Inequality and Exclusion in Latin America: Health Care Commodification, Gendered Norms, and Violence

Since the early 1990s, a market‐orientated policymaking in Latin American countries did nothing to secure decent and productive jobs or eliminate gender inequities. It served, rather, to limit social investments that were needed to increase wellbeing, social cohesion, and, eventually, productivity. The pioneering scholarly work of the authors in this thematic issue, using either qualitative or quantitative methodologies, deepens our interdisciplinary understanding of the causes and dynamics of inequality and exclusion in these countries. Contributions are organized in three dimensions: (a) the com‐ modification of health care, (b) gendered social norms, and (c) fragile life and violence. Based on our authors’ findings and suggestions, an agenda for change emerges that emphasizes autonomy from external pressures, community action and representation, eradication of the patriarchy, and expansion of social protection programs.


Introduction: Inequality and Exclusion
Inequality and exclusion in Latin America trace back to a three-century-long colonial rule, when foreign control of natural resources and sociopolitical domination denied the redistribution of economic growth gains through public and social policies. Since Latin America's political independence in the 19th century, income, opportunities, and property have continued to be largely concentrated in the hands of interest groups. With few exceptions, a string of development strategies across countries failed to ensure the social integration of left-out communities. In the last three decades, neoliberal policies-central to financial integration and globalization-promoted the institutional modernization of Latin American societies (admittedly, their value added was pulled significantly by China's growth and demand for commodities). But regionally, the eco-nomic and social progress was mixed. While nominal poverty-measured by the proportion of people under a per capita poverty threshold-decreased (until the onset of the Covid pandemic), inequality surged and the middle class compressed.
Social dissatisfaction grew in view of the missed opportunities to increase living standards and the excessive vulnerability of large communities left behind. A market-orientated policymaking since the early 1990s did not secure decent and productive jobs or eliminate gender inequities but did serve to limit social investments that were needed to increase wellbeing, social cohesion, and, eventually, productivity. Thus, political movements and perspectives that challenge minimalist social policies have resurged. In many instances, elected governments re-reformed social protection or enacted new programs that provide universal benefits to traditionally marginalized populations: a new consensus.
A salient example of the rejuvenated political commitment to increased equality and social integration through an institutional transformation is the Chilean Constitutional Convention. Although the writing of the new Constitution is a work-in-progress at the moment, the eyes of Latin American countries are fixed on this opportunity to change the neoliberal model towards more equality and social integration.
Social exclusion has many faces: the fragile livelihood of unregistered workers with precarious jobs; the discrimination of girls and women; farmers who survive without support; marginalization of indigenous communities; criminalized migrants; forgotten older persons; persons with disabilities whose fate is indifferent to many. To nobody's surprise when the Covid pandemic hit, a large number of communities in Latin America were illequipped to mitigate contagion and mortality rates (number of deaths over confirmed cases). The latter was 8.8% (202,741 deaths) in Peru and 7.5% (299,525 deaths) in Mexico respectively. Brazil, with a mortality rate of 2.8% and 619,401 deaths ranks second after the USA in terms of deaths, 826,060 (the mortality rate in the USA is 1.5%; see John Hopkins University of Medicine, 2021).
This thematic issue presents the pioneering scholarly work of authors who use qualitative or quantitative methodologies to deepen our interdisciplinary understanding of the causes and dynamics of inequality. The six articles focus on three inequality dimensions: The first of these is the "commodification of health care" proposed by the World Bank (WB) as part of its lending conditionalities consistent with globalization recommendations that Latin American countries reduce the scope of government to attain fiscal balance. De Carvalho (2021) analyzes the role of the WB in shaping health care reform legislation in five Latin American countries. The second dimension refers to "gendered social norms" that discriminate against girls and women. Three articles delve into the question of patriarchy, gender inequity, and activism. Vaccaro et al. (2021) analyze the gender labor income gap among working-age Peruvians. Cruz Saco et al. (2021) asses the labor income gap among persons 60 years and older, who remain active in the Peruvian labor force. Finally, Perry and Borzutzky (2021) study the Chilean women's movement and its role in the Constitutional Convention to draft a new political constitution that can help move toward more equality and gender equity. The third dimension is "fragile lifestyles and violence." The articles by Quesada (2021) and Pérez and Freier (2021) study how the absence of social policies, decent employment opportunities, and safety nets create the structural disempowerment of residents in Guatemalan marginalized communities and of Venezuelan migrants in Peru respectively.

Commodification of Health Care
In the 1990s, international financial institutions-e.g., the InterAmerican Development Bank, the International Monetary Fund, and the WB-played leading roles in influencing the globalization and marketization pathways of Latin America. Through lending and technical support, Latin American policymakers adopted economic liberalization measures that furthered trade, foreign investment, and new social protection schemes. The market-oriented paradigm revamped institutional frameworks through the passing of statutes that affected government responsibilities and transferred the provision of services to the for-profit private sector. Using content analysis (NVivo) of health care reform legislation in five Latin American countries (Argentina, Bolivia, Colombia, Paraguay, and Peru) over 1993-2000, de Carvalho (2021 assesses the impact of the WB's flagship World Development Report: Investing in Health (WB, 1993) on the five national welfare systems. The main finding is that national governments in the selected countries adopted WB recommendations to reduce the coverage and cost of publicly provided services with a focus on vulnerable groups. Lowand middle-income countries in the sample (Bolivia, Colombia, and Peru) had a higher degree of adherence to WB dictums which can be related to weaker negotiation capability and higher dependence on external funding. De Carvalho provides evidence on the impact of the WBs prescriptive ability in affecting social protection arrangements, health care in particular. This research raises important questions on how national policymakers negotiated external pressures toward financial and trade liberalization and the provision of social services that were believed to sustain economic growth and wellbeing.

Gendered Social Norms
Like many other Latin American countries, Chile and Peru are societies characterized by patriarchal structures that inhibit the attainment of gender equity and hinder women's full participation in the labor market. Despite major progress in the educational attainment of women in both countries, gendered norms are resilient. The situation for girls and women is worse than the acknowledgment of traditional caregiving roles in the family or work compensation. In Peru, for example, the incidence of femicides has increased, becoming a public danger that threatens the core of society.
In their study, Vaccaro et al. (2021) conduct a thorough investigation of the evolution of the Peruvian gender wage gap over 2007-2018. Using the Oaxaca-Blinder decomposition method and a Mincer type wage equation, the authors conclude that an unexplained gender gap in favor of men has remained stable over the period of analysis. This gender gap can't be explained by observed variables and therefore structural barrierssocial norms, gender stereotyping, and discriminationare impediments to attaining the same pay for equal work. The study finds that level of education does play an equalizing impact on the income gender gap, however, it operates mostly among more educated women.
In contrast, the incidence of the unexplained gender gap is higher among the poorest women who are usually less educated and work as unregistered workers. Vaccaro et al. (2021) suggest that measures to support the full participation of women in the labor market should include their continuous training and education, in particular among low-income women. In addition, they suggest the creation of a national social protection that includes subsidized or free daycare for small children.
In several Latin American countries, coverage of pensions systems is low; often, even when there is coverage through a contributory or social pension, the pension is insufficient. As a result, older persons continue to participate in the labor market. As documented by Cruz Saco et al. (2021), more than half of Peruvian older persons (60 years of age and older) remain in the labor force. Their article uses the Oaxaca-Blinder decomposition to assess the labor income gap of older persons who work. The main finding of this article is that institutional patterns and value systems perpetuate female discrimination in the labor force and during old age, thus expanding the findings in Vaccaro et al. (2021) for working-age workers to older persons. The income gender gap is stronger among low-income and rural women. One suggested intervention is the increase of social pensions to reach universal coverage with transfers that are livable. Secondly, pension programs should adopt compensation mechanisms for women who stop contributing when they give birth or take on caregiving at home. Finally, governments should provide effective health care services and adequate housing with care options for older persons.
The October 2019 social protest in Chile and the creation of the Constitutional Convention are an opportunity for the transformation of the legal basis to fight against or end gender inequality and violence. Perry and Borzutzky (2021) argue that the 1980 Constitution prevented reductions of inequality and limited opportunity for impactful democratic participation. The massive protests were rooted in the "various inequalities Chileans experienced in education, health, gender-based violence, work, and pensions" (p. 54) and on Chile's feminist movement that protested the patriarchal system and "the precarity of life, that is, the violence and vulnerability that is promoted by Chile's neoliberal political and economic system" (p. 53). Representation of women in the Constitutional Convention (50% of the elected officials) is a success for the feminist movement whose reach is transnational and whose work is closely followed elsewhere in Latin America.

Fragile Life and Violence
Quesada (2021) analyzes living conditions in two marginalized communities in the ravines of Guatemala City. Residents are poor and engage in incomegenerating occupations in a context of enormous violence and gang activity, environmental risks, and lack of proper services. Gender-based violence is rampant and exacerbates the painful disempowerment of families and human rights violations. The atrocious vulnerabilities in poor urban communities in Guatemala and throughout Latin America are testament to weak or absent interventions and/or community-based corrective actions. In this well-documented qualitative research, Quesada (2021, p. 69) asserts that a clear understanding of the causes, dynamics, and manifestations of urban violence and exclusion in poor marginalized communities is needed: Deciphering these processes helps to ground the search for spatial justice and shine a light on the urgent need for better access to democratic rights in the city, as well as the need to promote more inclusive urban planning practices. Even if spatial injustice has been historically and socially produced, it can and must be changed.
An examination of Venezuelan migrants' responses to claims of criminalization in Peru contributes a useful analytical framework and provides evidence on the intersectionality of class, gender, and race in south-south migration corridors. Pérez and Freier (2021) argue that Venezuelans devised the use of satire and intragroup boundary-making to cope with such claims. Most migrants who participated in the labor market did so as unregistered (informal) workers thus competing with Peruvian workers and Venezuelan late-comers who also try to find a space for themselves. To protect their employability and social integration, Venezuelan migrants established differences between themselves and late-comers. Hence, their coping strategies were indispensable to remain employed.

Conclusion
The scholarly contributions in this thematic issue provide unambiguous evidence about the extent of inequality and exclusion in Latin America. This is a fundamental step for corrective actions to address policy failures. Contributing authors have assembled an agenda for change. National policymakers should be autonomous of external pressures. Consideration should be given to legislation, policies, and programs to attain equality and gender equity. Patriarchy structures and traditional allocation of roles by age, class, ethnicity, gender, or any other marker must be eradicated. Girls and women should be supported throughout their lifespan to prevent inequity due to maternity or caregiving jobs at home. Their full participation in the labor market should be ensured through training and the elimination of stereotypes. Universal basic social services and other social protection coverage should be enacted as a human right. Students, workers' organizations, and other collective representations should actively participate in the political life of their communities to ensure social integration.