Committed to a holistic and collective approach to individual and community health, Alejandra Sánchez Cabezas has created an inclusive, interdisciplinary and social approach that builds bridges among communities and public health and related institutions which enables the former to take a leading role to ensure their own health.
A nova ideia
Alejandra is challenging the orthodoxy of the Argentine public health system by stressing civic participation to transform mindsets and perspectives about healthcare. With her organization, Surcos, she promotes a network-based, holistic vision of healthcare that broadens communities’ perspectives of themselves. Alejandra promotes an approach of collective empowerment that recognizes all of the factors that determine a community’s health, including the social, economic, and environmental aspects that traditional medicine neglects or dismisses. She envisions a new type of wellness-based civic engagement for poor rural and urban populations that are relatively estranged from decision-making and are only passive actors in the public health of their communities.
Surcos is founded on a multidisciplinary healthcare perspective, applying strategies that it constructs with each community with which it works. At its core are the principles of community organization to address health problems and community empowerment—it is the active participation of all persons and institutions that drives social change. Alejandra distinguishes herself with an extremely professional program that is nonetheless completely malleable and can adapt to any local circumstance, process, or pattern. This allows each community to determine the sources and root causes of its health problems, without the influence of the public health hierarchy. Together with the community she helps weave networks and promote sustainable social change, activating existing but perhaps dormant systems and skills. In this sense, community healthcare makes possible new opportunities that will enable the community to better maximize its resources, networks, and people to influence the major determining factors of healthcare and thereby improve their quality of life.
Alejandra’s simple yet multifaceted approach relies on three critical phases. First, Surcos helps the community identify the principal health problems of each locale. Then members plan an action plan that forms networks and makes people the protagonist in their health. Finally, the community works with Surcos to institutionalize the projects and practices that they developed together, thereby ensuring their longevity. Alejandra has produced key experiences and projects with communities across Argentina and is looking to produce a full-fledged strategy to change public health infrastructure and university study to adopt her community-driven mission.
While most basic indicators of poverty rely on economic measures to determine a person’s or family’s financial disadvantage, a state of poverty means far more than just a lack of money or disposal income. Because of the enduring cycle that poverty sets in motion, people often have little access to the education and healthcare they would need to rise out of misery. In Argentina, many impoverished people suffer from malnutrition and high rates of communicable disease. In impoverished communities social structures and customs disintegrate, and violence, domestic abuse, and intergenerational conflict are rampant—the elderly disdain the young who are often unemployed and cannot resist the temptation of drug and alcohol use, while the young perceive the elderly as having outlived their productive years. All of these social consequences have an impact on a community’s health and wellness.
The institutions in Argentina, though, are not organized or prepared to respond appropriately to these healthcare challenges among poor communities. For instance, the formal practice of medicine is segmented into rigid, distinct fields of study. Medical professionals do not respond with an interdisciplinary approach that also regards the economic, social, cultural, and environmental dimensions that greatly influence one’s health. The public health infrastructure is also by and large prepared to attend only to a single person’s biological/physiological needs, rather than take into account that person’s relationships and influences within his/her community. This community, though, is a critical stimulus for certain behaviors or phenomena that affect the patient. The bureaucracy of the public health system has not evolved to attend to the practical needs of urban and rural communities in poverty, and a diversity of institutional stakeholders in the public and social sectors creates unnecessary redundancy in some areas and absolute neglect of others. Siloed thinking, hierarchy and reluctance to change further diminish the possibility of cross-sector collaboration to achieve a holistic approach to medicine.
Communities themselves lack the know-how and spaces to reflect and take action to confront their healthcare problems and to engage effectively with the public health system and other bodies which could be resources to support the communities’ needs. Within impoverished communities, there is little tradition of engagement in civic activities and municipal decision-making. Those in positions of authority who could assist have not demonstrated the foresight to deal with social problems effectively, such as fostering connections with the electorate and facilitating new community-based processes of social change. They do not make an effort to extend pathways to their citizens to interact with them and influence their own community health. As a result, the communities and their principle healthcare providers are isolated from one another and ignore the social and contextual factors that play a major role in the overall wellness of the people there.
Alejandra launched her life’s work out of her deep concern about the healthcare in the poorest communities in Argentina. In 2010, the actions she was carrying out within distinct communities became formalized by establishing Surcos, a citizen organization (CO) comprised of professionals from a variety of disciplines. Currently twelve people work in the organization, which also maintains an advisory board of specialists and leaders in the field of health. Alejandra has managed to secure a wide portfolio of private sector and foundation support to slowly influence how the municipal and provincial public health authorities deal with their constituents.
Surcos intervenes with each community in a different way based on the social phenomena and needs there, but then ties each tactic with its overall vision and other strategies implemented with other communities to achieve a comprehensive, nationwide paradigm change. Alejandra starts by identifying and mapping the most relevant aspects and institutions that have a direct and indirect impact on the community’s healthcare. She does this with the clear input of the members, engaging in lengthy dialogue to pinpoint the actual stimuli. While the main causes of the healthcare problems can range from those more conventionally perceived as medical (such as alcoholism) to other, less directly medical ones (such as intergenerational conflict), Surcos keeps at the core an emphasis on how these phenomena produce an undesirable healthcare outcome. This keeps the frame of reference within the scope of health while at the same time creating a multidisciplinary dimension, overcoming the individualistic and biological focus of traditional public health. After reflection, Surcos works together with the community to prepare an action plan that enables civic participation, making every person a protagonist and changemaker in protecting and preserving their wellness.
Surcos also mobilizes the infrastructure of local healthcare agencies and grassroots organizations and COs to promote new ways of cross-sector and cross-institutional cooperation, through practices designed by the citizens and institutions themselves. To ensure long-term sustainability of the plan, Surcos helps the agencies and COs recognize and overcome obstacles to institutionalize the changes that take place, through public policy reform or building congruence of public and private sector actors. For instance, Surcos may help draft and sign agreements among distinct municipal authorities, community representatives and advocates, and interagency networks. The local media too serves a fundamental role in this construction of a new “health citizenship.” After participating in the initial stakeholder convening, they spread the new holistic projects and programs to help their formal institutionalization. What distinguishes the Surcos approach is how it takes advantage of processes that are never less than 3 years old, allowing it to weave together networks and promote sustainable social change, activating and stepping on existing capabilities and systems.
For example, in 2009 the Perez Companc Foundation invited Surcos to work with a population in the northeastern province of Misiones that had suffered damage sustained after a tornado struck the area. The first responders and emergency aid pulled out six months after the incident, but the community still suffered from the tremendous damage wrought, and Perez Companc and Surcos started their intervention. Their first diagnostic showed a clear misalignment of priorities and poor engagement between the different levels of the healthcare system in Misiones, whose local clinics and outposts were located far away from the isolated communities, which had little means of transportation and adequate roadways to reach them. Surcos helped the community form a cross-sector health working group made up of municipal health clinics, the hospital, leaders from the M’bya Garaní indigenous group (the first time that members of a tribe participated in this way with the health department), educational institutions, environmental agencies, and other community and national stakeholders. Surcos carefully trained 22 representatives of local organizations in the vision of community healthcare and helped them to map out the principal health problems affecting the region and established new initiatives to address and monitor them. Surcos also trained 30 local healthcare promoters and 10 doctors in prevalent issues of healthcare. Most importantly, they demonstrated throughout the intervention the principle of community healthcare, placing health as a key topic in the media and public frame of mind, thereby making public policy change more feasible and raising a demand for quality healthcare among the population.
As part of the project, the network in Misiones and Surcos are developing an online platform to register vital statistics about the population, align priorities and carry out the health program by the local government. If this plan succeeds, Alejandra expects to employ this new online system in other areas. This experience also emblemizes the flexibility of the Surcos model: Alejandra sees that many of the concrete outcomes—strategies and tools—are replicable in other communities with the appropriate contextualization.
Another example of Surcos’s adaptive and flexible methodology is its project in Pilar, in Buenos Aires province. With Surcos the community identified that domestic violence and social conflict among younger and older generations was in fact a source of many problems with health-related consequences. With this in mind, community leaders in Pilar followed a principle of community health and formed a stakeholder working group in conflict prevention. They trained teachers and city leaders in conflict identification and resolution, and they also built the capacity of the local police force to improve their practices in receiving and responding to such cases. They also involved other local organizational specialists. Together, the working group built a space to supervise allegations of violence in the local precinct departments. With older people, the team established a weekly series of activities to help them in memory recovery and improved communication and integration with young people. Then the working group established two semimonthly segments on the local radio to discuss public issues such as respectful birthing, nursing, child-rearing, infant and child development, nutrition, prevention of child abuse, pediatric respiratory infections, and healthy aging. Representatives of the community health centers, healthcare professionals and members of the social center took part in these segments. After these radio shows proved a success in spreading the concept and importance of holistic community health, the community health network in Escobar, also in Buenos Aires province, modeled a similar initiative with a half-hour segment every two weeks on television. During this broadcast they still promote new activities in healthcare and testimonials.
Surcos performs a detailed evaluation to monitor its advances and improvement in community healthcare awareness. In 2012, Alejandra partnered with the prestigious medical university Center for Medical Education and Clinical Research that enabled residents in family medicine, whom Surcos was preparing in the field of community health, to take part in field-based experiences. Alejandra expects that this productive relationship will be vital as she prepares the next generation of doctors in holistic, community health, thereby beginning to dismantle the rigid public health system with disciples in the community of multidisciplinary treatment and prevention. She recently published a lengthy and fully comprehensive textbook Community Health Promotion: A Dialogue Between Theory and Experience that documents in very concrete steps, exercises and modules the different experiences that Surcos has had with community health incidence. This textbook, in the form of a practical manual, will also help in spreading the methodology to other medical institutions and practitioners. Alejandra foresees that the institutionalization of the projects in the field plus the educational component encompassed by the textbook and medical school strategy will both act as multiplier effects that will catch the enthusiasm of other communities demanding a multidiscipline approach to wellness.
Alejandra’s youth was marked by the sacrifices of her grandparents, immigrants to Argentina from Spain, who forever lived in poverty, and of whose eight children, three died young and two suffered from mental and psychological illness. Upon finishing school, she studied medicine, from a desire fundamentally rooted in helping others. Yet her experience in medical school began to pull her away from her social motivation, as the curriculum that had been imposed by the military dictatorship dismissed any mention of social issues. During her medical residency in gynecology, though, she interned at two hospitals where she attended patients who mainly came from the slums in Buenos Aires. This reality, and the close relationship she felt with her roots, tugged at her while she worked in private practice at a clinic she opened with three colleagues. Questioning her professional trajectory and her vocation, she left the comfort of her practice and started to challenge the dominant healthcare paradigms. This paradigm, she felt, only benefited certain elite multiple interests and did not correspond to the needs of the communities, especially the poorest.
Alejandra felt that her formal medical training failed to provide adequate preparation to address this complex issue. She decided to start studies that would equip her with more resources and tools to challenge the difficult realities and poverty in the interior of Argentina. Alejandra completed a master’s degree in Epidemiology, Administration and Health Policy, which only seemed to raise more questions and challenges, and now she is pursuing a PhD in Collective Health. Alejandra fervently believes in education and training as a critical resource for work and social change. For this reason, key to the Surcos methodology is the collective reflection and analysis. Convinced that citizens must learn to exercise their rights and responsibilities through careful education and a wide-ranging systemic view, now Alejandra aspires to transform healthcare systems to enable their active participation in their wellness.