Medical brigade sees universal health care in action
An eye-witness account of universal health care in El Salvador from Amanda, a participant in the 2012 Medical Brigade. (Re-posted from UltraViolet) Universal Health Care in El Salvador by Amanda In August I went to El Salvador with a group of healthcare students and professionals from across the US. We traveled under the auspices of El Salvador’s Ministry of Health to learn firsthand about the health reforms initiated by the current FMLN government to provide free health care to all. We went with CISPES, the Committee in Solidarity with the people of El Salvador, who has been providing solidarity and opposing US intervention in El Salvador since 1980 (along with many other activists, including LAGAI members). One of the things that we heard repeatedly from former guerillas was how much solidarity from US activists meant to them while up in the mountains. Also, we were told what a precious moment this is for the FMLN to hold electoral power…the first time in El Salvador’s history that the left has led the country. “Transformation is not easy but it is possible. We have the opportunity to rewrite and construct a new history.” Before talking about the specifics of the new health care system, I’ll give a little general background. El Salvador is about the size of Massachusetts with a population of nearly 7 million, most of whom live in the capital, San Salvador. The major natural resources are its beautiful people and fertile, volcanic soil. It is the only country in Central America without a Caribbean coast. Earthquakes and hurricanes are common, often with devastating destruction. Generations of people have been fighting in El Salvador for an end to oppressive and brutal conditions. El Salvador was originally inhabited by Pipil, Lenca, and several other indigenous tribes. The Spaniards arrived in the 1500’s and, despite decades of fierce resistance by the indigenous peoples, eventually established settlements. In the late 1800’s campesinos, largely indios, had their communal lands expropriated so that the wealthy could use the land for plantations to grow coffee for export and exploit the labor of those whose lands were stolen. With the world depression in 1929, the bottom dropped out of the coffee market and starvation became rampant. An armed insurrection in 1932 by campesinos and the young communist party resulted in the massacre of over 30,000 people and the near genocide of the remaining Indian population. Indians who weren’t massacred went underground and denied any Indian heritage in order to survive. Decades of dictators and the wealthy skimming off whatever they could produced conditions for a protracted guerrilla war in 1980, under leadership of the FMLN coalition (named after Faribundo Marti, one of the martyred leaders of the 1932 rebellion). The US backed the right wing to the tune of $3.5 billion, nearly $1million/day. The right wing was forced to enter into negotiations with the FMLN and declare a cease fire in 1992. Until the FMLN victory of the presidency in 2009, El Salvador was run by the right wing ARENA party, with continued US backing. Neoliberalism flourished with privatization of many sectors and an end to market regulation. In 2001 a decision was made at 3:00 am to switch El Salvador’s currency from the colon to the US dollar, cementing Salvadoran dependence on the US, profiting the ruling class, and worsening the poverty for all others. El Salvador was the first country to ratify CAFTA (Central American Free Trade Agreement) in 2006, which decreased tariffs on US imports and made it no longer economically viable for El Salvador to grow its own food. What was left of the agricultural sector was destroyed. Tax -free business zones were established with maquiladores and KFC, McDonalds, and the like sprang up in San Salvador. Corruption was rampant. IMF loans for hundreds of millions of dollars disappeared with nothing to show. Twice funds were borrowed to rebuild the Maternity Hospital destroyed in the 2001 earthquake; not a brick was laid. (Former officials and an ex-Minister of Health have been recently arrested on corruption charges.) Millions of dollars were borrowed to upgrade the telecommunication infrastructure which was then privatized and sold for less than the IMF loan. Corruption was rampant; the state sold businesses without any transparency or accounting. The petroleum industry, banks and financial institutions, the cement company, electricity distribution, and technological institutes were all privatized. Property taxes were eliminated and income taxes, import and export taxes were slashed. A sales tax was instituted making poor and working people bear the tax burden while greatly reducing the State income. The government is stuck paying on this huge foreign debt; one of the priorities of the FMLN government is to restructure it. In 2002, with pressure from the World Bank, an attempt was made to privatize the country’s public healthcare system for workers, the ISSS. The powerful Social Security Workers Union (STISS) fought back against privatization of the health care system, organizing months of massive marches. Students shut down the University of El Salvador in support of the union’s demands. 1,800 doctors and nurses went on strike for months, marching in their whites, while keeping emergency services open. Support came from many sectors of this impoverished country who understood that privatization would result in a “pay or die” health care system. When the FMLN came to power, the country was an economic disaster. The previous administrations had deliberately restricted access to health care as part of the attempt to privatize. In 2006, 47% of Salvadorans were outside of any health care system. To go to a public hospital, a “voluntary” donation was demanded; that was abolished the day that FMLN President Funes was inaugurated. El Salvador had the most expensive medicines in the world as the right wing politicians were also the owners of the biggest pharmaceutical industries with a monopoly so that even the Ministry of Health had to buy medicines from them. (A major triumph of the FMLN was the passage of a law in February 2012 which cut medication costs and assures quality control). Under the 2009 Health Reform, medicines, clinic visits, specialty services, and hospitalization are free. The two-year-old reform, still in its initial stage of implementation, has sought to retain healthcare in the public sector, maintaining a pledge to health as a human right for all Salvadorans. Pregnant women and children under 5 are prioritized for food and vitamin supplements as well as outreach for preventative care. The Ministry of Health says health is dependent on access to a health care system, political will, economic justice, and a more equal distribution of resources. The health care reform is based on primary care, prevention, and public health. Clinics, Ecos, have been located out in communities, where people “live, love, and have fun.” The Eco team is composed of a nurse, doctor, nurse’s aid, and several health promoters. This team is charged with surveying the entire population in their area (6-9,000 people) through home visits to document health risks of individuals and families as well as community/public health problems. Patients also come into the clinic for preventative care and sick visits. There are “clubs” of adolescents, pregnant women, seniors, and others which meet regularly for health education and fun. We attended a number of very well-attended meetings. People are very well-informed; all pregnant women we visited could name the danger signs of pregnancy. The health care workers are all extremely committed, work long hours with a lot of love and care. We walked hours with promoters to visit patients who live at the end of muddy paths, across rivers, up mountains, in areas with no vehicle access. The health promoters live in the area and know all the people. They go into schools to present health education and can be mobilized to travel to areas where immediate attention is needed. Recently all the health promoters in the La Palma area we visited were sent for a weekend to the nearby city to help local teams prevent a Dengue epidemic and conduct door to door visits to educate people about public health measures they could take. In two years, 450 Ecos were created in the poorest areas, largely rural, which had the least available health care services. There are plans to expand the Ecos to the entire population as resources become available. They are now in 153/262 municipios. A network of 4-6 Ecos have a specialty clinic for referrals with a lab, pediatrician, internist, gynecologist, dentist, health educator, nutritionist, and physical therapist as well as psychological and ER services. I was repeatedly told that people who needed emergency specialty evaluations could get seen in 24 hours and that routine consultations were available within 15 days. Compare that to the many months my patients in the US have to wait! There is a local hospital for more serious referrals with primary, secondary, and tertiary levels of care available at the regional and national level, all in an integrated system. The Ecos also treat Hondurans and Guatemalans who cross the border for health care; “we take responsibility for them as their government won’t”. The FMLN’s healthcare reform raises the standards for other countries by providing world-class universal healthcare. These programs improve and sustain the health of people that have been historically underserved. The Ecos have been able to accomplish so much with so little. In just two years, and with limited resources available to them, they have made extraordinary progress. Maternal and infant mortality have been decreased. The FMLN government increased the budget for the Ministry of Health from 1.7% to 2.5% of GDP despite the opposition of the right wing, US, and the IMF. The fight for continued increases in financial support will be made possible by fiscal reform including requiring corporations and the wealthy to pay their fair share. (Sound familiar?) We met with union workers at the Children’s Hospital in El Salvador who told us there is a serious lack of resources and “free health care” can still mean parents of a patient may have to go buy a syringe so that an injection can be given to their child when the hospital has no syringes. Their yearly budget for supplies only lasts 6 months. The union had to raise funds themselves for a refrigerator to store vaccines. A nurse told us that she cared for 29 patients by herself at this tertiary level hospital which sees children from all over Central America. These workers were organizers of the marches that saved health care from privatization and are very supportive of the FMLN government but are concerned about the conditions of their hospital. These militant workers were very clear that fiscal reform to make the wealthy pay taxes is the solution. International evidence overwhelmingly demonstrates that health care systems oriented towards primary care produce better outcomes at lower costs and with higher user satisfaction. In its initial phase, the primary care model of the Ecos has improved health outcomes in rural communities. As it is expanded, more municipalities, including urban regions, will experience the positive effects, both by reducing demands on the far more costly tertiary and more specialized urban care centers and by the bolstering of urban ECOS. This initial investment in preventive integrated care will ultimately pay off as the burdens on these sectors are reduced. Health care is a basic human right. We must call upon our government for universal healthcare with access to quality care for all instead of enriching the insurance companies. We must also oppose any attempt by the US government to intervene in El Salvador in an attempt to privatize their health and other social services. There are proposed Public-Private Partnerships, pushed by the US government under the Partnership for Growth, which would divert funds away from the public sector and undermine the amazing work being done. The World Bank and IMF are constantly pushing for a decrease in social spending. The health reform is based on the political will of the FMLN Funes administration, not law. A change in government could end the reform. Supporters are hoping that the political cost will be too great as millions of people are benefiting daily. People must learn to internalize their right to health care and a better life and be able to struggle against the well-funded right-wing, US -backed opposition to these rights. In the last two years FMLN’s social reforms in areas such as healthcare, agriculture, and education are fundamentally transforming the lives of all Salvadorans. School children now receive free shoes, uniforms, school supplies, and a meal at school. For many children this was their first pair of shoes ever. The government contracted with small producers to make the shoes, uniforms, and provide the food at a fair price. A literacy program has begun. In El Salvador there is an intense class struggle. Nearly half the population is poor with nearly 20% in extreme poverty, not having enough to eat. Many families live on less than one dollar a day. Meanwhile, the wealthy live well with the lowest tax collection rate in Central America. In the 2009 election, ARENA and the other right wing parties had plenty of money for TV ads and lots of media. People were told if the FMLN won their children would be taken away like in China under Mao, and the old people would be turned into soap. With little money, the FMLN was still able to win the presidency. However, the Right is intent on making it impossible for the FMLN to govern with chaos and unprecedented challenges through the judicial branch. With the FMLN popularity, changes have been made to the way elections are conducted to do away with party slates and only have individual names listed on the ballots. Numerous electoral irregularities were noted in 2009, many more are likely in 2014. The US is already planning on how to intervene in the 2014 elections in El Salvador to get rid of the FMLN government. Cuts have been proposed to the Millennium Challenge Fund to help defeat the FMLN. The messages I was asked to covey to the US people were that El Salvador is a small country struggling to make a better world. The FMLN government is young and still learning, making mistakes, and working to improve. I was asked to let people know about the health reform so that we in the US can help prevent the destruction of its gains. “Our big fear is that the US will intervene in the internal affairs of El Salvador. We have the maturity to solve our own problems. Please tell the US not to intervene in our internal election process.” The pioneering reforms that I’ve seen in action are inspiring. As this effective healthcare model continues to be developed and implemented, the Salvadoran people will achieve better health and the Salvadoran government will meet its goal of improving people’s quality of life, even with limited resources. The FMLN’s social reforms in areas such as healthcare, agriculture, and education are fundamentally transforming the lives of all Salvadorans. I am grateful for the opportunity to have witnessed the gains being made by Salvadoran society. I will fight for their right to continue. Stopping the intervention of the US government will be a challenge for us all.