Apuntes para construir democracia moderna en Colombia

El interés de este artículo es evaluar el tema de la construcción de “una opinión pública” ilustrada como camino de consolidación de la democracia moderna en Colombia. Este aspecto constituye un elemento fundante, pues integra la complejidad de la democracia a través del diálogo entre sistema y mundo de la vida. Igualmente, desde la opinión pública y sus posibilidades, puede evaluarse la consolidación democrática como prueba de funcionamiento del conjunto de las instituciones sociales, en su búsqueda de libertades en ámbitos de eficiencia, justicia y armonía social; en el sentido de una democracia deliberativa-radical, y siguiendo a Amartya Sen, por un desarrollo como libertad. En el caso colombiano, con las debilidades de su estructura estatal, fenómenos como el narcotráfico y la lucha guerrillera, el precario desarrollo de una ilustración entre la población, y en particular la inequidad económica y social, se erigen como impedimentos en el proceso de construcción de una opinión pública madura, beligerante y decisoria.-----This article aims at evaluating the topic of “public opinion” construction illustrated as a road toward modern democracy consolidation in Colombia. This aspect constitutes a basis element, because integrates democracy complexity through a dialog between life system and life world. Furthermore, from the public opinion and its potentialities, the democratic consolidation can be evaluated as evidencing that social institutions work as a group on seeking freedom in the realms of efficiency, justice, and social harmony; within the meaning of a radical-deliberative democracy and following Amartya Sen in the pursuance of development as freedom. As for Colombia with the government structures’ weaknesses, phenomena such as narcotrafic and guerrilla group fight, poor development of population literacy and particularly, the social and financial inequity arise as impairments to the process of building a mature and belligerent public opinion with decisionmaking power.

Factores asociados a deficiencia de zinc en niños colombianos entre 1 y 4 años de edad

Introducción: Las deficiencias de micronutrientes continúan siendo un problema de salud pública en la población infantil, dentro de las ellas se ha encontrado a la deficiencia de zinc causa importante de morbi-mortalidad en los países en desarrollo, la nutrición adecuada de zinc es esencial para un crecimiento adecuado, inmunocompetencia y desarrollo neuroconductual; se dispone de información insuficiente sobre el estado de zinc en la población preescolar lo cual dificulta la expansión de las intervenciones para el control de su deficiencia. Colombia presenta una deficiencia de este micronutriente, considerándose a nivel mundial como un problema de salud pública moderado a severo. Una evaluación sobre la prevalencia y factores determinantes asociados puede proporcionar datos sobre el riesgo de deficiencia de zinc en una población, considerando factores demográficos, sociales y nutricionales que podrían predisponer a la población preescolar colombiana a sufrir este déficit. Metodología: Estudio observacional de corte transversal que incluyó 4275 niños entre 1 y 4 años, utilizando datos de la Encuesta Nacional de Situación Nutricional (ENSIN-2010). Se realizaron análisis bivariados y multivariados para determinar factores asociados positiva y negativamente con deficiencia de zinc. Resultados: El 49,1% de los niños encuestados cursaban con deficiencia de zinc. Los factores de riesgo asociados a deficiencia de zinc encontrados fueron menor edad, peso y talla bajos, vivir en región Atlántica, región Central, Territorios Nacionales, vivienda en área de población dispersa, pertenencia a etnia afrocolombiana, pertenencia a etnia indígena, estar afiliado a régimen subsidiado, no estar afiliado a ningún régimen de salud, madre sin educación, no asistencia a programa de alimentación dirigido y el grado severo de inseguridad Conclusiones: El déficit de zinc en los niños entre 1 y 4 años de edad es multifactorial, siendo un reflejo probable de la situación de inequidad de la población colombiana, en especial, la más pobre y vulnerable. Palabras clave: Zinc, Deficiencia de zinc, factores asociados, niños entre 1 y 4 años, Colombia

Influencia del bajo peso al nacer en el cumplimiento del esquema de vacunación en Colombia

INTRODUCCION. En Colombia y a nivel mundial la vacunación es una estrategia que ha reducido la mortalidad infantil, sin embargo existen bajas coberturas en algunas zonas del país, dentro de las causas de la no vacunación se encuentra el bajo peso al nacer, tema de gran importancia y poco estudiado, encontrándose como una causa controlable y que permitiría a la población acceder a la protección frente a enfermedades inmunoprevenibles. MATERIALES Y METODOS. Se realizó un estudio de tipo observacional de corte trasversal, la muestra fue tomada de la ENDS realizada por Profamilia en el año 2010, se tomó el número total de los encuestados que cumplían con los criterios de inclusión, en total fueron 9694 registros a los que se les realizo; análisis descriptivo, bivariado y multivariado. RESULTADOS. Los niños con bajo peso al nacer tienen menor probabilidad de estar vacunados con el esquema completo con respecto a los niños con peso normal, OR 0762 (IC 95% 0,650; 0,895), se observó que las vacunas en forma individual tienen un comportamiento similar al esquema completo, específicamente en la aplicación en el tiempo indicado para su aplicación, exceptuando triple viral donde no se encontró asociación. CONCLUSION. El bajo peso es un factor determinante en la vacunación a tiempo de los menores y del cumplimiento posterior del esquema, se encontraron variables asociadas al no cumplimiento como el lugar del parto, el índice de pobreza y pertenecer a la etnia afrodescendiente.

Tributo a la calidad institucional. Un desafío para la sociología jurídica latinoamericana (Tema Central)

El principal desafío de América Latina consiste en encontrar el modo de afrontar la fragmentación social, el individualismo extremo y las inequidades oprobiosas en el marco del más absoluto respeto a las instituciones. El Estado aún tiene en sus manos dos herramientas formidables: la educación y el sistema tributario. La insistencia en el cumplimiento de las obligaciones tributarias contribuye decisivamente a formar una conciencia ciudadana, fundamento, a su vez, de una mayor calidad institucional. Y, en una suerte de causalidad circular, el correcto funcionamiento de las instituciones legitima el reclamo de cumplimiento de las obligaciones tributarias a un habitante que va, así, tomando creciente conciencia de los deberes y derechos emergentes de su condición de ciudadano. Para comprender el modo en que pueden darse estos procesos en la región, es preciso contar con una nueva disciplina: la sociología de las finanzas públicas.

The Assault on Human Rigths and the Resilience of the Andean Dream: Health Inequities in Ecuador. IV Annual Distinguished Lecture sponsored by the Center for Research on Ethnicity, Culture and Health; School of Public Health; University of Michigan

The point of departure for these reflections is life, since its protection is the central purpose encouraging the defense of human rights and of public health. Life in the Andes has an exceptional diversity. Particularly in Ecuador, my country, this diversity constitutes a characteristic sign that is expressed in two main forms: natural megadiversity and multiculturalism. Indeed, Ecuador’s small territory synthesizes practically all types of lifezones that exist on Earth, having received the gift of high average rates of solar energy and abundant nutritional sources, which have facilitated the natural reproduction of countless species that show their beautiful vitality in the variety of ecosystems that compose the Andean mountain range, the tropical plains, the Amazon humid forests, and the Galapagos Islands. But besides being a highly biodiverse country, it is also a plurinational and multi-cultural society, in which the activity of human beings, organized into social conglomerates of different historical and cultural backgrounds, have formed more than a dozen nations and peoples. Regrettably this natural and human wealth has not been able to bear its best fruits due to the violent operation of a deep social inequity – unfortunately also one of the highest in the Americas—which conspires against life and is reproduced in national and international inequitable relations. This structural inequity has changed its form throughout the centuries and currently has reached its highest and most perverse level of development.

La renuncia a la equidad y la domesticación de la salud pública

Under present historical conditions of extreme social inequity, sustained by structural impoverishment, the destruction of living conditions and deterioration of environmental integrity, under the logic of big business, and precisely when the people’s organizations are working intensely in defending creatively human rights and health, academic public health evidences an exasperating passiveness; university departments, local and federal government agencies and even non-governmental organizations, keep implementing ineffective and innocuous health programs -some of them sustained by an expensive propaganda apparatus- that reproduce the same conventional plans, most of which end up reinforcing the rules of the neoliberal game. The present paper seeks to explain this historical surrender of public health; the institutional incapacity to foresee the structural roots of that flourishing pathology of inequity; and its divorce from the struggle of the most progressive social organizations. To accomplish this critique of hegemonic public health, the author analyzes the historical and epistemological roots of that “blindness” and the ideological fundaments of that political passiveness.

Adaptive governance: livelihood innovation for climate resilience in Uganda

Adaptive governance is the use of novel approaches within policy to support experimentation and learning. Social learning reflects the engagement of interdependent stakeholders within this learning. Much attention has focused on these concepts as a solution for resilience in governing institutions in an uncertain climate; resilience representing the ability of a system to absorb shock and to retain its function and form through reorganisation. However, there are still many questions to how these concepts enable resilience, particularly in vulnerable, developing contexts. A case study from Uganda presents how these concepts promote resilient livelihood outcomes among rural subsistence farmers within a decentralised governing framework. This approach has the potential to highlight the dynamics and characteristics of a governance system which may manage change. The paper draws from the enabling characteristics of adaptive governance, including lower scale dynamics of bonding and bridging ties and strong leadership. Central to these processes were learning platforms promoting knowledge transfer leading to improved self-efficacy, innovation and livelihood skills. However even though aspects of adaptive governance were identified as contributing to resilience in livelihoods, some barriers were identified. Reflexivity and multi-stakeholder collaboration were evident in governing institutions; however, limited self-organisation and vertical communication demonstrated few opportunities for shifts in governance, which was severely challenged by inequity, politicisation and elite capture. The paper concludes by outlining implications for climate adaptation policy through promoting the importance of mainstreaming adaptation alongside existing policy trajectories; highlighting the significance of collaborative spaces for stakeholders and the tackling of inequality and corruption.

Pregnant Adolescents in Vietnam : Social context and health care needs

Background: The number of childbearing adolescents in Vietnam is relatively low but they are more prone to experience adverse outcome than adult women. Reports of increasing rates of abortion and prevalence of STIs including HIV among youth indicate a need to improve services and counselling for these groups. Midwives are key persons in the promotion of young people’s sexual and reproductive health in Vietnam. Aim: The overall aim of this thesis is to describe the prevalence and outcome of adolescent pregnancies in Vietnam (I), to explore the social context and health care seeking behavior of pregnant adolescents (II), as well as to explore the perspectives of health care providers and midwifery students regarding adolescent sexuality and reproductive health service needs (III, IV). Methods: The studies were conducted from 2002 to 2005, combining qualitative and quantitative research methods. A population based prospective survey was used to estimate rates and outcomes of adolescent pregnancies (I). Pregnant and newly delivered adolescents’ experiences of childbearing and their encounters with health care providers were studied using qualitative interviews (II). Health care providers’ perspective on adolescent sexual and reproductive health (ASRH) and views on how to improve the quality of abortion care was explored in focus group discussions (FGD). The values and attitudes of midwifery students about ASRH were investigated using questionnaires and interviews (IV). Descriptive statistics was used to analyse quantitative data (I, IV) and content analysis were applied for qualitative data (II, III, and IV). Findings: Adolescent birth rate was similar to previously reported in Vietnam but lower when compared to other Asian countries. The incidence of stillborn among adolescents was higher than for women in higher reproductive ages. The proportion of preterm deliveries was 20 % of all births, higher than previous findings from Vietnam. About 2 % of the deliveries were home deliveries, more common among women with low education, belonging to ethnic minority and/or living in mountainous areas (I). Ambivalence facing motherhood, pride and happiness but also worries and lack of self-confidence emerged as themes from the interviews; and experience of ‘being in the hands of others’ in a positive, caring sense but also in a sense of subordination in relation to husband, family and health care providers (II). Health care providers at abortion clinics and midwifery students generally disapproved of pre-marital sex, but had a pragmatic view on the need for contraceptive services and counselling to reduce the burden of unwanted pregnancies and abortions for young women. Providers and midwifery students expressed a need for training on ASRH issues (III, IV). Conclusion: Cultural norms and gender inequity make pregnant adolescent women in Vietnam vulnerable to sexual and reproductive health risks. Health care providers experience ethical dilemmas while counselling unmarried adolescents who come for abortion and this has a negative impact on the quality of care. Integrated ASRH in education and training programmes for health care providers, including midwives, as well as continued in-service training on these issues are suggested to improve reproductive health care services in Vietnam.

'They would never receive you without a husband' : Paradoxical barriers to antenatal care scale-up in Rwanda

OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss'). DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda. FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy. CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

Influência do autoconceito e da institucionalização nas reações a inequidade

A presente pesquisa teve como finalidade investigar os efeitos da inequidade quando a pessoa é a vítima e a beneficiada na relação, bem como, verificar também a influência do autoconceito e da institucionalização nas reações e tipos de restaurações que são feitas nas situações inequitativas. Participaram do estudo 568 adolescentes, sendo 504 de colégios públicos e particulares e 64 da FUNABEM e FEEM. Os resultados mostraram que tanto os sujeitos na condição de vítima como na de beneficiado optam pelo tipo de restauração que busca anular a situação inequitativa. Porém, a percepção da injustiça é mais acurada para os que estão em desvantagem na relação. Na análise foram detectados, também, que os tipos de respostas que são buscadas para diminuir o desconforto advindo da inequidade parecem depender tanto das características de personalidade dos indivíduos -no caso o autoconceito -como de fatores institucionais.

Ranking de municípios para políticas públicas de educação: comparação entre avaliações multicritério a partir do IDH

Neste artigo se desenvolvem alternativas de abordagem multicritério visando à seleção de municípios para a implementação de políticas públicas de educação. Considerando que a situação da educação no Brasil apresenta grande variabilidade, o que impacta as demandas educacionais por políticas públicas de educação de forma diferente em diferentes regiões, verifica-se a necessidade de critérios objetivos para a seleção de pontos de aplicação de recursos para o combate a desigualdades nessa área. Em particular, se discute o emprego do Índice de Desenvolvimento Humano como fundamento para decisões na área educacional. Além disso, visa-se a estabelecer condições para a comparação dessas situações segundo diferentes critérios utilizados para fundamentar políticas públicas de educação.

Associação entre as narrativas em saúde bucal e condições socioeconômico-culturais: a dentição como reflexo da desigualdade social

This anthropological study investigates the lived-experience of oral diseases in the context of poverty in Northeast Brazil. During six months in 2004???, ethnographic interviews, narratives and participant-observation with 31 residents of the low-income community, Dendê, located in Fortaleza, Ceará were conducted and analyzed utilizing a hermeneutic-dialetic method. It is revealed that precarious life conditions make prioritizing caretaking a difficult task. Despite suffering tooth pain, seeking a dentist's care is perceived as "a luxury" not a citzens' right. Difficulties in accessing services and poor quality restorations, favor tooth extractions as the most effective intervention. The deterioration of one's oral health is lamented by community members who seek help from popular clinics, politicians and traditional healers. The experience of dental disease differs according to social class, leaves oral scars of inequity, harms self-esteem and inhibits social inclusion. In this context, "treating" the Teeth of Inequity demands that we deepen our comprehension of the social determinants of health, reduce injustice in the access to quality care, remove demoralizing stigmas and empower the community to confront structural forces which affect its life

A incorporação da saúde bucal no programa saúde da família do Rio Grande do Norte: investigando a possibilidade de conversão do modelo assistencial

The Health Family Program (HFP) was founded in the 1990s with the objective of changing the health care model through a restructuring of primary care. Oral health was officially incorporated into HFP mainly through the efforts of dental professionals, and was seen as a way to break from oral health care models based on curative, technical biological and inequity methods. Despite the fast expansion of HFP oral health teams, it is essential to ask if changes are really occurring in the oral health model of municipalities. Therefore, the purpose of this study is to evaluate the incorporation of oral health teams into the Health Family Program by analyzing the factors that may interfere positively or negatively in the implementation of this strategy and consequently in the process of changing oral health care models in the National Health System in the state of Rio Grande do Norte, Brazil. This evaluation involves three dimensions: access, work organization and strategies of planning. For this purpose,19 municipalities, geographically distributed according to Regional Public Health Units (RPHU), were randomly selected. The data collection instruments used were: structured interview of supervisors and dentists, structured observation, documental research and data from national health data banks. It was possible to identify critical points that may be impeding the implementation of oral health into HFP, such as, low incomes, no legal employment contract, difficulty in referring patients for high-complexity procedures, in developing intersectoral actions and program strategies such as epidemiologic diagnosis and evaluation of the new actions. The majority of municipalities showed little or no improvement in oral health care after incorporating the new model into HFP. All of them had failures in most of the aspects mentioned above. Furthermore, these municipalities are similar in other areas, such as low educational levels in children from 7 to 14 years of age, high child mortality rates and wide social inequalities. On the other hand, the five municipalities that had improved oral health, according to the categories analyzed, offered better living conditions to the population, with higher life expectancy, low infant mortality rates, per capita income among the highest in the state as well as high Human Development Index (HDI) means. Therefore, it is possible to conclude that public policies that include aspects beyond the health sector are decisive for a real change in health care models

Sofrimento solitário, mal-estar compartilhado :um estudo sobre a doença dos nervos

Nerves has been perceived as generalized suffering with multiple complaints, such as pain and other physical sensations, usually followed by symptoms of anxiety and/or depression. Even after medications have been prescribed, mainly psychotropic drugs to reduce these symptoms, exams aiming to discover the causes of the disorders, and a significant referral to health services, the problem tends to get progressively worse. The objective of this study is to characterize the diseases of clients who complain of nerves at the Unidade Mista de Felipe Camarão, Natal/RN, through in depth interviews, allowing for the clarification of ideas, beliefs and the meanings attributed to nerves by that person; to identify the symptoms and to know how they interfere in daily activities; to investigate the causes attributed to the problem and their relation to the biographical and psychosocial context of the patient. Thirteen women, health service clients, aged 30 to 59 years old, participated in the research. It was observed that they perceive, feel and act in unique ways with relation to symptoms, as well as to the attributed explanations and treatments given, showing the influence of life conditions, family context and their own subjectivity. Daily concerns and overwhelming responsibilities in the domestic environment, which usually stem from their precarious survival conditions, as well as marital conflicts motivated by the inequity of gender relations, contribute to trigger this type of suffering. The methodology of the research itself proved to be crucial to the comprehension and understanding of the meanings attributed to the complaints as well as to the argumenting process and the redefinition of the illness experience. Therefore, the importance of interdisciplinary intervention must be emphasize and specially the role of listening as relevant intervention resource

Relação das condições socioeconômicas com as condições de saúde bucal em capitais brasileiras

Despite the improvement of Brazilian s living conditions in recent decades, this improvement occurred in a polarized way between groups of better social position. Then, there is still a health inequity´s panorama in Brazil which encompasses the oral health state. This panorama instigated the attainment of this ecological study that aimed to evaluate the relationship of socioeconomic conditions, and public health policies with oral health status in Brazilian capitals. Thus, we performed factor analysis and linear regression using oral health indicators collected from SB Brasil 2010, of socioeconomic conditions from Brazilian Census 2010 and related to water´s supply fluoridation from SISAGUA. Factor analysis with indicators of living conditions revealed two common factors, economic deprivation and socio-sanitary condition. Economic deprivation showed statistically significant positive correlation with DMFT 12 years (p= 0,03) and mean missing teeth (p = 0,002) and negative correlation with caries-free population (p=0,012). Socio-sanitary negatively correlated with DMFT (p <0,0001) and a positive correlation with caries-free population (p = 0.002). Fluoridated water had a significant association with DMFT (p <0,0001), mean missing teeth (p <0,0001) and caries free population (p <0.0001). Multiple linear regression analysis for the DMFT of capital was estimated by socio-sanitary condition and fluoridation, adjusted by economic deprivation, whereas the model for the mean missing teeth was estimated only by fluoridation and economic deprivation, and finally the model the rate for the population free of caries in Brazilian capitals was estimated by economic and socio-sanitary status adjusted fluoridated water supply. Therefore, factors related to living conditions and public policies are intrinsically linked to tooth decay issues. Thus, actions, beyond dental care assistance, must be development to impact positively in social and economic conditions, especially, between the most vulnerable populations