In 2012, the government of the Community of Madrid released a proposal to restructure the health system which would result in privatization of several hospitals and clinics. In response, the marea blanca, or white tide, movement rose in opposition of the proposal. PHM-North America was able to speak, on separate occasions, with two activists who were part of the marea blanca. Carmen Esbrí is part of the Mesa en Defensa de la Sanidad Pública–Madrid and Mónica García Gómez who was involved through the Asociación Facultativos de Madrid. Unfortunately, because of technical problems we were not able to produce a podcast this time. But please read below what we learned from these activists!
The marea blanca, or white tide, is a movement that began in the Community of Madrid in 2012 in response to the proposal of the region’s government to privatize several hospitals and community health centers.
Following the 2008 crisis, Spain took sweeping action to recover from recession and meet EU limitations on debt. In 2011 the Parliament voted to reform the constitution to require a cap on the country’s budget deficit and also to require the payment of public debt before any other state expenditures, including public services.
A little over a year later, in October 2012, the minister of health of the Community of Madrid, Javier Fernández-Lasquetty, announced a plan to lower the costs of the health system, stating that following the crisis funds to finance the system had dwindled drastically. This plan, called Plan for measures to guarantee the sustainability of the public health system, proposed numerous changes that would have direct impacts on users of the health system: it would require copayments for prescriptions, would change the status of the level of care for some hospitals, and privatize several hospitals and community health centers.
The proposal, if passed, would result in the privatization of the operation of six hospitals and 27 health centers across the region. The hospitals would be outsourced to private entities, and private group practices would be given priority in running the health centers. Further, all non-sanitary services (cleaning, laundry) would be outsourced to private companies. To justify its decision, the government noted that the move to privatize would increase efficiency, result in improved clinical outcomes, and increase satisfaction among patients.
When doctors across Madrid learned about the proposal, they immediately recognized the impact it would have on their patients and the public health system as a whole. During our conversation, Mónica García Gómez observed that over several years doctors had been seeing the effects of small steps toward privatization that the government previously imposed in 2003 and later in 2008, for which the government also blamed the economic crisis. Some of these effects were longer waiting lists and lack of availability of some medical devices. However, the 2012 proposal would mean drastic changes to the system that would create even greater problems for patients and posed a threat to the health system as a whole.
The health system is a pillar of our welfare state. The proposal was an attack on our system…the system that belongs to all of us. All of the doctors here are trained in the public health system; it was like killing our mother. A lot of people understood that this was an attack to the system—not only on the hospitals or the doctors or specialists. –Mónica García Gómez
Doctors also recognized the magnitude of this threat to the public health system, understanding that the private health care model, such as that in the United States, does not achieve the benefits the government stated in its Plan. They knew that the research says the exact opposite: private health systems are more expensive, less efficient, and have worse health outcomes. To make sense of the plan, doctors came to the realization that profit was the only motivation for such an attack on their public health system.
The news spread to hospitals, health centers, and health workers across the region and several, independent actions took place. As Mónica described, opposition to the plan caught on like a wildfire, spreading rapidly from city to city across the Community of Madrid and finally culminating in a region-wide strike which gained the support of their patients and local people. Doctors were on strike Monday through Thursday every week. This led to 40,000 canceled appointments and over 6,000 non-emergency surgeries being postponed. The system only functioned for urgent cases.
However, after five weeks of the strike, on 27 December 2012, the government of the Community of Madrid—the Partido Popular which held an absolute majority in the government—passed the proposed plan. In response to passing the law the Asociación Facultativos de Madrid (AFEM), who initially called for the strikes, petitioned the High Court of Justice of Madrid to stop implementation of the plan. On 11 September 2013, the Court ruled that the plan for privatization must stop stating that the plan is so extraordinarily broad that if the plan was to be carried out it would create irreversible legal situations if later any irregularities were discovered.
After an appeal to the decision by the government, the Court upheld its decision against the privatization plan. On 14 January 2014 the president of the government, Ignacio González announced that they would abandon the plan to privatize the public health system and the minister of health, Javier Fernández-Lasquetty, resigned.
The white tide rises
I thought that my medical practice was threatened. Practical, clinical, and day-to-day with my patients, with my colleagues, my relationship with the health system was all threatened. So, we had to do something because it made no sense, we have a lot of studies in other countries that prove that our system was strong and good and we have to do something to defend it. Because the future of our health system was attacked. –Mónica García Gómez
Doctors in Spain, Mónica said, have a special relationship with the public health system. They are all trained in the public health system, many of them work in the public health system, and they are also users of the system. Thus, when they learned of the sweeping impact of the proposed plan—with no reasonable explanation from the government—they, and other health workers, were compelled to do something about it.
The Asociación Facultativos Especialistas de Madrid (AFEM), an association of doctors which formed in 2012 in response to this privatization plan, organized a meeting of about 100 people, including health systems experts, doctors, and other associations, to examine the issue and discuss what could be done. Attendees to this meeting proposed the first marea blanca demonstration and a doctors strike.
The idea of a doctors strike was new. Generally, Mónica noted, it’s very difficult to get doctors to join a strike, and Carmen pointed out that the health sector is usually very conservative. But this case was exceptional because doctors of all ideologies personally felt the harshness of the threat on many levels. And because of the respect doctors hold in Spanish society, their participation raised the profile of the issue.
It was also significant that patients supported the doctors in this movement. The strike did cause problems for the patients as not all services, only minimum, urgent services, were available. But patients allied with doctors, understanding their doctors were not striking to cause them harm but to save the system.
In that spirit, the Mesa en Defensa de la Sanidad Pública de Madrid (MEDSAP-Marea Blanca) formed as group that included and extended beyond doctors and the hospital sector. The group included unions, neighborhood associations, and individuals who were all fighting against the government’s push to privatize Madrid’s public health system. MEDSAP-Marea Blanca worked to develop a common strategy so that these groups would not duplicate efforts but be a unified front against the privatization efforts of the government.
[In bringing different groups together] you have to look at the objective. The objective is to defend the human right to health, life, and equality. That has been the center of our solidarity activity. –Carmen Esbrí
Using all available resources in the face of unwaivering opposition
A major challenge for the marea blanca was the force of a government controlled absolutely by a party driven to reform the health system through privatization. Moreover, the government was making this decision based on its own data and justifications and without consulting doctors or other experts. Under these circumstances, there was no opportunity or opening to have a dialogue with policymakers.
While the marea blanca doctors strike was strong and gained broad public support, the movement also relied on further means to make its message clear and to pressure the government to withdraw the proposal.
MEDSAP-Marea Blanca’s broad network was able to coordinate its efforts to sensitize people to the issue, particularly to how this proposal would affect their relationship with the health system. They were able to get people out to large demonstrations and to join other actions.
While doctors led the strike, there were also demonstrations including flash mobs, die-ins, rallies, and marches. Many of the street actions, which amplified the message of the marea blanca, were led by young doctors (residents). However, when asked whether more seasoned doctors participated in these actions, Mónica reflected that it took a little pressure, but many did join.
According to Mónica, without the efforts of all involved the marea blanca would not have grown to be as big and dominant as it was.
This report from February 2013, “Madrid’s ‘marea blanca’ Continues” (in Spanish), demonstrates the magnitude of the public demonstrations.
The movement produced its own reports in response to the government’s proposal. Doctors, working with the health system every day, knew firsthand the costs associated with care were able to counter the government’s rationale for the proposal. For example, Mónica explained that the text of the proposal claimed that specialized care at hospitals that are a public-private mix costs 600 Euros on average per person but full privatization would decrease this cost would be 441 Euros. AFEM was able to produce information estimating that the cost of care at the time was actually only 360 Euros per person per year, well below the government’s estimated savings. Mónica reflected that being able to produce this type of well-researched evidence was a great strength of their movement.
AFEM filed a petition challenging the government’s plan as being unconstitutional. Carmen explained that many activists supported the legal action through financial donations as well as publicly calling for a decision to stop the plan. The court ruled in favor of AFEM, however it did not go as far as calling the proposal unconstitutional. The court ruled that the plan was too broad and lacked clarity to determine whether or not it would cause eventual harm to citizens and, thus, had to be withdrawn.
Civil movements have to work in other places—through judges in courts, in other institutions. I think that only social movement wasn’t enough. If the court hadn’t ruled as it did the hospitals would be privatized now. But I think marea blanca had influence in the court and in the conscience of the people. –Mónica García Gómez
The marea blanca continues to rise
Although the court ruling to stop privatization of public health services in Madrid was a huge success, it did not stop the government’s efforts to dismantle the public health system. So, the struggle continues.
MEDSAP-Marea Blanca continues to organize marea blanca actions in Madrid. Once a month, organizers and activists gather to protest the continued efforts to privatize Madrid’s public health system. Carmen explained that MEDSAP also supports and joins other civil society groups in causes including decent employment, decent housing, education, pension, and equality between women and men. This solidarity contributes to MEDSAP’s ultimate commitment to defending the right to life.
Mareas blancas have grown across Spain, in other regions, since those first actions of October 2012 in Madrid.
In 2016 organizers of these groups came together to form the Coordinadora Estatal de Mareas Blancas (National Coordination), of which Carmen is now the spokesperson. The group aims to develop strategic lines of work to link all of the mareas blancas across the country and to also be an essential partner with government entities and political parties in order to protect the public health system.
In May of 2017, the National Coordination presented its 38 Measures to stop the deterioration of the public health system to the Ministry of Health and to the Congreso de los Diputados, a house of Spain’s national legislative branch. The National Coordination continues to hold meetings with political parties and congressional groups to advocate for and continue to develop ways to prevent privatization of the public health system.
The National Coordination also works with EU-wide movements to advocate for European policies that will strengthen, rather than privatize or commercialize, public health systems. Carmen represented the National Coordination at a conference at the European Parliament on April 2, 2019, organized by the European Network against Privatization and Commercialization of Health and Social Protection, as part of its “Our Health Is Not For Sale” action.
They have given us the possibility to learn from others…to know what happens in other places and encourage equality that transcends geographical boundaries. Participating in this network gives us a richer vision. –Carmen Esbrí
After her participation in the marea blanca, Mónica was elected as a member of parliament for the Assembly of the Community of Madrid, representing the Podemos party. She explained that she has always had a long interest in politics but being a part of this movement helped her understand the extent to which politics permeates every aspect of our lives. She recognized that she can help patients in the operating room as well as from the floor of the Assembly:
All the things are politics. We have to stay in the places where politicians make decisions. If you aren’t in these places other people, for example people who want to privatize your health system, are going to make decisions instead of you. –Mónica García Gómez
Carmen continues her work in the marea blanca movement in Madrid with MEDSAP-Marea Blanca and with the National Coordination. In reflecting on lessons learned during her activism with marea blanca, Carmen shared:
You always learn things from others. What I’ve concluded is that quantity doesn’t make quality. Are people willing to defend something as important as fundamental human rights without stopping? Therefore, for me, I’ve learned to put what is important on the table. Only continuity, and sustained resistance will defeat the neoliberal model. As people committed to this cause, we have to maintain our core values and principles as a foundation of our movement so that we do not ever risk undermining our own work. –Carmen Esbrí