LATIN AMERICAN PERSPECTIVES, Issue XXX, Vol. XX No. XXX, Month 201X, 1–17
© 2018 Latin American Perspectives
Social Inequality and Mental Health in Chile,
Ecuador, and Colombia
Yanet Quijada, Loreto Villagrán, Pamela Vaccari Jiménez,
Carlos Reyes, and Luz Dary Gallardo
Victoria J. Furio
The results of a comparative study of social inequality and mental health show that
Chile and Colombia, which have enormous social gaps despite their economic growth, are
characterized by poor mental health indicators and social discontent, while the better
equity indicators in Ecuador are not clearly linked to mental health. The concept of social
defeat is suggested as a mediator between social inequality and individual and collective
mental health, and participation and empowerment are suggested as ways of improving
Los resultados de un estudio comparativo de desigualdad social y salud mental muestran
que Chile y Colombia, que tienen enormes brechas sociales a pesar de su crecimiento
económico, se caracterizan por indicadores de salud mental deficientes y descontento social,
mientras que los mejores indicadores de equidad en Ecuador no están claramente vincula-
dos a la salud mental. El concepto de derrota social se sugiere como un mediador entre la
desigualdad social y la salud mental individual y colectiva, y la participación y el empodera-
miento se sugieren como formas de mejorar el bienestar social.
Keywords: Mental health, Social well-being, Social inequality, Social defeat, Public
It is recognized worldwide that social variables influence people’s health
(WHO, 2008). In Latin America, however, an increase in macroeconomic indi-
cators has not always translated into improved individual health and/or
well-being, and this may be related to inequality. Most studies of the relation-
ship between health and inequality focus on epidemiological variables
(Kaufman and Mezones-Holguín, 2013; Muntaner etal., 2003) or on power
relations and the control of capital (Domingo-Salvany etal., 2013; Rocha etal.,
2013) rather than on the way people construct and represent the sociopolitical
context in which they live. For this reason, the guiding question for this essay
is what psychosocial processes make it possible for social inequality to affect
Yanet Quijada is an associate professor of psychology at the Universidad San Sebastián, Chile.
Pamela Vaccari Jiménez and Loreto Villagrán are professors of psychology at the Universidad de
Concepción. Carlos Reyes is a professor at the Universidad Andina Simón Bolívar, Ecuador and
Luz Dary Gallardo is a professor at the Universidad San Buenaventura, Colombia. Victoria J. Furio
is a translator living in New York City.
803682LAPXXX10.1177/0094582X18803682Latin American PerspectivesQuijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH
2 LATIN AMERICAN PERSPECTIVES
Studies emphasize the social dimension, including aspects such as empa-
thy, the ability to establish interpersonal relations (Jahoda, 1958), satisfying the
need for bonds (Ryan and Deci, 2000) and establishing positive relations with
others (Ryff, 1989), as a basic component of health. The WHO (2002: 2) defines
health as “a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity,” incorporating the concept of social
well-being originally proposed by Corey Keyes (1998) and including self-
esteem, satisfaction with life, sense of well-being, social sensitivity, and posi-
tive affect (Keyes, 2005; Shapiro etal., 2008). From this we infer that the
inequality and discontent that characterize Latin American countries make it
highly likely that their health will be affected. This is not an assertion of social
determinism but a relational view in which people cannot be separated from
their physical and mental features or from the social and cultural contexts in
which they are imbedded.
The effects of inequality can be explained in terms of the inability of
lower-income groups to acquire the material conditions necessary for good
health (Lynch, Smith, and House, 2000). Another approach suggests that
physical and psychological discomfort develops when people evaluate
themselves as having lower status than a reference group (Hounkpatin
etal., 2015). Empirical studies such as that of Daly, Boyce, and Wood (2015)
show that a low social position based on gross income compared with var-
ious reference groups (gender, age, education, and place of residence) is a
better determinant of various indicators of physical health problems than
gross income per se. The same occurs in predicting psychological distress
(Wood etal., 2012). Low social position has been found a better predictor
than gross income of symptoms of depression (Hounkpatin etal., 2015),
low overall satisfaction (Boyce, Brown, and Moore, 2010), and even sui-
cidal ideation and attempts (Wetherall etal., 2015). These studies use data-
bases with macroeconomic and social indicators, leading some writers to
point to the need for more research into the psychological mechanisms that
link social context with individual malady, with social comparison being
fundamental to their understanding (Hounkpatin etal., 2016; Wilkinson
and Pickett, 2006).
Developmental models of social functioning show that subjects with low or
subordinate social positions will display physiological and behavioral reac-
tions that make them more vulnerable to health problems (Mendelson,
Thurston, and Kubzansky, 2008). When applying this to mental health, the term
“social defeat” surfaces. This concept involves negative behavioral and cogni-
tive reactions to failure to attain status or goals in comparison with others
(Gilbert, 2006). This mechanism, which assumes social comparison, has been
studied empirically only in relation to individual clinical variables. Therefore,
its association with social variables is still unexplored, and we suggest that it
could be useful in understanding mental health in Latin America. Accordingly,
this essay will analyze figures on inequality and studies that relate it to mental
health and well-being in the past 20 years in Latin America and examine the
concept of social defeat as a possibility for explaining the impact of inequality
on mental health.
Quijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH 3
The SociopoliTical conTexT of inequaliTy
Latin America has been viewed historically as founded on relations of ine-
quality. This can be traced back to the colonizing enterprise, which set up strict
power relations based on the oppression of the original peoples, imposing
European cultures on the local ones. In the continent’s historical development,
these power relations were reproduced by the establishment of social classes
that concentrated power and resources, supporting forms of government that
perpetuated them. The history of the continent between the 1950s and the
1990s created dictatorial processes for Chile, Colombia, and Ecuador that per-
petuated the asymmetry of power and resources among their citizens, the
basis of the economic models that maintain inequality in these societies today
The case of Chile is emblematic. During the Pinochet dictatorship of the
1970s, under heavy repression and social control, a Milton Friedman–style neo-
liberal economic model consisting of the imposition of a free market, drastic tax
reductions, privatization of services, cuts in social spending, and general liber-
alization and deregulation was implemented (Klein, 2008). As a result, a domi-
nant elite pursuing free-market business arose, and it was allowed to concentrate
economic resources and power in contrast to a working class that saw its work-
ing conditions become insecure, losing social benefits through the privatization
of public services such as health care, pensions, and education (Espinoza,
Barozet, and Méndez, 2013). The return to democracy in the 1990s did not
improve those conditions; the postdictatorship governments maintained the
economic model despite implementing social policies that allocated economic
resources to the most vulnerable. This led to an improvement in poverty indica-
tors without its translating into a more egalitarian society or an improvement
For example, considering suicide as the extreme of psychological distress,
Moyano and Barría (2006) found a direct relation (r = 0.87) between the growth
curves of the suicide rate and the gross domestic product (GDP) during the
period from 1981 to 2003. Between the 1990s and 2000 Chile had an approxi-
mate annual growth of 5 percent (Espinoza, Barozet, and Méndez, 2013), and
between 2006 and 2013 it reduced poverty rates from 29.1 percent to 14.4 per-
cent (MDS, 2015). At the same time, the Gini coefficient fluctuated between
0.50 and 0.51, above the regional average and one of the most noteworthy
among the OECD countries (MDS, 2015; OECD, 2015a). The average indepen-
dent income of a household in the top 10 percent was 27.6–38.8 times that of a
household in the bottom 10 percent (MDS, 2015). Likewise, reviewing national
stratification and mobility data for the past 10 years Espinoza, Barozet, and
Méndez (2013) concluded that Chile has a relatively mobile and permeable
class structure in its middle sector but a tendency toward polarization at the
extremes, since social distances increase despite economic growth. Health care
reform with explicit health guarantees was implemented in 2005, and in both
4 LATIN AMERICAN PERSPECTIVES
2000 and 2013 people at the highest social levels continued to have a greater
likelihood of obtaining above-average health care than people in the lowest
strata (Cabieses etal., 2015). Chile’s case shows that economic growth indica-
tors can be deceptively optimistic, concealing a highly unequal distribution of
income among the population, and leads us to conclude that the mere fact of
subsidizing the disadvantaged is no guarantee of social mobility or improve-
ments in health.
The past 30 years in Ecuador have been marked by abrupt political, eco-
nomic, and social changes reflected in successive presidential overthrows and
an economic crisis that led to a profound imbalance in the country. The 1999
banking crisis, based on economic deregulation reforms (Larrea, 2002), concen-
tration of credit for businesses, and lack of government monitoring or evalua-
tion (Espinosa, 2000), was a landmark event. Added to this were the drop in the
price of oil, the country’s principal resource, and the effects on agriculture of
natural disasters (Fontaine, 2002). Government measures included a freeze on
deposits and widespread bank closures or takeovers by the state, leading to the
dollarization of the system as a means of adjustment and stabilization. As a
result, unemployment rates increased from 8 percent to 17 percent in 1999 and
underemployment to 57 percent, while the minimum wage dropped to US$53
and urban poverty rose from 36 percent to 65 percent (Espinosa, 2000; Fontaine,
2002; Larrea, 2002). Ultimately, some 700,000 Ecuadorians emigrated, mostly to
the United States, Spain, and Italy.
Despite an economic recovery following the crisis, there were frequent
changes of president until Rafael Correa came to power in 2007. His measures
for achieving stability included an economic policy assumed almost com-
pletely by the state, the creation of a new constitution, and the development
of social policies based on the concept of “living well” (buen vivir; Secretaría
Nacional de Planificación y Desarrollo, 2009). These initial policies involved
a distancing from the neoliberal paradigm that garnered massive citizen sup-
port for the “Citizens’ Revolution” in Correa’s first term. In addition, an eco-
nomic bonanza achieved with the rise in oil prices to historic levels allowed
for a strengthening of the state in income distribution and implementation of
measures aimed at development, access to rights, and institutional consolida-
tion (Martínez, 2015: V. Silva, 2016). A significant reduction in poverty was
achieved between 2006 and 2014, from 37.6 percent to 22.5 percent (World
Bank, 2016), along with a reduction in extreme poverty from 16.9 percent to
8.6 percent (INEC, 2014). The Gini coefficient, 0.55 in 2007, dropped to 0.47 in
2015 (INEC, 2014; World Bank, 2016) and was practically identical in urban
and rural areas. By the same token, the inequality index dropped by 1.7 per-
cent (UNDP, 2014). Thus inequality as measured by income level has displayed
a sustained reduction over the past 10 years. A measure that provided monthly
vouchers to almost 2 million people may have influenced the sustained rise in
the human development index, which reached 0.732 (UNDP, 2013). Despite
these advances, 23.7 percent remain at the poverty level, with significant dif-
ferences between the urban (15.6 percent) and rural (39.3 percent) popula-
Quijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH 5
tions (INEC, 2014; World Bank, 2016)—figures that call the progress in the
Gini coefficient into question.
In health, coverage in the more vulnerable quintiles increased from 35 per-
cent to 80 percent between 2006 and 2013, and health insurance increased from
17 percent to 34 percent in the same period (INEC, 2014). However, a recent
report from Aldeas Infantiles SOS (2015) noted the lack of psychological and
mental health services for the treatment of addiction and severe mental disor-
ders. Additionally, there are few reports on the epidemiology of specific disor-
ders, and the data currently available on mental health tend to be presented
separately from epidemiological variables. As a result, it is difficult to find an
analysis that promotes a comprehensive explanation of the progress reported
in these areas. For example, issues such as the 3.4 percent increase in suicides
among youth from 2000 to 2012 (WHO, 2014) point to the need to know more
about the social and economic factors involved in this situation.
In recent years, increasing labor flexibilization and privatization in mining
projects have signaled a return to the neoliberal economic policies implemented
during the 1990s (Acosta and Hurtado-Caicedo, 2016). Although the current
administration has not fully recognized it, a crisis exists in the form of economic
recession and deterioration of growth prospects (IMF, 2016), along with discon-
tent among those displaced by the mining industry and an increase in unem-
ployment from 4.2 percent to 5.4 percent (ILO, 2016).
In short, indicators in Ecuadorian society over the past decade demonstrate
economic and social progress tending toward a more equitable society, but
there are no data from national or international organizations that consider the
relationship between social inequality and health variables. Finally, the current
crisis has produced changes in the country’s political and economic stability
that are causing noticeable changes in the reported trend.
Colombia joined the trend toward the use of the neoliberal economic model
in the 1990s, implementing significant changes in the comprehensive social
security system and prioritizing investment in industry (Observatorio Nacional
de Salud, 2015). These processes redefined the land and its relationships in
terms of production and marketing needs (Bello, 2004), setting the stage for a
widening of the gap between rich and poor. In particular, small farmers and
indigenous populations cannot compete with large agricultural businesses and
struggle against expulsion from their lands to make way for road building and
commercial enterprises. The 2006–2010 National Development Plan was cre-
ated to reduce poverty and improve health care for vulnerable groups, and
when it achieved only meager results new policies with similar objectives for
2012–2021 were implemented. The social and economic policies employed by
the National Planning Department to address inequality have been deemed
successful in light of the decline in the Gini coefficient from 0.53 in 2014 to 0.52
in 2015 (DANE, 2015). However, UN-Habitat (2014) ranked Colombia among
the 10 least equitable countries. Between 2010 and 2015, 4,574,000 people rose
out of extreme poverty because of the United Network and Families in Action
program, focused on support and the provision of housing. The indicators on
6 LATIN AMERICAN PERSPECTIVES
access to basic services such as electricity, sewage systems, and potable water
improved, but those on education, health care, the environment, and the social
system were judged inequitable (Observatorio Nacional de Salud, 2015).
All these changes in economic variables and inequality in Colombia pro-
ceeded in parallel to the so-called internal armed conflict that goes back at least
to the 1950s, pitting the state, the guerrilla groups (the Fuerzas Armadas
Revolucionarios de Colombia and the Ejército de Liberación Nacional, among
others), and the “self-defense” paramilitary groups against each other. The
country has the largest number of internally displaced persons in the world
(IDMC, 2013) and ranks eighth in the number of refugees outside its borders
(UNHCR, 2012). The farmer population is bitter about the consequences of the
introduction of the neoliberal model and the market for illegal crops (Bello,
2004: 21), along with the increase in drug trafficking and the traffickers’ par-
ticipation in the struggle for control of territory (Castillo, 2004).
Colombia has improved its poverty indicators and slightly reduced inequal-
ity in recent years, but government policies are currently failing to provide
services and/or quality resources. Added to this, violence and the displace-
ment of civilians present a challenge to the state to assist various vulnerable
groups by promoting agricultural development and political participation,
solving the problem of illegal drugs, attending to the victims of the armed con-
flict, and ending the war. All of this produces socioeconomic uncertainty
because of the increase in the number of beneficiaries of these policies and the
challenge for coordination between the state, the private sector, and organiza-
tions to guarantee social security, education, health care, and well-being.
aSSeSSing inequaliTy in healTh care
Ortiz-Hernández, López-Moreno, and Borges (2007) point out that a combi-
nation of criteria is employed to analyze the social determinants of health: epi-
demiological (mortality rates, morbidity, or life expectancy), sociological
(educational level, income, and socioeconomic position), and economic (pov-
erty, Gini coefficient). Measures that assess inequality and health tend to use
social stratification, through nominal or ordinal categories, because of practical
considerations or the availability of databases (Galobardes etal., 2006; Muntaner
etal., 2003). They add that in general inequality is considered an expression of
stratification (as in Colombia, where the ranking from 1 to 6 that is applied to
housing ends up being the focal point of discrimination among people). The
effects of this are significant because the social relations resulting from inequal-
ity are not questioned (Muntaner etal., 2003; 2012). Variables that focus on
income level or on consumer goods do not analyze employment situations,
control/authority relations on the job, or power differences between social
classes. Methodological problems in evaluating social class are also evident,
especially with regard to the social strata at the extremes, where people are less
accessible to research efforts (Muntaner etal., 2003). For all of the above, meas-
uring inequality could be improved if other dimensions, such as educational
level in income distribution and purchasing power, were used. When the
UNDP’s human development index is applied to Latin America, it is clear that
Quijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH 7
purchasing power sets the conditions for health and education. If this index
were analyzed from the perspective of inequality, it would drop from 0.83 to
0.67 in Chile, from 0.72 to 0.54 in Colombia, and from 0.73 to 0.57 in Ecuador.
From this example and Wilkinson’s (2002) inputs, it is possible to assume that
the countries with better health indicators are those with the smallest gap
between wealth and poverty. Another measure supplementing those currently
used to measure inequality might be the International Index of Social and
Health Problems, which includes, among other things, inquiries into mental
disorders, social mobility, and confidence (Wilkinson and Pickett, 2010).
Instead of considering wealth and/or home furnishings, measures of income
inequality tend to include the financial assets, real estate holdings, and savings
instruments that are usually possessed by the higher-income sectors, reflecting
a position handed down over time that directly influences health (Hounkpatin
etal., 2015). When wealth is included, the description of inequality appears
with a greater gap, and figures such as the global Gini soar to values close to
0.8 (UNICEF, 2012). If current poverty indicators were supplemented with
measures that assessed the relationship between social determinants and
health, policies could be tailored to the design of more equitable communities.
Social defeaT aS a mediaTor beTween
healTh and Social inequaliTy
At the individual level, it has been suggested that mental depression may
explain the way inequality affects health, presenting it as a mediator of this
relationship. Symptoms of depression may be a reaction to contexts such as
dangerous neighborhoods and/or high levels of family conflict (Chen and
Miller, 2013). Following this logic, improving people’s life settings could
improve their mental health. At the same time, theories of depression indicate
that human beings, like other primates, are highly sensitive to social hierarchies
because they provide information on the resources available to them and the
likelihood of obtaining them (Price, 1972). Those who consider themselves of
low social status will have little expectation of obtaining what they need; their
tolerance for frustration will drop and they will avoid conflict with those more
powerful by displaying submissive behavior. All these reactions will have a
physical correlation involving the serotonergic system and the stress regulator,
which are associated with symptoms of depression (Hounkpatin etal., 2015).
In this approach, manifestations of depression are understood as defensive
responses to the perception of low social status and not just reactions to an
adverse condition (Taylor etal., 2011).
We have established that Chile is a highly unequal country, and, consistent
with this, epidemiological studies there show a prevalence of major depressive
disorders of 9.2 percent, very similar to that found in the United States (9.6
percent) and among the highest in the world (D. A. Silva and Valdivia, 2013;
Vicente etal., 2006). Similarly, we have pointed to the country’s sustained eco-
nomic growth and the GES plan for subsidizing health care, both of which
should have had a positive impact on mental health in recent decades.
Instead, while in 2003 (before the GES) 17.5 percent of the population showed
8 LATIN AMERICAN PERSPECTIVES
symptoms of depression, in 2009 (after the GES) the figure had changed only
changed slightly, to 17.2 percent (Errázuriz etal., 2015). These figures show that
provision of resources without a transformation of the social structure does not
produce the desired effect. In fact, while the GES plan improved access for the
disadvantaged sectors, inequality in health care associated with educational
level, income, and type of retirement system increased between 2000 and 2013
(Cabieses etal., 2015), which could explain the sustained figures on depression
and other indicators of poor health. In Colombia, a country with a socioeco-
nomic model and inequality indicators similar to Chile’s, indicators of well-
being for the 18–44-year-old population were between 32.5 percent and 42.2
percent depending on the question and gender. In this regard, Hounkpatin
etal. (2016) suggest that in inequitable settings comparisons can result in phys-
ical and psychological distress.
Not all those who consider themselves of low social status will develop a
depressive disorder; it has been suggested that this will require psychological
characteristics that interact with the setting and the individual’s biological
makeup. The concept of social defeat, defined as a sense of failure associated
with the loss of a valued status or important personal goal (Gilbert and Allan,
1998), has social comparison at its core but adds an individual component in
proposing that human beings develop their own psychological hierarchies of
goals and are conscious of their social positions in relation to those goals. In
nonpathological conditions unfavorable social comparison implies accepting
the defeat—feeling its consequences (submission, low motivation, hormonal
reaction) only temporarily before redirecting motivation and behavior toward
new goals (Sloman, Gilbert, and Hasey, 2003). Nevertheless, when one is inca-
pable of overcoming the defeat, a psychopathological condition—feeling
trapped and chronically suffering its consequences (Taylor etal., 2011)—will
appear. This mechanism has received broad empirical support for explaining
depression, anxiety, and suicide (Siddaway etal., 2015; Taylor etal., 2011).
People in the disadvantaged classes in Chile can be assumed to live with a
chronic sense of defeat and distress over the inability to attain valued goals
because of the lack of the resources to reach them. This constant sense of defeat
may help us to understand why the prevalence of depressive symptomatology
increases as the socioeconomic level declines (Jiménez and Orchard, 2013)
independent of mental health subsidies and of the relation between low social
status and the prevalence of mental disorder or symptoms of comorbidity and
anxiety in general (Vicente etal., 2006). In terms of working conditions, social
class, and mental health the data also support our suggestion, showing that
upper-class people are less likely to display mental health problems than
supervisors and formal and informal workers (Rocha etal., 2014).
With regard to the perception of their social position, qualitative studies
show that Chileans view their society as highly classist and provide many
examples of the advantages of having economic resources or belonging to a
high social class. Worse, they maintain that this situation is inherited by certain
individuals or groups (Garretón and Cumsille, 2002). The inability to overcome
defeat has been put forward as the variable most highly associated with suicide
(Siddaway etal., 2015). The idea of the heritability of class may be related to the
increase in the suicide rate by 54.9 percent between 1995 and 2009, especially
Quijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH 9
among youth (OECD, 2015b). In Colombia a measure of socioeconomic strati-
fication in which 1 is extreme poverty and 6 is economic solvency (Alzate, 2006)
has led to a demarcation of classes, conditioning the perception of social posi-
tion and identifying the opportunities of each stratum in terms of certain social
criteria, which makes social mobility difficult for the less favored social classes.
Consequently the 2015 national mental health survey indicates that the adoles-
cents of the lower strata have a higher frequency of depressive, anxious, and
psychotic symptoms and that disorders are more prevalent at the lower levels
of the social scale. In particular, anxiety disorder is more frequent in persons
living in poverty. If we focus on a specific population of “the defeated” in
Colombia such as those displaced by the internal conflict, studies show a
greater frequency of mental disorders than in the nondisplaced population: 47
percent for anxiety disorder, 37 percent for major depression, and 37 percent for
risk of suicide (Londoño etal., 2005). It is striking that, following the Chilean
trend, we have begun to see a rise in adolescent suicide rates from 1.57 per
100,000 in 2008 to 1.75 in 2012 (Instituto Nacional de Medicina Legal y Ciencias
From a more collective standpoint, the low motivation and submission that
social defeat produces limit individuals’ ability to take advantage of opportu-
nities to improve their situation (Gilbert, 2006). More specifically, remaining
in defeat is a link to fatalism, defined by Martín-Baró (1973: 486) as “an atti-
tude of passive acceptance of a present and a future in which everything is
already predetermined.” This is a maladaptive strategy characterized by inac-
tion despite constant discomfort. In this regard, Vidal etal. (2014) point out
that Chileans with higher incomes demonstrate better social strategies for
dealing with distress. Similarly, members of the disadvantaged classes display
less participation and less confidence in public institutions (INJUV, 2012;
Latinobarómetro, 2015; OECD, 2015a; UNDP, 2012). In Ecuador, a country
with better equality indicators than Chile or Colombia, political participation
in the elections of 2013 and 2014 showed a rate of 83.2 percent, an increase of
22.6 percent (Consejo Nacional Electoral, 2015). In contrast, abstention in Chile
reached 58 percent, the highest in Latin America among nations with non-
obligatory voting, followed by Colombia, with 52.1 percent (International
The consequences of social defeat can be softened by social support (Williams,
1997, cited in Taylor etal., 2011). Rocha etal. (2014) found that Chileans with
less perceived social support had worse self-perceived physical and mental
health. If support is sought through social media, collective action may result
(Sullivan etal., 1980), and action over time may amount to a social movement
(Turner and Killian, 1987). The formation of social movements has intensified
over the past 10 years and come to cover a variety of issues (Garcés, 2012). In
Chile, the defeated have organized themselves to demand rights that, under
the socioeconomic model, have become acquirable goods according to one’s
purchasing power, leaving aside a large portion of society without the possibil-
ity of attaining education, quality health care, or a dignified retirement. From
another point of view, we could conclude that any country’s measure against the
collective demand serves to maintain the defeated in their state of inaction. For
example, in Ecuador, with the latest government move toward neoliberalism
10 LATIN AMERICAN PERSPECTIVES
communities have been stripped of their territories to the benefit of large-scale
mining (Acosta and Hurtado, 2016; Colectivo de Investigación y Acción
Psicosocial, 2015; 2017) and subjected to the detention of their leaders, militari-
zation, and violence (CONAIE, 2017). These actions seek to break up collective
action, fostering the submission and inaction that stem from the state of defeat.
diScuSSion and concluSionS
Latin America is a region of extreme socioeconomic inequality (UNICEF,
2012). This is apparent, for example, in the concentration of wealth in small
portions of the population as a result of the capitalist and neoliberal model
operating in countries such as Chile and Colombia, where limited and sub-
sidiary states have left supplying goods and services to the population to the
private sector (García-Castro, 2010; Harvey, 2007; Katz, 2015). Although the
model of the state in Ecuador is different, its progress in the area of health care,
as in Chile and Colombia, has been slow because not everyone can afford this
subsidized service (OECD, 2015a; UNDP, 2013). This has led to persistent dis-
content and mistrust of institutions and governments (Baletti, 2016;
Latinobarómetro, 2015). The region has historically been characterized by social
movements, and during the past decade they have become widespread and
their demands wide-ranging. Critiques of the neoliberal model, which, in the
guise of free development, fuels individual growth through capital accumula-
tion and the reproduction of profit, touching aspects of life that in welfare states
are considered rights, are thereby highlighted (Garcés, 2012; Katz, 2015).
Discontent also appears when a state is unable to reduce poverty indicators or
offer a range of basic and varied services to the population. Ecuador is in this
situation, and, although there is less inequality among its citizens, discomfort
and discontent persist.
In the case of Chile, strategies for assessing and taking action on social
inequality since 1990 have had a positive effect on poverty reduction, but indi-
cators of mental disorder, levels of participation, and confidence in institutions
have not improved. Health care continues to vary in quality with the type of
coverage, and there has been little investment in mental health treatment
(Errázuriz etal., 2015). High levels of inequality persist, with extensive segrega-
tion of social classes and little social mobility. Currently, this structure is being
strongly questioned by social movements advocating for equality in education,
health care, and pensions and opposing the assignment of the status of “com-
modity” to these basic rights.
Ecuador has seen significant economic and social progress in the past 10
years, but there is a crisis caused by the decline in the price of petroleum and
excessive state control of the country’s figures on health care. This, along
with punitive actions against those who question the administration, has
provoked changes in political and economic stability. The prearranged agree-
ments for the expected sale of oil and the impact of the 2016 earthquake
forced government budget cuts that created uncertainty about how the
advances of recent years might affect the health and well-being of Ecuadorians
subjected to them.
Quijada et al. / SOCIAL INEQUALITY AND MENTAL HEALTH 11
In Colombia the state has committed itself to responding with public policies
to improve the quality of life for the most vulnerable, and analysis of social
determinants has served to measure mental health in the population. Because
of the country’s history, this includes identifying the conditions for peace,
whose link to health is a challenge requiring public policies that include all
In all three countries, better health and greater satisfaction require reducing
the gap between rich and poor. Guaranteeing access to quality services and
promoting citizen participation and empowerment are, however, still pending
items in Latin America because of the tension that exists between civil society
and the state (Astete and Vaccari, 2017). On the one hand, the state needs to
provide guarantees of access to services; on the other, it limits participation in
decision making in the political realm, preventing people from controlling
wage inequalities and the reduction of poverty in a given sector (Katz, 2015).
The Gini coefficients in 2015 were 0.45 in Ecuador, 0.52 in Colombia, and 0.49
in Chile, and no measures have been aimed directly at improving them. The
increase in funding for various programs does not guarantee better health for
the population or any reduction in these coefficients. In Chile and Colombia,
suicide rates, for example, remain largely unchanged (11 per 100,000 inhabit-
ants in Chile and 3.8 in Colombia) (Errázuriz etal., 2015; Instituto Nacional de
Medicina Legal y Ciencias Forenses, 2013). In Ecuador, the increase in social
investment, including the human development voucher paid monthly to a
large portion of the population, has not reduced the poverty rate (currently 23.7
percent). Ecuador has no public figures on the effects of the holistic “living
well” plan, and studies that link the Gini, the human development index, pov-
erty measured by income, and percentage of informal labor with mental health
epidemiology do not exist. However, there are many inconsistencies between
its high human development index (0.732), its 0.45 Gini coefficient, and its pov-
erty level (INEC, 2014; World Bank, 2016). The efforts made in health care do
not specify the issue of social determinants as the point of departure. Therefore,
a more comprehensive analysis will be required to demonstrate the impact of
For these reasons, evaluating psychological factors in relation to inequality
and health seems an appropriate way of guiding possible individual or collec-
tive action. People are conscious of their positions in society, and this makes
the social composition of their country a fact that helps define their position in
life. In Chile, where purchasing power conditions the “purchase” of important
personal goals, the feeling of defeat is generalized, explaining the elevated
indicators of mental health problems. Despite this, a culture that promotes
social support persists, demanding equality through collective action. In
Colombian society disadvantaged groups are marked by the subsidy policy
and by a history of displacement and seizure of their lands. While in the for-
mer the perception of defeat predominates, the second has objectively been
“defeated” and will require focused attention on mental health given that the
social divide leaves them with few tools for dealing with the consequences.
Both groups display poor mental health indicators. Reporting on Ecuador’s
social composition has left aside groups such as indigenous populations in
economically coveted areas whose attempts to overcome defeat have been
12 LATIN AMERICAN PERSPECTIVES
heavily repressed. Added to this is the quarter of the population that is steeped
in poverty and job insecurity, an issue that cuts across the three countries
because of the effects of the prevailing economic model. Our analysis suggests
that part of the Ecuadorian population may be at risk of developing psycho-
Becoming conscious of one’s social position intersects with elements of iden-
tity that shape beliefs about oneself and one’s goals and expectations of their
achievement. Adolescence may be a phase particularly susceptible to the effects
of defeat, since identification of reference groups and future goals and, because
of progress toward more abstract thought, the incorporation of macrosocial
aspects into one’s understanding of society are under way. In this regard, the
idea of the heritability of class and the conditioning factor of money in the per-
sonal goals of Chileans and the identification of class in terms of numbers in
Colombian society could exacerbate the perception of defeat, a mechanism
associated with suicide. Here we may find an explanation of the increase in the
suicide rate in this age-group in these two countries. Reactions to social defeat
may involve passivity and apathy, which may lead to resistance and opposi-
tion. However, we found no studies of the transformation of social defeat into
social movements. The transcultural validation under way in Chile, Colombia,
and Ecuador of the main scale of evaluation of social defeat will allow us to
corroborate our concept of mental health at the individual and collective levels.
Social defeat should be included in the explanation of the effect of inequality
on mental health, and mechanisms for dealing with social defeat should be
promoted. From a clinical standpoint, action can be taken to reinforce the social
support of surrounding networks. Experiments on this exist in the area of
social-communal psychology, where actions are focused on strengthening par-
ticipation and empowerment. Solidifying strategies for collective coping and
community organization, along with the development of leadership and nego-
tiation skills, could provide true alternatives for coping with social defeat,
improving subjective well-being, and contributing to the changes advocated by
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