Developmental Impacts of PANS/PANDAS and Inadequate Support for Children and Families.

This article examines the degree to which major domains of child development are affected by Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)/Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Using cross-sectional survey data collected with an international sample of parents who identify as having children with PANS/PANDAS (N = 402), this study analyzed parent-reported developmental impacts and access to treatment and adequate supports. Parents reported that PANS/PANDAS negatively impacted their children's development across all domains: Emotional Development (92% of children), Social Development (90%), Cognitive Development (86%), Academic Growth (86%), Identity Development (83%), Talent Development (73%) and Language Development (50%). In addition, developmental impacts were likely to be more severe for children whose parents reported a greater number of inadequate supports with parenting, school, extracurricular activities, and crisis situations. These results indicate that children and families affected by PANS/PANDAS need better support to maximize children's opportunities, at home, in school, and in their communities, to continue developing despite challenging neuropsychiatric symptoms.

Untimely care: How the modern logics of coverage and medicine compromise children's health and development.

How do families manage when health care systems do not "cover" and clinicians do not acknowledge their children's condition? This article presents an ethnographic study in the Northeastern region of the United States with 20 families with children diagnosed with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)/Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Two of the 20 families had moved to the U.S. seeking care. The for-profit structure of the U.S. health care system resulted in costly and lengthy therapeutic journeys to access a diagnosis and adequate treatments. In the U.S., PANS/PANDAS coverage depends on legislation, advocacy, clinical characteristics of each child, and how for-profit insurance companies react to an increased demand for a given service. Many medical professionals, both in the U.S. and in other countries, refuse to acknowledge the condition or offer effective treatments that lack "acceptable" evidence. We argue that the financial logic behind coverage exists across modern health care systems and imposes restrictions and exclusions that impede access to care. Thus, untimely care, the time gap from PANS/PANDAS symptoms to diagnosis and treatment is the result of the modern logics that structure medicine and coverage. The results of this study illustrate how modern medicine and coverage fail to protect families with children with PANS/PANDAS against catastrophic expenses and often block care that would prevent developmental disruptions and losses, avoid much suffering, and even save costs to health care systems. New and controversial conditions like PANS/PANDAS highlight the importance of separating the financial logics behind proposals such as "universal health coverage" from the provision of comprehensive forms of care that acknowledge uncertainty and prioritize action and flexibility.

Medical labour under neoliberalism: an ethnographic study in Colombia.

OBJECTIVES: In order to increase the knowledge about the impacts of neoliberal market forces on physician's labour, this article's objectives are to analyse how and why the labour of physicians is transformed by neoliberalism, and the implications of these transformations for patient care. METHODS: Ethnographic investigation is carried out through semi-structured interviews with 20 general practitioners at public and private facilities in Colombia. The interviews were contrasted with national studies of physician's labour since the 1960s. A "mock" job search was also simulated. The analysis was guided by Marxian frameworks. The study was approved by a Human Research Ethics Committee, and informed consent was obtained from all participants. RESULTS: The overpowering for-profit administration of the Colombian healthcare system imposes productivity mechanisms on physicians as a result of a deregulated labour market characterized by low salaries, reduced and self-funded social security benefits, and job insecurity. Overworked physicians with reduced autonomy become frustrated for not being able to provide the care their patients need according to clinical standards. CONCLUSIONS: Under neoliberal conditions, medical labour becomes exploitable and directly productive through its formal and real subsumption to Capital. The negative consequences of a progressive loss in physician's autonomy unveil the incompatibility between neoliberal health systems and people's health.

Primary Health Care for Universal Health Coverage? Contributions for a Critical Anthropological Agenda.

Forty years after the Alma-Ata declaration, the WHO has reaffirmed its commitment to Primary Health Care (PHC). We argue that this renewed interest in PHC is being coopted by the neoliberal agenda on health via its application to Universal Health Coverage (UHC) reforms as part of the Sustainable Development Goals (SDGs). We offer an overview of classic anthropological studies on PHC, and more recent ones on UHC, as a way to propose some research foci and a set of questions for emerging critical anthropological research. Lastly, we suggest the careful reading of five recently published articles in Medical Anthropology.

Social Class for Collective Health Research: A Conceptual and Empirical Challenge.

Social Determination of Health (SDH)/Collective Health is a Latin American framework that sees the Marxist core concept of social class as fundamental for understanding health inequalities. In contrast to social stratification approaches, Marxist proposals seek to understand health as part of the historical transformations of capitalism's mode of production. In this article we aim to analyze the relationship between social class and health inequalities using data from the IV Oral Health National Study in Colombia. We conducted hierarchical cluster analyses to classify the population in five class positions and three living conditions clusters, which reflect how the spheres of production and social reproduction relate to social classes in Colombia. To measure oral health we use DMFT, as well as care and treatment needs indexes. Through variance analysis models we found that people from more exploited class positions and worse living conditions have more active disease and higher treatment needs. Despite technical and conceptual challenges, we conclude that a social class analytical framework can be operationalised via the interrelated spheres of production and social reproduction, which sheds light on the relationship between health inequalities and the class structure of the capitalist system.

Sociocultural dynamics that influence Chagas disease health care in Colombia.

Chagas disease (CD) is a Latin America endemic and neglected tropical disease that affects primarily poor people living in rural areas. Its current low profile leads to many diagnostic, treatment, and control challenges. This study aimed to identify and characterize the sociocultural dynamics that influence CD health care in Colombia. Data for our ethnographic study was collected in 2013 and included participant observation in two main endemic areas in Colombia. In addition, 81 people belonging to four groups (patients and family members; health care workers; researchers; and officers) were recruited through snowball sampling technique and participated in informal and semi-structured interviews. People from the first two groups also participated in social cartography excercises. Data analysis resulted in the identification of three main sociocultural dynamics. Local Understandings: Patients reported confusions around disease transmission, treatment effectiveness and development of future complications. Providers' Knowledge and Training: Failures in professional's knowledge and training mostly affect the primary level of care in rural areas. Professionals undergo minimal training during medical school and lack access to continuous education. In contrast, clinicians working at tertiary university hospitals or at the CD unit of the Colombian National Institute of Health (NIH) exhibited great knowledge and competency. Health Care System Barriers: The Colombian market-based health care reform augmented access barriers, which impacted CD care greatly. We identified geographic and bureaucratic itineraries that depended on type of insurance plan, insurance contracts with service providing institutions, and levels of care. This study shows that people's experience of these sociocultural dynamics vary depending on their mobility from rural to urban contexts. It unveils the importance of analyzing the structure of the health care system. In the Colombian case, its for-profit orientation has become one of the most important obstacles for comprehensive, integrated, and timely health care responses.

Kangaroo Mother Care in Colombia: A Subaltern Health Innovation against For-profit Biomedicine.

This ethnographic study presents the origins, growth, and collapse of the first Kangaroo Mother Care (KMC) program, a well-established practice for neonatal care created in 1978 in Colombia. The WHO and UNICEF praised this zero-cost revolutionary technique for its promotion of skin-to-skin contact between premature and low-birth-weight newborns and family members. KMC facilitates early hospital discharge, brings many clinical and psychological benefits, and constitutes an excellent alternative to placing babies in incubators. However, these benefits and political potential against biomedical interventions were undermined after being relabeled as a "reverse innovation," a business concept that encourages corporate investments in low-income countries to develop technologies that can both solve global health problems and boost multinational corporations profits. In response, I propose "subaltern health innovations" as a label for KMC that accounts for the power dynamics in global health between health care initiatives that originate in the Global South and neoliberal configurations of for-profit biomedicine.

Work-related illness, work-related accidents, and lack of social security in Colombia.

The impacts of neoliberal or market-based social security reforms in health have been extensively studied. How such reforms transformed employment-related insurance and entitlements, however, has received significantly less attention. This study aims to understand how the employment insurance system operates in Colombia and to assess how the experience of workers seeking social security entitlements relates to the system's structure. We conducted an ethnographic study of the Colombian Occupational Risk System between May 2014 and March 2016, with two main components: 1) analysis of the system itself through in-depth interviews with 32 people working in leadership positions and a systematic review of the system's most important legislation, and 2) a study of people who experienced problems receiving entitlements and were challenging the assessment of their work-related illness or accident. We conducted in-depth interviews with 22 people, followed up with half of them, and reviewed their case files. We found that difficulties accessing health care services, payments for medical leave, job reassignments, severance packages, and filing for pension benefits were common to all cases and resulted from overwhelming bureaucratic and administrative demands. Regional and national evaluation bodies dictate whether a given illness or accident is work-related, and establish a percentage of Loss of Wage Earning Capacity (LWEC). People's disabled bodies rarely reached the threshold of 50% LWEC to qualify for disability pensions. The lengthy process that workers were forced to endure to obtain work-related entitlements always involved the judiciary. The three competing for-profit financial sectors (health insurance, pension funds, and Occupational Risk Administrators) actively challenged workers' demands in order to increase their profits. We conclude that these for-profit sectors work contrary to the principles that sustain social security. Indeed, they push sick and disabled workers to unemployment, informality, economic dependence, and ultimately dire poverty.

Syndemic vulnerability and the right to health.

Investigators working both in syndemics, a field of applied health research with roots in medical anthropology, and in the field of health and human rights recognise that upstream social, political, and structural determinants contribute more to health inequities than do biological factors or personal choices. Syndemics investigates synergistic, often deleterious interactions among comorbid health conditions, especially under circumstances of structural and political adversity. Health and human rights research draws on international law to argue that all people deserve access not only to health care, but also to the underlying determinants of good health. Taking the urgent matter of migrant health as an empirical focus, we juxtapose the fields of syndemics and health and human rights, identify their complementarities, and advocate for a combined approach. By melding insights from these fields, the combined syndemics/health and human rights approach advanced here can provide clinicians and other key stakeholders with concrete insights, tools, and strategies to tackle the health inequities that affect migrants and other vulnerable groups by: (1) mapping the effect of social, political, and structural determinants on health; (2) identifying opportunities for upstream intervention; and (3) working collaboratively to tackle the structures, institutions, and processes that cause and exacerbate health inequities. Undergirding this approach is an egalitarian interpretation of the right to health that differs from narrow legalistic and individual interpretations by insisting that all people are equal in worth and, as a result, equally deserving of protection from syndemic vulnerability.

Care and consumption: A Latin American social medicine's conceptual framework to comprehend oral health inequalities.

This article offers a conceptual framework that arises out of the Latin American Social Medicine/Collective Health (LASM/CH) tradition to comprehend inequalities in oral health. We conducted a dialogue between the LASM/CH proposal called social determination of health (in particular one of its nuclear categories 'ways of living together') and studies that address social inequalities and oral health. This dialogue allowed us to redefine oral health-disease-treatment as a process that either promotes or harms well-being and is modulated by different ways of living together where not only patients and professionals, but also governments, supranational bodies, and national and international markets represented by food, pharmaceutical, insurance, personal care, and cosmetic companies interact. The article proposes the cycle particular-consumption care/institutional-consumption care as the construct that allows investigators to think about how ways of living together relate to oral health inequalities. 'Particular-consumption care' includes ways and possibilities to access healthy foods and practice protective hygienic measures. 'Institutional-consumption care' refers to institutional responses related to supply, access to services, capabilities for resolution, and pedagogical practices.

Interacciones entre el cuidado doméstico y hospitalario durante la gestación y el puerperio entre mujeres que viven en condiciones socio-económicas adversas que asisten a una clínica de maternidad en Cartagena, Colombia / Interactions between home care and hospital care during pregnancy and postpartum among low-income women in a maternity clinic in Cartagena, Colombia

Introduction: This paper proposes an approach to maternal health from the care process perspective to understand how determinants of health manifest in the daily experience of women. Objective: To describe and analyze the interaction between the domestic and clinical care during pregnancy and post-partum among women who live in adverse socio-economic conditions. Methodology: Qualitative study based on semi-structured and in-depth interviews, participant observation, and analysis of secondary sources. Twenty women who received care at a maternity clinic in the city of Cartagena, Colombia were interviewed. Participants had an average age of 25, lived in adverse socio-economic conditions and had at least one of the following obstetric risks: preterm labor symptoms, previous abortions, or mild preeclampsia. Participant observation took place at the clinic and at the residence of four patients. In addition, six in-depth interviews were conducted with health workers of the clinic. Results: The socio-economic conditions of women and their family dynamics determine their experiences of maternity. Relatives, usually other women, are the main agents of care. The most important care activities revolve around physical activities, transportation, nutrition, and exposure to the environment. The characteristics of domestic care play an important role in the clinical environment. Conclusion: Family-centered care requires acknowledging the role of relatives and other members of the women's social networks as guides in the healthcare process. Likewise, recognizing the socio-economic conditions of women requires adapting health services to the needs of women and their families in order to avoid reproducing social inequalities.

Introducción: Este estudio aborda la salud materna desde el enfoque del proceso de cuidado a fin de entender cómo los determinantes de la salud se expresan en la experiencia cotidiana de las mujeres. Objetivo: Describir y analizar la interacción entre el cuidado doméstico y el cuidado hospitalario durante la gestación y puerperio en mujeres gestantes que viven en condiciones socio-económicas adversas. Materiales y métodos: Estudio cualitativo basado en entrevistas, observación participante y análisis de fuentes secundarias. Participaron 20 mujeres que asistieron a una clínica de maternidad en la ciudad de Cartagena en el 2013. Las participantes tenían una edad media de 25 años, vivían en condiciones socio-económicas desfavorables y contaban con uno o más de los siguientes riesgos obstétricos: amenaza de parto prematuro, antecedentes de aborto y/o pre-eclampsia leve. Se realizaron observaciones en el hospital y en la residencia de cuatro mujeres. Adicionalmente, se entrevistaron 6 profesionales de salud de la clínica. Resultados: Las condiciones socio-económicas adversas que reportaron las mujeres y las dinámicas familiares de su contexto determinan sus vivencias de maternidad. Las familiares son las principales agentes de cuidado. Los cuidados más importantes están relacionadas con actividades físicas, transporte, alimentación y exposición al ambiente. Los cuidados domésticos se trasladan al ambiente hospitalario. Conclusión: Los modelos de atención hospitalarios deben reconocer el rol de las redes de apoyo de las mujeres como guiadores del proceso de cuidado y entender las condiciones de vida de las mujeres para adaptar los servicios a las necesidades de las pacientes y evitar reproducir situaciones de desigualdad.

Neoliberal Justice and the Transformation of the Moral: The Privatization of the Right to Health Care in Colombia.

Neoliberal reforms have transformed the legislative scope and everyday dynamics around the right to health care from welfare state social contracts to insurance markets administered by transnational financial capital. This article presents experiences of health care-seeking treatment, judicial rulings about the right to health care, and market-based health care legislation in Colombia. When insurance companies deny services, citizens petition the judiciary to issue a writ affirming their right to health care. The judiciary evaluates the finances of all relevant parties to rule whether a service should be provided and who should be responsible for the costs. A 2011 law claimed that citizens who demand, physicians who prescribe, and judges who grant uncovered services use the system's limited economic resources and undermine the state's capacity to expand coverage to the poor. This article shows how the consolidation of neoliberal ideology in health care requires the transformation of moral values around life.

The Transformation of the Value of Life: Dispossession as Torture.

Workers at the oldest maternity hospital in Colombia experienced the privatization of health care and the flexibilization of their labor. Drawing on their experience, I illustrate how neoliberalism transforms the value of life. This transformation occurs first in terms of its moral worth: the worth of life changes over time, as people and public hospitals are stigmatized as the 'living memory' of the old. Second, the hospital buildings, the land on which they sit, and the roles of workers within the hospital are all transformed. Both similarities and differences emerge between a type of systemic or chronic violence that is inherent to the capitalist system and modern practices of torture. Examining how capitalist forces transform the value of life opens up new fields of inquiry to study links between critical political economy and subjectivity.

Repensar la salud desde una Academia crítica y comprometida. Vida, acumulación y emancipación / Rethinking Health from a Critical and Committed Academy: Life, Accumulation and Emancipation / Repensar a Saúde desde uma academia crítica e comprometida. Vida, acumulaqáo e emancipado

Se plantea la necesidad de cuestionar la hegemonía epistemológica, teórica y política de categorías como salud-enfermedad y bienestar, para proponer una perspectiva analítica diferente. Esta implica centrarse en la comprensión de las relaciones entre la praxis de los agentes sociales, la estructuración del régimen local de acumulación capitalista y el sufrimiento subjetivo que producen los diferentes sistemas de dominación y desigualdad social. Se presenta, en primer lugar, una reflexión sobre algunos elementos de teoría crítica que permiten contestar los marcos analíticos hegemónicos sobre las diversas dimensiones de las políticas de la vida y la salud, seguida por algunas alternativas para su comprensión. Posteriormente, se expone una aproximación a las problemáticas sociales claves que comprenden el desplazamiento analítico propuesto. Finalizando, se sintetiza la relevancia de una epistemología crítica del "cuidado de la vida" que logre contribuir, acompañar y potenciar luchas emancipatorias que enfrentan las expresiones violentas de distintos órdenes de dominación.

We bring up the need to question the epistemological, theoretical and political hegemony of categories such as healthillness and well-being, to propose a different analytical perspective. This implies focusing on the understanding of the relationships between the praxis of social agents, the structuring of the local capitalist accumulation regime, and the subjective suffering produced by the different social inequality and domination systems. Firstly, we present a reflection on several critical theory elements that lead to an answer on the analytical hegemonic frameworks on the different dimensions of life and health policies, followed by several alternatives for its understanding. Afterwards, we present an approach to the key social problems that cover the proposed analytic shift. Finally, we summarize the relevance of a critical epistemology of the "care for life" that manages to contribute, accompany and strengthen the liberating struggles, faced with the violent expressions of different orders of domination.

Coloca-se aqui a necessidade de questionar a hegemonía epistemológica, teórica e política de categorías como saúde-doenca e bem-estar, para propor uma perspectiva analítica diferente. Esta implica se centrar na compreensao das relacóes entre a práxis dos agentes sociais, a estruturacao do regímen local de acumulacao capitalista e o sofrimento subjetivo que produzem os diferentes sistemas de dominacao e desigualdade social. Apresenta-se, em primeiro lugar, uma reflexao sobre alguns elementos de teoria crítica que permitem contestar os quadros analíticos hegemónicos sobre as diversas dimensóes das políticas da vida e a saúde, seguida por algumas alternativas para sua compreensao. Posteriormente, expóe-se aproximacao as problemáticas sociais chaves que compreendem o deslocamento analítico proposto. Finalizando, sintetiza-se a relevancia de uma epistemologia crítica do "cuidado da vida" que permita contribuir, acompanhar e potenciar lutas emancipatórias que enfrentam as expressóes violentas de diferentes ordens de dominacao.

Cáncer de piel: barreras de acceso e itinerario burocrático. Una experiencia colombiana / Colombian experience regarding skin cancer: healthcare-related barriers to access to healthcare and bureaucratic itineraries

RESUMEN Objetivo Describir y comprender de forma integral las experiencias que han vivido personas con cáncer de piel no melanoma en su lucha por recuperar la salud, descifrando el itinerario que recorren en busca de atención, describiendo las relaciones con el sistema de salud, estableciendo la tasa de tutelas y el porcentaje de servicios negados, y documentando los determinantes relacionados con el diagnóstico oportuno. Métodos Se realizó un estudio con metodología mixta desde la perspectiva combinada de la epidemiología y la antropología médica critica. El trabajo incluyó una cohorte retrospectiva con 369 personas, tres grupos focales con 48 participantes y entrevistas en profundidad a 20 casos. Resultados Se documentaron barreras propias del sistema de salud, barreras intermedias (laborales y geográficas) y barreras estructurales (economía, ingresos, poder adquisitivo, cohesión social y educación). Los diagnósticos oportunos fueron del 32,5 %. Los determinantes relacionados fueron: escolaridad igual o superior a la formación técnica (OR:4,4), vivienda propia (OR:4,8), vivir en medio urbano (OR:3,5) y afiliación al régimen contributivo (OR:1,9). El 28 % reportaron la negación de algún tipo de servicio (biopsia, cirugía), y la tasa de uso de recursos legales fue de cinco por cada 100 casos nuevos año. Se documentó el itinerario desde la aparición de la enfermedad, hasta la atención definitiva. Discusión Las personas en condiciones desfavorables presentan los casos más complejos y paradójicamente enfrentan la mayor cantidad de barreras de acceso. Estas barreras trascienden el sistema de salud, y no dependen exclusivamente de una reforma al sector.

ABSTRACT Objectives Describing and understanding the experiences of people suffering non-melanoma skin cancer in their struggles to recuperate, deciphering their itinerary regarding their health-seeking behavior, describing the relationship between patients and the Colombian healthcare system by referring to the number of pertinent writs and the percentage of denied services, and documenting the determinants which are related to timely diagnosis. Methods This was a mixed-methods study, combining epidemiology and critical medical anthropology; the study involved a retrospective cohort of 369 people, 3 focus groups including 48 participants and in-depth interviews regarding 20 cases. Results The data revealed specific healthcare system-related barriers to access to healthcare, intermediate barriers (work-related and geographical) and structural barriers (economic-, income-, purchasing power-, social cohesion- and education-related). Timely diagnosis was made in 32.5% of the reported cases. Related determinants consisted of educational level equal to or above technical training (OR 4.4), home ownership (OR 4.8), living in an urban area (OR3.5) and contributory regime affiliation (OR 1.9); 28% of the people involved in the study reported that they had been denied access to a service (biopsy, surgery) and the rate of resorting to legal means (i.e. writs) was 5 out of every 100 new cases per year. The itinerary from the time of the appearance of a particular disease to definitive resolution was established. Discussion People living in unfavorable social conditions were involved in the severest cases and, paradoxically, faced the largest set of barriers to access to healthcare in Colombia. Such barriers extend beyond the healthcare system and will not become resolved solely through healthcare reform.

[Colombian experience regarding skin cancer: healthcare-related barriers to access to healthcare and bureaucratic itineraries]. / Cáncer de piel: barreras de acceso e itinerario burocrático. Una experiencia colombiana.

OBJECTIVES: Describing and understanding the experiences of people suffering non-melanoma skin cancer in their struggles to recuperate, deciphering their itinerary regarding their health-seeking behavior, describing the relationship between patients and the Colombian healthcare system by referring to the number of pertinent writs and the percentage of denied services, and documenting the determinants which are related to timely diagnosis. METHODS: This was a mixed-methods study, combining epidemiology and critical medical anthropology; the study involved a retrospective cohort of 369 people, 3 focus groups including 48 participants and in-depth interviews regarding 20 cases. RESULTS: The data revealed specific healthcare system-related barriers to access to healthcare, intermediate barriers (work-related and geographical) and structural barriers (economic-, income-, purchasing power-, social cohesion- and education-related). Timely diagnosis was made in 32.5% of the reported cases. Related determinants consisted of educational level equal to or above technical training (OR 4.4), home ownership (OR 4.8), living in an urban area (OR3.5) and contributory regime affiliation (OR 1.9); 28% of the people involved in the study reported that they had been denied access to a service (biopsy, surgery) and the rate of resorting to legal means (i.e. writs) was 5 out of every 100 new cases per year. The itinerary from the time of the appearance of a particular disease to definitive resolution was established. DISCUSSION: People living in unfavorable social conditions were involved in the severest cases and, paradoxically, faced the largest set of barriers to access to healthcare in Colombia. Such barriers extend beyond the healthcare system and will not become resolved solely through healthcare reform.

Machismo, public health and sexuality-related stigma in Cartagena.

This paper reports on an ethnographic study in Cartagena, Colombia. Over a seven-month fieldwork period, 35 men and 35 women between 15 and 60 years of age discussed the social context of HIV/AIDS through in-depth interviews, life histories and drawing. Participants considered the transgression of traditional gender roles as prescribed by machismo a major risk factor for HIV infection. In addition, they integrated public-health concepts of risk groups with these long-standing constructions of gender roles and sexuality-related stigma to create the notion of 'AIDS carriers'. The bricolage between machismo, public health and sexuality-related stigma that participants created and consequent preventive measures (based on an avoidance of sex with people identified as 'AIDS carriers') was a dynamic process in which participants were aware that changes in this particular interpretation of risk were necessary to confront the local epidemic.

Structural actions toward HIV/AIDS prevention in Cartagena, Colombia: a qualitative study.

OBJECTIVE: To obtain a thorough understanding of the complexity and dynamics of the social determination of HIV infection among inhabitants of Cartagena, Colombia, as well as their views on necessary actions and priorities. METHODS: In a five-year ethnography of HIV/AIDS in collaboration with 96 citizens of Cartagena, different methods and data collection techniques were used. Through 40 in-depth interviews and 30 life histories of inhabitants, the scenario of HIV vulnerability was summarized in a diagram. This diagram was evaluated and complemented through group discussions with key representatives of local governmental and nongovernmental organizations and with people who were interested in the epidemic or affected by it. RESULTS: The diagram illustrates the dynamic and complex interrelationships among structural factors (i.e., social determinants) of HIV infection, such as machismo; lack of work, money, and social services; local dynamics of the performance of the state; and international dynamics of the sexual tourism industry. On the basis of the diagram, groups of key representatives proposed prioritizing structural actions such as reducing socioeconomic inequalities and providing access to health care and education. CONCLUSIONS: The social determinants displayed in the diagram relate to historic power forces that have shaped vulnerable scenarios in Cartagena. Collaboration between participants and researchers generates conceptual frameworks that make it possible to understand and manage the complexity of HIV's social determination. This way of understanding effectively connects local inequalities with international flows of power such as sexual tourism and makes evident the strengths and limitations of current approaches to HIV prevention.

Structural actions toward HIV/AIDS prevention in Cartagena, Colombia: a qualitative study / Medidas estructurales para la prevención de la infección por el VIH/sida en Cartagena, Colombia: estudio cualitativo

OBJECTIVE: To obtain a thorough understanding of the complexity and dynamics of the social determination of HIV infection among inhabitants of Cartagena, Colombia, as well as their views on necessary actions and priorities. METHODS: In a five-year ethnography of HIV/AIDS in collaboration with 96 citizens of Cartagena, different methods and data collection techniques were used. Through 40 in-depth interviews and 30 life histories of inhabitants, the scenario of HIV vulnerability was summarized in a diagram. This diagram was evaluated and complemented through group discussions with key representatives of local governmental and nongovernmental organizations and with people who were interested in the epidemic or affected by it. RESULTS: The diagram illustrates the dynamic and complex interrelationships among structural factors (i.e., social determinants) of HIV infection, such as machismo; lack of work, money, and social services; local dynamics of the performance of the state; and international dynamics of the sexual tourism industry. On the basis of the diagram, groups of key representatives proposed prioritizing structural actions such as reducing socioeconomic inequalities and providing access to health care and education. CONCLUSIONS: The social determinants displayed in the diagram relate to historic power forces that have shaped vulnerable scenarios in Cartagena. Collaboration between participants and researchers generates conceptual frameworks that make it possible to understand and manage the complexity of HIV's social determination. This way of understanding effectively connects local inequalities with international flows of power such as sexual tourism and makes evident the strengths and limitations of current approaches to HIV prevention.

OBJETIVO: Explorar la comprensión de los habitantes sobre la determinación social de la infección por el VIH en Cartagena, Colombia, y sus criterios sobre las medidas necesarias y las prioridades. MÉTODOS: Se usaron diferentes métodos y técnicas de recolección de datos en una investigación etnográfica quinquenal de la infección por el VIH/sida en colaboración con 96 ciudadanos de Cartagena. Se resumió en un diagrama la situación de vulnerabilidad al VIH tras analizar la información obtenida en 40 entrevistas a profundidad y 30 historias de vida de los habitantes. Este diagrama se evaluó y se complementó por medio de análisis grupales con representantes clave de organizaciones gubernamentales y no gubernamentales locales y con personas interesadas en la epidemia o afectadas por ella. RESULTADOS: El diagrama ilustra las interrelaciones dinámicas y complejas que existen entre los factores estructurales (es decir, determinantes sociales) de la infección por el VIH, como el machismo; la falta de trabajo, dinero y servicios sociales; la dinámica local de la función del estado; y la dinámica internacional de la industria del turismo sexual. Sobre la base del diagrama, los grupos de representantes clave propusieron medidas estructurales prioritarias, como reducir las desigualdades socioeconómicas y proporcionar acceso a la atención de salud y la educación. CONCLUSIONES: Los determinantes sociales que se muestran en el diagrama se relacionan con las fuerzas de poder que históricamente han configurado situaciones de vulnerabilidad en Cartagena. La colaboración entre los participantes y los investigadores genera marcos conceptuales que permiten comprender y gestionar la complejidad de la determinación social de la infección por el VIH. Este enfoque permite relacionar las desigualdades locales con los flujos internacionales de poder, como el turismo sexual, y pone de manifiesto las ventajas y las limitaciones de los métodos actuales para la prevención de la infección por el VIH.