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The accomplishments of Latin American social medicine remain little known in the English-speaking world. In Latin America, social medicine differs from public health in its definitions of populations and social institutions, its dialectic vision of "health-illness," and its stance on causal inference. A "golden age" occurred during the 1930s, when Salvador Allende, a pathologist and future president of Chile, played a key role. Later influences included the Cuban revolution, the failed peaceful transition to socialism in Chile, the Nicaraguan revolution, liberation theology, and empowerment strategies in education. Most of the leaders of Latin American social medicine have experienced political repression, partly because they have tried to combine theory and political practice--a combination known as "praxis." Theoretic debates in social medicine take their bearings from historical materialism and recent trends in European philosophy. Methodologically, differing historical, quantitative, and qualitative approaches aim to avoid perceived problems of positivism and reductionism in traditional public health and clinical methods. Key themes emphasize the effects of broad social policies on health and health care; the social determinants of illness and death; the relationships between work, reproduction, and the environment; and the impact of violence and trauma.

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As their expansion slows in the United States, managed care organizations will continue to enter new markets abroad. Investors view the opening of managed care in Latin America as a lucrative business opportunity. As public-sector services and social security funds are cut back, privatized, and reorganized under managed care, with the support of international lending agencies such as the World Bank, the effects of these reforms on access to preventive and curative services will hold great importance throughout the developing world. Many groups in Latin America are working on alternative projects that defend health as a public good, and similar movements have begun in Africa and Asia. Increasingly, this organizing is being recognized not only as part of a class struggle but also as part of a struggle against economic imperialism--which has now taken on the new appearance of rescuing less developed countries from rising health care costs and inefficient bureaucracies through the imposition of neoliberal managed-care solutions exported from the United States.

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There is little knowledge about Latin American social medicine in the English-speaking world. Social medicine groups exist in Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, and Mexico. Dictatorships have created political and economic conditions which are more adverse in some countries than others; in certain instances, practitioners of social medicine have faced unemployment, arrest, torture, exile, and death. Social medicine groups have focused on the social determinants of illness and early death, the effects of social policies such as privatisation and public sector cutbacks, occupational and environmental causes of illness, critical epidemiology, mental health effects of political trauma, the impact of gender, and collaborations with local communities, labour organisations, and indigenous people. The groups' achievements and financial survival have varied, depending partly on the national context. Active professional associations have developed, both nationally and internationally. Several groups have achieved publication in journals and books, despite financial and technical difficulties that might be lessened through a new initiative sponsored by the US National Library of Medicine. The conceptual orientation and research efforts of these groups have tended to challenge current relations of economic and political power. Despite its dangers, Latin American social medicine has emerged as a productive field of work, whose findings have become pertinent throughout the world.

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The United States is experiencing one of its largest migratory waves, so health providers are caring for many patients who do not speak English. Bilingual nurses who have not been trained as medical interpreters frequently translate for these patients. To examine the accuracy of medical interpretations provided by nurses untrained in medical interpreting, we conducted a qualitative, cross-sectional study at a multi-ethnic, university-affiliated primary care clinic in southern California. Medical encounters of 21 Spanish-speaking patients who required a nurse-interpreter to communicate with their physicians were videorecorded. Encounters were transcribed by blinded research assistants. Transcriptions were translated and analyzed for types of interpretive errors and processes that promoted the occurrence of errors. In successful interpretations where misunderstandings did not develop, nurse-interpreters translated the patient's comments as completely as could be remembered and allowed the physician to extract the clinically-relevant information. In such cases, the physician periodically summarized his/her perception of the problem for back-translation and verification or correction by the patient. On the other hand, approximately one-half of the encounters had serious miscommunication problems that affected either the physician's understanding of the symptoms or the credibility of the patient's concerns. Interpretations that contained errors that led to misunderstandings occurred in the presence of one or more of the following processes: (1) physicians resisted reconceptualizing the problem when contradictory information was mentioned; (2) nurses provided information congruent with clinical expectations but not congruent with patients' comments; (3) nurses slanted the interpretations, reflecting unfavorably on patients and undermining patients' credibility; and (4) patients explained the symptoms using a cultural metaphor that was not compatible with Western clinical nosology. We conclude that errors occur frequently in interpretations provided by untrained nurse-interpreters during cross-language encounters, so complaints of many non-English-speaking patients may be misunderstood by their physicians.

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This article presents the results of the comparative research project, "Managed Care in Latin America: Its Role in Health System Reform." Conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States, the study focused on the exportation of managed care, especially from the United States, and its adoption in Latin American countries. Our research methods included qualitative and quantitative techniques. The adoption of managed care reflects the process of transnationalization in the health sector. Our findings demonstrate the entrance of the main multinational corporations of finance capital into the private sector of insurance and health services, and these corporations' intention to assume administrative responsibilities for state institutions and to secure access to medical social security funds. International lending agencies, especially the World Bank, support the corporatization and privatization of health care services, as a condition of further loans to Latin American countries. We conclude that this process of change, which involves the gradual adoption of managed care as an officially favored policy, reflects ideologically based discourses that accept the inexorable nature of managed care reforms.

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Somatization is a significant problem for clinical medicine. Unlike somatization disorder, which is relatively rare, abridged somatization, a less severe form of somatization, is prevalent in primary care clinics. The authors examined the clinical status and functioning of patients diagnosed with a depression or anxiety disorder comorbid with abridged somatization and compared them with patients diagnosed with a depression or anxiety disorder alone. The authors examined severity of physical functioning and psychopathology in relation to diagnostic status. Patients diagnosed with both abridged somatization and a depression or anxiety disorder were more physically impaired and more anxious than those diagnosed with a depression or anxiety disorder alone. The results suggest that abridged somatization frequently coexists with depression and anxiety and thus complicates the presentation of these disorders.

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OBJECTIVE: To examine among immigrants and others seeking primary care: (1) the prevalence, types, and predictors of traumatic life events; and (2) the relations among traumatic life events, psychiatric disorders, and utilization of primary care services. DESIGN: Survey with structured diagnostic interview. SETTING: Community-based, university-affiliated primary care clinic in southern California. PARTICIPANTS: Fourteen hundred fifty-six adult patients representing 4 ethnic groups (Mexican immigrants, Central American immigrants, US-born Latinos of Mexican descent, and US-born non-Latino whites). DEPENDENT MEASURES: Rates of traumatic events measured with the Posttraumatic Stress Disorder section of the Diagnostic Interview Schedule; psychiatric disorders identified by the Composite International Diagnostic Interview using Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria; physical functioning (Short Form Health Survey); and the number of medical clinic visits during a 6-month period. RESULTS: Nearly 10% of patients had experienced a traumatic event in the previous year, and 57% had experienced at least 1 during their lifetimes. The most common forms of trauma were interpersonal violence occurring outside the family (21%), acute losses or accidents (17%), witnessing death or violence (13%), and domestic violence (12%). When compared with the US-born non-Latino whites, Mexican immigrants were half as likely, and Central American immigrants were 76% more likely, to report having experienced a traumatic event. Married individuals were significantly less likely to report traumas. Traumatic experiences, female gender, and non-Latino ethnicity were associated with the presence of a psychiatric disorder. One-year and lifetime psychiatric disorders were associated with poorer physical functioning and an increased number of clinic visits during a 6-month period. CONCLUSIONS: Traumatic life events are common and associated with psychiatric disorders other than posttraumatic stress disorder in an ethnically diverse sample of primary care patients. Psychiatric disorders, in turn, are strongly associated with poor physical functioning and higher rates of primary care utilization. Screening for traumatic experiences should accompany assessments of psychiatric disorders to ensure adequate treatment of patients seeking primary care services.

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PURPOSE: Patient-centered interviewing is associated with greater patient satisfaction and better medical outcomes than traditional encounters, but actively seeking patients' views of their illnesses and encouraging patients to express expectations, thoughts, and feelings is difficult in encounters that require an interpreter. We sought to examine physicians' use of the patient-centered approach with patients who required the assistance of an interpreter. SUBJECTS AND METHODS: A cross-sectional sample of patients was videorecorded during visits with physicians at a multi-ethnic, university-affiliated, primary care clinic. Nineteen medical encounters of Spanish-speaking patients who required an interpreter and 19 matched English-speaking encounters were coded for frequency that patients mentioned symptoms, feelings, expectations, and thoughts (collectively called "offers"). Physicians' responses were coded as ignoring, closed, open, or facilitative of further discussion. RESULTS: English-speaking patients made a mean (+/- SD) of 20 +/- 11 offers, compared with 7 +/- 4 for Spanish-speaking patients (P = 0.001). Spanish-speaking patients also were less likely to receive facilitation from their physicians and were more likely to have their comments ignored (P <0.005). English-speaking patients usually received an answer or acknowledgment to their questions even if the physicians did not encourage further discussion on the topic. CONCLUSION: Spanish-speaking patients are at a double disadvantage in encounters with English-speaking physicians: these patients make fewer comments, and the ones they do make are more likely to be ignored. The communication difficulties may result in lower adherence rates and poorer medical outcomes among Spanish-speaking patients.

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This article presents the results of the comparative research project "Managed Care in Latin America: Its Role in Health Reform". The project was conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States. The study's objective was to analyze the process by which managed care is exported, especially from the United States, and how managed care is adopted in Latin American countries. Our research methods included qualitative and quantitative techniques. Adoption of managed care reflects transnationalization of the health sector. Our findings demonstrate the entrance of large multinational financial capital into the private insurance and health services sectors and their intention of participating in the administration of government institutions and medical/social security funds. We conclude that this basic change involving the slow adoption of managed care is facilitated by ideological changes with discourses accepting the inexorable nature of public sector reform.

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As managed care proliferates in the United States and other countries, its structure has patterned changes in patient-doctor relationships, including those between older patients and their physicians. The physician as gatekeeper now limits the access of the patient to information and services. Patient trust in the physician, essential to an effective patient-doctor relationship, will be damaged under this system of care. Additionally, examples from medical encounters demonstrate that many of the problems in the doctor-older patient relationship found under fee for service will remain, including the lack of attention to the contextual issues of health care of older adults.

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BACKGROUND: The Composite International Diagnostic Interview (CIDI) has been developed as a state-of-the-art, structured diagnostic instrument, designed to diagnose psychiatric disorders across cultures and languages. Partly because it has been validated in a number of countries and cultural settings, the CIDI has become widely accepted as a diagnostic instrument in epidemiologic and clinical research. OBJECTIVES: As part of a larger study of psychiatric disorders in a multi-ethnic, primary care setting, we tried to clarify the limitations of the CIDI in diagnosing somatoform symptoms among Latino patients. DESIGN: Relevant sections of the CIDI were administered in English or Spanish to new patients seeking primary care services at an inner-city, university-affiliated community clinic. Interviews were tape recorded and pertinent passages were transcribed for qualitative analysis. SUBJECTS: One thousand, four hundred and fifty six new patients, comprising 4 ethnic groups: Central American; Mexican; Chicano; and non-Latino White. MEASURES: The CIDI's diagnostic algorithms for somatization were examined in relation to the transcriptions of interviews for Latino patients whom the CIDI diagnosed as somatizers. RESULTS: The CIDI led to the inaccurate identification of somatoform symptoms resulting from such issues as financial barriers to healthcare access, cultural syndromes that were not recognized by Western medicine, and language differences between patients and physicians. Like other structured instruments, the CIDI also forced a range of complex experience into a fixed-choice interview format. CONCLUSIONS: Despite the advantages of such structured instruments as the CIDI, their capacity to reach accurate psychiatric diagnoses in some cultural groups and clinical settings requires clarification. These findings also call into question the relatively high rates of somatization among Latino patients reported in previous studies that have used structured psychiatric diagnostic instruments.

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This study used a clustering model, Hierarchical Classes Analysis (HICLAS), to examine patient groupings in a multiethnic sample of 1456 patients using primary care services at a university-affiliated community clinic in southern California. Somatic symptoms, psychiatric diagnoses and disability were studied using a survey instrument that included portions of the Composite International Diagnostic Interview (CIDI), the Diagnostic Interview Schedule (DIS) and the RAND-MOS Short Form Health Survey's (SF-36) 'physical functioning' dimension. HICLAS identified 11 clusters of patients with distinct patterns of medically unexplained somatic symptoms. These patient clusters varied with respect to psychiatric diagnoses and symptoms, gender, immigration status and disability. Results of this study suggest that the type of presenting symptom(s) and their various combinations may have diagnostic and prognostic value in primary care settings. These new findings may lead to further refinement of current diagnostic constructs for somatizing syndromes.

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OBJECTIVE: We examined the prevalence, correlates, and predictive value of an abbreviated somatization index, based on specific symptom thresholds, in primary care patients using services at a university-affiliated clinic. METHOD: We interviewed 1456 patients with a survey instrument that included the Composite International Diagnostic Interview (CIDI) to elicit symptoms and diagnoses of several psychiatric disorders as well as demographic information and a measure of disability. Statistical analyses examined the relationship of abridged somatization with physical functioning and various demographic and diagnostic factors. RESULTS: About one fifth of this primary care sample met the abridged somatization criteria. "Somatizers," defined according to these criteria, had significantly higher levels of psychiatric comorbidity and disability than "nonsomatizers". Analyses taking into account the number and type of organ/body systems represented by the unexplained symptoms showed that this dimension adds specificity to the prediction of outcomes. Thus, regardless of the total number of medically unexplained symptoms, abridged somatization with unexplained symptoms attributable to four or more organ/body systems showed the strongest association with disability and psychopathology. CONCLUSIONS: Abridged Somatization is a frequent syndrome in primary care that is strongly associated with psychopathology and physical disability. Our research also yielded a new series of abridged somatization subtypes (eg, "discrete" vs. "comorbid" and "simple" vs. "polymorphous") that may effectively separate among various psychopathologies, and may become useful tools for future research with somatizing patients.

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The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

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Three case histories show how work in the medical social sciences--to the extent that such work reveals the origins of health problems in social structures of wealth and power--can become dangerous enough to threaten one's livelihood and in some instances one's very life. In this presentation, I encourage critical and engaged scholarship by referring to examples of dangerous work that should receive more attention: social medicine in Latin America and the critique of managerial ideology in the United States. Although social medicine has become a widely respected field of research, teaching, and clinical practice in Latin America, its accomplishments remain little known in the English-speaking world. For centuries, indigenous cultures in Latin America have held belief systems linking social conditions to patterns of illness and death. Latin American accounts of social medicine's history emphasize its European origins, especially in the contributions of Rudolf Virchow. In the United States, with the impact of the Flexner Report (1910) and its supporters, Virchow's vision of social medicine went into decline. On the other hand, in Latin America, social medicine flourished as a focus of education and research. Since social medicine's "golden age" during the 1930s, teachers, researchers, and practitioners have produced major achievements despite the dangers of this work, which in several instances have included torture, imprisonment, or death. An ideology favoring managerial decision making in the United States has influenced crucial policy decisions, and the justifications for these decisions have manifested symbolic politics in addition to the evaluation of factual evidence. With ambiguous empirical support, managerial ideology has fostered the general growth of managed care, the implementation of Medicaid managed care by state governments, the expansion of managed care in rural areas, and the impact of "evidence-based medicine" on policy and clinical decisions. If the occupational risks of critical work in the medical social sciences are not taken, we forfeit some of the most important gifts offered by "the sociological imagination."

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BACKGROUND: Somatisation is a common and frustrating clinical problem in primary care. METHOD: Using structural diagnoses and functional measures, we examined the prevalence and associated features of somatisation disorder defined by three current nosologies and an abridged construct in subjects using primary care services. RESULTS: Somatisation disorder, diagnosed according to the standard criteria, was found to have a very low prevalence (range 0.06-0.5%), while more than one-fifth of the sample (22%) met the criteria for the abridged diagnosis. There was poor agreement between succeeding versions of the DSM system for identifying cases of somatisation disorder, each system ending up with rather disparate sets of individuals as well as variable levels of psychopathology and disability. CONCLUSIONS: According to these data, standard somatisation disorder diagnoses add little to the prediction of disability/psychopathology beyond the contributions of an abridged construct of somatisation.

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