Panem et Circenses
Thoughts from a Public Healthcare Worker in the Spanish State
May 1, 2023
translated by Ari Parra
Here in Spain, over the past months, we have seen mass mobilizations in defense of the national public healthcare system. Madrid was the first city to express its indignation at the drastic cuts to the system, which has seen emergency rooms and clinics without a single physician to attend to patients. The waiting lists for medical attention in the public system has caused emergency rooms to overflood. Pediatricians and family and community-medicine physicians have been especially affected, as they are usually the first doctors patients see. Their working conditions have become more and more precarious as they are forced to support an increasing number of patients, even going so far as to have to limit each consultation to less than ten minutes—an insurmountable task.
As a result of the current situation, healthcare workers have begun to organize unprecedented strikes that are yet without resolution, due to the refusal of the government of the Autonomous Community of Madrid to propose real solutions to a more and more alarming crisis. Protesting healthcare workers have been joined by tens of thousands of Madrileños in the streets, demanding their right to public healthcare. Neighborhood associations of patients have been key in organizing the protests, which have seen huge turnouts of the elderly and retired. The current situation calls to mind the attempts by Margaret Thatcher to eliminate the National Health Service in the United Kingdom. Indeed, the healthcare system in Spain is organized under the Beveridge model, the same model as the system in the United Kingdom.
But Madrid is not the only place fighting for the national healthcare system. Andalucía and Cantabria have also seen similar mobilizations. In the case of Catalunya, where I work, there are patient groups that have been denouncing the continued attacks on the public healthcare system since 2017, but only this past January have we seen healthcare workers join the mobilizations to express our discontent with the government of the Generalitat de Catalunya. Among our demands are: increasing the length of patient consultations; reducing the number of patients seen per day, not only for physicians, but for all healthcare workers; and increasing wages, which were cut considerably in 2014 and have not gone up since, despite the continuous rise in prices due to inflation from the COVID-19 pandemic and the war in Ukraine.
One of the major unions present in the strikes of January 25 and 26 of this year was Metges de Catalunya (Physicians of Catalonia), which announced its demand for better working conditions in light of the ongoing exodus of physicians. Many physicians in the Spanish state have left the public sector for the private sector or gone to work in other European countries with better working conditions and pay, leading to a severe shortage of doctors. The Spanish medical education system is one of the most prestigious in Europe, but the money that the government has invested in the training of physicians and healthcare workers is being lost to medical exile because it refuses to offer improved working conditions. There are also many autonomous communities, like Catalunya, where thousands of physicians will retire in the next ten years without enough young physicians to replace them. As of now, there have been no steps taken to address this crisis.
I began working as a medical resident in Barcelona in 2016. Residency programs to train physicians in the national healthcare system last four or five years, depending on the specialty. An important part of the residency is training physicians who will treat patients in the emergency room. An average resident’s shift in the emergency room lasts 16 to 24 hours and, due to cuts to the system, are often without breaks given the skyrocketing number of patients to whom you have to attend in the fastest and most efficient ways possible. A few years ago, residents began mobilizing to improve their working conditions, but very little has come of it. Residents’ wages depend on the autonomous community in which they work, but the hourly wage is less than that of many other jobs, including jobs that require lower levels of responsibility.
I currently work as a junior physician in the neurology department of a “third-level” public hospital (a hospital that serves patients who need specialized medical services and diagnostic tests, which are limited) in a working-class neighborhood of Barcelona. The hospital is part of the Catalan Institute of Health, so it is 100 percent publicly financed. The hospital serves the most densely populated neighborhood in all of Europe, with over 2 million people.1“Bellvitge en xifres,” Bellvitge Hospital Universitari. A significant portion of the population are migrants from the Global South and the periphery of the Spanish state—specifically Morocco, Latin America, and Andalucía. Since 2017, I have worked under temporary contracts performing neurophysiological exams and serving patients with chronic neuropathic pain. But my situation is one of many.
In Catalunya, a process exists to make permanent many of the positions of healthcare workers such as myself who work under precarious contracts. The Generalitat has announced that 12,480 positions will be made permanent under this process, to be finalized in 2025. Most of these workers have worked under precarious contracts for over three years, and a process of stabilization of this kind has not occurred since 2017. Nearly 3,000 of these positions are for physicians.
In the Spanish state, the public healthcare system is made up of competing forces whose direction is transferred over to autonomous communities, which must guarantee access and equality of services to their inhabitants. The care and maintenance of the national public healthcare system is fundamental to guaranteeing the right to health. The system is composed of a complex network of different centers and hospitals, and offers various programs, such as for vaccination, smoking cessation, and the prevention of sexually transmitted infections. Perhaps the most internationally renowned program is the National Organization of Organ Transplants, an area in which Spain has been the world leader for over twenty consecutive years.2“Darias: El Programa Nacional de Trasplantes es un éxito compartido de las autoridades, los profesionales y la sociedad,” La Moncloa, January 19, 2023. All these programs must be protected.
While attacks to the public system have been occurring since the global economic crisis of 2008, the pandemic in 2020 was another major blow to the system. From March 14 to June 21, 2020, Spain declared a state of emergency in all territories due to the COVID-19 crisis.3“COVID-19 health crisis: Regulations and useful information,” Directorate-General of Public Governance, January 2, 2023. The pandemic had an unimaginable impact on the working conditions of healthcare workers, halting daily activity in an attempt to reduce the number of patients infected.4COVID-19: RECOMENDACIONES SANITARIAS PARA LA ESTRATEGIA DE TRANSICIÓN, Centro de Coordinación de Alertas y Emergencias Sanitarias, Dirección General de Salud Pública Calidad e Innovación, April 25, 2020. In my hospital, we had access to necessary materials and personal protective equipment, but many hospitals did not. In the first weeks of the initial wave of the pandemic, the number of infected people that needed a hospital bed outnumbered the available beds. I remember seeing beds put in makeshift rooms in the hallways of buildings. Perhaps the most perverse measure adopted by the government was allowing private hospitals to outright reject COVID patients, to be transferred to public hospitals instead. This meant that public hospitals became flooded with COVID-19 patients and, to avoid infection, non-COVID patients were sent to private hospitals.
The public sector is now in debt to the private sector for those patients. Just as the state refused to make private hospitals accept COVID patients, it refused to cancel the debt owed to the private hospitals and to nationalize the private healthcare sector. Moreover, the state implemented an “extraordinary payment” to physicians, nurses, and technicians prior to the availability of the vaccine to incentivize us to keep working. However, the extra payment was hierarchical, with technicians receiving much less than physicians. Workers responsible for cleaning rooms and equipment, who were equally if not more vulnerable to infection, were not given any additional payment because they are contracted by private companies (which are contracted by public hospitals).
In Madrid, governor Isabel Díaz Ayuso, who models herself after Donald Trump and has made it her mission to destroy the public healthcare system, authorized the state purchase of masks produced by a private company run by her brother at overly inflated prices, for use in public hospitals and to be distributed on public transportation. She continues to occupy her position as governor without impunity.
Public health should be run by and for all people, guaranteed to anyone who needs it, without discrimination. Equality and justice are principles fundamental to any healthcare system. Private healthcare, however, is based on providing healthcare services as commodities to be purchased, and to offer quick solutions to health problems. It is a business, where the profit margin determines the services offered. In Spain, when a patient has a complex condition that requires more advanced medical assistance, the private system, after performing many unnecessary exams and treatments that often exacerbate the patient’s condition, ends up sending them to the public sector for treatment.
In my personal experience working with patients with chronic pain, there are non-invasive treatments, such as repetitive magnetic stimulation, that are available in public hospitals and not in private ones. Week after week, I see patients who come to me desperate, who, after having received multiple treatments in private clinics, are now suffering from permanent iatrogenic effects and have been referred to public hospitals once the private system evicts them for being overly “medically complex.” At this point, there is very little I can do for these patients and I am often left feeling useless and enraged by the private system.
The pharmaceutical industry, which remains in private hands, also has important detrimental effects on the care and treatment of patients. In Spain, the elderly and retired are those who have the greatest part of their medications fully covered by the public healthcare system. People who are not retired must pay a portion of the costs of their medications, while the rest is covered by the state. This portion can be considerable depending on the type and number of medications. This, of course, means that there are patients who cannot afford the medications they are prescribed.
Despite having access to the public system, the socioeconomic stratification of patients is deepened by the private nature of the pharmaceutical industry. There is a major lack of transparency in the regulation of prices of medications and medical equipment, even in autonomous communities. In some cases, it has been argued that this way of stratifying prices is necessary for the economic sustainability of the public healthcare system, but patients and the medical community must be made aware that the pharmaceutical sector is disproportionately profiting from widening inequalities.
I do a lot of work around access to “orphan drugs” used to treat rare diseases, from which the pharmaceutical industry continues to profit. As a result, patient associations have been very active, especially in promoting the recognition of rare diseases. In Europe, rare diseases affect at least 1 out of every 2,000 inhabitants. It is estimated that there are 7,000 rare diseases in the world. The Spanish state, with 40 million inhabitants, has around 3 million people with rare diseases. These patients in Spain primarily receive medical assistance in the public healthcare system. The national system is responsible for covering these patients’ medical treatment, which in some cases has been approved for a finite protocol with orphan drugs. Although the pharmaceutical industry depends on public hospitals to carry out a large part of its research in clinical trials to discover treatments for these diseases, the industry then sets exorbitant prices for these treatments, where the benefits will only be passed onto pharmaceutical companies, despite the fact that the work was done by public healthcare workers and investments were made by the public system.
When we study medicine, we are required to take an oath to treat all patients. As a physician, I am often forced to tell patients that there is a treatment that could help them, but it is too expensive and not covered. For all these reasons, the pharmaceutical industry must be nationalized to ensure equal access to healthcare for everyone. There must be a healthcare budget that presides over the use of public money, which is increasingly spent on weapons to fund imperialist wars and the maintenance of a monarchy that should have been eliminated a long time ago, or at least voted on in a national referendum so that the people can decide whether to keep maintaining the legacy of a dictatorship, the transition out of which never really ended.