Juan César García and the Latin American social medicine movement: notes on a life trajectory
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ARTICLE / ArTíCULO 285
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
Juan César García and the Latin American social
medicine movement: notes on a life trajectory
Juan César García y el movimiento latinoamericano
de medicina social: notas sobre una trayectoria de
vida
Galeano, Diego1; Trotta, Lucía2; Spinelli, Hugo3
1
Professor and resarcher, ABSTRACT This article analyzes the trajectory of Juan César García, one of the referential
Institute of Collective Health,
Universidad Nacional de figures of the latin american social medicine movement. The question that inspired this
Lanús (UNLa), Argentina. work sought to uncover in what moment and in what circumstances García incorpora-
dgaleano.ufrj@gmail.com
ted a Marxist framework into his way of thinking about health problems. Following the
2
Professor and researcher, methodological guidelines proposed by Pierre Bourdieu, we used the concept of “life tra-
Institute of Collective Health, jectories” to reconstruct a life path that divides in various directions: from his birthplace
Universidad Nacional de
Lanús (UNLa), Argentina. in necochea to the city of la plata, from there to Santiago de Chile and, finally, his nu-
luciatrotta.2@gmail.com merous trips from Washington DC to a large part of latin america. in order to trace these
paths, we carried out semi-structured interviews with key informants: family members,
3
Director, Institute
of Collective Health, friends, and colleagues from argentina, Brazil, ecuador and Cuba. We also analyzed the
Universidad Nacional de books included in his personal library, donated after his death to the international foun-
Lanús (UNLa), Argentina.
hugospinelli09@gmail.com dation that carries his name, and documents from different personal archives.
KEY WORDS History; Social Medicine; Public Health; Social Sciences; Pan American Health
organization.
RESUMEN Este artículo analiza la trayectoria de Juan César García, uno de los referentes
del movimiento latinoamericano de medicina social. la pregunta que desencadenó
este trabajo buscó indagar el momento y las circunstancias en que García incorporó
para sí la matriz del marxismo para pensar los problemas de salud. De esta manera,
siguiendo los lineamientos metodológicos propuestos por pierre Bourdieu, utilizamos
la noción de “trayectoria de vida” para reconstruir un recorrido vital que se bifurca en
varias rutas: de su Necochea natal a la ciudad de La Plata, desde allí hasta Santiago
de Chile y, finalmente, sus innumerables viajes desde Washington hacia gran parte de
américa latina. para ello, realizamos entrevistas semiestructuradas con informantes
clave: familiares, amigos y colegas de argentina, Brasil, ecuador y Cuba. asimismo,
analizamos los títulos de su biblioteca personal, donada a la fundación internacional que
lleva su nombre, y documentos de distintos archivos particulares.
PALABRAS CLAVES Historia; Medicina Social; Salud pública; Ciencias Sociales; organización
panamericana de la Salud.
Universidad Nacional de Lanús | Salud Colectiva | English Edition ISSN 2250-5334286
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011 Galeano D, Trotta L, Spinelli H.
INTRODUCTION of health and disease, disregarding the
qualitative difference between these states.
Therefore, social medicine emerged as a
Juan César García (1932-1984) is known in “modern” conception, adapted to the new
many parts of Latin America as one of the leaders modes of production that were developing in
of “social medicine,” a school of thought that in Europe. (3 p.22) [Own translation]
the second half of the twentieth century began
to change the way health-disease-care processes Latin American hygienism, developed as a
(HDCP) were studied. In fact, social medicine was political rationality starting in the mid-nineteenth
something more than a school of thought, as it century, implied an institutionalization of social
had many elements of a real political movement. medicine and its more ambitious intervention
There was a certain consensus about what the projects, often limited by liberalist resistance. By
concept of “social medicine” meant, although it contrast, during the postwar period of the following
coexisted with the ideas of “public health,” “sani- century, the “preventive medicine” paradigm pro-
tarism” [sanitarismo], “preventive medicine” and moted by the United States provided a new idea of
“community medicine.” Each of these notions health care that articulated private medicine with
has a specific and relatively autonomous gene- public health through specific mechanisms such as
alogy. The public health paradigm emerged in the “community medicine” or “family medicine” (1).
modern European States, particularly in France The Latin American social medicine movement
and Germany during the eighteenth century, emerged from a critical view of this inherited
through historical processes that – as countless knowledge, emphasizing the necessity of paying at-
scholars have studied (1,2) – were closely related tention to the “social determinants” of the HDCP as
to social moral reform projects and hygienist well as to inequalities in the distribution of health
codes for population control. care services. This change was closely related
However, the Latin American thinkers iden- to a growing dialogue between the medical and
tified with the social medicine movement ac- social sciences, particularly sociology and history.
knowledged this lineage quite late; during the This path from the medical sciences to the social
1960s and 1970s they tended to regard “social sciences was precisely the intellectual trajectory
medicine” as a counter-hegemonic movement, of Juan César García, who studied medicine at
opposed to the medicine provided by the indi- the Universidad de La Plata (UNLP) (Province
vidualistic, liberalist and capitalist market. In the of Buenos Aires, Argentina) and later decided to
last text García wrote before his death, a sort of continue his academic education at the Santiago
self-interview he was able to outline – although de Chile branch of the Latin American School of
not finish – when he was seriously ill, he acknowl- Social Sciences (FLACSO, from the Spanish Fac-
edged that long history. He asked himself: “What ultad Latinoamericana de Ciencias Sociales).
is the history and the meaning of the term social Both the choice to study sociology and the
medicine?” and answered: scholarship provided for graduate education
abroad were paths marked by particular university
Eighteen forty-eight (1848) is the year the policies related to developmentalism [desarro-
concept of social medicine was born. It is also llismo]. Nevertheless, García’s decision was also
the year of great European revolutionary move- influenced by his individual trajectory shaped by
ments. Like the revolutions, the concept of his social and political activism. This is the least
social medicine emerged in various European known aspect of García’s biography, which may
countries at the same time. [...] The concept, be connected to the little attention he has received
although ambiguously used, attempted to in his own country (Argentina), as compared to the
highlight that diseases were related to “social influence he has had and still has in others such as
problems” and that the State should actively Brazil, Ecuador, Mexico and many parts of Central
intervene to solve health problems. Simi- America and the Caribbean.
larly, the term “social medicine” was interre-
lated with the new quantitative conceptions
Universidad Nacional de Lanús | Salud Colectiva | English Edition ISSN 2250-5334Juan César García and the Latin American social medicine movement 287
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
SOME METHODOLOGICAL and making the material produced during the re-
CONSIDERATIONS search process available to the general public.
The task of reconstructing a life trajectory
enters into some amount of tension with the legacy
In order to reconstruct the life and profes- of Juan César García and the social medicine
sional trajectory of Juan César García, we utilized movement. Any historiographical reconstruction
different types of sources. First, we reviewed his of the life of a physician has as a backdrop the
own writings and the existing literature about him, model of the traditional history of medicine, made
as well as literature regarding the social medicine up of a collection of biographies of illustrious
and collective health movement. Secondly, thanks doctors. This paradigm was highly criticized by
to the generosity of his family, friends and col- the school of thought called the “new history of
leagues, throughout the research process we had medicine,” which, using various theoretical ap-
access to different documentary sources: pho- proaches, prioritized the study of healthcare
tographs and letters from his youth; copies of a systems and large processes and structures. Conse-
newspaper in which he participated while he was quently, life stories were left aside in order to give
studying in La Plata; writings, newspaper clippings way to the analysis of healthcare institutions and
and correspondence from his years in the Pan to the criticism of knowledge-power mechanisms.
American Health Organization (PAHO). During To what extent, then, would a research study of
this documentary search we also had access to this nature imply a return to the traditional history
material about García’s years as a student activist, of medicine, even when this study is based on the
kept in the Intelligence Office of the Buenos Aires life of a physician who was paradoxically against
Police Force (DIPBA, from the Spanish Dirección traditional approaches?
de Inteligencia de la Policía de la Provincia de This question leads to an utterly current
Buenos Aires) and now under the custody of the debate; some Latin American historians of HDCP
Provincial Commission for Memory (Comisión are discussing the necessity and importance of “a
Provincial por la Memoria). return to life stories” as a new and fresh impetus
We also conducted interviews with family in an increasingly saturated field of study. This
members, friends, fellow students from UNLP, impetus has already proved fruitful, as shown
and peers from FLACSO and from García’s first ex- in the publication of works that have achieved
periences organizing Latin American social med- a more or less successful synthesis of the critical
icine networks. The link with the Brazilian “saúde corpus produced by the new history of medicine
coletiva” movement was fundamental, for which and the use of biographical analysis as a method-
reason we interviewed representatives of this ological tool (4).
movement, in addition to analyzing interviews In this work, the concept of “life story” was
from the oral archive at the Osvaldo Cruz Foun- replaced by the notion of “trajectory,” following
dation and from the project on Sergio Arouca’s Pierre Bourdieu’s suggestions about the risks
trajectory carried out by Universidade Federal do of using life history methodology, very much in
Estado do Rio de Janeiro. Finally, we interviewed vogue within the social sciences (5). This French
colleagues from other countries who were closely sociologist made a suggestive criticism of what he
connected to the leftist thought being developed calls “biographical illusion,” that is to say, the ten-
surreptitiously within the PAHO, in particular the dency to regard a whole life as if it were a coherent
Ecuadorian Miguel Márquez. story. Instead, Bourdieu proposes analyzing life as
Many of these interviews became part of a trajectory, the way in which an actor takes posi-
archive of the Thinking about Health Documen- tions in a social field, using resources and means
tation Center (CEDOPS, from the Spanish Centro that are always limited, negotiating and competing
de Documentación “Pensar en Salud”) at the In- against others for the control of economic and
stitute of Collective Health (ISCo, from the Spanish symbolic capital.
Instituto de Salud Colectiva) of the Universidad This trajectory, like any other, not only con-
Nacional de Lanús, with the aim of enriching the sists in a movement through time, but also a series
oral memory of Latin American social medicine of displacements through space. The first path is
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SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011 Galeano D, Trotta L, Spinelli H.
traced by García’s arrival in the city of La Plata in UNIVERSITY, STUDENT ACTIVISM AND
1950 from his hometown (Necochea, Province of SOCIAL SCIENCIES
Buenos Aires, Argentina) to his departure for San-
tiago de Chile halfway through the next decade.
His most well-known facet in Latin America draws Juan César García was born on June 7, 1932,
a second path that goes from Chile to the United in Necochea, an Argentine town located in the
States, where he first joined a research team at coastal area of the Province of Buenos Aires, where
Harvard University and then started work at the he spent his childhood and adolescence. There, in
PAHO. And, based in this organization, García his seaside hometown, many of García’s school-
coordinated the creation of various social med- mates who we interviewed remember him to this
icine networks in Latin America, an activity he day as a lively student, a sensitive person who
conducted quite anonymously, since its political was always ready to listen to others (7,8). García
content was incompatible with the hegemonic came from a humble household; his father was a
ideas within the PAHO. farmworker and his mother did the housework, so
This article is therefore structured in two the possibilities of intergenerational upward social
parts. The first part comprises García’s education mobility depended on what his academic edu-
at UNLP and his participation in university pol- cation was able to provide him.
itics; his specialization in pediatrics at the same In secondary school, García experienced a
institution; his first medical work at the Medical very particular climate of the time in which politics
Student Association (Sociedad de Estudiantes de began to permeate the educational sphere: in fact,
Medicina); and his role in the creation of a Nec- the Head of Necochea National School (Colegio
ochea Student Union (Centro de Estudiantes Nec- Nacional de Necochea), where he studied, was a
ochenses) and of a team of physicians that traveled socialist leader of the area and a promoter of novel
through the Province of Buenos Aires. The expe- pedagogical methods and tools (a). According to
rience of this physician traveling to Santiago de some of the interviewees (9,10), the political in-
Chile in order to study at FLACSO, the context of fluence from García’s uncle Julio Laborde, his
that decision and its implications are also explored mother’s brother, was also important for him. The
in this part. In summary, this section looks into a Laborde family came from Basque immigrants who
decade and a half of academic and political ex- arrived in Argentina in the nineteenth century and
perience to detect many of the problems García settled in the area of Quequén as agricultural land
would attempt to analyze with new intellectual tenants. García’s uncle came be a leader in the Mar
tools during the following years. del Plata Communist Party and later Secretary of
The second part is focused on García’s expe- the Central Committee of the party in Avellaneda
rience in the PAHO’s Human Resources and Re- as well as the director of the newspaper Nuestra
search areas, that is, the almost two decades of his Palabra and the journal Nueva Era. During the in-
life he spent in Washington. During this period, terview, Miguel Márquez recalls conversations in
the first research study carried out by García under which Juan César told him that it was this uncle
the sponsorship of the PAHO proved to be key; who introduced him to readings related to so-
it was carried out from the time he joined the or- cialism, such as the works of José Ingenieros (11).
ganization in 1967 until 1972, when the results Once García had finished secondary school,
were published in the book La Educación Médica his family decided to sell the house in Necochea
en America Latina (6). This research was signif- and move to the city of La Plata so that Juan César
icant because it made it possible for him to dis- could continue his studies and attend the uni-
cover in depth the teaching of social medicine in versity. He settled there with his mother, sister
various Latin American countries and to start to and brother. His decision to study medicine – ac-
build a network of contacts, accumulating an im- cording to a schoolmate from Necochea – was
portant social and political capital that helped him framed by the climate of the time, when opting
maintain certain lines of work inside the PAHO, for a traditional and professional course of study
even under the suspicious eye of many directors in the university meant attempting to achieve
who were not sympathetic to these activities. upward social mobility (7).
Universidad Nacional de Lanús | Salud Colectiva | English Edition ISSN 2250-5334Juan César García and the Latin American social medicine movement 289
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
This possibility of accessing higher edu- María Ludovica Children’s Hospital in La Plata
cation arose within a historical context in which and then to a health clinic in Berisso, a locality
a university degree would be the key to the labor contiguous to La Plata, where he would take his
market and a better social position. Having studied first steps in professional and community medical
in the town’s National School would enable many practice. As a result of these experiences and the
students, who like García came from humble close contact with the social problems that they
backgrounds, to get a good education and think provided him, at the end of 1958 García and other
about the possibility of continuing their studies. colleagues decided to travel around the Province
The value that a professional degree had in Ar- of Buenos Aires in order to collect information
gentina led people to attend educational institu- about health conditions in the towns and cities
tions, and in particular universities, which for the within the province. They thus traveled to Tandil,
middle class was the avenue for social mobility Balcarce and their own hometown, Necochea,
par excellence. In this type of societies, where among other places (Figure 1).
the production (and educational) structure is little Another important moment at the beginning
diversified and the professional fields are only of his trajectory was his relationship with the
slightly specialized, obtaining a university degree School of Journalism. Once his studies at the
becomes of utmost importance to the composition Medical Sciences School were advanced, he
of the social classes (12,13). looked for other areas in the university where he
During the nine years he lived in La Plata could channel interests and questions outside the
(1950-1959), García passed through not only reach of medical knowledge. According to the
university classrooms, but also several collective interview with one of his fellow students at that
spaces where he built social networks that were time, García formally enrolled in the School of
undoubtedly central to his trajectory, and in Journalism, although he did not finish this course
which he left his own mark. During his first years of study (14). However, while studying in this re-
in La Plata, he worked as a medical assistant in cently created school, he was one of the advocates
the periphery of the city, a position provided by of the Student Union statute and of the library, and
the Medical Student Association that helped him had considerable influence in the proposals which
alleviate the economic difficulties his family was would result in the transfer of this school to the
experiencing at that time. jurisdiction of the UNLP. García’s enterprising
At the same time, García was an advocate nature, as well as his interest in cultural debates,
of the Necochea Student Union, which brought was also reflected in the creation of the newspaper
together the university students from Necochea Edición (Figure 2), which was produced with other
that were studying in La Plata, the capital city of fellow students from the School of Journalism and
the province. Their lives as university students in 1955 published two issues. Far from focusing
and the concerns they shared as students coming on one specific area of culture, the newspaper in-
from a small outlying city brought together these cluded articles about science and art as well as
young people with different courses of study and various essays and interviews. This social network
different ideological backgrounds. Among them also facilitated book exchanges among students;
were two well-differentiated groups: one con- authors as diverse as Borges, Sábato, Estrada,
sisting of García, his sister and other students, all Macedonio Fernández, Sartre and the French
of more humble origins; and the other consisting existentialists provided Juan César with readings
of students from the Faculty of Agronomy – future that fascinated him and which he would often rec-
agronomical engineers – connected to nationalist ommend to those around him.
Peronism, who came from a higher socioeco- Juan César García started his studies at the
nomic status (9). UNLP at a particular moment in the history of
After his graduation, García would once higher education in Argentina. The university
again become involved in the types of tasks that reform of 1918 had created a series of tensions that
had steered him toward the study medicine. His would persist throughout time, with core debates
decision to specialize in pediatrics led him to regarding different “university models”: the primary
complete his residency in the third ward of Sor dilemma at stake was the creation of an institution
Universidad Nacional de Lanús | Salud Colectiva | English Edition ISSN 2250-5334290
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011 Galeano D, Trotta L, Spinelli H.
Figure 1. Juan César García (on the left) and the group of physicians from La Plata touring the
Province of Buenos Aires (Tandil, December 8, 1958).
Source: Photograph provided by García’s family.
more concerned with scientific production versus the period prior to the university reform (including
an institution concerned with issuing degrees for suspension of institutional autonomy; derogation of
professional practice. What was so particular about the tripartite government [among faculty, students,
the configuration of the Argentine university after and graduates]; absence of academic freedom and
the reform was how it maintained a highly profes- of a public, competitive faculty selection process),
sional structure, in relation to the relative weight by means of political overhauls, purges and an in-
of the studies of liberal professions, while at the creasing regulation of the political activity at the
same time containing modernizing and democratic university. This regulation became tighter over time
elements such as student participation in university and, during the first years of the 1950s, students
government (15-17). Undoubtedly, the reform became the most fervent opponents of State inter-
made it possible to conceptualize a university vention, forming one of the main fronts of resistance
with open doors, thereby democratizing access to against the national government. In this respect, it
higher studies; but also, by removing the conser- should be clarified that the dynamic of this student
vative elites from the university government, the opposition did not represent a rupture with the past,
reform allowed for a strong connection with pro- but rather a deepening of the defense of university
fessional organizations (18 p.137-143). autonomy and of reformist principles that had been
Perón’s first administration (1946-1955), which carried out since the 1930s. It also brought together
coincided with García’s years as a student, was a an amalgam of different sectors within the student
time of changes in the classrooms, and universities federations, joined not only by their defense of the
began to be increasingly politicized. Party politics university reforms but also their anti-Peronist stance
burst onto the academic scene with regressions to (19 p.79, 20 p.150).
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SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
On the other hand, these years were marked The Medical Student Union (CEM, from the
by a world context of a growing tendency toward Spanish Centro de Estudiantes de Medicina),
the massification of higher education studies and of which García was an activist, had a strong
increased student enrollment. In Argentina, this presence among the student federations organized
process had particular characteristics, not only be- against the national government. The tension
cause it was a country with one of the highest rates which permeated the university sphere during the
of secondary school attendance in all Latin America first Peronist administrations took on particular
(that is to say, it had larger potential enrollment characteristics within each academic department.
pool for higher education), but also because the One example was the implementation of Act
Peronist government introduced policies that fa- 13.031 in 1947, which established student rep-
vored access to the university for students from resentation in the Governing Council through a
working class sectors. Although the real scope of student elected by the university authorities from
these policies is controversial, what stands out is among those students with the highest grade point
the amplification of access implied in the system averages; this representative had the right to voice
of scholarships in effect during the late 1940s, the an opinion but not the right to vote.
elimination of student fees in the 1950s as well At the UNLP the student representatives at-
as the abolition of the entrance examination in tempted on one occasion to voice reformist posi-
1953. At the same time, a model centered on pro- tions of the student assembly before the governing
fessional development was strengthened, as was
reflected in the composition of the enrollment: at
the beginning of the 1950s, 30% of the university Figure 2. First page of the newspaper Edición. 1955.
student enrollment of the entire country was con-
centrated in medical studies (18 p.160).
The amplification of university access within
the Faculty of Medical Sciences in La Plata serves
as a case study of these national and international
transformations. Unlike the rest of the medical
schools in the country, not only did the Faculty
have an entrance examination, but also an en-
rollment quota policy. The abolition of these re-
quirements together with the establishment of
free university education had a bearing on the
substantial increase in the number of students en-
rolled: in 1945, there were 128 students enrolled
in the Faculty; this number had more than doubled
by 1952 (288 students), and in 1953 it jumped ex-
ponentially with 630 new enrolled students (21).
García spent his years as a medical student
in La Plata immersed in this context of university
access amplification and politicization. Moreover,
he actively experienced these tensions in the
education field, positioned within the pro-reform
forces, where he was an activist against the na-
tional government. For that reason, security forces
burst into his house on two different occasions to
arrest him. On the first occasion García remained
in custody for several days, while on the second
his family prevented the arrest by showing the se-
curity forces a photo of Perón that by chance they
Source: Original provided by María Luisa Gainza.
had in the house (9).
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SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011 Galeano D, Trotta L, Spinelli H.
council; in response, the General University Con- Peronism. The student unions called for a resto-
federation (CGU, from the Spanish Confederación ration of democratic values and the principles of
General Universitaria) sought to generate parallel the reform, positioning themselves against what
channels of dialogue with the authorities. The they called the “totalitarian advance,” the “dic-
members of this confederation, aligned with the tatorship” that “tried to control them with hired
Peronist government, developed a regulation to thugs and political overhauls in the universities”
allow all students the possibility to petition the au- (22) (b). This confrontation increased with certain
thorities and, thus, also submit their own demands. measures taken by the university authorities in
During the first years of the 1950s, the confronta- favor of the national government. Such was the
tions between students in favor of Perón’s gov- case of the commotion caused by a formal speech
ernment and students of the reformist wing were by the UNLP rector and professor of the Faculty of
increasingly intense. All the positions in the Faculty Medical Sciences that urged the university com-
tended to become more polarized; the authorities munity to vote for Perón’s presidential reelection,
were sympathetic toward the national government, or by those proposals of the CGU to rename the
while the student federations were opposed to it. faculty after Perón and to give the main lecture
Thus, the atmosphere of the time among hall the name of “Evita Perón” (21 p.73).
the student representation was tinged with anti- Several fights were therefore carried out by
the La Plata University Federation (FULP, from
the Spanish Federación Universitaria de La Plata)
Figure 3. Pamphlet of the University Federation of La (Figure 3). These included fights in favor of a
Plata (FULP). 1952. student cafeteria; against the Act of Residence
[that allowed the government to deport immi-
grants without previous trial] and against the il-
legal pressure exerted upon students who carried
out political activities; against the political over-
hauls, the presence of the CGU inside the uni-
versity, arbitrary professional appointments,
budget cuts, the image of the university as an
“unidad básica” [a name given to basic electoral
district organizations of the Peronist Party, in
charge of disseminating its ideas, qualifying its
members and promoting affiliation to the party,
among other tasks], the promotion of courses re-
lated to the “National Justicialist [Peronist] Doc-
trine” and, in the Faculty of Medical Sciences,
a specific struggle to eliminate the premedical
entrance course (22).
In 1954, García participated in the Pro-
Reform Student Organization (ADER, from the
Spanish Agrupación de Estudiantes Reformistas)
(23,24). This organization created a candidate list
in order to contest the leadership of the Medical
Student Union, in which García is listed as can-
didate for substitute representative of the FULP
for the period 1954-1955 (Figure 4). The ADER
list competed against the list of the Unitary Or-
ganization of Medicine (“Agrupación Unitaria
Medicina”) and another presented by Freedom
and Reform (“Libertad y Reforma”) according to
Source: DIPBA archives. Table A, student factor, File No. 1 (FULP).
a DIPBA report (c).
Universidad Nacional de Lanús | Salud Colectiva | English Edition ISSN 2250-5334Juan César García and the Latin American social medicine movement 293
SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
ADER had a deep pro-reform bent; it was asso-
Figure 4. Ballot paper of the Reformist Stu-
ciated with the Radical Party, and its members were dent Organization (ADER), of the Medical
working class students, while “Libertad y Reforma” Student Union of Universidad Nacional de
shared the reformist ideals from a more libertarian La Plata. 1954.
perspective, but most of its members came from the
middle and upper classes. This suggests that, like
many university students of that time, García’s in-
sertion into student politics was not only influenced
by his political ideas, but also by the people who
were close to him and the social capital he had ac-
cumulated, which reflected some distance from the
local elite families that historically produced the
most distinguished medical professionals.
During the beginning of the following decade
(1955-1966), known as the “golden age” of the
Argentinean university, García actively took part
in the debates going on behind the scenes in the
university. From the start, the Argentine University
Federation played an essential role in recovering
autonomy and also in appointing rectors and
deans within the political overhaul (in La Plata, the
overhaul dean of the Faculty of Medical Sciences
was proposed by the reformist students). The Exec-
utive Order No. 6403/55 of the administration of
the so called “Liberating Revolution” (Revolución
Libertadora) determined the direction of the uni-
versity reorganization, by reestablishing not only
the principle of autonomy, but also the policy of
Source: DIPBA archives. Table A, student factor, File No. 39 (CEM).
a competitive and public faculty selection process
in order to reinstate those who had been dismissed
throughout the previous decade and to discrim-
inate against those who had connections with the a contentious and unresolved issue in the history
overthrown government. This executive order also of the school. At that time, the dean, a number of
established – in Article 28 – the authorization to professors and the graduates of the Advisory Board
create “universidades libres” [private universities fought for the creation of some kind of mechanism
free from State control], one of the sources of that would partially limit admission to the school,
tension that would later undermine the harmony on the grounds that the scarcity of material and
that prevailed during this university renaissance. human resources was further complicated by the
In 1956, an Advisory Board was created at massive influx of new students.
the UNLP Faculty of Medical Sciences made up In representation of the students, García de-
of professors, graduates and student representa- manded issues more central to the Argentine edu-
tives, of which García was one. There were two cational system be addressed, related to the quality
central debates during the existence of this board: of secondary school education and the budget
the competitive faculty selection process and the deficit, as well as proposing a non-eliminatory
entrance examination. With regards to the se- entrance examination. This debate clearly placed
lection process, despite the rebuttals presented into evidence a new antinomy between the old re-
by graduates and students, the dean approved a formists and the younger ones, who had become
rather limited quantity of faculty members. The reformists in the heat of the fight against the Per-
debate over entry requirements to the medical onist government, but had also mostly been able to
school continued for years, and is still to this date gain access to the university thanks to its policies.
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Restrictions on the access to higher education stay at FLACSO-Chile proved to be fundamental to
were no longer imaginable to them, generating a his career. The prevailing climate in the institution
mixture of reformist ideas with advances achieved during that time was one of great effervescence,
during Perón’s administration (25 p. 17-18). creativity, and commitment to knowledge and to
Major historical processes therefore allow the development of local human resources. This,
us to understand the political positions taken by at least, is how García explained his experience:
García during his years as a student activist. The
cultural and social changes experienced in the It should be kept it mind that the Latin
postwar world serve as the framework within American School of Social Sciences, sponsored
which these events took place, and, in Argentina, by UNESCO to raise the standard of social sci-
these changes took on singular characteristics of ences education, was created at the end of the
a clearly political nature, starting with the over- 1950s. At the same time, scholarships were
throw of the Peronist government (26 p.54). In a awarded to foreigners with the aim of gener-
context in which Peronism was synonymous with ating, through this and other mechanisms, a
an archaic past to be left behind, the diagnosis “critical mass” of social scientists. Of course,
made was one critical of a university that had been for how could it have been otherwise, the edu-
emptied. Breaking with the immediate past went cation provided was under the hegemony of
hand in hand with the restoration of the reforms sociological positivism, which does not mean
and the uplifting of democratic values (27). that other schools of thought did not flourish
This de-Peronization of the university oc- and that students did not react against the pre-
curred in a context in which the prevailing de- vailing education. (3 p.XX) [Own translation]
velopmentalist ideas were promoted in most of
Latin America. Science and technology were the García studied at FLACSO between 1960 and
two privileged areas upon which all economic 1962. Later, at the suggestion of Peter Heintz, dean
and social development programs were based, of the ELAS during those years, García became a
and the State was considered the privileged agent member of the teaching staff as professor of Social
for making those changes viable. Within this Theory until the end of 1963. Heintz himself then
framework, several innovative practices of cultural recommended García to work with Alex Inkeles,
modernization were adopted and the university sociologist of the institution, although this job did
became a legitimate space for knowledge pro- not work out and was one of the incentives for him
duction and creation. This was accompanied by to accept the scholarship that would take him to
an accelerated academic institutionalization and Harvard the following year (28). García came into
the strengthening of disciplinary fields that, as was contact with this US university as a result of an
the case with the scientific sociology promoted by international research study carried out in seven
Gino Germani, would contribute new theoretical countries regarding “The influence of the working
elements such as American structural function- environment on the behaviors of individuals,” in
alism as well as a local view of the development which García participated along with other col-
processes of peripheral societies. leagues. This research, based at FLACSO, required
It was within this panorama that García, en- a group of students to systematize information col-
couraged by a friend from the School of Journalism, lected by means of 1,500 surveys conducted in
decided to dedicate himself to social studies, and Chile, which gave them important methodological
applied to study at the FLACSO branch in Chile. experience and led to the consequent invitation
By means of a scholarship, he was able enroll in from Harvard University.
the Latin American School of Sociology (ELAS, The possibility of participating in fieldwork was
from the Spanish Escuela Latinoamericana de part of a pedagogical strategy promoted by Heintz
Sociología), which was dependent on FLACSO. within the institution, where education was based
Thus, in 1960, García travelled to Santiago de on teaching content related to sociological theory,
Chile with the intention deepening his search for methodology, research methods and empirical as-
answers to his questions and finding a more in- pects of economic and social development. Such
tegrated approach to the study of the HDCP. His a course of studies implied the participation of
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SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
students in concrete research studies seeking to on the role of social sciences in the medical cur-
combine theory, methodology and empirical re- ricula: this main object of study in his 1965-1972
search in a single process. According to several writings will be analyzed in the following section.
interviews and the work of García during those Hence, the training of health professionals at
years, the education had an eminently structural- higher education institutions would be decisive in
functionalist approach combined with some ele- the construction of a new paradigm. For García,
ments of Germani’s sociological approach that universities were historically determined and in-
came from Argentina. A student from the third tegrated the production, transmission, and social-
cohort describes it as follows: ization of knowledge according to the concrete
social formation in which they operated. In this
I found that FLACSO had an extremely con- way, the role of medical education became central
servative climate. The dean at that time was to the reproduction of healthcare services. At the
Peter Heintz, a Swiss man heavy influenced same time, García ascribed these institutions
by US trends – Parsons, Merton – and also by certain autonomy and ability to create spaces for
the powerful influence of Gino Germani from change and innovation (33,34).
Argentina. There were no courses in Marxism, García’s first experiences as a university actor
everything was structural functionalism, with in that context of student politicization and in the
a slight anthropological orientation (29 p.73) disputes over the definition of the university model
[Own translation] may have been the elements that, in the following
years, served as the foundation from which to ask
As the archives at FLACSO-Chile’s library questions about the relationship between social
show, García graduated with a thesis entitled “Vari- structure and the prevailing mode of production
ación en el grado de anomia en la relación médico- of health professionals.
paciente en un hospital” (Variation in the level of
anomie in the doctor-patient relationship at a hos-
pital) (30). This was the first of a series of studies SOCIAL MEDICINE AND LATIN
with topics centering on the medical elite, the AMERICAN COOPERARION NETWORKS
doctor-patient relationship and authoritarianism,
considered by García to be a defining element in
the doctor-patient relationship. These first works In March 1966, Juan César García joined
showed an incipient dialog between the social sci- the Human Resources Department of the PAHO,
ences and medicine, a horizon he would never with headquarters in Washington DC, where he
abandon. Also written by García during this period worked until his death. It was a time of great po-
(1961-1964) were the articles “Sociología y me- litical upheaval; the backdrop was marked by the
dicina: bases sociológicas de la relación médico- Vietnam War, the escalation of anti-imperialism,
paciente” (Sociology and medicine: sociological the May of 1968 in France and the revolutionary
bases of the doctor-patient relationship) and “Com- movements in Latin America, with the Cuban
portamiento de las elites médicas en una situación Revolution as their symbol. When García joined
de subdesarrollo“ (Behavior of the medical elite in the PAHO, he was 33 years old; he had a degree
a context of underdevelopment) (31,32). in Sociology from FLACSO-Chile and experience
In these works from the early 1960s, García as research assistant at Harvard University.
used categories from American medical sociology, In the 1960s, a sector of the PAHO led
but also a critical analysis of the practical “problem projects to reformulate public health courses from
solving” approach in medicine. As a result of his a perspective critical of the biologicist paradigm of
investigation and his critical interpretation of this the natural history of disease. It was fundamental
literature, he organized a collection in 1971 with in this process to incorporate knowledge from the
the aim of informally circulating a series of works by social sciences which permitted awareness of the
Talcott Parsons, John Simmons, Edward Suchman multi-causality of health problems, knowledge
and Joan Hoff Wilson. This interest led him to grad- originating from both the US preventive model as
ually focus on the medical education processes and well as from the historical-structural perspectives
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that were emerging in Latin America as a new One such colleague, the Ecuadorian phy-
approach (35,36). From Harvard, García was in- sician Miguel Márquez, summarizes what many
corporated into the PAHO through an ambitious highlight regarding García’s work style, displayed
research project sponsored by the Milbank Foun- all over Latin America with medical colleagues
dation, whose aim was to map the advances made and other health professionals: “he had a great
by the preventive and social medicine disciplines ability to bring people together” (11). García
in the education of health professionals in Latin put Márquez in charge of the data collection
America; this project would then extend to a cur- in Ecuador and six Central American countries.
ricular analysis of medical education in general. Márquez explains that he met García in Cuenca
The fieldwork for this research study gave before the fieldwork began, when García took a
García the opportunity to visit a large number of trip through the countries to be included in the
countries, to see first-hand hundreds of schools of study. According to this interviewee, great effort
medicine, to engage in dialogues with numerous was required on García’s part to convince many
colleagues and to being to weave social networks colleagues to take part in the study; those who
that would later give way to the first meetings on belonged to university federations aligned with
“social sciences applied to health,” according to communist ideals were at first suspicious of a
the name that was in use in the 1970s. Once more, research study based out of Washington and fi-
as had happened during his years of activism at nanced by a US foundation.
the UNLP Medical Sciences School, the question When García arrived in Ecuador to visit
of curriculum design became an area of dispute schools of medicine, Márquez was advisor to the
and the site of an array of possibilities for change. Medical Student Federation in Cuenca. Garcia’s
García explained that this interest in drawing a first step was to talk to the students and explain
map of the medical education processes in Latin to them the objectives of the project. The students
America had some precedents at the PAHO, (some Maoists, others more pro-soviet) then went
which had previously organized two seminars: to their advisor to express their suspicions: they
one held in Chile in 1955 and the other in Mexico thought García was a CIA secret agent. Márquez
in 1956, “both attended by representatives of asked them to allow him to speak with García per-
almost every school of medicine in the continent” sonally. They had an extremely long conversation,
(6 p.2). Meeting participants recommended that one that lasted the whole day. “I encountered a
the PAHO take on the task of assessing the actual man of few words, and I learned where he came
reach of social sciences knowledge within the cur- from,” said Márquez in regard to García’s socialist
riculum design of these schools. origins and sociological education (35). That
Following this suggestion, the PAHO decided day a long-standing friendship began, one full of
to gather a team of experts in Washington, who collaborations.
discussed (between 1964 and 1967) the possibility In 1972, the same year that García published
of developing a research study that would serve La educación médica en América Latina (Medical
as “frame of reference” for the recommendation education in Latin America), he managed to bring
of policies whose aim was to homogenize criteria together a number of these colleagues in the city
for medical education. García was hired as one of of Cuenca, Ecuador, where for the first time the
the coordinators of the fieldwork, carried out be- incipient group took an explicitly critical position
tween the end of 1967 and the beginning of 1968. regarding the functionalist theoretical framework
Altogether, the work took more than four years that prevailed in the sociological analyses of health
and local professionals from 18 countries collabo- at that time. Just before his death, García assessed
rated in the data collection; they were in charge of the results of this meeting whose aim was, at that
administering questionnaires previously designed moment, “to define more clearly the field” of social
by PAHO’s Human Resources Development De- sciences in health; that is, he acknowledged that it
partment. Among them were several colleagues implied a search for the theoretical and method-
with whom García would later strengthen his con- ological foundations that could support this field of
nections in the organization of the movement of study in the making. The group was growing but,
santitarists related to social medicine (d). in García’s own words, “it was lacking the ideo-
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SALUD COLECTIVA, Buenos Aires, 7(3):285-315, September - December, 2011
logical cement needed to go beyond these friendly Berlmartino, the Latin American Social Medicine
relationships, differentiating social medicine from Association (ALAMES, from the Spanish Asoci-
public health and separating it from preventive ación Latinoamericana de Medicina Social) was
medicine” (3 p.XX). established. In the endnotes of its founding doc-
In order to understand the context in which ument, the signatories decided to make “a special
the Cuenca discussions took place, it is necessary mention” of Juan César García, in recognition of
to recall what “social sciences applied to health” “his pioneering work in social medical thought in
meant in Latin America at the beginning of the Latin America, his substantial theoretical contri-
1970s. Firstly, the institutional insertion of this bution to this thought and his leadership in our As-
knowledge did not extend beyond a handful of sociation” (39). Paradoxically, what was probably
courses on preventive and social medicine. Within García’s greatest aspiration came to pass the same
the bibliography the most abundant references year as his death.
were to the “behavioral sciences” approach, which Although functionalism had contributed to the
was developed in the US after the Second World incorporation of social sciences in the analysis such
War. García, critical of this approach, questioned problems as the doctor-patient relationship and the
its positivist methodology and the use of a term link between social structure and health, the crisis
(behavior) which made invisible the historical root of the developmentalist project and the emergence
of human actions. In that sense, the group gathered of other approaches, such as dependency theory,
in Cuenca jointly expressed that the “application strengthened resistance to the prevailing function-
of the functionalist analysis to health issues,” as alist paradigm. The “ideological cement” García
well as the reductionist view of works based on referred to was Marxism and, as Hugo Mercer well
the natural history of disease paradigm and on the described, the transition from functionalism to his-
studies of the determinants of individual behavior, torical materialism was a process of “substitution of
all contributed to a “static conception” and to a one structuralism for another,” since the Marxism
“formalist description” of health processes (37 that took hold in Latin America was in line with
p.XIX). Althusserian thought (40).
According to the opinion of several of our Consequently, García’s work (not only his
interviewees (11,38,50,71), García was the main written and published works but also the more
advocate of that first seminar and of the internal silent work of organizing the Latin American
consolidation of this group that remained in close social medicine movement), showed, at the be-
contact during the following years. They planned ginning of the 1970s, what might be called a
to hold another meeting similar to the one held in “Marxist turn.” Glimpses of this shift can be ob-
1972, which was finally held in 1983 once again served in previous years, when García traveled
in Cuenca. Everardo Nunes, one of the attendees to Harvard with his colleague Carlota Ríos, an at-
at both meetings, stated during his interview that torney who had also studied at FLACSO and was
García, who was already quite ill, commissioned trained in Chilean socialist thought. Their schol-
him to compile the works submitted to that second arships at Harvard were to work with George
seminar (38). That request was fulfilled and resulted Rosen and Milton Roemer, both of whom had
in the release of the book entitled Las ciencias so- studied under Henry Sigerist (11).
ciales en salud en América Latina: tendencias y Sigerist (1891-1957), known as one of the
perspectivas (Social Sciences and Health in Latin most important historians of medicine, was head
America: Trends and Perspectives), published of the Institute of the History of Medicine at John
both in Spanish and Portuguese (37). Hopkins University in Baltimore from 1932 until
Not long after the second meeting in Cuenca, the mid-1940s, and was one of the pioneers in
García died. Several of the attendees – Saúl Franco using a historical and sociological analysis to think
Agudelo, Asa Cristina Laurell, Hesio Corderio, about medicine. He was able to understand the
Jaime Breilh, Sergio Arouca and Everardo Nunes, limitations that the social structure imposed on
among others – met again at the end of that health phenomena, incorporating into his scien-
year in the Brazilian city of Ouro Preto. At that tific processes a Marxist perspective which would
meeting, attended also by Mario Testa and Susana lead him to consider socialism a superior way of
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life for the human being (41). The presence of this García’s library makes it possible to map
author in García’s work can be observed in the not only his readings, but also his contacts, since
bibliography he used within a number of writings many of the volumes stemmed from trips and
after this period, such as in the work entitled “Las networks with other colleagues. In this sense, al-
ciencias sociales en medicina” (Social sciences in though García was living in Washington, there are
medicine), which was presented in the 23rd World numerous books in Spanish and Portuguese: half
Congress of Sociology held in Caracas, Venezuela, of his books (approximately 1,170) are written in
in November 20-25, 1972 (42). Undoubtedly, this Spanish, one-third are in English and the rest are in
change of direction was related to a particular en- other languages, especially in Portuguese. During
vironment of readings and theoretical discussions, his successive trips to Brazil, he collected close
but there was also a leaning toward the Cuban and to a hundred titles from a great variety of fields,
Nicaraguan experiences, where Marxism went which suggests that his library was not only made
beyond a reality drawn by books. Miguel Márquez, up by gifts from his Brazilian colleagues of the san-
a colleague of García’s very close to the Cuban Rev- itarist movement. In fact, there are very few books
olution, remembered that during the 1960s, before on health topics, as compared to the number of
García’s turn towards Marxism, they had met along publications by sociologists such as Caio Prado
the path of social medicine, to which they had ar- Junior, Octavio Ianni or Gilberto Freyre; econo-
rived with very different ideological backgrounds: mists and political scientists of dependency theory
García with socialism and Márquez with Liberation such as Celso Furtado; as well as numerous works
Theology. The 1970s, however, only consolidated on Brazilian history and a considerable amount
this structuralist Marxist point of view, incorpo- of books on the labor movement, anarchism and
rating different texts. Marxism.
An inside look at his personal library, donated Although in his library a trace of Anglo-Saxon
after his death to the International Social Sciences functionalist literature (of which he amassed
and Health Foundation of Ecuador (e), allows at least many books) remains, the number and diversity
an approximate reconstruction of these readings. of books on Marxist theory, anti-imperialism and
Several sources indicate that García was not only Latin American history is noteworthy. Shortly after
an avid reader but also a regular buyer of books. His the first meeting in Cuenca, García presented his
library consists of approximately 3,700 volumes; programmatic work “Las ciencias sociales en me-
half of these are periodical scientific journals, dicina” (Social sciences in medicine), in which
conference proceedings and institutional reports, Marxist thinking already fully permeated his reflec-
while the other half consists of books of individual tions. In this work, García proposed the study of
and collective authorship. Among the scientific the social structure to understand the production of
journals, a series of US journals on sociology stand diseases and of healthcare services; he also stated
out (American Sociological Review, Theory and that the “position taken by a physician” as a social
Society, The American Journal of Sociology, etc.); actor was “determined by the mode of production,”
journals of sociology of science and education (So- be it slavery, feudalism or capitalism (42 p.21).
ciology of Education, Science in Society, Harvard However, this search for “ideological cement”
Education Review); and several publications on the and for a new “frame of reference” different from
social sciences and health fields, some in English that of US functionalism was far from an abstract
(Social Science and Medicine, Journal of Health and meta-theoretical task. Based in the PAHO,
& Human Behavior), but most of them in Spanish García supported two complementary processes
and in Portuguese: Revista Panamericana de Salud developed during the 1970s: a remarkable impetus
Pública, Gaceta Médica de México, Revista Cubana toward empirical research and the institutional
de Salud Pública, Revista Ecuatoriana de Higiene y design of graduate courses in social medicine.
Medicina Tropical, the Chilean Cuadernos Médico- An anecdote told by Miguel Márquez clearly
Sociales, and the Brazilian Cadernos de Saúde illustrates this interest in quickly turning theoretical
Pública. PAHO bulletins and various publications of discussions into tangible results. At a meeting
the World Health Organization (WHO) constituted held in 1978, it occurred to García to address his
a great number of the publications he received. colleagues with a parable he called “the beast
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