Social Participation within a Context of Political Violence: Implications for the Promotion and Exercise of the Right to Health in Guatemala

abstract Social participation has been understood in many different ways, and there are even typologies classifying participation by the degree of a population's control in decision making. Participation can vary from a symbolic act, which does not involve decision making, to processes in which it constitutes the principal tool for redistributing power within a population. This article argues that analyzing social participation from a perspective of power relations requires knowledge of the historical, social, and economic processes that have characterized the social relations in a specific context. Applying such an analysis to Guatemala reveals asymmetrical power relations characterized by a long history of repression and political violence. The armed conflict during the second half of the 20th century had devastating consequences for a large portion of the population as well as the country's social leadership. The ongoing violence resulted in negative psychosocial effects among the population, including mistrust toward institutions and low levels of social and political participation. Although Guatemala made progress in creating spaces for social participation in public policy after signing the Peace Accords in 1996, the country still faces after-effects of the conflict. One important task for the organizations that work in the field of health and the right to health is to help regenerate the social fabric and to rebuild trust between the state and its citizens. Such regeneration involves helping the population gain the skills, knowledge, and information needed in order to participate in and affect formal political processes that are decided and promoted by various public entities, such as the legislative and executive branches, municipal governments, and political parties. This process also applies to other groups that build citizenship through participation, such as neighborhood organizations and school and health committees.

social participation within a context of political violence: implications for the promotion and exercise of the right to health in guatemala Walter Flores, Ana Lorena Ruano, and Denise Phé Funchal abstract Social participation has been understood in many different ways, and there are even typologies classifying participation by the degree of a population's control in decision making.Participation can vary from a symbolic act, which does not involve decision making, to processes in which it constitutes the principal tool for redistributing power within a population.This article argues that analyzing social participation from a perspective of power relations requires knowledge of the historical, social, and economic processes that have characterized the social relations in a specific context.Applying such an analysis to Guatemala reveals asymmetrical power relations characterized by a long history of repression and political violence.The armed conflict during the second half of the 20th century had devastating consequences for a large portion of the population as well as the country's social leadership.The ongoing violence resulted in negative psychosocial effects among the population, including mistrust toward institutions and low levels of social and political participation.Although Guatemala made progress in creating spaces for social participation in public policy after signing the Peace Accords in 1996, the country still faces after-effects of the conflict.One important task for the organizations that work in the field of health and the right to health is to help regenerate the social fabric and to rebuild trust between the state and its citizens.Such regeneration involves helping the population gain the skills, knowledge, and information needed in order to participate in and affect formal political processes that are decided and promoted by various public entities, such as the legislative and executive branches, municipal governments, and political parties.This process also applies to other groups that build citizenship through participation, such as neighborhood organizations and school and health committees.introduction Over the past 40 years, the concept of social participation has gained increasing attention among groups as diverse as anti-globalization social movements, actors working for the right to health, and international financial organizations such as the World Bank. 1 Although it appears that these groups agree on the importance of promoting social participation, it is unlikely that they have the same understanding of what the concept means or how to promote it.
The literature on social participation over the last four decades has developed typologies for classifying the various forms of participation, ranging from participation as a symbol, which does not include decision making, to processes through which participation becomes an effective instrument for achieving redistribution of power among the population.These processes allow citizens to take control and have more power over the decisions that affect their lives and their communities.This article discusses social participation from a power-relations approach, particularly as it operates in Guatemala, a country whose framework of asymmetrical power relations has been shaped by a long history of repression and political violence.The first section provides a brief overview of social participation and human rights in order to address participation from a power-relations standpoint.The next section recounts the political violence experienced in Guatemala over more than three decades and its effects on social participation.In the last section, we look at today's enormous challenges for social participation and the different strategies and activities being employed to address those challenges.The conclusion summarizes the resulting implications for promotion and exercise of the right to health.

social participation as a means to demand and realize human rights
The concept of participation has gained increasing acceptance since it was first introduced into the literature in the 1960s. 3Its use has expanded due to a growing emphasis on democratic rules in processes of discussion, consultation, and social mobilization, and the ways in which they serve to influence institutions and public policies. 4Participation is understood as a right that is realized only when it is active, free, and meaningful. 5This understanding has further developed to include an emphasis on the "citizen" nature of participation.That is, participation is viewed as creating a relationship between citizens and their government, one in which both have the obligation to reduce the distance between them through processes of dialogue and creation of agency. 6 part of the observations and general recommendations on the human rights treaties developed in 2004 by the United Nations Committee on Economic, Social and Cultural Rights (CESCR), the role of social participation is emphasized as a means of involving the civilian population in decision making and various aspects of social and political life.Further, according to Paragraph 54 of CESCR General Comment 14, social participation is considered a means of achieving equality of opportunity through the proposal, design, and implementation of public policies from various social sectors. 7e effectiveness of social participation processes depends on the exercise of specific civil and political rights, such as the right to take part in conduct-ing public affairs and the right to seek, receive, and share all types of information and ideas. 8In the case of countries with populations that are not ethnically homogeneous, the participation process may involve specific rights of indigenous peoples to participate in decisions on policies that affect their development and access to land. 9cial participation is essential to implementing the right to health.This participation includes the provision of services as well as political decisions about the right to health and the organization and structure of the health system.In addition, political decisions must be deliberated at both the national and the local/community level. 10icia Ely Yamin asserts that applying a human rights framework to public health shifts attention from biological and behavioral determinants to power relations. 11Expert scholars writing about human rights tend to agree that true participation is related to "power;" however, very few define what power means. 12The concepts held regarding the notion of power reflect different ideologies, as we will see below. 13

Power relations and social participation
As is the case with social participation, power can be defined in many ways and is associated with various theoretical schools of thought. 14According to Mark Haugaard, the difficulty in defining power lies in the familiarity of the term and in the difficulty capturing its meaning in a single definition. 15If we see power as the ability to produce changes in society, we must be aware that these changes can be the product of either conflict or consensus. 16om the perspective of conflict, power is a determinist force "possessed" by an actor, and it can be taken away by another through struggles that may even be revolutionary processes. 17Actors can legitimize their power and dominance through social structures that reproduce their interests and create dynamic relations of autonomy and dependence. 18Thus, conflict is inherent to power, and power is inherent to social relations. 19om another perspective, we can also create and multiply power through consensus.According to Hannah Arendt, power is based on the human capacity to act together. 20Therefore, power does not belong to only one actor but rather to a social group and is volume 11, no. 1 health and human rights • 39 critical concepts relations requires understanding and treatment of the historical, social, and economic processes that have characterized social relations within a particular context.In the sections that follow, we take up a specific historical process in the Guatemalan context: political violence.

social participation in the context of political violence
In the period between 1960 and 1996, Guatemala experienced one of the most violent armed conflicts on the American continent. 27In a report published in 1999, Guatemala's Historical Clarification Commission (Comisión de Esclarecimiento Histórico, or CEH) estimated that 200,000 persons were affected by arbitrary execution or forced disappearance and that the number of orphans of the armed conflict approached 150,000.The massacres and destruction of villages gave rise to forced displacement of the civilian population internally as well as abroad.The CEH report also estimated that 1.5 million persons were displaced during the critical phase of the armed conflict (1981-1983).These figures indicate that more than one-quarter of the country's total population was affected by the political violence -through assassination, forced disappearance, and kidnapping -or by forced displacement from their dwellings.
Although all age groups suffered violence, it was mainly aimed at the population between 16 and 45 years of age (see Figure 1 on next page).This range represents adolescent children who contributed to the family's livelihood, parents of children under five, and adults in their productive prime.In other words, the violence attacked the core of Guatemalan society's human capital and dismantled its potential for social leadership.

Repression and social leadership
Even as the government of Guatemala signed the Alma-Ata declaration in 1978 (which included a commitment to promoting social participation), it was repressing social leadership that appeared to be opposed to the state's ideology.In the years following Alma-Ata, more than 650 social leaders were assassinated. 28The national university was one of the focal points of repression.Table 2 shows the arbitrary executions suffered by that population and demonstrates that the peak of repression occurred in the early 1980s, in the years following the Alma-Ata declaration.
generated through the creation of agency. 21However, the authors of the present article believe that, in the Latin American context in general, and in Guatemala in particular, applying this perspective creates naïve perceptions about social relations.Inclusion of traditionally excluded groups in decision-making processes does not create agency unless there are actions or policies that improve the material conditions of that population.Likewise, assigning resources to improve the status quo can generate opposition and conflict with those actors who benefit from the existing power structure, which also interferes with the creation of agency.
Nevertheless, we feel that the two approaches are not mutually exclusive.In both the Latin American and Guatemalan contexts, the creation of agency and consensus coexists with conflicting relations of power and domination.This occurs because the interests of the actors, the goals of the participation process, and the rules of the social space act to limit and shape both power as consensus and power as conflict. 22Examples of this coexistence of conflict/consensus can be found in the piqueteros movements in Argentina, in Ecuador's indigenous protests in 2000, and in the mobilization of unionized peasant workers in Bolivia. 23In all of these social processes, elements of conflict and consensus promoted social change.
In Guatemala, the power relations existing within social participation processes have taken place in the context of a history of repression and political violence that has affected the country since colonial days. 24The case of the indigenous uprising led by Atanasio Tzul and Lucas Akiral in 1820, and its social and political consequences for indigenous peoples, illustrates that violence and repression have been part of the Guatemalan state's operation since before its independence. 25In addition, the way in which the government of the liberal revolution of 1871 crushed the desires for independence of the State of Los Altos contributed negatively to the creation of the bipolar categories of ethnicity that currently exist in Guatemala. 26These dynamics of uprising and repression are found throughout the history of the country.Those most widely known and documented are probably the ones that took place in the second half of the 20th century, in the context of the Cold War and anti-Communist struggle.
In sum, analyzing social participation, including participation in health, from a perspective of power volume 11, no. 1 with 4.1% in Honduras and 3.7% in Nicaragua. 29ecause Guatemala had a significant gap in professionals in comparison to other countries, students and other professionals were vital for the country's development.However, it was precisely in this group that the greatest repression was concentrated.
Along with student leaders and professionals, local and community leaders were also targets of government repression.The CEH documented more The repression aimed at student and academic leadership was particularly significant in Guatemala in light of the country's low rates of university education compared to other countries in the region.In the early 1980s, less than 2% of the university-age population (20- bers.However, the increasing repression along with an increase in social demands served only to politicize many social action organizations and to radicalize their positions.The insurgency also created links with organizations in the social movement, which, in turn, led to even greater repression by the state.From assassinations of leaders, they moved to assassinations within grassroots groups, thus demonstrating the government's desire to destroy the social and political organizations. 34

Political violence and its effect on social participation
One of the most extensive and profound effects of the armed confrontation was the breakdown of community structures.Obligatory mechanisms of "participation," such as the "civil defense patrols"paramilitary groups supported by the army, whose objective was to combat incursion of guerrillas into the communities -were imposed over ancestral practices of social participation promoting local development in rural indigenous communities.Local indigenous authority no longer rested with a council of elders but rather with the head of the patrols (paramilitary forces), who were permitted to use violence, often aimed at families and leaders of their own communities. 35These fractures affected systems of authority, norms in community relations, and even elements of identity. 36other negative effect of the armed conflict was the climate of generalized terror that gripped the population.Victims of the conflict have reported experiencing intense feelings of fear, despair, mistrust, and insecurity that they could not explain or attribute to any particular "culprit."Carlos Beristain, a Spanish physician and psychologist who spent many years in Guatemala, suggested that these reactions occurred because the mechanisms of repression created a "phantom" that disoriented the population and made them feel high levels of insecurity. 37en today, communities continue to experience the negative consequences of the period of repression and political violence.Among these consequences is a commonplace notion in many communities, particularly rural ones, that "public" spaces (by which they mean, for example, municipal governments), are merely administrative entities without a political dimension. 38This view can be understood as a consequence of the armed conflict since, during the years of violence, any organized community was in than 319 cases in which community health workers (health promoters and traditional midwives), rural teachers, agricultural extension workers, catechists, and Mayan priests were victims of political violence (assassination and forced disappearance) during the conflict. 30In the decade from 1970 to 1980, health promoters were social leaders who played an important political role, not only in health matters but also in community development in general.This political involvement caused the army to associate the figure of "health promoter" with subversion, and guerrilla groups attempted to recruit them into the armed movement.For example, among the specific cases of violence aimed at health promoters, the CEH noted that "[b]etween 1980 and 1984, in the department of Chimaltenango, between 30 and 40 persons, most of them health promoters trained by the Behrhorst Foundation, were victims of forced disappearance, extrajudicial executions or displacement carried out by the Guatemalan army." 31 A health promoter who survived the armed conflict summarizes the situation in this way: We promoters were in the midst of the armed conflict and many colleagues were forced by the warring bands to take a position in order to save their lives.
If they didn't work with the army they were accused of being guerrillas, and if they didn't enlist in armed struggle with the guerrilla movement, they were accused of being army informants. 32e right to inform and to be informed was also violated during the conflict.One leader of health promoters from that time states: [W]e would meet in the corn and bean fields to discuss the problems affecting us and how we might solve them. . . .we had to pretend that we were working in the fields, because we weren't allowed to meet. . . .[T]hat was how we related what was going on, the risks that we faced, and the ways we might resolve them. 33pressing the leadership of professionals, students, and community leaders was part of the counterinsurgency strategy of state forces.The selective elimination of leaders was intended to weaken the social movement and provoke fear among its mem-lence occurred, how they were planned, and how the counterinsurgency state operated.
The 1999 report of the CEH, which had come out of the Peace Accords, presented the facts of the internal armed conflict, including the number of victims, along with specific information on the social and historical context of the political violence and the experiences of the victims.In response to pressure from the Guatemalan government, the signatories of this report agreed, however, that the CEH would not identify individual authors of the acts.Such a decision limited the possibility to use information gathered by the report to try the intellectual and material authors of the violations that had occurred.Instead, the report concentrates on specific recommendations for reparations to the victims and outlines social and political conditions that would prevent these acts from being repeated. 43Although compliance with the recommendations would have provided a chance to heal the social fabric and move toward reconciliation, many of the key recommendations were never implemented. 44spite some initial questions on the probative quality of the REMHI and CEH reports, they have in recent years been considered as proof in cases of violence during the internal armed conflict by national as well as international courts.The Xamán massacre and the Plan Sánchez cases are examples of this. 45Additional positive steps include the fact that preliminary inquiry and magistrates' courts have increased by 74%, along with a growth in staff and institutions that bring the justice system closer to citizens, including the Office of Defense for Indigenous Women (Defensoría de la Mujer Indígena), community legal offices, and the Public Service for Criminal Defense. 46Yet, despite these and other positive initiatives, there is a generalized perception in the population that progress has been minimal and that impunity still abounds in the country.The impact of the increase in justice workers is limited due to the great inefficiency of the justice agencies, where 96% of the cases remain unresolved. 47om the victims' perspective, impunity means prolonging their suffering; that is, the idea of "obtaining justice" is still far from their minds, not only because of the inaccessibility of the country's judicial system but also because of possible retaliation against them. 48The 1998 danger of being repressed or attacked because it was considered a political threat to the state. 39cent surveys of citizen participation reveal that overall levels of political and social participation are low and that people generally do not trust political and social institutions. 40These views are in part a result of the violations of human rights during the internal conflict and the history of violence that helps to explain the difficulty in consolidating the rule of law in the current democratic era.

Effects of impunity on the population's trust of the state
From a human rights standpoint, the population's relationship to the state is critical, since only governments can guarantee the human rights of their citizens. 41In post-conflict societies such as Guatemala, one of the major challenges lies in making the transition from a repressive state to one that promotes national reconciliation, justice, and the rights of citizens.In this transition, impunity becomes one of the greatest barriers to the pursuit of justice and compensation and inhibits citizens' confidence in the government.Guatemala's situation as it relates to the peace agreements is discussed below.
In 1998, the Catholic Church published a report titled Guatemala: Never Again! on the internal armed conflict, as part of its Guatemalan "Recovery of Historic Memory" project (known as REMHI, for Recuperación de la Memoria Histórica), documenting the acts of institutional violence that had occurred in the country after 1960. 42 and universities in the region.COCODES representatives are substituted by indigenous peoples' representation, and this system is replicated at the regional and national levels.
The development council law and its implementation are far from perfect and have many limitations, ranging from the legitimacy of the representatives to representation quotas in the councils themselves.In addition, government institutions are represented disproportionately with respect to the citizenry, especially where the indigenous population and women are concerned.Indigenous representatives at the national level reflect only 11% of the members.Representation by women is even less, at 3%.These figures are not very different at the regional level (9% indigenous participation and 6% from the sector of women's organizations) or at the departmental level (10% representation by indigenous peoples and 3% from the women's sector).In addition, there are continual accusations of manipulation of the councils by district representatives in Congress and departmental governors. 51spite these limitations, however, the system of development councils provides the public space for debate and dialogue between the municipal authorities and the population (at the municipal level) and citizen and government representatives at the departmental, regional, and national levels.The councils therefore create an opportunity for these groups to work together in a way that can help them reestablish relationships of trust.For these efforts to be successful, however, they must be accompanied by mechanisms that generate greater transparency and effectiveness throughout the system.
Civil society should use spaces for citizen participation, even with their imperfections and limitations, to assassination of Monsignor Gerardi, two days after his REMHI report was officially released, reinforced this vision of retaliation associated with impunity. 49punity not only affects the victims but also creates within the rest of the population generalized feelings of mistrust toward the state and its institutions.These reactions impede progress in rebuilding the country's social fabric and the relationship between citizen and state, which are vital to reconciliation and social development.Given these circumstances, we must ask: What opportunities exist for getting these efforts underway?
new spaces for social participation: opportunities for building trust and strengthening the social fabric Although the previously noted concerns have been significant, an opinion poll carried out in 2004 among local elites (political, social, and economic) and the citizenry revealed that they had perceived significant advances in freedom of association, demonstration, meeting, election of authorities, and expression since the end of the armed conflict.Likewise, they acknowledged a broadening of spaces for participation, as well as opportunities to discuss the national agenda, the emergence of new political actors, and the strengthening of mechanisms for dialogue between government and society. 50e poll suggests that the perception of advances had developed in response to the legal framework created by the Peace Accords.The National Congress approved a series of laws that promote and guarantee the social participation of the population in the development, implementation, and evaluation of public policy.It also implemented decentralization processes at the municipal level.Of special significance is the "Urban and Rural Development Councils Law," which creates mechanisms for participation in the allocation of public budgets from community to central government levels.One of the principal tasks of the development councils is to prioritize and designate public investment in municipal infrastructure.
To do so, the councils receive an allocation of about 11% of the country's total fiscal resources.
The council structure contains five different levels of representation.At the lowest levels there are com-ments, while at the same time taking concrete actions that help promote citizen trust in the state.
At the civil society level, we must go beyond the legal framework and provide citizens with the skills, knowledge, and information that they need to be able to participate in and influence formal political processes that are decided and advanced by various entities, such as the legislative and executive branches, municipal governments, and political parties.Citizens can also impact other processes of participation that build citizenship, such as neighborhood organizations and school committees. 54e challenge of fostering social participation that promotes redistribution of power through democratic processes is enormous.Doing so, however, is crucial in achieving social justice for the people of Guatemala.Only through redistributing the current balance of power toward greater equity and citizen inclusion can the country draw closer to full rights for all.This view of participation should include critical modification of existing utilitarian approaches to participation as well as reductionist concepts of power.
A discussion of participation that is divorced from its inherent socio-political elements does not contribute to the objective of promoting social changes that create conditions for attaining a decent life for all.
All health and human rights organizations should broaden and diversify their work teams and strengthen their skills in order to truly be multidisciplinary.
Only in this way will they be able to analyze and facilitate social participation as the principal tool for making the right to health demandable.

acknowledgments
The research that led to this article was possible thanks to the financial support of the Centre for Global Health Research, University of Umeå, Sweden.The authors are also grateful to Marco Tulio Gutierrez for his assistance during data collection.We especially thank the health promoters from the internal war period who shared their experiences with us.For comments on earlier versions of the manuscript we are grateful to Gustavo Estrada, Miguel San Sebastián, Ignacio Saiz, and Cote Parada.Finally, we thank the two anonymous external reviewers and the editors for their comments.
create and propose solutions.This is not an easy task since it requires dealing with the existing power structure, with a lack of political will, and with a system of political parties lacking in credibility and legitimacy. 52evertheless, it is precisely in these spaces where social changes can begin to be created, among them, those recommended by the CEH.
conclusion: implications for promotion and exercise of the right to health The Guatemalan experience illustrates and contributes to the notion held by various authors who have stated that a "legalistic" view of human rights is not always useful or sufficient to understand social contexts and promote the exercise of human rights. 53The Guatemalan government has ratified the principal international treaties and has accepted international declarations such as Alma-Ata.Despite this, it systematically violated them with impunity and unleashed a wave of repression against the Guatemalan population for almost four decades.
Guatemala is a post-conflict society whose scars are very present.Fostering social participation presents great challenges for the population as well as for institutions and organizations that promote it.The population must relate to a government that recently assaulted their most fundamental rights.The organizations that promote social participation (among them, the health and human rights sectors) have an obligation to know the history of Guatemala in order to understand the population's individual and group behavior regarding social participation.They must also understand and recognize the new spaces of participation that have emerged in the last 12 years.These organizations can play an important role as intermediaries that may help rebuild trust between institutions of the state and the citizenry and facilitate the regeneration of the social fabric, which are essential elements that cannot be separated from the processes of social participation.
The Guatemalan government, through its institutions, must earn the confidence of the citizenry.One of the essential steps toward achieving this is for government agencies to fulfill citizens' demands for improvements in areas such as health services, education, and housing.In this way, by advancing in the progressive achievement of the CESCR, the government will be fulfilling its obligations and commit- 29 years of age) was registered in any university.During the same time period, this percentage was 7.8% in Mexico, 10% in Costa Rica, and 8.8% in Panama.Even poorer Central American countries had greater university registration than Guatemala, Figure 1.Number of victims of assassination and forced disappearance by age range, 1959-1995.Adapted from P. Ball, P. Kobrak, and H. F. Spirer, State violence in Guatemala, 1960-1996: A quantitative reflection, Table 16.1, "Number of killings and disappearances by year, 1959-1995."Available at http://web.archive.org/web/20010908071715/hrdata.aaas.org/ciidh/qr/english/chap16.html.
volume 11, no. 1 health and human rights • 45 critical concepts sector