Courtesy: The Tricontinental

[In the United Nations’ Universal Declaration of Human Rights (1948), Article 25 offers an expanded vision of what it could mean to be a human being. Human beings, it notes, have ‘the right to a standard of living adequate for [their] health and well-being’. This includes ‘food, clothing, housing and medical care and necessary social services’; human beings also have the ‘right to security’, which means they have the right to compensation for any lack of livelihood due to circumstances beyond their control.

Little of this vision has come to pass for the majority of the world’s people. What workers’ movements and anti-colonial movements have been able to gain in the past hundred years has been chipped away at by a regime of austerity that cuts public funds for the right to health and well-being, that sells the right to provide these services for profit to the private sector, and that therefore cheapens human rights into commodities that remain outside the reach of those without sufficient income.

During the global pandemic, there has been much talk about ‘essential’ workers and about reforms such as shorter work hours, better working conditions, and higher wages. But—as in previous crises—all of this is likely to be forgotten once the crisis is seen to have ended. The bourgeois governments are not capable of making these reforms permanent, or of permanently rewarding the healthcare workers in a ‘normal’ situation. Ruling classes around the world punish any government that attempts this small dose of humanity because—they argue—such welfare payments create a ‘moral hazard’, and any permanent workers’ rights create a bad example to other workers.

In this essay, we argue against the return to normal—specifically in the healthcare systems of the bourgeois order. In Part 1, we go over what the pandemic has shown us about the healthcare system; then, in Part 2, we attend to the voices of leaders of healthcare workers; in the final part of this dossier, we lay out an agenda for a new healthcare compact based on the demands of healthcare workers.]

Part 1: What Capitalism Has Done to Our Health System

In 2016, the World Health Organization (WHO) and the High-Level Commission on Health Employment and Economic Growth created by the United Nations’ Secretary-General looked carefully at the global healthcare sector and concluded that ‘Business as usual is untenable’. This was a very strong judgment. The 2014-15 Ebola epidemic in West Africa was fresh on the minds of the members of the Commission; looking at that outbreak, the Commission’s final report noted, ‘We have seen how inaction and chronic underinvestment can compromise human health, and also lead to serious economic and social setbacks. Investing in health workers is one part of the broader objective of strengthening health systems and social protection and essentially constitutes the first line of defence against international health crises’. By 2030, the Commissioners wrote, the world would need at least an additional 40 million healthcare and social service workers; they projected that there would be a shortfall of at least 18 million health workers—most of them in the poorer nations. This was years before the coronavirus swept across the globe.

In February 2018, a group of thirty microbiologists, zoologists, and public health experts met at the WHO headquarters in Geneva. They created a priority list of dangerous viruses, particularly those that had no vaccines; the final list contained SARS, MERS, and one named Disease X. Peter Daszak, chair of the Forum on Microbial Threats at the National Academies of Science, Engineering, and Medicine, who was at that meeting, recently said that COVID-19 is similar to how the scientists understood Disease X. Speaking of anticipating COVID-19, Daszak told The New York Times, ‘The problem isn’t that prevention was impossible. It was very possible. But we didn’t do it. Governments thought it was too expensive. Pharmaceutical companies operate for profit’.

A year later, in September 2019, the Global Preparedness Monitoring Board—co-chaired by Gro Brundtland (former Director General of the WHO) and Elhadj As Sy (head of the Red Cross and Red Crescent)—warned that ‘the world is not prepared for a fast-moving, virulent respiratory pathogen pandemic’. The report went further:

The 1918 global influenza pandemic sickened one third of the world population and killed as many as 50 million people—2.8% of the total population. If a similar contagion occurred today with a population four times larger and travel times anywhere in the world less than 36 hours, 50–80 million people could perish. In addition to tragic levels of mortality, such a pandemic could cause panic, destabilize national security and seriously impact the global economy and trade.

Their warning was not heeded.

On 15 February 2020, the WHO’s Director General Dr. Tedros Adhanom Ghebreyesus gave an impassioned speech at the Munich Security Conference. ‘The world’, he said, ‘has operated on a cycle of panic and neglect. We throw money at an outbreak, and when it’s over, we forget about it and do nothing to prevent the next one. The world spends billions of dollars preparing for a terrorist attack, but relatively little preparing for the attack of a virus, which could be far more deadly and far more damaging economically, politically, socially’.

In September 2019, world leaders gathered at the UN to take a pledge for universal healthcare by 2030. Gro Brundtland, who had been the head of the WHO, said that healthcare could not be left to the free market, since such a model would allow only the wealthy to access healthcare, with healthcare costs driving the poor deeper into poverty. There is an urgent need for public finance. Cutting health budgets, she said, is a ‘huge mistake’. The current head of the WHO, Dr. Tedros, emphasised that ‘health is a political choice’.

Over the past forty years, as the regime of austerity has driven governments to cut social and health spending, healthcare systems have been eroded. The impact can be summarized as follows:

• Cuts in public spending for healthcare, notably for public health.
• An increase in private sector involvement in healthcare delivery.
• An increase in unregulated fee-for-service medical care.
• An increase in the reliance on private insurance to pay for medical services.
• A reduction of healthcare workers, cuts in their wages and pensions, and erosion of unionisation.
• A rise in the price of medical care and of pharmaceutical drugs.

A review of 161 International Monetary Fund (IMF) country reports in 2018-2019 shows that the governments of the poorer nations are under pressure to make substantial budget cuts; one of the areas where the cuts are significant is in the public health sector.

Dr. Bernard Lown, a cardiologist who invented defibrillation, taught at the Harvard School of Public Health, and is a Senior Physician at the Brigham and Women’s Hospital in Boston (USA), puts his view on the privatisation of healthcare plainly:

Healthcare does not lend itself to the efficiencies of industrialization. Common sense indicates that patients cannot be standardized, and most of their parts are not interchangeable. Healthcare is a customized service resisting commodification and is incompatible with the efficiencies of [the] industrialized assembly line or other mass production technologies. Such basics are ignored by the high priests of market medicine. Market medicine is additionally flawed because it diverts economic resources from the community, from medical education and from research. The profits generated are not reinvested locally but are distributed to remote investors and senior management as large dividends, hefty bonuses and egregious salaries. The market has been presented as the solution, but now we know it to be the problem.

Part 2: What the Healthcare Workers Say

Tricontinental: Institute for Social Research spoke to four leaders in healthcare workers’ movements, one from each of the countries where we are based. Each of these leaders speaks at a different scale of struggle, giving us a window into the levels of the challenges that healthcare workers face. (We are giving interviews with two leaders below – Editor.)

Argentina

Understanding the situation in Argentina without considering the World Bank’s intervention in South America would be inadequate. In 1993, the World Bank focused its World Development Report on the issue of public health. While the Bank called for an increase in government spending in healthcare, it focused its attention on what it called ‘Promot[ing] diversity and competition’. By ‘diversity’ and ‘competition’, the Bank meant that the healthcare field must be diversified by increasing the for-profit sector, which would provide competition against the public sector. Rather than call for universal health coverage, the Bank encouraged the creation of private insurance schemes, the emergence of for-profit delivery of medical services, and the end to protections for domestic pharmaceutical companies.

Viviana Garcia, a leader in the healthcare workers’ union in Argentina (The Trade Union Federation of Health Professionals of the Argentine Republic or FESPROSA), told us that the impact of the World Bank policy hit most of the countries of South America very hard. She offers the examples of Chile, Colombia, Peru, and Ecuador, which saw the increase of private-public partnerships in healthcare delivery, the entry of profit-driven insurance schemes, and the overall commodification of healthcare. In these countries, the COVID-19 pandemic highlights the disaster caused by the destruction of public health systems. Ecuador’s health system has utterly collapsed, with the bodies of many of those killed by COVID-19 piling up in the streets.

In Argentina, the National Constitution of 1994 established that health is an essential public right. In 1946, the country developed a healthcare system inspired by the United Kingdom’s National Health Service. Since then, there have been several significant attempts to reform the system, particularly in the 1970s and 1980s. The health system is a mixed one, with a State sector (available to everyone), a sector for union members (Obras Sociales), and a private sector (predominantly used by the wealthy). Despite its fragmentation, the mixed system covers almost the entire population.

Pressure from the World Bank report of 1993 pushed the government to erode the public character of the state institutions in healthcare, notably with the creation of self-managed hospitals that had to rely on private financing and the privatisation of services, as well as on the creation of a precarious workforce. The new plan led to the decentralisation of healthcare to the provinces, cities, and towns, but without any proper funding mechanism; this meant that these levels of healthcare provision had to rely upon private funds, which led to inequality in the system.

The highly privatised and unequal Chilean and Colombian models could not be applied in Argentina thanks to the decisive action of organised workers. It was because of the unions and the emergence of progressive governments from 2003 to 2015 that important advances were made to defend the people’s right to healthcare and the rights of medical workers. For example, a universal child allowance was provided, health plans were developed for reproductive and sexual health, a national vaccination plan was established, job security was guaranteed for the country’s 26,000 health workers, and a path was opened for the improvement of their working conditions. Even as these were important reforms, they were insufficient to respond to the collective needs of a segmented and unequal society produced by the neoliberal policies of the 1990s.

The government of Mauricio Macri (2015-2019) swung the political pendulum to the right, pushing healthcare to an unsustainable limit. The 2016 budget for the Ministry of Health vastly underfunded the work of healthcare provision during a lethal dengue epidemic, and the Macri government cut the budget even further in 2017 and 2018. During Macri’s tenure, according to the Ministry of Finance, the government cut the healthcare budget by 22%. In 1990, the healthcare budget was around 10% of the GDP, which would fall to 9.6% in 2015 when Macri took over; by the time Macri left office, the WHO calculates, the health budget had fallen to 8% of GDP.

The Macri government cut the budgets for programmes to reduce and treat sexually-transmitted diseases (which then saw a dramatic increase in congenital syphilis and HIV-AIDS), vector-borne diseases (dengue, chikungunya, and zika), and vaccine-preventable diseases (which saw doses discontinued through a national scheme); the government also cut programmes to treat cancer. Macri went to the International Monetary Fund (IMF) for a loan, whose interest payments alone could have funded 3,200 modern hospitals. The work on four hospitals in the Buenos Aires suburbs had to be put on hold. During the Macri years, the medical system in Argentina saw an increase in informal work, the destruction of hospital services, the lack of funds for equipment, cuts in salaries, and layoffs of 1,600 workers from the country’s iconic El Hospital Nacional Posadas.

The current progressive government led by President Alberto Fernández took office in December 2019, just before the pandemic swept into South America. One of the first acts of the new government was to restore the Ministry of Health to its full stature, although it will take time for the government and the unions to recover the devastation left behind by Macri.

South Africa

On 22 April, South Africa’s president Cyril Ramaphosa announced a stimulus package of R500 billion. Stunningly, the package did not directly provide funds for healthcare providers who are at the forefront in the struggle to contain COVID-19. Lerato Madumo, the President of the Young Nurses Indaba Trade Union (YNITU), an affiliate of the South African Trade Union Federation (SAFTU), told us that this speech spurred her union to start a campaign calling for COVID nurses to stay home. The YNITU had planned a May Day strike but called it off the day before and held a press conference instead. They wrote to the president asking for urgent attention for the health providers; if their reasonable demands for compensation and safe working conditions are not addressed, this ‘will leave us with no choice but to put down our tools and stay at home’.

Sufficient testing kits and PPE are not available. Testing of providers is essential, and yet it is not happening anywhere near the scale that it is needed. ‘If one nurse contracts the virus’, Madumo says, ‘the whole shift of nurses end up being COVID-19 positive’. The medical practitioners’ union, the South African Medical Association, said that what PPE is provided is of such a poor quality that when a doctor walks, the PPE tears. In Johannesburg’s Chris Hani Baragwanath Hospital, the nurses had to come to work with raincoats that they purchased and which they had to disinfect; all this in lieu of proper PPE. The money for this improvised PPE comes from the nurses, who are paid abysmal salaries. What PPE is being provided by the government does not seem to have reached the nurses.

‘Even before we got into COVID-19’, Madumo told us, ‘our health system was already ailing. At the top of the list was the shortage of nurses. We went into this pandemic with a skeleton nursing staff’. In South Africa, 84% of the population is served by the public sector, and yet the private sector—which only serves 16% of the people—hires 60% of the health professionals; there is a structural understaffing of the public sector health system. The union carried out a survey which shows that there are unemployed qualified nurses. Because the government refuses to hire them, the nurses on staff are working harder than is healthy for them. ‘Nurses—besides contracting coronavirus—are getting emotionally and psychologically crushed; there is no other word to use’, said Madumo.

The level of attrition among nurses and other medical staff is extremely high, and it is often linked to widespread overwork, emotional distress, dissatisfaction, and burnout. Managers of hospitals have gained authority at the expense of clinicians and nurses; they run the hospitals like a business proposition. The hospitals have begun to rely upon nursing agencies, which traffic in the casualised employment of nurses. Madumo suggests that these agencies are dangerous because they send nurses from one hospital to another, and if these nurses contract COVID-19—and are not tested—then they can carry the disease across hospitals. ‘It becomes very difficult for infection control’, Madumo says.

Finally, Madumo told us that her union, YNITU, argues that this pandemic shows why healthcare should be nationalised. Each district, each province is doing what it wants, she says. ‘Nationalisation will ensure that every facility will get to be under the eagle eye of our national department of health’, Madumo said. ‘We feel that we cannot allow the private sector to do as they please as they have been doing for years. Their focus is profit-making: they insist that their nurses use one mask for five days’, she told us, even when the mask is only viable for far less time. While the masks are supposed to be disposed of after treating each patient, the nurses are also being asked to recycle them, putting themselves and their patients at an increased risk of contracting the virus.

Part 3: What Healthcare Workers Want

Tricontinental: Institute for Social Research studied the demands of healthcare worker unions across the world and, based on these demands, we have constructed a list. Most of the unions have very broad demands that go far beyond those of their own profession. These include broader social and economic transformation, which provides a new foundation for social life and which minimises the health hazards produced by capitalist social relations. For instance, the abolishment of the condition of homelessness (and not of homeless people, as attempted by neoliberal governments) would both help people to practice physical distancing and improve the health conditions of those who are forced—because of a lack of money—to live on the streets.

• Immediately focus the capacity of all healthcare services—both public and private—towards the treatment of serious cases of COVID-19.
• Provide special assistance to regions and communities that are severely impacted by the pandemic.
• Enforce policies such as isolation to stem the spread of the virus; institute necessary subsidies and policies to allow workers to obey the quarantine without going hungry—including informal workers—such as minimum income programs, social rent, unemployment insurance (even for non-contributors), and enable emergency access to idle properties to provide housing for those who need it.
• Protect workers by providing high quality PPE and masks, as well as other necessary equipment. Frontline workers must be adequately trained to confront the disease.
• Guarantee proper health worker identification cards for frontline health workers so that they can carry out essential health work without facing fines, violence, or other punishment issued by the State under isolation, curfew, and quarantine orders.
• Substantially increase COVID-19 testing for health workers.
• Increase equipment for hospitals and other medical centres, including ventilators and Intensive Care Unit beds.
• Acknowledge that workers have the right to withdraw their labour if they decide that to work entails an imminent risk to their health or life (this is based on the International Labour Organisation Conventions 155 and 187).
• Immediately disburse funds to set up training schools for health workers, including doctors, nurses, and public health workers.
• Increase the salaries of health workers and pay them on a frequent and regular basis.
• Guarantee the most generous health and life insurance schemes for health workers, who are the most likely to fall ill or die from the disease. All people should be guaranteed free and universal healthcare.
• Guarantee the inclusion of health workers’ unions on committees that formulate policies for the health sector in general and for the COVID-19 crisis in particular, and that they have a voice in helping to determine such policies.
• Immediately channel significant funds towards an expansion of public health programmes, including for primary healthcare, and lift austerity policies.
• Shift the entire health sector—from hospitals to rural clinics, from medical equipment manufacturers to pharmaceutical makers—into the public sector.
• Immediately turn over adequate funds for research related to this virus and to similar viruses.
• Ensure that the measures achieved in the period of the epidemic are maintained after its resolution.

(Tricontinental: Institute for Social Research is an international, movement-driven institution that carries out empirically based research guided by political movements.)