The truncated project towards a modern national health system
Just over a century ago, Spaniards faced another global pandemic that caused many deaths and suffering: the influenza epidemic of 1918-1919. It stayed with the name 'Spanish flu' because Spain was one of the few countries that openly reported on the ravages of this infectious disease in its population. This health catastrophe revealed the serious health situation in the country, with an alarming lack of infrastructure and a weak state organization of health care. This episode in history made both the general population and medical groups aware of the importance of allocating efforts and resources to develop a health system that could reach the various corners of the country.
Following this direction, there were modest increases in the budgets of the General Directorate of Health (DGS), within the Ministry of the Interior, since 1920. However, it was the Government of the Second Republic that multiplied considerably and in a short time the percentage of investment in this area. Thus, the money allocated to the DGS went from almost 10 million pesetas in 1931 to more than 31 million in 1933.
Marcelino Pascua, doctor and scientist of international relevance, was at the head of this institution during this brief period of two years, considered the 'transformative biennium', in which he tried to establish the foundations of an innovative public health system.
The doctor, professor of Hygiene at the Complutense University of Madrid, was critical of the situation and denounced "the shameful backwardness in which the State health apparatus had traditionally been had." Health care in Spain at that time was organized locally, with limited economic resources, supported by charities and with many sectors of the population that were left on the sidelines, especially in rural areas. A large percentage of citizens did not have the right to free healthcare and, if they wanted to access it, they had to pay the healthcare professional directly or through private insurance. In practice, this meant that many people were left out of healthcare, not having enough money.
Pascua referred to his policy as a "socializing direction of medicine" and focused on three main fronts to reform health in Spain: the reinforcement of disease prevention, the expansion of public health care to all groups and the creation of organizations to coordinate health activities. He launched important campaigns for the prevention and treatment of widespread diseases in Spain such as tuberculosis, trachoma or venereal diseases. He also promoted health research in the country, reinforcing public hygiene, epidemiology and statistics as tools in health policies.
The doctor was also an advocate for health care from a team of doctors, with different specialties, instead of a single doctor as was usual at that time. The Second Republic created 45 rural hygiene centers with teams of doctors who, in addition to the typical care work, also carried out preventive medicine activities. At the head of each of these centers was a doctor who was part of the National Health Corps.
Mental Health also received significant attention from the Government, with the creation of a technical section of Psychiatry and Mental Hygiene in the DGS, with a clear declaration of intent contained in the Decree of November 12, 1931: “It is necessary that From now on, the state of affairs that handed over the mentally ill to the care of people without any prior preparation, either psychiatric or medical, disappears. The consequence of this has been the inadequate and even harmful treatment to which the mentally ill have been subjected. The progress of psychiatric science and modern ideas of mental hygiene demand the solution ”.
In addition to being a firm promoter of the national health reform, Marcelino Pascua proposed the abolition of prostitution, studied the establishment of an organic law on Health and pointed out the lines of work to be developed, among which, firstly, hygiene of food, particularly the supply of milk. Second, modernization, rather humanization, of hospitals, asylums, etc. Third, the promotion of the fight against cancer in its public aspect, that is, the treatment and early diagnosis of malignant tumors. Fourth, the great problem of the care and prevention of blindness and other disabilities. Fifth, industrial hygiene. Sixth, the unsustainable situation of medical and pharmaceutical professionalism. And finally, the preparation of the environment and studies of scientific and moral rigor on the problem of birth control.
The implementation of the Constitution of 1931 revealed the will of the democratic government to protect the health of the population. In Chapter II, referring to "Family, economy and culture" it can be read: "The State will provide assistance to the sick and elderly, protection of maternity and childhood, endorsing the Declaration of Geneva or table of the rights of the child ”. And also that “the Republic will assure every worker the necessary conditions for a dignified existence. Its social legislation will regulate: cases of insurance for sickness, accidents, forced unemployment, old age, disability and death; the work of women and young people and especially maternity protection ”.
Today such statements might seem the most normal in the constitution of any developed country, but it was a true historical milestone in Spain that the State committed itself to protecting the population, especially those most vulnerable such as the elderly, the sick, children and the elderly. mothers It became the starting point for multiple reforms aimed at recognizing and expanding social rights. In this sense, the protection of workers was increased thanks to the creation of the Compulsory Insurance of Work Accidents, the Law of Compensation for Work Accidents and the National Fund of Insurance of Work Accidents.
Pascua failed to develop his health reform proposals as he would have liked, since he resigned in 1933 motivated, among other reasons, by the opposition of the most conservative medical and pharmaceutical groups to the changes he wanted to implement. In a talk, the director of the DGS himself said goodbye saying: "As I leave this position I fervently hope that one day they will call me again in more favorable circumstances, where I can develop broader plans and a profound renewal of ideas and people can be done. ". Years later, Pascua became a professor at the prestigious Johns Hopkins University, contributed to the birth of the World Health Organization as an expert in health statistics, and developed important health and scientific work in multiple countries.
Despite the departure of Marcelino Pascua, some of his proposals continued. Thus, in 1934, the Sanitary Coordination Law was established, the main purpose of which was to reinforce the state's role in the organization of sanitary services at the local level. In the Law on the Bases of the Sanitary Regime (July 11, 1934) it could be read: "As the mission of ensuring the maintenance of Public Health, and the care of diseases of any nature, became a function of the State, no longer it is that each citizen has only one protection against those whose disease state may constitute a danger to society, but rather that the State will take care that each man or woman of the town remains healthy and is duly treated if they fall ill ".
This Sanitary Coordination Law establishes the mandatory sanitary associations, whose purpose is to organize the sanitary authorities of all the municipalities of each province, including also the provincial council. Thus, health was understood as "a public function of regulated collaboration of municipal, provincial and state activities, under the technical and administrative direction of the State." The regular health workers became technical officials of the State, although the local administrations continued to participate in their salaries.
Later, on November 4, 1936, the first Ministry in Spain dedicated exclusively to health was created: the Ministry of Health and Social Assistance. The event was linked to another historical circumstance: the first woman minister in the history of the country was in charge of said Ministry: Federica Montseny. However, the presence of Health with its own portfolio in the Government was an ephemeral event, as it only lasted six months. With the arrival of Juan Negrín to the Government, the Ministry of Health disappeared and its powers passed to the Ministry of Labor in 1937.
Almost all the varied and progressive projects that were proposed by the Ministry would not materialize. These were initiatives aimed at protecting the most vulnerable: soup kitchens for pregnant women, a list of professions suitable for the disabled, a reception center for children, liberations from prostitution to help women who wanted to abandon their exercise ... In the end, only a center for children and a dining room for pregnant women were opened.
With Montseny at the helm, the first draft of the abortion law in Spain was also defined, which never saw the light of day due to the opposition of other ministers and due to his departure from the Government in 1937. It would take around 50 years for the first Law decriminalizing abortion came to the country in 1985.
We will never know what health achievements the Second Republic could have achieved had it not abruptly ended the Civil War and the subsequent dictatorship. The will and the roadmap set out to bring health care to all the inhabitants of Spain were not guarantees for this proposal to become a reality, in an unstable political climate and in a time of limited economic resources. However, the objectives and ideals set by the then republican democratic government on public health would end up being fulfilled many decades later, by far, in our country, including its greatest achievement: universal health. Would it have been possible to reach this social milestone much earlier with another course in history? It is a question that we can only imagine.
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