Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico.

Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Challenges of health services related to the population displaced by violence in Mexico.

OBJECTIVE: To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails. METHODS: This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria. RESULTS: The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population. CONCLUSIONS: The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.

Tecnologías de la información y comunicación para el cuidado y atención del embarazo en el primer nivel de atención / Information and communication technologies for pregnancy care in primary attention level

Resumen El cuidado materno es un asunto prioritario en la prestación de servicios de salud, por lo que se trabaja continuamente en la mejora de la atención a las embarazadas. Este esfuerzo requiere información que ayude a establecer la efectividad de las estrategias empleadas, acorde a las necesidades de la población. El objetivo del presente estudio fue determinar la disponibilidad, el acceso y uso de las tecnologías de la información y comunicación (TIC) en las embarazadas atendidas por la Secretaría de Salud del Estado de Veracruz, México, así como identificar las necesidades que pueden ser resueltas o apoyadas mediante su uso. Se diseñó y aplicó un cuestionario a una muestra estratificada de 709 embarazadas, usuarias de servicios de salud del primer nivel de atención, de la ciudad de Xalapa. Los resultados mostraron que el 91.9 % del total de las mujeres encuestadas usarían alguna de las TIC para el cuidado de su salud durante el embarazo. El 95.0 % de las entrevistadas disponía de teléfono móvil, de las cuales, el 68.4 % podían conectarse a internet exclusivamente a través del celular por las funciones que poseían sus teléfonos, aunque solo el 58.0 % lo utilizaría para el cuidado de su salud. El uso de la internet representó una herramienta de gran utilidad para prestar servicios administrativos, preventivos, de promoción a la salud o de atención. Este grupo manifestó interés por el uso de las TIC para el cuidado y atención durante su embarazo, especialmente para recibir información de salud, detectar riesgos en el embarazo o problemas y necesidades específicas de la mujer. Dichos resultados sugieren que es viable promover estrategias de eSalud y mSalud en el primer nivel de atención en México.

Abstract Maternal care is a priority issue in the provision of health services, this is why we continuously work on improving care for pregnant women. This effort requires basic information that helps establish the effectiveness of the employed strategies, according to the needs of the population. This paper aims to determine the availability, access and use of information and communication technologies (ICT) in the primary care of pregnant women treated by the Health Secretary of the State of Veracruz, Mexico. It also intends to identify the needs that can be resolved or supported through the use of ICT. A questionnaire was designed and administered to a stratified sample of 709 pregnant women who were users of primary care health services in the city of Xalapa. The results showed that 91.9 % of all surveyed women would use at least one of the ICT for their health care during pregnancy. 95.0 % of those interviewed had a mobile phone, of which 68.4 % could connect to the Internet exclusively through cell phones because of the functions that their phones possessed. However, only 58.0 % would use it for their health care. The use of the internet represented a very useful tool to provide administrative, preventive, health promotion or care services. This group expressed interest for the use of ICT for care and attention during their pregnancy, especially to receive health information, detect risks in pregnan-су or problems and specific needs of women. These results suggest that it is feasible to promote eHealth and mHealth strategies at the primary care level in Mexico.

Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico / Experiencias y percepciones de personas que usan heroína: lecciones de salud pública desde Hermosillo, México / As experiências e percepções de usuários de heroína: lições de saúde pública de Hermosillo, México

Abstract: Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Resumen: El consumo de heroína en México es bajo si se compara con su consumo en EE.UU.; no obstante, esta práctica es más común en la zona norte de México que en el resto del país, estando documentada solamente en ciudades que están localizadas exactamente en la frontera entre México y EE.UU. El marco legal mexicano está centrado en la rehabilitación, sin embargo sus efectos en las vidas de los consumidores son desconocidos. El objetivo de esta investigación fue analizar cómo se conceptualiza el marco regulatorio mexicano, y cómo se hace realidad en la vida diaria de un grupo de personas usuarias de heroína, procedentes de una ciudad del norte, donde recientemente el consumo se ha extendido y no se ha documentado. Nosotros recogimos datos oficiales registrados de consumidores y realizamos un estudio cualitativo en Hermosillo, Sonora. Se realizó una investigación sobre el marco legal, así como del contexto de la ciudad. Los datos sobre los consumidores de heroína sólo se pueden encontrar en centros de salud especializados en VIH, pues que no existe otra fuente para tales registros. El marco legal mexicano pretende la rehabilitación y evitar la criminalización; sin embargo, la vida diaria de los consumidores les conduce hacia los circuitos del crimen: la gente comete delitos para estar en prisión, donde pueden controlar la adicción y conseguir heroína, en caso de abstinencia. El estado mexicano no cuenta con información empírica para mejorar los programas y leyes relacionadas con el consumo de heroína. Las prácticas diarias de los consumidores se han convertido no sólo en riesgos epidemiológicas, sino tambiém en riesgos sociales para la comunidad y los propios consumidores. Asimismo, la falta de acceso debido a la estigmatización, la criminalización y la violencia, incrementa las inequidades, creando un círculo vicioso que reproduce la pobreza y el sufrimiento, como parte de la estructura social. Por ello, es necesario que se produzcan cambios en el sistema judicial.

Resumo: O consumo da heroína é baixo no México, comparado ao uso nos Estados Unidos, porém essa prática é mais comum na região Norte do México em comparação com o resto do país, sendo documentada apenas nas cidades localizadas justamente na fronteira com os Estados Unidos. A legislação mexicana visa principalmente a reabilitação, mas seus efeitos sobre a vida dos usuários não são conhecidos. Este estudo teve como objetivo analisar a maneira pela qual o arcabouço regulatório mexicano é conceituado e praticado na vida diária de um grupo de usuários de heroína de um município no Norte do México, onde o consumo tem sido disseminado recentemente, mas sem ter sido documentado até então. Foram coletados os dados oficiais sobre usuários, seguido por um estudo qualitativo em Hermosillo, no Estado de Sonora. Foram estudados a legislação pertinente e o contexto local em Hermosillo. Os dados sobre os usuários de heroína foram encontrados nos centros de atendimento a pessoas com HIV, uma vez que não existe outra fonte desses registros. A legislação mexicana visa a reabilitação dos usuários, evitando sua criminalização, mas sua vida cotidiana os empurra para os circuitos do crime. Assim, os indivíduos cometem crimes para permanecer na prisão, onde conseguem controlar a dependência e obter a droga em casos de síndrome de abstinência. O governo mexicano não dispõe de dados empíricos para melhorar os programas e leis relacionados ao uso da heroína. As práticas diárias dos usuários se transformam em riscos, não apenas epidemiológicos como também sociais, tanto para a comunidade quanto para os próprios usuários. Além disso, a falta de acesso a serviços, em função da combinação de estigmatização, criminalização e violência, aumenta as desigualdades, criando um ciclo que reproduz e o sofrimento enquanto parte de uma estrutura social. Portanto, são necessárias mudanças urgentes no sistema de justiça.

Challenges of health services related to the population displaced by violence in Mexico / Retos de los servicios de salud relacionados con la población desplazada por la violencia en México

ABSTRACT OBJECTIVE To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails. METHODS This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria. RESULTS The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population. CONCLUSIONS The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.

RESUMEN OBJETIVO Analizar las implicaciones de la atención de la población desplazada por violencia para el sistema de salud y los retos que le implica. MÉTODOS Revisión narrativa de literatura nacional e internacional en PubMed, SciELO, WHO/OPS, y Bireme. Los criterios de inclusión fueron, la fecha de publicación (a partir de 2000), la relación con el tema, y el idioma (español o inglés). Se encontraron 292 documentos, de los cuales 91 cumplían con los criterios de inclusión. RESULTADOS Los principales retos se referirán: al enfoque integral (con énfasis en la salud mental y la salud sexual y reproductiva), intersectorial, y participativo; a la garantía de la accesibilidad a los servicios de salud; a la necesidad de un sistema de información y registro confiable de la población desplazada por violencia y sus características; y al abordaje de las problemáticas biopsicosociales de los diferentes grupos, especialmente mujeres, personas con discapacidad o con enfermedades infecciosas, de adolescentes, niños y niñas, minorías étnicas, población adulta mayor y la población lésbica, gay, transexual, bisexual y intersexual. CONCLUSIONES La ausencia de voluntad política para la aceptación y visibilización del desplazamiento interno por violencia y de su importancia como problema humanitario y de salud pública, constituye un obstáculo para atender a la población desplazada por violencia de forma adecuada y oportuna en México.

Pobreza multidimensional y determinantes sociales de la salud. Línea de base para dos comunidades vulnerables / Multidimensional poverty index and social determinants of health. Baseline for two vulnerable communities

Resumen Introducción. Las políticas y programas del gobierno, orientados a disminuir las inequidades, tienen efectos sociales, económicos e impacto sobre las condiciones de salud; además, suelen carecer de procesos de evaluación que midan el impacto de sus intervenciones. Por lo tanto, este estudio plantea una línea de base del índice de pobreza multidimensional (IPM) en dos comunidades vulnerables, que permitirá evaluar, con posterioridad, el impacto del desarrollo en una zona franca. Materiales y métodos. El diseño del estudio fue observacional, descriptivo y transversal, a fin de establecer la línea de base de determinantes sociales de la salud, contenidos en el IPM y el efecto potencial de la intervención sobre las variables y dimensiones del IPM en dos corregimientos, antes del desarrollo de una zona franca. Resultados. Los hallazgos muestran las condiciones de vida precarias y de inequidad de las dos poblaciones, sobre todo en la dimensión educativa, los derechos de la población infantil y las condiciones de la vivienda. Las variables que mejor explican la pobreza son el analfabetismo, el rezago escolar y los pisos de tierra sobre los que es inadecuado habitar. La prevalencia de pobreza en Caimalito (80.9%) y Puerto Caldas (66.5%) supera la general de Colombia (24.8%) y de la región central (26.1%). Asimismo, la incidencia ajustada de pobreza en Caimalito (20.1%) y Puerto Caldas (18.5%) son mayores que la de Colombia (13%). Conclusión. Es necesario modificar variables del índice que no discriminen hogares pobres. La simulación de intervenciones aisladas tienen poco o ningún efecto en la reducción de la pobreza.

Abstract Introduction: Government policies and programs, aimed at reducing inequities, have a social and economic and impact on health conditions. However, they often lack evaluation processes that measure the impact of their interventions. Therefore, this study sets out a baseline of the Multidimensional Poverty Index (MPI) in two vulnerable communities, which will allow to assess the impact of development on a free zone. Materials and methods: Observational, descriptive and transversal study directed to establish the baseline of social determinants of health contained in the MPI, as well as the potential effect of the intervention on the variables and dimensions of the MPI in two precincts, before a free zone is developed. Results: Findings show the precarious living conditions and inequity in both populations, especially in the educational dimension, the rights of children and housing conditions. The variables that best explain poverty are illiteracy, education lag, and gravel floors which make habitability inappropriate. The prevalence of poverty in Caimalito (80.9%) and Puerto Caldas (66.5%) surpasses general poverty indexes in Colombia (24.8%) and in the central region (26.1%). Likewise, the adjusted incidence of poverty in Caimalito (20.1%) and Puerto Caldas (18.5%) is higher than in Colombia (13%). Conclusion: It is necessary to modify index variables that do not discriminate poor households. Simulation of isolated interventions have little or no effect on poverty reduction.

Prevalence and factors associated with violence and abuse of older adults in Mexico's 2012 National Health and Nutrition Survey.

BACKGROUND: Factors associated with violence and the abuse of older adults are understudied and its prevalence in Mexico has not been reported. The aim of this study was to identify the prevalence and factors associated with violence and abuse of older adults in Mexico. METHODS: We used Mexico's 2012 National Health and Nutrition Survey, which included a sample of 8,894 individuals who are 60 years or older and who self-reported a negative health event related to robbery, aggression or violence in the previous 12 months. We used chi-squared test and Fisher's exact test to analyze the variables related to violence. Adjusted estimates were completed with multiple logistic regression models for complex surveys. RESULTS: The prevalence of violence was 1.7 % for both men and women. In 95 % of the cases, the aggression was from an unknown party. Verbal aggressions were the most prevalent (60 %). Among men, physical aggression was more common. Violence frequently occurred in the home (37.6 %); however, men were primarily assaulted in public places (42.4 %), in comparison to women (30.7 %). There were also differences in the risk factors for violence. Among men, risk was associated with younger age (60-64 years), higher education (secondary school or above) and higher socioeconomic status. Among women, risk was associated with depression, not being the head of the family, and region of the country. CONCLUSIONS: Violence against older adults presents differently for men and women, which means it is necessary to increase knowledge about the dynamics of the social determinants of violence, particularly in regards to the role of education among men. The relatively low prevalence found in this study may reflect the difficulty and fear of discussing the topic of violence. This may occur because of cultural factors, as well as by the perception of helplessness perpetuated by the scarce access to social programs that ensure protection and problem solving with regards to the complex social determinants of individual and family violence that this population group endures.

Inequidad en la utilización de servicios de salud reproductiva en Colombia en mujeres indígenas y afrodescendientes / Ethnic disparities in the use of reproductive health services by indigenous and African-descendant Colombian women / Disparidades étnicas no uso de serviços de saúde reprodutiva por mulheres colombianas indígenas e afrodescendentes

Resumen Se analizó la utilización de servicios de salud reproductiva (atención prenatal, parto y posparto), según la etnia de las mujeres, a partir de la Encuesta Nacional de Demografía y Salud 2010 de Colombia. La etnia fue medida por auto- reconocimiento (indígenas, afrodescendientes y ninguna) y se estimaron modelos logísticos para cada servicio. Encontramos que, respecto a quienes no pertenecen a ninguna etnia, la utilización de servicios de salud reproductiva es menor en las mujeres indígenas y afrodescendientes. En los modelos de regresión se encontró que mujeres indígenas tienen menores posibilidades de un número adecuado de controles prenatales (OR = 0,61), así como también afrodescendientes. Igual situación para la atención institucional del parto: indígenas (OR = 0,33), afrodescendientes (OR = 0,60); y en control posparto: indígenas (OR = 0,80), afrodescendientes (OR = 0,80). En conclusión, existen inequidades en la utilización de servicios de salud reproductiva en las mujeres de grupos étnicos de Colombia que deben ser atendidas con estrategias gubernamentales que garanticen el derecho a la salud.

Abstract The aim of this study in Colombia was to analyze the use of reproductive health services (prenatal care, childbirth, and postpartum) according to women’s ethnicity, based on the National Demographic and Health Survey for 2010. Ethnicity was self-reported (indigenous, African-descendant, or neither), and logistic models were performed for each service. The use of reproductive health services was lower among indigenous and African-descendant Colombian women when compared to those that did not declare their ethnicity. According to the regression models, indigenous women showed lower odds of having an adequate number of prenatal visits (OR = 0.61), and the same was true for African-descendant women. The same situation prevailed for institutional childbirth care: indigenous women (OR = 0.33) and African-descendant women (OR = 0.60); and postpartum follow-up: indigenous (OR = 0.80), African-descendant (OR = 0.80). In conclusion, there are inequities in the use of reproductive health services by women belonging to ethnic groups in Colombia, who should be targeted with government strategies to guarantee their right to health.

Resumo O objetivo deste estudo na Colômbia foi analisar o uso de serviços de saúde reprodutiva (pré-natal, parto e pós-parto) de acordo com a identidade étnica das mulheres, com base na Pesquisa Nacional sobre Demografia e Saúde de 2010. A identidade étnica era autorreferida (indígena, afrodescendente ou nenhuma das duas), e modelos logísticos foram aplicados a cada serviço de saúde. As mulheres colombianas indígenas e afrodescendentes usavam menos os serviços de saúde reprodutiva, quando comparadas àquelas que não informaram a identidade étnica. De acordo com os modelos de regressão, as mulheres indígenas mostravam menores chances de ter um número adequado de consultas de pré-natal (OR = 0,61), o mesmo valendo para as afrodescendentes. As mesmas disparidades apareciam em relação ao parto hospitalar: parturientes indígenas (OR = 0,33) e afrodescendentes (OR = 0,60); e atendimento puerperal: indígenas (OR = 0,80) e afrodescendentes (OR = 0,80). O estudo concluiu que há desigualdades no uso de serviços de saúde reprodutiva por mulheres pertencentes a grupos étnicos na Colômbia, e que estas devem ser alvo de estratégias públicas para garantir seu direito à saúde.

Determinantes sociales de la mortalidad infantil en municipios de bajo índice de desarrollo humano en México / Social determinants of infant mortality in socioeconomic deprived rural areas in Mexico

ResumenINTRODUCCIÓN: Se realizó un estudio con el objetivo de identificar determinantes sociales de mortalidad infantil en zonas rurales en México, y recomendar estrategias para disminuir esta mortalidad.MÉTODOS: Se tomó una muestra por conveniencia de 16 municipios de bajo índice de desarrollo humano. Se identificaron fallecimientos de menores de un año de edad a través de registros oficiales y de entrevistas con autoridades civiles, personal de salud y líderes comunitarios. También se realizaron entrevistas a las madres de menores fallecidos.RESULTADOS: En casi todos los casos confluyeron determinantes intermedios relacionados con condiciones de vida y servicios de salud. Los eslabones críticos de la atención más frecuentes fueron el de los programas preventivos, y la demora de mayor ocurrencia fue en la provisión de atención en las unidades de salud. Se encontraron deficiencias en las políticas públicas intersectoriales que garanticen el acceso efectivo a los servicios.CONCLUSIONES: Para reducir la mortalidad infantil en áreas rurales de México, es imprescindible mejorar el acceso geográfico y cultural a los servicios de salud, así como incrementar los recursos y las competencias técnicas y de interculturalidad del personal de salud.

AbstractBACKGROUND: The aim of this study was to identify determinants of infant mortality in rural areas in Mexico and recommend strategies for its decrease.METHODS: A study was conducted in a sample of 16 municipalities among those with the lowest index of human development. Infant deaths were identified through official data, records and through interviews with civil authorities, health workers and community leaders. Mothers of children who died were also interviewed.RESULTS: In most cases, deaths were related with intermediate social determinants (living conditions and health services converged). The most important critical factors were the prevention programs and delays in receiving healthcare. Deficiencies in intersectorial policies to guarantee effective access to health services were found.CONCLUSIONS: To decrease infant mortality in rural areas of Mexico, geographic access has to be improved as well as investment in resources and training health personnel in intercultural competence and primary health care skills.

[Social determinants of infant mortality in socioeconomic deprived rural areas in Mexico]. / Determinantes sociales de la mortalidad infantil en municipios de bajo índice de desarrollo humano en México.

BACKGROUND: The aim of this study was to identify determinants of infant mortality in rural areas in Mexico and recommend strategies for its decrease. METHODS: A study was conducted in a sample of 16 municipalities among those with the lowest index of human development. Infant deaths were identified through official data, records and through interviews with civil authorities, health workers and community leaders. Mothers of children who died were also interviewed. RESULTS: In most cases, deaths were related with intermediate social determinants (living conditions and health services converged). The most important critical factors were the prevention programs and delays in receiving healthcare. Deficiencies in intersectorial policies to guarantee effective access to health services were found. CONCLUSIONS: To decrease infant mortality in rural areas of Mexico, geographic access has to be improved as well as investment in resources and training health personnel in intercultural competence and primary health care skills.

[Ethnic disparities in the use of reproductive health services by indigenous and African-descendant Colombian women]. / Inequidad en la utilización de servicios de salud reproductiva en Colombia en mujeres indígenas y afrodescendientes.

The aim of this study in Colombia was to analyze the use of reproductive health services (prenatal care, childbirth, and postpartum) according to women's ethnicity, based on the National Demographic and Health Survey for 2010. Ethnicity was self-reported (indigenous, African-descendant, or neither), and logistic models were performed for each service. The use of reproductive health services was lower among indigenous and African-descendant Colombian women when compared to those that did not declare their ethnicity. According to the regression models, indigenous women showed lower odds of having an adequate number of prenatal visits (OR = 0.61), and the same was true for African-descendant women. The same situation prevailed for institutional childbirth care: indigenous women (OR = 0.33) and African-descendant women (OR = 0.60); and postpartum follow-up: indigenous (OR = 0.80), African-descendant (OR = 0.80). In conclusion, there are inequities in the use of reproductive health services by women belonging to ethnic groups in Colombia, who should be targeted with government strategies to guarantee their right to health.

[A health care model for the Wayúu people on the Colombian-Venezuelan border]. / Un modelo de atención en salud al pueblo Wayúu en la frontera colombo-venezolana.

At meetings and workshops with Wayúu communities and government officials from Colombia and Venezuela, after validating the analysis of the health situation and its determinants, the components of a binational health care model for the Wayúu people living on the border between the two countries were identified. Although both countries have made progress in intercultural health care, some aspects of their legislation and service organization still need to be strengthened to make the guaranteed right to health a reality. The allocation of new national resources-or the redistribution of current resources-should be ensured, as well as the management of international resources for conducting a short-term pilot project and implementing the model in the medium term.

Un modelo de atención en salud al pueblo Wayúu en la frontera colombo-venezolana / A health care model for the Wayúu people on the colombian-venezuelan border

En reuniones y talleres con comunidades wayúu y funcionarios de gobierno de Colombia y Venezuela, tras validar el diagnóstico de salud y sus determinantes, se identificaron componentes para un modelo de atención binacional en salud destinado al pueblo wayúu que habita la frontera entre ambos países. Si bien ha habido avances en la atención sanitaria intercultural en ambos países, todavía hace falta fortalecer algunos aspectos de la legislación y la organización de los servicios para hacer posible la garantía del derecho a la salud. Se debe asegurar la asignación de nuevos recursos nacionales - o la redistribución de los actuales- y la gestión de recursos internacionales para ejecutar un proyecto piloto en el corto plazo e implementar el modelo en el mediano plazo.

At meetings and workshops with Wayúu communities and government officials from Colombia and Venezuela, after validating the analysis of the health situation and its determinants, the components of a binational health care model for the Wayúu people living on the border between the two countries were identified. Although both countries have made progress in intercultural health care, some aspects of their legislation and service organization still need to be strengthened to make the guaranteed right to health a reality. The allocation of new national resources-or the redistribution of current resources-should be ensured, as well as the management of international resources for conducting a short-term pilot project and implementing the model in the medium term.

[National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla]. / Políticas nacionales de salud y decisiones locales en México: el caso del Hospital Mixto de Cuetzalan, Puebla.

OBJECTIVE: To identify the changes brought about by various national and international factors in an intercultural hospital of the municipality of Cuetzalán, Puebla. MATERIAL AND METHODS: A case study was conducted during 2000 and 2001 in two Intercultural Hospitals of Mexico; the Cuetzalán Hospital in Puebla and the Jesús María Hospital in Nayarit State. Data were collected by means of 72 semi-structured interviews with allopathic therapists, indigenous therapists, and authorities of the different health care levels. Moreover, documental research was carried out on national policies for indigenous peoples as well as on indigenist policies. These policies were related with the five organizational stages of the hospital. State authorities gave their permission and interviewees signed informed consent. RESULTS: The hospital was created in 1958 by the Ministry of Health as a biomedical institution, in agreement with the integrationist indigenist policies going on at the time. It remained so during the beginning of the administration by the National Indigenist Institute. In 1990, the new participative indigenist policy trends and the creativity and sensitivity of some authorities, under the influence of international strategies, helped to transform the hospital into an Intercultural Hospital (offering both types of medicine, indigenous and allopathic) with regional coverage. In 2000, the devolution of the hospital to the State Ministry of Health, based on financial rather than socio-cultural considerations, caused the temporary loss of its intercultural character. The last stage as an Integral Hospital with Traditional Medicine (from 2003 onwards) was due to a combination of state official initiatives and the new political stance acquired by the Mexican indigenous movement. The hospital is now part of a regional project of five such hospitals officially denominated Integral Hospitals with Traditional Medicine, to be financed by the Puebla-Panama Plan of regional development. CONCLUSIONS: Our results confirmed that health organizations follow a historical process in which selected national and international forces open opportunities to promote intercultural health models that respond to the needs of indigenous populations. Despite the formerly held belief that traditional and scientific medicines were incompatible, this study demonstrates the viability of intercultural health care models that may become a real possibility in the country, based on new conventions to establish alternative and intercultural health services, thereby setting an example for other regions and countries. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Políticas nacionales de salud y decisiones locales en México: el caso del Hospital Mixto de Cuetzalan, Puebla / National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla

OBJETIVO: Identificar la evolución del hospital del municipio de Cuetzalan a partir de la influencia que diversos elementos del contexto nacional e internacional han tenido sobre ella. MATERIAL Y MÉTODOS: Estudio de caso, realizado en 2000 y 2001 sobre los Hospitales Mixtos en México -el de Cuetzalan, en el estado de Puebla, y el de Jesús María, en el estado de Nayarit-. Durante el trabajo de campo se obtuvo información a través de 72 entrevistas semiestructuradas con terapeutas alópatas e indígenas del hospital y con directivos de los diferentes niveles del sistema de salud. Además, se hizo una revisión documental, tanto de las políticas nacionales de salud para pueblos indígenas, como de las indigenistas, para relacionarlas con las cinco etapas organizacionales del hospital. Además de la autorización de los directivos estatales para el estudio, se pidió el consentimiento informado de los entrevistados. RESULTADOS: El hospital fue creado en 1958 por la Secretaría de Salud con carácter biomédico, acorde con el indigenismo integracionista de la época, y continuó con ese carácter durante la administración inicial del Instituto Nacional Indigenista. Pero las nuevas tendencias del indigenismo participativo y la sensibilidad y creatividad de algunos funcionarios del Instituto, sumadas a estrategias internacionales para lograr una mayor integración de las culturas indígenas, impulsaron su transformación, en 1990, en Hospital Mixto (que ofrecía las dos medicinas, la indígena y la alopática) con proyección regional. En la devolución del hospital a la Secretaría Estatal de Salud en 2000, que causó retrocesos temporales en el carácter mixto del hospital, primaron los criterios financieros sobre los socioculturales, mientras que en la actual versión del hospital como Hospital Integral con Medicina Tradicional influyeron, además de la iniciativa de funcionarios estatales, el reposicionamiento político de los indígenas en el país y la disponibilidad de recursos internacionales del Plan Puebla Panamá. CONCLUSIONES: El análisis ratifica el carácter histórico del desarrollo de las organizaciones de salud, y las oportunidades que las coyunturas y políticas nacionales e internacionales constituyen para impulsar modelos alternativos e interculturales de atención para la salud de los pueblos indígenas que respondan a sus necesidades. A pesar de que...

[Western medicine and alternative medicines: can they be complementary? Conceptual reflections]. / Medicina occidental y otras alternativas: ¿es posible su complementariedad? Reflexiones conceptuales.

The present article is part of a series of reflections from an intercultural approach to health systems and corresponding public policies, motivated by findings from a study on two intercultural hospitals in rural Mexico. The frequent utilization of complementary and alternative medicines by the local population and the hegemonic health model that excludes them make the existing health system an unsatisfactory response to people's needs. We present the concept of complementariness as a health system component and propose priorities on this issue, taking different approaches: complementariness as a public policy, as an institutional project, or as an individual decision by the therapist or patient.

Medicina occidental y otras alternativas: ¿es posible su complementariedad? Reflexiones conceptuales / Western medicine and alternative medicines: can they be complementary? Conceptual reflections

El presente documento hace parte de una serie de reflexiones sobre el abordaje intercultural de los sistemas de salud y las políticas públicas que le corresponden, provocadas por el estudio de dos hospitales mixtos (interculturales) creados en áreas rurales de México. El uso cada vez más frecuente de diversas medicinas alternativas y complementarias y la existencia de un modelo médico hegemónico que las excluyen, hacen del sistema de salud occidental una respuesta que no satisface las necesidades de toda la población. Se discute el concepto de complementariedad como componente del desarrollo del sistema de salud y se proponen prioridades en el tema desde diferentes enfoques: la complementariedad como política pública, como proyecto institucional y como decisión individual del terapeuta o del paciente