By Javier Segura del Pozo
health doctor
In the third and fourth installments we will try to better understand community health by describing some principles, values, ideas and dimensions who are behind their practice (today we will look at 6 of the 11 that have occurred to us). It is an exercise in deconstruction so that each one looks at the separate pieces and assembles them as they see fit in their area of action.[1]
1. Demand-based health care has limits
Community health arises from reflection on the limits of health care based on demand. The image of an individual consultation, starring the doctor-patient relationship, is the one that will be most familiar to us when thinking about health services. However, this query has some limitations, which can be summarized in three points:
- The people who consult are not always the ones who need it the most, that is, there is a difference between demand and need
- Individual health problems are related to the context family, community and work
- Diseases and health risks are socially determinedTherefore, the solutions cannot only be based on medications and individual advice, instruments that are more at hand for the professional, but must also be social.
2. Social inequalities in health as an object of work
This social determination of the disease gives rise to unfair and avoidable differences in health, which are called social inequalities in health and which are usually hidden. They emerge in maps such as the one that reflects a difference in average life expectancy of more than 9 years between the richest and poorest neighborhoods in Madrid, or in graphs such as those resulting from the analysis of the National Health Survey, which show a gradient according to social class, in the prevalence of the main chronic health problems (hypertension, high cholesterol, osteoarthritis, diabetes, chronic depression, etc.). Only if we take these social health inequalities into account in our practice can we be effective in reducing the burden of disease and premature deaths in the territory or community we serve.
3. From gowns to boots
This motto “from the robes to the boots” synthesizes the “Healthy Neighborhoods Strategy”[2]developed between 2010 and 2019 in the municipality of Madrid by the 16 municipal community health centers (CMSc), whose professionals, from time to time, diverted their gaze from the waiting room (the lawsuit), they took off their robesgarment that symbolizes the medical-clinical referent, and they put on the symbolic boots to go out into the community, kick around and get to know the neighborhood (its need), meet and ally with other actors, at the service of the health of those neighborhoods. As we will see later, it is a look changebut also a change of frames and scenarios usual work of the clinic
This change of perspective implies an important process of change in which it is necessary to operate with new concepts such as the neighborhood, daily life, discomforts, health assets, etc., but also to recognize the limits of action from the health sector.
4. The need for alliances
The health professional cannot and should not aspire to achieve certain community health objectives alone (or alone) and from their exclusive professional knowledge or health sector. Although any voluntarist impulse has merit, poorly dimensioned, it leads to frustration, inefficiency and to increase the legion of burned out and disillusioned professionals with community health, who populate our health centers, hospitals and offices. The changes sought by community health are psychological, social, cultural and environmental changes of great complexity and that, in addition, defy privilege of powerful enemies.
It takes the confluence of knowledge from different disciplines and professions, in addition to obtaining the complicity of multiple actors and actresses who inhabit or have important influences in a territory. For this reason, any community health project needs: from the professional point of view, multiprofessional and interdisciplinary teams; from the institutional, intersectoral transversality (social, health, educational, urban, environmental, sports, consumer sectors, etc.) and from the political, a participatory and democratic space that takes into account the social majority and its priorities, along with respect for minorities. In these spaces you must work, at the same time, the power conflicts and resistance to changefinding the window of opportunities that identifies the possible change at that moment and in that context.
The reality is that it is very difficult for us to find ourselves in the beginning with all these elements of interdisciplinarity, intersectoriality and social participation. This should not paralyze us, but seek alliances that are accessible and, from them, expand them. For example, there may not be social educators, sociocultural mediators, artists, nutritionists, sports technicians or architects in our health team or institution, but we can articulate our action with other institutions or organizations where these professionals are present. Likewise, it is most likely that there are no institutionalized neighborhood spaces for participatory governance, but surely there are small experiences of neighborhood associations or networks with a community vocation that we must identify and promote.
5. The neighborhood[3] as a basic scenario of the health and disease process
Talking about community in a city is talking about a neighborhood. The neighborhood is the significant territory for those who inhabit it, borderline between the private and public world, where daily life unfolds and relationships and social bonds are built. The neighborhood is where the most important behaviors for health (related to food, physical activity, sexuality, leisure, addictions, etc.) are forged. It is in the neighborhood where health inequalities determined by social class, gender, ethnicity, migratory status, employment status, sexual orientation, etc. can be revealed. and where you can intervene on them. Facilitated intervention when the significance of this territory for its inhabitants generates a feeling of belonging (neighborhoodalism) and solidarity, especially among the different (demanding cooperation), as we said before.
Community health practice makes it essential to have in-depth knowledge of this scenario: a good knowledge of the geography, history, and sociology of that neighborhood, beyond the partial knowledge obtained with home visits.
The other fundamental scenario for health is the labor sphere. It is the place where one works, spends many hours, establishes important social ties and on which a social identity is built. Work, time, bonds and identities that have important implications for health. Although action in the workplace (occupational risk prevention and promotion of occupational health) is generally separated from community health[4]always has to be taken into account by it, since it is the same people who transit daily between the residential and work environment.
6. The value of everyday life
From being experts, as health professionals, in what breaks the norm, in the extraordinary: a disease or an epidemic outbreak, we went as community health professionals to interest in the ordinary, the repetitive, the normal: the ways and conditions of life in the neighborhood. That is, everyday life[5].
Health habits (harmful or positive) are generated in the daily life of the neighborhood, both in the private space (the house) and in the public space (the street). Most of the habits are associated with the care and, therefore, to that female reproductive world[6]. At home we learn the guidelines for eating and hygiene, including sleep and body cleanliness (showering, washing hands, brushing teeth, etc.) [7]. We learn to familiarize ourselves with the signs and languages of the sick body: to take the temperature, to lower a fever, to deal with a digestive problem, to apply home remedies, before “going to the doctor.” Wisdom and remedies transmitted from mothers to sons and daughters, and from the latter to their sons and daughters.
You also learn how to care for the elderly and disabled, to wash them, to change their posture, to feed them, to give them medication, etc. This knowledge of care, however, is fundamentally transmitted from mothers to daughters (caregivers) and much less from mothers to sons. On the street, however, we learn other habits and skills for life, especially to get together and interact with others.[8].
The problems and worries of everyday life have great potential to generate links and participatory dynamics to solve them. From these dynamics focused on solving specific daily problems (food, housing, education, upbringing, work, etc.), reflections on their social determinants and how to address them can arise. This is especially important in the case of women, who are always more easily attracted to participatory processes focused on concerns linked “to their own space” of reproduction and daily life, determined by their gender role.[9].
However, daily life is not usually the object of attention of health devices, despite the importance it has in the development of these skills for life and, therefore, for health, or in the generation of bonds of mutual support. In the case of community health, it is essential to have an anthropological perspective on its rhythms, settings and scripts.
[1] Text based for the most part on the presentation presented at the International Forum on Loneliness, Health and Care, organized by the Madrid City Council and held in Madrid, between November 21 and 23, 2018
[2] Segura del Pozo, J. The video summary “From the robes to the boots” (Community reorientation process of the CMSc of Madrid, 2008-2019). Public Health and other doubts, March 2020, https://saludpublicayotrasdudas.wordpress.com/2020/03/07/el-video-resumen-de-las-batas-a-las-botas-proceso-de-reorientacion-comunitaria -of-the-cmsc-of-madrid-2008-2019/
From 2010 to 2015, the community reorientation project of these centers (started in 2008) was called the “Healthy People Strategy”. In the 2015-2019 legislature, it was called the “Healthy Neighborhood Strategy” by incorporating the changes inherent in the “Madrid, City of Care” Plan.
[3] As we have said in past deliveries, the “significant territorial unit” in which we operate in community health may be different from the neighbourhood: in the rural environment, it may be a town or a region; in the urban environment, it may be a neighborhood, urbanization or neighborhood that does not coincide with the administrative neighbourhood. For this reason, when reading the text, the word “neighborhood” should be replaced by the appropriate one.
[4] Frequently, the place of residence (the community) does not coincide with the place of work.
[5] Agnes Heller. Sociology of everyday life. Peninsula, 2004
[6] With this expression we do not intend to naturalize the greater dedication of women to care, but to point out that it is intimately linked to this gender role and that, therefore, it is a social construction.
[7] Michel de Certeau, Luce Guiard, Pierre Mayol. “The invention of the everyday”. Vol 1: arts of making; vol 2: inhabit, cook” Universidad Iberoamericana, Mexico 1999.
[8] Segura del Pozo, J. The care neighborhood (2).: health habits and daily life. Blog “Public Health and other doubts”. February 12, 2019. https://saludpublicayotrasdudas.wordpress.com/2019/02/12/el-barrio-de-los-cuidados-2a-parte-habitos-de-salud-y-vida-cotidiana/
[9] Fasin, Didier. Beyond the myths: the political participation of women from popular sectors in Ecuador In: Eduardo L Menéndez and Hugo Spinelli (cords). Social Participation, What for?, Editorial Place, page, 177