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Marching for Health Care
in El Salvador

By Kelly Creedon and Chris Ney

hen 700 Salvadoran doctors went on strike last September, tens of thousands of Salvadorans from all sectors of society took over the streets of San Salvador to support them. The doctors—along with nurses and other medical technicians and support staff—were protesting plans to privatize the country’s public health services. The marchas blancas (“white marches”), with participants wearing white as a sign of peace and solidarity with white-clad health care workers, were the largest demonstrations El Salvador has seen since the 1992 peace accords that ended the nation’s civil war.

“Health care is a right, not a commodity.” Photo: Kelly Creedon

The walkout began September 18 in the sector of El Salvador’s public health system called seguro social (social security). Unlike the social support program of the same name in the United States, social security in El Salvador provides health coverage for all Salvadorans employed in the formal economy; costs are covered through employer contributions. Another system provides health care for people who are unemployed, underemployed or indigent. Although the privatization proposal covered only the seguro social system, it threatened all health care in the country, explaining why the strikers enjoyed such widespread public support.

The strike was the culmination of a long-simmering conflict between health-care workers and the public on one side and those who sought to privatize care on the other. It was provoked by a series of proposals offered by the National Association of Private Business geared toward “modernization” of health care services, and announced by President Francisco Flores of ARENA, the right-wing Republican National Alliance party. ARENA was born out of the civil conflict that claimed more than 70,000 lives, and its founders are widely believed to have led the dreaded death squads. The ARENA leadership, largely composed of private business owners and with long-standing ties to the country’s economic elites, has held the presidency since the end of the war.

Photo: Kelly Creedon

In a country where 70 percent of the people live in poverty, just as many depend on public health care, and privatization would put that essential service beyond the reach of many. Recent experiences with privatization efforts reinforce this concern. Successive ARENA governments have made a series of privatization deals for public services including banking, telecommunications and electricity. In each case, consumer prices rose without any noticeable improvement in service; a study conducted by a Salvadoran NGO, the Center for Constitutional Studies for Human Rights, concluded that rather than spur competition, privatization resulted in public services becoming private monopolies.

At the same time, some politicians benefitted personally from the deals after leaving office. The most prominent example is former President Alfredo Cristiani, who negotiated the peace accords. After his administration privatized the Salvadoran banking system, Cristiani moved out of the presidency of the country and into the presidency of the Salvador’s largest bank, Banco Cuscatlán.

To the surprise of some observers, the Legislative Assembly supported the health-care strikers and approved a decree on October 17 that would have stopped the privatization and guaranteed state-provided health care. The decree passed despite Flores’ threat to veto it; Flores himself had released his own proposal a few days earlier that reflected the concerns of the business interests while promising to expand coverage.

Around the same time, massive protests began in support of the strike. October 23 saw the second and largest in a series of marchas blancas. Although crowd estimates vary, international news agencies reported between 50,000 and 80,000, and it was widely recognized as the largest demonstration since the end of the civil war. At the march, a representative of the Lutheran church of El Salvador said, “Since the peace accords, privatization has made life impossible for Salvadorans. If the population doesn’t act now to demonstrate that we are not in agreement, the government will privatize health [and] education, and we will end up sold to foreign interests. So here today we are protesting in defense of life.”

But the public protest did not immediately stop the drive toward privatization, and in November riot police confronted protesters with a water cannon, rubber bullets and tear gas. At least 15 people were hurt and many more were treated for exposure to toxic gas. The incident provoked criticism by the Human Rights Ombudsperson’s office for excessive use of force by the police. Then, on December 19, in a last-minute deal with Flores, the Legislative Assembly overturned its earlier decree against privatization.

As the strike continued into 2003, the human rights situation deteriorated. Mutilated bodies started to appear around the country. Although the government blamed the gruesome acts on street gangs, the crimes looked more like the actions of death squads than gang wars. During the war and the years of repression leading to it, death squads frequently mutilated or dismembered the bodies of their victims as a tactic to terrorize the population. Despite this familiar pattern, the police investigation focused exclusively on street gangs, ignoring other possibilities. Whatever the cause or motive for the killings, they drew attention away from the health-care strike during a hotly contested election season.

Meanwhile, patients were suffering from the lack of attention due to the lengthy strike. But, said Isaías Cordero del Cid, secretary of the striking doctors’ union, “Although immediately we were causing difficulties for the patients, we knew that in the long run we would be holding back the much worse problem of privatization.” He added, “We have earned a clear conscience. When people are no longer able to access the hospitals, I will at least be able to say that I opposed privatization of health-care in this country.”

By early 2003, the striking doctors had also endured great personal sacrifice, depleting savings and even selling property. Of the original 700 striking doctors, 550 remained away from their jobs with no sign of resolution in sight at that point.

Initially, the government had sponsored a media campaign accusing striking doctors of abandoning patients and quoting daily the numbers of missed appointments, surgeries, etc. But as the strike continued and the government put into place a contingency plan replacing striking workers and doctors with new hires, the image changed to promote the idea that the health-care system was functioning normally. At the end of January, the government announced that there was no longer a need to negotiate with striking workers, and that the strike had essentially ended, assuring the public that all services were 100 percent functional. But many of the specialists on strike had been replaced with doctors who were not trained in the same specialty, and as a result, the doctors’ union said, the quality of services was not the same.

As spring drew near, the situation appeared to be stalemated. No longer barred by law from privatizing, the government was nevertheless taking no steps to implement the plan; but it also was not renouncing the plan. The doctors decided to go back to work and try to prevent privatization from their jobs, at which point another crisis developed: The government took the position that the striking doctors had been fired and replaced.

On April 1, seven of the remaining striking doctors began a hunger strike to pressure the government to reinstate them in their jobs. Eleven days later, the Legislative Assembly passed a decree reinstating all the strikers. The doctors ended the hunger strike but waited to return to their jobs in anticipation of a possible presidential veto of the reinstatement decree. While the striking doctors await action by President Flores on the amnesty bill, they have vowed to continue the struggle against privatization, regardless of the immediate outcome of this job action.

Kelly Creedon is the Communications Coordinator for Christians for Peace in El Salvador. Former WRL Disarmament Coordinator Chris Ney is now U.S. Coordinator of CRISPAZ.