumes its sense of belonging to this proposal of the State. These centers, in addition to providing traditional services such as medical, dental and laboratory care, offer other recreational activities, promotion of physical activity, recreational activities, all necessary for physical, mental and spiritual health.
From the Program of Social Sciences and Health of FLACSO we have been working for years on a project called "Te Escucho" based on Article 12 of the Convention on the Rights of the Child which refers to the right of every child to be heard and taken in seriously. This project is aimed at promoting the culture of rights in the field of health services and is part of the Safe Motherhood Initiative and Family Center Initiative (promoted by UNICEF). Those of us who work on this project believe that health facilities have deficiencies in listening skills. Listening, in our case, involves perceiving the differential needs of people, recognizing the value of diversity, understanding that not all issues that affect people are not interpreted or perceived in the same way, value otherness.
As an example, not all pregnancies are the same, not all are desired or longed for or dreamed idyllically. 50% of women who become pregnant in our country do so as a result of decisions not sought, not thought and, in some cases, as a product of violation of rights when we refer to rapes and situations of sexual abuse. It is time to begin to recognize these differences with a positive discriminating sense. Recognizing these differences will improve the quality of relationships between professionals and the population.


On different occasions, some officials have determined that neighbors of other localities or municipalities can not use the facilities of the health sector. What do you think of these measures?

Recall that the worst pandemic that affects humanity is, precisely, social exclusion and inequities. The prevailing neoliberal model permeates the realities of people's lives and politicians are no stranger to them. Sometimes, in an effort to protect the accounts of their municipality, as if it were a company, they do not take into consideration the negative social impact of their decisions. All this once again recognizes health as a right and the need not to violate it. If a person transgresses when crossing the border of a municipality or a province, coming from the Province of Buenos Aires to the Capital, is not to put a bad mood to the politicians, but because they are looking for a response that is not being offered in his place of residence. A successful society is an inclusive society, without any fences. Physical walls are added symbolic walls, those that arise from prejudices, taboos, beliefs, homophobia, discrimination. Sometimes, these symbolic walls generate more damage than physical fencing. The more cohesive societies are healthier than the more fragmented societies. The prevailing model aims to generate a fragmented and individualistic culture. All of this implies the need for a new process of social learning that seeks to understand the meaning of health and the co-responsibility that fits us as a society in its construction. •

  • Raúl Mercer is a pediatrician, a veteran sanitarist. He has coordinated areas of maternal and child health both at the provincial level and at the Ministry of Health of the Nation. He works in the Social Sciences and Health program of FLACSO and in CISAP, Center for Population Health Research at Durand Hospital, Argentina.
  • Interview: Nara Saccomano.

Performed according to google translator translation.


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