Health care reform in Chile, reconsidered
CANCHA CARRERA, at the border between Argentina and Chile – We noticed the contrast when we crossed over into Chile. The Argentinian border post at Cancha Carrera was 10 miles down a dirt road, and was as Third World as it gets: a squat white stucco building with a tin roof, sitting on the side of the road, with a light-weight chain little better than a clothesline stretched across the road, hanging from a simple hook. There was no guard standing at the border, but there were plenty of soldiers in green uniforms hanging around inside the building. No signs, no one giving directions; just a bunch of people hanging around. Cars and buses would pull up, and their occupants, somehow knowing the drill, would get out and walk into the stucco building. Inside the building, there was a soldier sitting at a card table, and two windows with people sitting behind them. We stood on the line in front of the soldier for a few minutes until a tour guide from one of the buses told us that we needed to go to the next window. The line in front of the soldier was for tourist buses, so that the military could check their fire extinguishers. We went from window to window so two different people could check and stamp our passports and rental car papers. The female soldier behind the second desk told us to wait, and then, after 10 or 15 minutes, came out from behind her desk and walked outside with us to unhook the chain that was across the road to let us drive across the border. A distant continent The Chilean side of the border was 7 kilometers away, but it felt like we were traveling to a distant continent. The border post was modern and efficient – a new building, border guards who were helpful and efficient, even clear signs that gave precise directions. We were in and out in a few minutes; there was a restaurant and a place to change money that looked like a souvenir shop in any U.S. national park. We would find Chile somehow more orderly than Argentina, and apparently more middle class – at least at first glance. That was not what I had remembered about Chile. Distant thunder, distant memories I was in high school in 1970 when Salvador Allende Gossens was elected the president of Chile, and in college when he fell in a 1973 military coup. [Allende either committed suicide or was assassinated, depending on which version of history you believe.] I recalled that about a third of Chile’s 10 million people where dirt poor. Many lived in shantytowns ringing the capital city of Santiago. Or, they were copper miners who were treated little better than slaves. I also recalled that Allende’s election was controversial. I distantly remembered that Allende himself was a doctor, like Michele Bachelet, the current socialist president of Chile, whose term will expire in March of 2018. Fear of socialism Allende was controversial because he was a socialist. In 1970, when the U.S. was deeply involved in the war in Vietnam, the dominant foreign policy concern was [what was known as] the domino theory – the notion that Communism was going to spread around the world by taking over one country at a time, and that every country – every domino – that fell to communism would cause another country near it to tumble in the same way. It became a policy tenet that unless the U.S. prevented every country from moving left, the entire world would be ruled by a Communist dictatorship. Policy conflicts U.S. foreign policy was not sophisticated about how to classify countries – any country that was moving towards socialism of any kind, and some days, any country that embraced the notion of more economic equality – looked to us like a communist country, as did any colony of a European power that was trying to move toward self-determination. [Just because you are paranoid doesn’t mean someone isn’t out to get you. In those years, the Union of Soviet Socialist Republics, or USSR, and its allies were likely involved in trying to get many countries – and many movements of national liberation – to ally themselves with the Soviet Union.] I recalled concern being voiced in the U.S. about Allende’s election. I also remembered reporting that there was a fair amount of turmoil inside Chile itself, as Chile’s Congress and political parties struggled with the reforms Allende tried to advance. And, in the background, there was a lot of noise about all sorts of charges and denials about American – and particularly CIA – covert involvement in Chile. Similar charges and denials often surfaced in countries around the world when there was political change in the air. These charges and denials were so frequent that it was hard to accredit all of them, but hard to ignore them either. When I demonstrated after Allende’s fall in 1973, it was a knee-jerk reaction. Allende seemed to be a progressive leader. People said the forces of reaction in Chile, perhaps supported by the CIA, had stopped a movement toward equality and justice. During the brutal 1973 coup, in which Allende and some 5,000 people died, thousands of people were brought to a soccer stadium and many were executed. I recalled the heroism of folksinger Victor Jara, who was brought to that soccer stadium, then tortured by soldiers who broke his hands and all his fingers, but he kept singing with the crowd in the stadium. It all felt so wrong, but I don’t remember knowing much more than that. The practice of social medicine But it is much more painful for me now, as a physician, to read the history of what really happened in those years, which is what travel in Chile has encouraged me to do. Before he was elected president, Allende was trained in and practiced social medicine among the poor of Valparaiso. Social medicine is the branch of medical care that also gave birth to scientific medicine, the tradition, dating back to Rudolf Virchow in the 1840s, which argues we need science to understand and repair the ill effects of our social organization on the health of individuals. Virchow, a German doctor who was known as the father of pathology, said that physicians are the natural attorneys for the poor, and that politics is just medicine writ large. By which he meant that we see the impact of our social organization on the health of the poor, who are often made poor by their ill health. Physicians and other health care workers, who have the ethical obligation to advocate for the well being of others, are also obligated to use what we learn about social organization from caring for the poor to advocate for improvements in social organization, which turn out to benefit everyone. To improve public health outcomes Physicians and other health care workers working in this tradition fought for and won public programs to make water and food safe, to clear slums, to build safe and healthy housing, to create sanitary and safe sewage systems across the nation, and to develop vaccines against childhood and other diseases [and today has focused public attention on the environment and on climate change] – all of which led to a doubling of human life expectancy in the last 100 years. It is a tradition that says we should think about – and sometimes change our social organization – to improve public health outcomes, a tradition that had had a strong influence on my life and the lives of many other American health care workers – and on the public health policy. What Allende did
Here’s what Allende’s government actually did: it created a national health care and educational system. It provided free health care and free education to all Chileans, and sent some 55,000 volunteers to the south of the country to provide health care to the poorest Chileans. It provided free milk to all of Chile’s children and free school lunches to Chile’s schoolchildren. Allende’s policies also redistributed the land held by the large estancias, expanding a program that had begun under Allende’s more middle-of-the-road predecessor, Eduardo Frei, which gave agricultural workers the chance to earn a better living and get more control over their own lives. A minimum wage was enacted. Allende also extended social security benefits to part-time workers and increased social security payments to retired workers, starting a program of housing construction to build some 120,000 homes. Those social programs, targeted at improving the incomes, health and well being of millions of poor Chileans, are exactly the kind of programs many health care workers believe would also benefit the U.S. today. Immediate impact In Chile, under Allende, there was an immediate positive impact of his policies following his election in 1970. The Chilean GDP grew by 8.6 percent that first year. The [always out of control] Chilean rate of inflation fell from 36 percent to 22 percent. Average real wages rose by 22 percent – both predicable outcomes of an economic program that puts more money into the hands of more people by stimulating employment through public investment in housing, education and health care while improving the funding of the social safety net. Controversy Other Allende government programs proved more controversial. The government nationalized the copper mines and the banking sector. It re-established diplomatic relations with Cuba, and invited Fidel Castro to visit. Castro came for a week and stayed a month, playing right into the fears of many conservatives in Chile and the U.S. Then things started to fall apart. There were constitutional challenges to the program of nationalization. The price of copper, Chile’s main export, suddenly dropped. Allende’s government answered with price controls and subsidies for poor and working people, so that they could afford rent and food, all of which made inflation explode to 140 percent by 1973. By the summer of 1973, the Christian Democratic Party, which spoke for a third of the electorate and supported Allende’s election, flipped into opposition, and the coup followed soon after, on Sept. 11, 1973. The art of the possible My grade-school friend and traveling companion, the Emmy award-winning documentary filmmaker Paul Stekler, has been reminding me that politics is the art of the possible. “Maybe Allende tried to move too fast, do too much, and he outran his political support,” Stekler said, adding that he was no expert and didn’t really know. Some supporters of Allende, then and now, argued that since Allende was limited to a single six-year term, he had to move quickly to convince the population that these reforms could produce palpable change. Looking back, one has to wonder if the truth wasn’t someplace in between, if the experiment might have changed if Allende had been given more time. Evidence that has emerged The question of more time is significant, particularly when we consider the craziness of American politics today. Unfortunately, the evidence that has emerged in the last 40 years suggests that the U.S. was involved up to our necks in in trying to bring Allende down. It turns out that the U.S. had been subsidizing Allende’s opposition to the tune of about $10 million dollars all during the 1960s to try and prevent his election. The October 1970 attempted kidnapping and murder of General Rene Schneider, commander in chief of the Chilean Army, an ardent constitutionalist, who was committed to civilian control of the military, was allegedly funded with $50,000 of American money and a shipment of American machine guns. In the short term, the murder of Scheider backfired, resulting the certification of Allende’s election by the Chilean Congress. In the long run, it appeared to have paved the way for a military coup. One unexplained factor in the economic challenges of the second and third year of the Allende government was the sudden collapse of copper prices, which might have been expected to rise after nationalization of a significant portion of the world’s copper reserves. The collapse raised questions of alleged manipulation of those prices by economic actors with a political agenda in the U.S. Chile today Chile today has made tremendous progress in the years following the coup. During the “time of the generals,” from 1973 to 1990, the country endured economic chaos, when the generals tried to adopt the free-market fundamentalism of Milton Friedman and the University of Chicago School of economics. They failed miserably, creating widespread unemployment and bank failures. In response, the generals decided to enact many of Allende’s reforms, which led Chile on a path to transition back to democracy. Today, Chile is a more middle class nation. It is the wealthiest nation in Latin America, per capital, but has the second highest rate of income inequality among the developed nations, although it is one of the few places income inequality is declining. [By comparison, the U.S. has the fourth highest rate on income inequality.] Chile’s infant mortality rate is 6.60 per 10,000 live births, just a little worse than ours, which was 5.8 per 10,000 live births in 2017. Its literacy rate is 97.5 percent, which is better than most of the world, but hard to really compare. [We don’t report ours, North Korea reports 100 percent, so who knows?] We also saw rows upon rows of new housing in Puerto Natales, which were all tiny little boxes that all looked alike, perhaps 20 by 20 feet, suggesting that there is still widespread relative poverty. Still, it seemed better than the slums I saw outside Buenos Aires. We didn’t travel to to Valparaiso or Santiago, so it is difficult to compare. Measuring economic progress I don’t know what all this says about the political and economic progress. It’s pretty clear to me that an engaged population that is trying to make life better for everyone – and fairer in the process – can succeed, but the path is neither straight nor clear. I wish we hadn’t interfered in Chile, because I think we likely made a difficult process more difficult and undermined democracy in the process, as we legitimized political repression and torture. That is something I hope and pray doesn’t come back to bite us, as we struggle through our own process of social, political and economic evolution. But what I wonder about most, when I think about Allende, is the physicians and health care workers who are politically active and in Congress today. When I think about Sen. Rand Paul [an ophthalmologist] and former Rep. Tom Price [an orthopedist] – two of 17 elected health professionals, 13 of whom are Republicans, and compare and contrast them to Salvador Allende and Michele Bachelet, it makes me wonder. Are health professionals the natural attorneys of the poor? Is politics just health care writ large? Are we really fulfilling our oaths?