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Although most political analysts cited El Salvador’s legacy of inequality as a central cause of the war, the social reform goals of the revolution were only partially met after the 1992 cease-fire. FMLN achievements in the pact included demilitarization of the country, creation of a new civilian-controlled National Police, and a program to transfer land to ex-combatants and some squatter settlements. But in the rush to achieve a peace accord by December 31, 1991 (the end of mediator Pérez de Cuéllar’s term as UN secretary general), rebel leaders dropped demands for social welfare reforms. Details on many issues remained to be negotiated during an extended “peace process” overseen by the United Nations. The accords called on the government and the FMLN to negotiate on future control of social services (including health) in the near one-quarter of the country under rebel control. Thus, questions of future control of health services in Chalatenango became a key focus of my study. In 1993 these negotiations brought advocates for popular health face to face with the Ministry of Health. For months following the February cease-fire, however, the level of distrust was so high that the talks degenerated into mudslinging. The confrontations reflected a dialectic between the ministry’s commitment to a centralized, biomedical model dominated by physicians and the popular system’s commitment to a strong degree of community control over health and reliance on local lay health promoters. The issues reflected similar debates on the international level over health development. Progress in international public health has often taken place in societies that have adopted strong government policies and public-sector investments in health services (Chen 1989). Canada, Costa Rica, Cuba, the state of Kerala (in southern India), and Nicaragua (under Sandinista rule) are examples 195 8 bbbbbbbbbbbbbbbbbbbbbbb Popular Health and the State Reasserting Biomedical Hegemony The supernatural virtue of justice resides in behaving exactly as though there were equality, when one party is the stronger in an unequal relationship. —Simone Weil of such public health efforts. These success stories span a spectrum of economic systems, but in each case health was but one of a number of social reforms aimed at achieving greater economic equity. As noted in chapter 7, such reformist interventions have often been shortlived due to political opposition in societies that have long-standing disparities in ownership and control of key resources. In many cases PHC projects that emphasized lay workers and community involvement have clashed with regional or state authorities. In an article titled “Will Primary Health Care Efforts Be Allowed to Succeed?” Heggenhougen (1984) reviewed the history of threats, harassment, and even assassinations of community health workers in Guatemala, predicting that in highly hierarchical societies, PHC initiatives “will be repressed when they begin to succeed, since success of necessity implies an attack on existing socio-political structures” (220). This implicit antagonism between grassroots-based health models and wider power structures is perhaps the reason so many promising PHC initiatives remain small projects in isolated rural settings (see Werner and Bower 1982; and Muller 1989). Even in national health system reforms, issues such as community control and lay participation sparked internal political struggles in Costa Rica (Morgan 1989) and Nicaragua (Scholl 1985). Many critiques use the term “political will” as a nod to the contentious power politics behind health reforms. But Morgan cautioned that the concept of political will implies that commitment by national leaders is central and may obscure internal debates and struggles as well as the roles of international aid agencies, thus diverting attention away from the “global relations of dependency and institutionalized inequality that create and perpetuate poverty and ill health” (1989, 233). In her study of Costa Rica, Morgan found that the government often backed paternalistic models of local health care that impeded the citizen participation that PHC was designed to encourage (1989, 1993). She documented inconsistent shifts in rhetoric and program goals as politicians adapted to party lines and international health trends while they continued to reap the political rewards of appearing to back public health. “A politician who deliberately promotes health places himself, by symbolic association, above the dirty business of politics. By . . . perpetuating the notion that health is above politics, political interest groups can and do manipulate . . . health to their own . . . advantage” (1989, 242). The tendency of politicians to trade on the moral reputation of health is particularly blatant in Latin America, where post-colonial capitalist states have traditionally mediated the...

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