The Treatment and Control of Chronic Disease in Chile

By Claire Boone

2019Summer-BOONE-MinistryOfHealth-750p

Very excited to be at the Ministry of Health in Santiago, Chile. (Photo courtesy of Claire Boone.)

Notes from the Field: Student Research in Latin America
CLAS awards financial support to graduate students to travel to Latin America for pre-dissertation research. The following is a reflection on one student’s summer fieldwork experience. (For more information, please see CLAS Summer Field Research Grants.)

Chronic diseases such as hypertension and type 2 diabetes are increasingly affecting Latin America: currently about half of the years of life lost in the region are attributable to chronic disease. (1) In Chile about a third of the adult population has hypertension, double the prevalence in the United States. (2) While Chile has recently been categorized as a high-income country by the World Bank, income inequality is extremely high, and the difference in quality of life between the richest and poorest wealth quintiles is stark. Unsurprisingly, the poorest sector of the population also bears a disproportionately large disease burden, particularly of chronic diseases.

Risk factors for chronic diseases are often more prevalent in low-income populations, and Chile is no exception. Common risk factors include being overweight or obese, a diet low in fruits and vegetables and high in sugars, and a sedentary lifestyle. In 2015, Chile set the then-record for the highest consumption of soda calories per capita, surpassing the United States.

So, how can a country halt or even reverse the trend of increasing chronic disease?

There are two main policy areas to focus on: prevention and treatment. Prevention – or preventing those who aren’t sick from becoming sick – has been the focus of a major policy movement in Chile, something the New York Times recently called “the world’s most ambitious attempt to remake a country’s food culture.” (3)

The movement includes several high-profile policies: a sugar tax introduced in 2014, which at 18% is one of the highest in the world. A ban on marketing of unhealthy foods to children, which includes the removal of all mascots from cereal boxes, cookies, and candy. And the Food Labeling Act, which adds stop sign-shaped labels to all foods high in sugars, salt, fat, or calories.

2019Summer-BOONE-OfficeCubicle-750p

The Primary Care Division (División de Atención Primaria, DIVAP) at the Chilean Ministry of Health in Santiago was where I called home this summer. My coworkers supplied me with a desk, great internet, and excellent lunch company. (Photo courtesy of Claire Boone.)

Evaluations of these policies are currently ongoing and it is likely too early to say whether they have successfully prevented any chronic disease. They do seem to be changing behavior, which is a crucial first step: a recent evaluation found the promising evidence that the food labelling policy was associated with a 18-25% reduction in sugar-sweetened drink consumption.

In the meantime, Chile is also working to better control disease among patients already diagnosed.

Health care in Chile is two-tired, with three quarters of the population using the large government-provided system, FONASA, and the rest paying for private insurance. In the public sector, the Ministry of Health established the Programa de Salud Cardiovascular (Program for Cardiovascular Health) over 15 years ago. This program includes free primary care as well as free medications for patients diagnosed with hypertension, type 2 diabetes, and/or dyslipidemia.

An interesting component of the cardiovascular program, and the focus of my research, is the appointment reminder system. Patients attending primary care facilities who are enrolled in the cardiovascular program receive an SMS reminder 24-48 hours before their scheduled appointment. If they do not have a cell phone, an automated call is made to their landline. Importantly, the patient has the option to respond either confirming or cancelling the appointment. If it is cancelled, the slot is automatically assigned to another patient.

In a public health care system health care provider working hours and wait times for appointments are major ongoing concerns. This appointment rescheduling program has the capacity to function both as a timely reminder to patients with chronic disease and as a way to improve efficiency within the system. Since patients are able to cancel on short notice the facility might be able to see more patients overall, as fewer slots will be wasted on no-shows.

Last summer, our team worked to evaluate the impact of the SMS appointment reminder program on the number of appointments made at each facility. Since the program was implemented in different facilities at different times, we were able to evaluate the program’s impact on two groups: chronic patients who receive the SMS reminders, and non-chronic patients who do not receive the reminders but who attend clinics where the SMS program was implemented.

Mornings were improved after the discovery of a cheap fruit vendor near to the metro! (Photo courtesy of Claire Boone.)

A typical work day at DIVAP included meetings, brainstorming with ministry of health workers, and lots and lots of wrestling with very large datasets. Mornings were improved after the discovery of a cheap fruit vendor near to the metro! (Photo courtesy of Claire Boone.)

Interestingly, we found that the SMS reminders did not change the number of appointments chronic disease patients attended, on average. While at the time we didn’t have the data to test this, it seemed that some chronic patients were cancelling on short notice. This allowed for more appointment slots to open up for non-chronic patients: we found that non-chronic patients who attend clinics with the SMS program attended more appointments.

This study left us with more questions than we started with, and so I returned to Santiago, Chile in summer 2019 to continue the work, this time more closely with the Ministry of Health.  I was based on the Primary Care Division of Chile’s Ministry of Health in Santiago (MINSAL DIVAP). During the month I spent there, I worked with local researchers to access and clean the four large datasets we will use in this new impact evaluation: electronic health records from primary care appointments, medication prescription and withdrawal data, emergency room records, and data on SMS reminders sent and received.

These data are huge in scale – they represent about 60% of all patients in Chile with a chronic disease. Now we will be able to measure not only the impact on appointment attendance, but also the impact of the program on health and health behaviors, such as prescription refills.

The evaluation team — myself, DIVAP, and collaborators at the public policy school at La Pontificia Universidad Católica de Chile — worked to create an evaluation plan and formalize study outcome definitions. Using very large datasets has its challenges, but working with the ministry’s IT team, we managed to transfer all the data we need to complete this evaluation in a couple of months.  The analysis is well underway, and the results of this study will be used to directly inform decisions at Chile’s Ministry of Health.

REFERENCES

  1. Anauati MV, Galiani S, Weinschelbaum F. The rise of noncommunicable diseases in Latin America and the Caribbean: challenges for public health policies. Lat Am Econ Rev. 2015 Dec 1;24(1):11.
  2. Fasce E, Campos I, Ibáñez P, Flores M, Zárate H, Román O, et al. Trends in prevalence, awareness, treatment and control of hypertension in urban communities in Chile: J Hypertens. 2007 Sep;25(9):1807–11.
  3. Caballero, Victor Ruiz, “In Sweeping War on Obesity, Chile Slays Tony the Tiger.” The New York Times, February 7, 2018.
    https://www.nytimes.com/2018/02/07/health/obesity-chile-sugar-regulations.html

Claire Boone.

Claire Boone is a Ph.D. student in Health Policy/Health Economics at UC Berkeley. She holds an MPH in epidemiology/biostatistics. She specializes in the evaluation of health policies and programs, and is particularly interested in the prevention and management of chronic diseases. She has been working with researchers and policy makers in Chile for three years, and plans to continue this work for her dissertation.

Claire is a recipient of the 2019 CLAS Summer Field Research Grant. 

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Por que Bolsonaro recuou e não demitiu Mandetta

Por Carolina Botelho

20/03/2020 Coletiva de Imprensa do Presidente da República, Jai
Presidente Bolsonaro e seu ministro da Saúde (à sua direita). (Foto de Isac Nóbrega/PR.)

A marcha à ré do presidente só foi possível porque uma parte considerável da elite brasileira se sentiu ameaçada

A última segunda-feira (6) foi um dia especialmente tenso para o país. Não pelos motivos ordinários que já estamos nos acostumando a naturalizar em relação ao presidente da República, seus filhos e seus apoiadores. Não, esse dia foi um pouco além. A ameaça real de demissão do único ministro que parece valorizar a ideia de república como se espera de um gestor público tornou-se quase palpável e já havia sido anunciada. Bolsonaro iria mandar embora o seu ministro da Saúde, o único do time que tem se preocupado e agido para poupar vidas num período horrível da história das epidemias com o qual o mundo “quase” todo, ou pelo menos, o mundo “civilizado”, tem se preocupado. O presidente ao final do dia voltou atrás, ou melhor dizendo, voltaram atrás na decisão de Bolsonaro. Quem foi?

Essa é uma importante interrogação neste momento. Quem fez Bolsonaro voltar atrás? Em uma democracia na qual os eventos ocorrem de maneira tranquila, seria esperado que as instituições políticas e sociais recomendassem ao presidente a prudência necessária diante da ameaça da covid-19, e ele aceitaria. No caso brasileiro, as instituições têm cumprido seu papel, mas Bolsonaro despreza todas elas, desqualifica o debate científico e deslegitima os especialistas. O resultado dessa equação é simples, nossa democracia perde diariamente, mas ontem pareceu diferente. Uma grande parcela dos analistas afirma que foram os generais que hoje circulam em torno de Bolsonaro para conter seus “excessos” que exigiram a marcha à ré do presidente. E eu concordo, só que essa não é toda a resposta. Dito isso, reformulo mais uma vez a frase: a quem os generais ouviram para depois fazerem Bolsonaro recuar?

AS ELITES SÃO CAPAZES DE EXERCER UM VERDADEIRO PODER DE VETO AOS RUMOS DO DESENVOLVIMENTO ECONÔMICO E POLÍTICO DE UM PAÍS

Tenho insistido em um tema muito frequente nos estudos das ciências sociais, aquela ciência mais desprezada e desqualificada por Bolsonaro (por quê?): a teoria das elites. Estudei um pouco sobre ela na graduação e também utilizei a teoria na minha dissertação de mestrado há quase duas décadas. Em 2019, ao oferecer um curso para a graduação, julguei o assunto importante para incluir na bibliografia e não me arrependo.

Jair Bolsonaro com o presidente dos EUA, Donald Trump, na Flórida, em 7 de março de 2020. Um membro da equipe de Bolsonaro testou positivo para o coronavírus alguns dias depois. (Foto de Alan Santos / PR.)
Jair Bolsonaro com o presidente dos EUA, Donald Trump, março de 2020. Um membro da equipe de Bolsonaro testou positivo para o coronavírus alguns dias depois. (Foto de Alan Santos / PR.)

Recentemente, o Datafolha mostrou que 51% das pessoas entrevistadas disseram que Bolsonaro mais atrapalha do que ajuda no combate ao coronavírus e 39% reprovam o presidente de modo geral. Seria algo simples de aceitar, mas esse dado traz um resultado mais interessante. Bolsonaro é mais mal avaliado por mulheres (43% de reprovação), pessoas com curso superior (50%) e mais ricos (acima de 10 salários mínimos mensais, 46%).

O presidente dirá que não confia em pesquisa, mas a teoria das elites explica por que o Datafolha está correto e parte dos brasileiros desembarcou da sandice do projeto Bolsonaro.

Embora a metodologia tenha sido alterada nas últimas pesquisas devido ao isolamento social, entre os mais ricos, a reprovação ao presidente subiu de 28% em dezembro para 46% em abril. A importância desse grupo nas sociedades não é trivial. Bottomore, um teórico das elites, já mostrou que elas são capazes de exercer um verdadeiro poder de veto aos rumos do desenvolvimento econômico e político de um país. Como observou Elisa Reis, até as possibilidades de uma mudança gradativa no Brasil dependem consideravelmente da aquiescência das elites. Segundo ela, “a importância das elites está na direção e no controle que elas podem exercer sobre a complexa e difícil transição de uma forma de organização social para outra”.

Abram De Swaan tratou da emergência de políticas nacionais de bem-estar social na Europa. Para ele, a percepção das elites sobre os problemas sociais possui um significado fundamental. No caso da Europa, e como bem lembrou também Elisa Reis, De Swaan mostra que as elites viram vantagens na coletivização de soluções a problemas sociais e que o poder público tornou-se o agente natural na provisão de “bens de cidadania” como educação, saúde e previdência. Para De Swaan, a elite é, em regra, interesseira e age com o objetivo de evitar os “negative external effects” que ele exemplifica com epidemias, poluição, crimes, rebeliões e migrações.

Ruas vazias em São Paulo, 5 de abril de 2020. (Foto de Elize Massard da Fonseca.)
Ruas vazias em São Paulo, 5 de abril de 2020. (Foto de Elize Massard da Fonseca.)

No meu estudo realizado no mestrado, a minha hipótese principal sugeria que não há, entre as elites brasileiras, semelhanças com as analisadas por De Swaan, ou seja, não existe entre elas uma consciência sobre a interdependência das classes sociais, o que viabilizaria uma mobilização para a solução dos problemas no Brasil, de forma cooperativa, para facilitar a criação de políticas sociais que favorecessem os pobres. Entretanto, até aquele momento, ainda não tínhamos sentido o peso de uma epidemia, ou melhor, de uma pandemia como o que estamos experimentando hoje em nossas vidas.

Concretamente falando, a sociedade corre muitos riscos, caso o governo não tome medidas urgentes. Digo toda a sociedade porque os efeitos negativos serão partilhados por todos. Está certo que recairá mais para alguns grupos do que para outros, mas todos vão perder. A começar pela contaminação por um vírus até então pouco conhecido e letal, que entrou no país via elite, mas também pela falta de leitos, a crise econômica que se agravará, a ameaça de convulsão social e de saques pelos grupos que estão desassistidos. Todos vão ser afetados.

A marcha à ré de Bolsonaro só foi possível porque uma parte considerável do grupo da elite captado pelas pesquisas se sentiu ameaçada. O que por sua vez, não garante longa permanência ao seu ministro da Saúde, mas dá fôlego a algumas políticas de controle da epidemia. Resta saber o que esse grupo pensa sobre a importância da democracia.

Publicado originalmente no Nexo, 7 de abril de 2020

Carolina Botelho.

Carolina Botelho é pesquisadora da PUC-Rio (Pontifícia Universidade Católica do Rio de Janeiro), professora e pós-doutoranda do Ence/IBGE (Escola Nacional de Ciências Estatísticas do Instituto Brasileiro de Geografia e Estatística). É doutora em ciência política pelo Iesp/Uerj (Instituto de Estudos Sociais e Políticos da Universidade Estadual do Rio de Janeiro), mestre em sociologia e antropologia pela UFRJ (Universidade Federal do Rio de Janeiro) e Visiting Scholar do CLAS/UC Berkeley (Estados Unidos).

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Covid-19 in Brazil: Lessons from a period of crisis

By Elize Massard da Fonseca

Empty streets in São Paulo, Brazil. (Photo by Elize Massard da Fonseca.)

Empty streets in São Paulo, Brazil. (Photo by Elize Massard da Fonseca.)

The new coronavirus is one of the most severe global health crises in history. 15 years ago, member countries committed themselves to the World Health Organization (WHO)’s International Health Regulation, which provides harmonized measures for global public health emergencies (World Health Organization 2005). As the Covid-19 emergency began, however, governments adopted starkly different approaches to fighting the epidemic. Despite established international norms and evidence-based guidelines based on previous influenza outbreaks, many government leaders, including President Jair Bolsonaro of Brazil, continue to sow doubt about the significance of the disease.

As Berkeley scholars have demonstrated, times of crisis create uncertainty but also shed light on political entrepreneurs. These crises are tough periods, but also carry the potential for change and policy innovation (Collier and Collier 1991, Pierson 2004). Therefore, there are several lessons we can draw from the Covid-19 outbreak.

A sign in a Brazilian pharmacy: We don't have masks. (Photo by Elize Massard da Fonseca.)

A sign in a Brazilian pharmacy: “We don’t have masks.” (Photo by Elize Massard da Fonseca.)

1) International guidelines for responding to global health emergencies will fail if they ignore politics. Crises are messy. They involve the cooperation of various interests, and coordination among political opponents is tough. In Brazil, a major obstacle to successfully countering the coronavirus epidemic is the dispute between the president and other government figures, including his health minister and state governors. This problem is not exclusive to Brazil — collaboration problems have appeared in many countries. Covid-19 emerged alongside a rise in nationalist politics and conservatism, which has influenced the direction and timing of the public response. Of course, such unexpected behavior would have been difficult to predict; however, the disarray makes clear that the WHO must be far more prepared to take on coordinating roles.

2) Evidence-based policies are crucial but they do not automatically translate into public policy; this is particularly true in watershed moments when many policy options are available. No matter how much pressure President Bolsonaro faces, be it from the Minister of Health, the public health community (which, in Brazil, is a powerful advocacy group), or the scientific community, it all falls on deaf ears. It is beyond the scope of this short blog post to analyze such political behavior but, echoing the call of Buse, Dickinson, and Sidibé (2008), it is clear that political scientists must have a role in the development of evidence-based policies. History tells us that the stubbornness of the South African President in denying the HIV/AIDS epidemic cost that country many lives. This is not very different from what is happening in Brazil and many other countries, unfortunately.

Henrique Mandetta, the Brazilian Minister of Health, in one of the ministry's trademark vests. (Photo by Isac Nóbrega/PR.)

Henrique Mandetta, the Brazilian Minister of Health, in one of the ministry’s trademark vests. (Photo by Isac Nóbrega/PR.)

3) We should be careful who we credit for taking effective action in response to public health crises. The Brazilian Minister of Health, Henrique Mandetta, has been in the limelight in the fight against the coronavirus. His popularity is now 21% higher than that of the president; he has been praised for making important technical decisions and being a strong voice for evidence-based policies. Mandetta is a physician by training, but also a savvy politician. Political entrepreneurship develops by circumstance, but also requires the construction of a social coalition and innovative framing (Pierson 2004); Mandetta has it all. He recently formed an alliance with governors in the opposition parties and gained the sympathy of the public health community. He is constantly wearing the national health system vest, and recently stated that “doctors do not abandon their patients.” In Mexico, Undersecretary of Health Hugo López-Gatell has also taken on a leadership role in the fight against the epidemic, while President Andrés Manuel López Obrador has adopted a discourse similar to that of Bolsonaro. The health officials are a product of the unique circumstances, and have shown themselves to be quite skilled at building coalitions.

It is difficult to know for certain whether this crisis will lead to a change in the direction of social protection and health policies in Brazil and around the world. It is certainly likely, however, that the world will come out of this crisis changed. From the structure of the economy to public health coverage to personal hygiene, coronavirus will have left a mark.

Government agents supervise sales of sanitizer, masks, and other medical supplies to prevent price gouging and hoarding, March 2020. (Photo by Paulo H. Carvalho / Agência Brasília.)

Government agents supervise sales of sanitizer, masks, and other medical supplies to prevent price gouging and hoarding, March 2020. (Photo by Paulo H. Carvalho / Agência Brasília.)

Finally, allow me to offer some insight for anyone worried or curious about what it is like to live with social distancing measures in Brazil. The uncertainty surrounding the epidemic is stressful in and of itself, but coupled with conflicting messages from the government and the apocalyptic sight of field hospitals being set up in soccer stadiums, I get the sense that the worst is yet to come. Please, stay at home and follow the guidelines from health authorities. Do what you can to ensure the safety of your community.

References

Buse, K, C Dickinson, and M Sidibé. 2008. “HIV: know your epidemic, act on its politics.” J  R Soc Med 101:572–573.
Collier, RB, and D Collier. 1991. Shaping the Political Arena: Critical Junctures, the Labor Movement, and Regime Dynamics in Latin America. Princeton: Princeton University Press.
Pierson, P. 2004. Politics in Time: History, Institutions and Social Analysis. Princeton/Oxford: Princeton University Press.
World Health Organization. 2005. International Health Regulations. Geneva: World Health Organization.

Elize Massard da Fonseca.

 

Elize Massard da Fonseca is Assistant Professor of Public Administration at the São Paulo School of Business Administration, Getulio Vargas Foundation (EAESP/FGV). She was a visiting scholar at CLAS in 2019, and can be reached at elize.fonseca@fgv.br.

 

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Boric: angustia y esperanza en Chile

Por Sofía Barahona y Felipe Vial

Chilean deputy Gabriel Boric speaks for CLAS at UC Berkeley, February 2020. (Photo by Nicolás Novoa-Marchant/www.sdpaudiovisual.com.)

El diputado chileno Gabriel Boric habla con la comunidad de CLAS en UC Berkeley, febrero de 2020. (Foto de Nicolás Novoa-Marchant / www.sdpaudiovisual.com).

Article in English

El pasado 10 de febrero, el diputado chileno de Convergencia Social, Gabriel Boric, estuvo en Berkeley invitado por el Centro de estudios Latinoamericanos (CLAS, por sus siglas en inglés). Se juntó a conversar con miembros de la comunidad de UC Berkeley sobre el estallido social en Chile y describió las principales agendas de reforma que se están discutiendo en su país: la agenda social, que busca dar respuesta a las problemáticas más urgentes de los chilenos; la de derechos humanos, cuyo fin es tanto garantizar el reconocimiento, sanción y reparación de los numerosos casos de vulneración de los derechos humanos de manifestantes, como también reformar las FF.AA y Carabineros; y la agenda constitucional que se manifestará, entre otras cosas, en el plebiscito que se realizará el 26 de abril para saber si se aprueba o no la redacción de una nueva constitución. (1)

Con respecto al proceso constitucional, Boric nos dejó varias reflexiones. Los niveles de violencia y manifestaciones que estamos viviendo como país son una respuesta a la violencia institucional que generó durante décadas la marginalización de un significativo porcentaje de la población. Los avances que nos posicionaban como uno de los países más desarrollados de Latinoamérica no reflejaban las realidades diarias que vivían miles de chilenos. Una de estas era un alto endeudamiento estudiantil ligado a títulos de instituciones que no cumplieron las expectativas. Las demandas de las movilizaciones reflejan también descontento con bajos salarios, pensiones, y un sistema educacional y de salud altamente segregado.

Es este clima político y social el que nos mantiene, como planteó el diputado, en una constante tensión entre la angustia y la esperanza. Angustia por las necesidades urgentes que aún no tienen solución, por la violencia, la represión, y la falta de soluciones concretas en el corto plazo a las necesidades más urgentes de los chilenos. Esto es utilizado como argumento por los sectores más conservadores para no avanzar en el proceso constitucional, declarando que no existen las condiciones mínimas que garanticen un proceso democrático. Además, plantean que un cambio constitucional tomaría mucho tiempo y que para solucionar los problemas más urgentes se pueden hacer reformas. Es irónico que aquellos son los mismos que se opusieron a un proceso constitucional durante el segundo gobierno de Michelle Bachelet – en condiciones mucho más “estables” que las de ahora – y son los mismos que han acusado de inconstitucionales muchas de las reformas propuestas en los últimos años.

A huge protest march in the Plaza Baquedano in Santiago, October 2019. (Photo by Hugo Morales.)

Marcha de protesta en la Plaza Baquedano en Santiago, Chile. Octubre de 2019.
(Foto de Hugo Morales.)

La segunda parte de esta tensión constante es la esperanza. El levantamiento social se sublevó contra la violencia institucional y dio paso a una gran oportunidad de cambio. Fueron los mismos ciudadanos que se autoproclamaron “despiertos” y sin intenciones de volver a dormir. El Congreso comenzó a legislar como nunca, los políticos lograron ponerse de acuerdo, la gente tomó las calles, volvió a conversar con el otro y a participar. La única certeza que tenemos es que, aunque los próximos años serán difíciles para todos, existe la inédita posibilidad de construir un nuevo pacto social impuesto por la razón y por la democracia, no la fuerza. Un acuerdo transversal para que, en nuestra carta fundamental, el marco social en el que nos desenvolvemos, quepamos todos.

1. La fecha del plebiscito constitucional fue cambiada al 25 de octubre de 2020 debido a la pandemia del coronavirus.
https://www.cnnchile.com/pais/plebiscito-nueva-fecha-25-octubre_20200319/

Sofia Barahona.

 

Sofía Barahona es la Coordinadora de Desarrollo de LYRIC, una ONG con sede en San Francisco que trabaja con jóvenes LGBTQ. También ha trabajado en East Bay Sanctuary Covenant y OLAS-LGBTQ Sanctuary Project, dos ONGs que trabajan con migrantes latinoamericanos en el Área de la Bahía. En 2017, antes de mudarse a los EE.UU., fue presidenta del sindicato de estudiantes de PUC Chile (FEUC) y portavoz del Movimiento de Estudiantes de Chile.

Felipe Vial.

 

Felipe Vial es un estudiante de doctorado de tercer año en el Departamento de Economía de UC Berkeley. Recibió tanto su B.A. y M.A en Economía en PUC Chile. Sus intereses de investigación giran en torno a la economía laboral y la economía política, particularmente centrados en los sindicatos y la acción colectiva

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Boric: Anguish and Hope in Chile

By Sofía Barahona and Felipe Vial

Chilean deputy Gabriel Boric speaks for CLAS at UC Berkeley, February 2020. (Photo by Nicolás Novoa-Marchant/www.sdpaudiovisual.com.)

Chilean Deputy Gabriel Boric speaks for CLAS at UC Berkeley, February 2020.
(Photo by Nicolás Novoa-Marchant/www.sdpaudiovisual.com.)

Artículo en español

On February 10, Chilean Deputy Gabriel Boric, of the Social Convergence party, spoke at Berkeley for CLAS. He discussed the social unrest in Chile and described the main agendas of reform that are being discussed in the country. There is a social agenda to find an answer to the most urgent problems of Chileans. There is also a human rights agenda, to guarantee the recognition, sanction, and reparation of numerous cases in which the rights of protesters have been violated, as well as the need to reform the armed forces and the police. Finally, there is the constitutional agenda that will be pushed forward by, among other things, the April 26 plebiscite to decide whether or not to begin the process of drafting a new constitution. (1)

On the constitutional agenda, Boric left us with several thoughts. The levels of violence and protests that Chile is experiencing as a country are a response to the institutional violence that generated decades of marginalization for a significant percentage of the population. The economic advances that positioned us as one of the most developed countries in Latin America are not reflected in the daily realities for Chileans. One reality is high student indebtedness linked to institutions that do not meet their promises of better jobs on graduation. Protesters’ demands also reflect widespread discontent with low wages, pensions, and a highly segregated education and health system.

It is this political and social climate that keeps Chile, as Boric stated, in a constant tension between anguish and hope. Its anguish is due to the urgent needs of the country that still have no solution, as well as ongoing violence, repression, and a lack of concrete programs to meet Chileans’ most urgent needs in the near future. The social upheaval these conditions have sparked is used by the most conservative politicians and their backers to oppose the constitutional agenda, arguing that the minimum conditions to guarantee a democratic process do not exist today. Those conservatives also argue that a constitutional change would take a long time, and that short-term reforms can solve the most urgent problems. It is ironic that those actors are the same people who opposed a constitutional reform process during Michelle Bachelet’s second government — in conditions that were much more stable than now — and have also labeled many of the recently proposed reforms as unconstitutional.

A huge protest march in the Plaza Baquedano in Santiago, October 2019. (Photo by Hugo Morales.)

A protest march in the Plaza Baquedano in Santiago, Chile, October 2019.
(Photo by Hugo Morales.)

The second part of this constant tension is hope. The social upheaval in Chile grew in the face of institutional violence and has created a great opportunity for change. It is citizens who have declared themselves “awake” and with no intention of going back to sleep. The Congress began to legislate as never before, politicians managed to reach agreements, the people took to the streets, dialogues ensued, and people continued to participate. The only certainty we have is that, although the next few years will be difficult for everyone, there is the unprecedented possibility of building a new social pact created through reason and democracy, not imposed by force. An intersectional agreement such as our fundamental document, the social framework in which Chileans operate, has space for everyone.

1. Please note, since this blog was written, the plebiscite has been postponed until October 25, 2020, in response to the Covid-19 pandemic.
https://www.cnnchile.com/pais/plebiscito-nueva-fecha-25-octubre_20200319/

Sofia Barahona.

 

Sofia Barahona is the Development Coordinator at Lavender Youth Recreation and Information Center, an San Francisco-based NGO working with LGBTQ youth. She has also worked in the East Bay Sanctuary Covenant and OLAS-LGBTQ Sanctuary Project, two NGOs that work with Latin American migrants in the Bay Area. In 2017, before moving to the U.S., she was President of PUC Chile’s student union (FEUC) and a spokesperson for the Chilean Student Movement.

Felipe Vial.

 

Felipe Vial is a 3rd year Ph.D. student in the Department of Economics at UC Berkeley. He received both his B.A. and M.A in Economics from PUC Chile. His research interests revolve around labor economics and political economy, particularly focused on unions and collective action.

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When “staying home” might not be an option for everyone: Reflections on the effects of Covid-19 in Brazil

By Laura Belik

The São Remo favela in São Paulo, Brazil. (Photo by Ben Tavener.)

The São Remo favela in São Paulo, Brazil. (Photo by Ben Tavener.)

In Brazil, according to the 2010 Census, 11,425,644 people (6% of the population) live in what is classified as Aglomerados Subnormais (Subnormal clusters), including favelas, comunidades, squatted land, invaded land, and the like. In a country where 81% of the people reside in urban areas, informal settlements are often overcrowded areas with low-income populations where access to basic infrastructure is not a given. Most of these people also make up a large part of the 41% of the population in the informal labor market, with jobs that are not regulated or protected by the state. While these unstable conditions already represent a struggle in their lives, a crisis such as Covid-19 make some of these issues ever more evident.

Common scenarios like families of nine or more sharing a one-room shack exemplify why social-distancing might simply not be an option. Intermittent access to water and open-air sewage systems right beside one’s home make it difficult to meet the World Health Organization’s sanitation regulations. On top of that, hand sanitizer has become an unaffordable item, or more commonly simply out of stock. When thinking about the effects of a fast-spreading virus in cities like São Paulo and Rio de Janeiro, wealth disparity and its consequences on the urban setting, how the urban form echoes social and economic inequality, become even more recognizable. No one can escape the effects of the coronavirus, but prevention methods to “flatten the curve” are a luxury that only the privileged can enjoy.

In Rio de Janeiro parties and the baile funk have been called off, and there is a curfew established by gangs and militias for people to return to their homes. At 8 pm, sirens normally used to announce risky situations such as storms and landslides are now an official Covid-19 curfew warning. Public health measures, as well as everyday practices, are once again determined and held informally by the ones that truly dominate these spaces. Neighborhood associations in peripheral areas have also been actively responding to the crisis in whatever ways they can, and collectively demanding official guidelines and support from the state.

Cleaning of public spaces in Brasilia, March 30, 2020. (Photo by Lúcio Bernardo Jr / Agência Brasília.)

Cleaning public spaces in Brasilia, March 30, 2020.
(Photo by Lúcio Bernardo Jr / Agência Brasília.)

Federal, state and local governments have been brainstorming specific measures to relieve at-risk populations during the spread of the epidemic. The use of hotels and even naval ships to house and isolate the elderly and other high-risk populations from informal settlements has been considered as an option.

“Stay at home” becomes a loaded term with multiple layers when cities heavily rely on informal relations. Many people cannot afford not to work, and will not be able to get help from the government precisely because of their lack of documentation. “If I don’t die of the virus, I will die of hunger,” says José Maria, 65, a street vendor who sells ice cream and is concerned with his income over the next few months. Home might also be an unstable place that has never symbolized safety in any sphere, not just considerations of health. In times of seclusion, Covid-19 makes clear how urban spaces in Brazil are disparate and unequal, and reemphasizing that thinking about our cities is a complex and interdisciplinary issue with no single solution at hand.

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Laura Belik is a Ph.D. Candidate in Architecture – History, Theory and Society at UC Berkeley. She holds an M.A. in Design Studies from Parsons – The New School (New York) and a B.Arch. in Architecture and Urban Planning from Escola da Cidade (São Paulo- Brazil). Her main research interests are urbanism, history of architecture, politics of space, design theory, and curatorial studies.  Her dissertation research focuses on the histories and dimensions of socio-spatial inequalities in the Brazilian Northeast region, and how to interpret the multiple memories related to the built environment.

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“Una mezcla de miedo y esperanza”

Por Enzo Nervi

Protesta chilena en Puerto Montt, diciembre de 2019. (Foto de Natalia Reyes Escobar).

Protesta en Puerto Montt, diciembre de 2019. (Foto de Natalia Reyes Escobar).

Reflexiones sobre la conversación entre Gabriel Boric y estudiantes hispanohablantes de la Universidad de Berkeley, 10 de febrero de 2020.

“Una mezcla de miedo y esperanza”. Con esta frase, el diputado chileno Gabriel Boric comenzó su conversatorio en UC Berkeley, refiriéndose al “estallido social”, el ciclo de manifestaciones sociales que han venido ocurriendo en Chile desde el 18 de octubre del 2019. Como chileno, sentí diversas emociones al escuchar esa frase. Primero, y bajo la esperanza de que una autoridad tendría respuestas sobre el futuro de mi país, no pude evitar sino sentir desesperanza al darme cuenta de que un Diputado de la República siente el mismo grado de incertidumbre que un ciudadano común. En segundo lugar, y luego de un mayor análisis, logré percibir las sinceras palabras del Diputado Boric como un intento de entregar completamente el protagonismo de las protestas a la ciudadanía, dejando atrás su pasado como líder estudiantil.

Como parte de la élite del país, según él mismo se identificó, Boric aprovechó para hacer un mea culpa sobre la percepción que se tiene actualmente respecto del Frente Amplio, coalición política a la que pertenece. Argumentó una excesiva “parlamentarización” donde, como Partido, se enfocaron en exceso en el Congreso, lo que se tradujo en una pérdida de cercanía e identidad con los movimientos sociales. Para Boric, todos los partidos políticos requieren una refundación después del 18 de octubre si quieren continuar en política, escuchando las demandas de la calle y replanteándose sus convicciones democráticas, para así lograr que la ciudadanía se sienta efectivamente representada por ellos.

Gabriel BorGabriel Boric escucha al congresista Giorgio Jackson, quien también asistió a la conversación. (Foto de Enzo Nervi.)ic escucha al congresista Giorgio Jackson, quien también asistió a la conversación. (Foto de Natalia Reyes Escobar.)

Gabriel Boric escucha al diputado Giorgio Jackson, quien también asistió a la conversación. (Foto de Enzo Nervi.)

Entendiendo plenamente el descontento con la clase política, Boric no intentó dar respuestas mesiánicas a la ciudadanía, ni ser el vocero de las actuales protestas, ni mostrarse como un experto en temas constitucionales. Boric procuró situarse como un ciudadano más, siendo su estrategia demostrar, a través de casos evidentes como la ley de pesca, o las disparidades en la justicia para ricos y pobres, que el contrato social instaurado en dictadura “tenía bases endebles que hicieron que colapsara”.

Según sus propias palabras, “no hay que ser experto ni abogado para darse cuenta de que la constitución del 80 está entrampada”. En este contexto, el Diputado se refirió a la votación del Senado para consagrar el agua como bien de uso público, donde, con 24 votos a favor y solo 12 en contra, se rechazó el proyecto. Mediante ese ejemplo, argumentó cuán necesario es crear una nueva Constitución que no tenga un vicio de origen, en vez de utilizar una sofisticada terminología legal para defender la opción aprobatoria en el tan esperado plebiscito.

Finalmente, el Diputado Boric citó al politólogo Juan Pablo Luna: “La élite está experimentando la incertidumbre que el resto de la sociedad tiene en su vida cotidiana”. A pesar de que, como la mayoría de los chilenos, esperaba tener respuestas concretas sobre la situación del país, después del conversatorio concluyo que hay certeza en cuanto a que el estallido social logró democratizar la incertidumbre en Chile, y así también, regaló esperanza a quienes han sido víctimas del modelo neoliberal implantado durante la dictadura de Pinochet.

Enzo Nervi.

Enzo Nervi

Enzo Nervi es estudiante del Programa de Maestría en Prácticas de Desarrollo de UC Berkeley y es de Valparaíso, Chile. Después de recibir una licenciatura en Economía y Administración y una Maestría en Economía y Políticas Públicas de la Universidad Adolfo Ibáñez, realizó una pasantía en la Comisión Económica para América Latina y el Caribe de las Naciones Unidas. También fue asistente de enseñanza para el curso “El impacto de la globalización en América Latina”.

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The Antihero

By Denise Dresser

Andrés Manuel López Obrador shakes hands with children at an event on March 15, 2020. (Photo from AMLO/Twitter.)

Andrés Manuel López Obrador shakes hands with children at an event on March 15, 2020.
(Photo courtesy of the Presidencia de la República Mexicana..)

March 16, 2020

Kissing and hugging. Going from meeting to meeting and from one restaurant to another. That is how Andrés Manuel López Obrador continues to move around Mexico, more like a tour guide than a president.

As if he were a cooking show host instead of the leader of a country confronting a global pandemic. As if he had not heard even one of the precautions against coronavirus shared by Hugo López-Gatell, the Subsecretary of Health. If we believe that epidemics reveal underlying truths about the societies they impact and the individuals they affect, then COVID-19 shows AMLO’s irresponsibility. A leader who does not lead, but avoids.

Far from Angela Merkel, who bravely told Germans that probably 70% of the population would become infected and they needed to prepare. Far from the Italian Prime Minister, who unequivocally declared, “There is no more time. Stay at home,” and quarantined 60 million of his fellow citizens. AMLO does not want to talk much about the coronavirus; he does not want numbers that show the scale of the problem; he believes that the virus is a conservative conspiracy rather than the biggest threat to his capacity to manage the country in times of crisis. He seems more interested in maintaining his approval ratings than in preventing the worst consequences of the infection.

To this day, many of AMLO’s followers are convinced that, when it comes to the coronavirus, Mexico is exceptional: more informed and with a better strategy than other countries. For them, there is no need to look at South Korea, Japan, China, Iran, Italy or the United States. Some say that additional testing is not needed because we are still in Phase 1 and there has been no community spread. They insist that we do not need to adopt more aggressive strategies – such as the ones adopted by countries that have flattened the curve of transmission – because of the very few reported cases.

Dr. Hugo López-Gatell Ramírez, Mexico's Subsecretary of Prevention and Promotion of Health, at a presidential press conference on Covid-19, March 19, 2020. (Photo from

Dr. Hugo López-Gatell Ramírez, Mexico’s Subsecretary of Prevention and Promotion of Health, at a presidential press conference on Covid-19, March 19, 2020.
(Photo courtesy of the Presidencia de la República Mexicana.)

It would be great to believe that López-Gatell and his team are right. But what is rapidly happening within and outside of Mexico contradicts the “do not worry” message that they are trying to disseminate. It is probable that Mexico will pay a steep price for not taking a more aggressive and preventative stance. It is possible that political loyalty to the president and his disdainful delay may have cost us the valuable time needed for more powerful measures. We now face the coronavirus with a health system that has been crippled by the current austerity and previous lack of investment: hospitals without sufficient beds, respirators, testing kits, medical teams or coordination. Serious mistakes have permitted the quiet spread of the virus while no one noticed and few suggested measures to stop it. Containment and mitigation efforts, early detection, and social distancing should have been implemented weeks earlier and with full presidential support. The same can be said about the distribution and administration of tests, which have reduced mortality rates in other regions. Instead of that, we go ahead with the “Vive Latino” music festival for economic reasons, and with the presidential tours for political reasons. As Alfredo Narváez wrote in Nexos, “The epidemic will not forgive mistakes.”

The coronavirus adds itself to the list of other current pathologies: deep polarization, a lack of trust in the institutions, the threat of an economic contraction that could become a recession, corruption that switches political parties but does not leave the government, the collapse of oil prices, a forecasted fall of the Pemex bonds, and the difficulty to unite our country when AMLO reviles anyone who does not applaud him. To point this out is not to be an alarmist but a realist; it is not to be the “opposition” who wishes a failure but a citizen who demands a correction.

Mexican cases of Covid-19. (Image from Wikipedia, data from Mexico's Secretariat of Health.)

Mexican cases of Covid-19. (Image from Wikipedia, data from Mexico’s Secretariat of Health.)

However, the president still thinks that he can stop a pandemic with kisses, hugs, handshakes and mass gatherings. He is more concerned about his personal popularity than the lethal virus. His narcissism is stronger than his patriotism. As Bob Dylan said, ” A hero is someone who understands the responsibility that comes with his freedom.” When acting irresponsibly, one kiss at a time, AMLO becomes the antihero.

This article originally appeared in Spanish in the March 16, 2020 edition of Reforma and was translated to English by Ana De Carolis, with the author’s permission.

Denise Dresser. (Photo by Paco Diaz.)

Denise Dresser. (Photo by Paco Diaz.)

Denise Dresser is Professor of Political Science at the Instituto Tecnológico Autónomo de México (ITAM). A political analyst and columnist writing for Reforma and Proceso, she is also the author of numerous publications on Mexican politics and U.S.–Mexico relations. Dresser received France’s Legion of Honor medal for her work on democracy,  justice, gender equality, and human rights.

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“We have seen the curve of history and it goes up” — An Evening of History and Humor with Isabel Allende

By Evan Fernández

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Adam Hochschild and Isabel Allende speaking at Berkeley, February 2020. (Photo by Peg Skorpinski.)

On February 25, the UC Berkeley Center for Latin American Studies hosted author Isabel Allende and Berkeley’s own Adam Hochschild to discuss the publication of Allende’s newest novel, Largo pétalo de mar (A Long Petal of the Sea). Published in 2019, the work is the most recent of Allende’s approximately two dozen novels and once again proves her ability to capture and process through fiction the drama and tragedy of real historical events. Despite her status as one of the world’s great literary figures, Allende exudes a disarming wit and a charming charisma. As she spoke before an excited audience of 300 people, her words throughout the evening wove together both humor and substantive contemplation. Punchy jokes ran alongside her more somber reflections on some of the tragic chapters of Latin American and world history in the stories which fill her books.

While I aspire to neither spoil the story of her new novel nor dare to think that I could concisely summarize the contours of a literary work à la Allende, the context in which Largo pétalo de mar is set goes something like this: in April 1939, the right-wing nationalist alliance led by Francisco Franco achieved victory in the Spanish Civil War, which had raged since 1936. The violence and suffering produced by the war led to the exodus of hundreds of thousands of Spanish refugees sympathetic to the left-leaning Republican coalition fighting against Franco. Many fled to France, where they were interned in concentration camps and forced to live in squalid conditions. Watching this crisis unfold was another giant of Latin American literature, Pablo Neruda, who at that moment served as a Chilean diplomat in Paris. Disturbed by the experiences of and sympathizing with the Spanish Republican refugees in France, Neruda, with the endorsement of the Chilean president, personally orchestrated the migration of 2100 of these individuals to Chile. Neruda acquired an old ship, the SS Winnipeg, which set sail from France in August of 1939 and arrived in the Chilean port of Valparaiso a month later. In a twist of historical coincidence too dramatic to make up, the Spanish refugees disembarked the Winnipeg in Chile on September 1, the very day that Germany invaded Poland and ignited the Second World War. Many of the 2100 on board resided in Chile for the remainder of their lives. Allende’s novel seizes the chaos and tragedy of this moment and narrates the stories of those on board as they sail across the Atlantic and begin their lives anew in Chile.

A packed Sibley Auditorium listens to Allende and Hochschild, February 2020. (Photo by Peg Skorpinski.)

A packed room listens to Allende and Hochschild, February 2020. (Photo by Peg Skorpinski.)

I am inevitably giving short shrift to the premise of the story Allende tells, but at least for me, grasping the history embedded in her work of fiction was central to understanding the lessons Allende sought to impart to her audience that night. The evening developed as a casual conversation between Allende and Hochschild before they both fielded questions from the audience. However, underneath her layers of charm, charisma, and humor, Allende’s words touched on numerous themes whose contemplation asks for a more serious response.

Adam Hochschild and Isabel Allende at Berkeley, February 2020. (Photo by Peg Skorpinski.)

Adam Hochschild and Isabel Allende at Berkeley, February 2020. (Photo by Peg Skorpinski.)

The aspect of Allende’s dialogue that most impacted me was her discussion of migration, mobility, and displacement; a trio of experiences to which she herself has extensive exposure. Allende narrated how she was born in Peru in 1942 and raised in Chile, where she matured as an author across her early life. She was then exiled to Venezuela after the coup d’état in Chile on September 11, 1973, which brought Augusto Pinochet’s right-wing military junta to power. Allende was one of thousands of Chileans who left during Pinochet’s 17-year dictatorship. While residing in the U.S., and now an American citizen, Allende transparently described how the trauma of exclusion from her own country informs her aspiration to process these experiences, which are shared by millions of refugees across the world, through the characters in her novels. Informed by her own experience, Allende thus conceives characters whose stories comment upon the feeling of a person displaced. She noted that her perseverance through years of exile was based on her philosophy that “we all feel pain, but suffering is optional.” On the broader point of exclusion and the tens of millions refugees across the world today, Allende called for the acceptance of people whom certain nationalist ideologies ostracize, and for reigning in the unchecked power of government officials. “My obsession since I was very young,” she asserted, “was justice.” One cannot separate the call for action implied in her words from a critique of the attitude towards immigration espoused by certain U.S. policy-makers today.

To say that the past remains with us is to repeat a truism. Even when articulated by a historian such as me, who is all too eager to point out the pressing lessons of history, it feels too obvious to need saying. Yet Allende assured that, among the crowd of 300 gathered to hear her speak, the weight of the past hung over the evening. Indeed, the author stated that she can only write fiction based on historical events. The vast majority of her work takes some inspiration from the human past, and Largo pétalo de mar sits alongside her previous novels (such as La isla bajo el mar, which takes place in the Haitian Revolution), in telling through fiction individual stories which could very well have happened.

Invoking though fiction the historical experiences of refugees in order to contemplate the world’s migration crisis today certainly leaves one exasperated and disheartened. However, Allende’s brilliance and inspiration as a public speaker lies in her ability to weave together tragedy, optimism, and humor. Despite raising these pressing themes, Allende left the crowd in Berkeley with a ray of hope, assuring that “we have seen the curve of history, and it goes up.”

Evan Fernández, UC Berkeley Ph.D. student in History.

Evan Fernández is a Ph.D. student in UC Berkeley’s Department of History, studying the history of Latin America, particularly Chile and Peru, as part of the Pacific world. His current project explores the Chilean sodium nitrate (salitre) industry and the sale of nitrates to Japan in the late nineteenth and early twentieth centuries. Evan also is working on a project concerning the Peruvian-Chilean border dispute in the 1920s and international relations in the Americas in the early 20th century.

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Upheaval in Chile

By Gabriel Boric

Written remarks prepared for a public talk at the University of California, Berkeley | Hosted by the Center for Latin American Studies (CLAS) | February 10, 2020

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A protest in Santiago, Chile, October 2019. (Photo by Carlos Figueroa.)

It’s incredible how language can limit your expression and even your imagination. As you know, my mother tongue is Spanish, so please excuse me if I have a hard time making myself clear in this talk. I’ll do my best, but I also might need some help to express some ideas.

I would like to thank CLAS and Beatriz Manz for giving me the opportunity to be here in Berkeley. For me it is very important to have the chance to talk to you and get a different perspective on what’s going on in Chile, because being in the center of the effervescence for so many weeks (months now), narrows your view of the problems and opportunities we’re facing.

Before I start I must say that I don’t pretend to be an impartial observer of the situation we’re living in Chile. I’m into politics and a militant of Convergencia Social (the name of our party that has just been legalized), which is part of Frente Amplio, a left wing coalition that in the last presidential election had the 20% of the votes. Therefore, I have a point of view, which of course doesn’t prevent me from questioning my own ideas, an exercise that for me at least is very important in politics and in life. As Albert Camus said, “doubt must follow convictions as a permanent shadow”.

I’m going to center my talk on what I believe are the main causes of the social rebellion in Chile, and leave the future perspectives, proposals and the constitutional challenge to the dialogue, so I can go deeper on those topics.

Neoliberal public policies were introduced after the overthrow of Salvador Allende in 1973. At the end of the 70’s, Chile became the guinea pig of this Chicago-made experiment in the whole world. Of course, these reforms could only have been made in an authoritarian regime, where no discussion was permitted.

These policies have been softened by the transition to democracy, but their essential pillars were preserved. Chile has had a remarkably good record of growth, and while in the 1960-70s it was in the middle of Latin American GDP per capita, it is now the richest Latin American country. The success in growth is incontestable.

But where are the hidden parts of this growth?

I’ve always thought that we should make efforts to link politics with cultural expressions, so I’m going to start this talk with a poem from Enrique Lihn that describes in a heart-rending way an endemic problem that is in the center of the discussion nowadays in our country. It’s called “Punta Arenas Cemetery” (the translation is mine with a friend so my excuses to Enrique Lihn if we didn’t express its power).

CEMETERY IN PUNTA ARENAS

Not even death could make these men alike

who give their names to different gravestones

or shout them into the sun’s wind that rubs them out:

some more dust for a fresh gust of wind.

Here, by the sea that matches the marble,

between this double row of generous cypresses,

peace rules, but a peace struggling to shatter itself,

ripping the burial parchments in a thousand pieces

to poke out the face of an ancient arrogance

and to laugh at the dust.

 

This city was yet to be built

when its first born sons raised another empty city

and, one by one, they settled deep into their place

as if they could still dispute it.

Each one forever on his own, waiting,

the tablecloths laid out, for his sons and grandsons.

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