Feature

When health care becomes a weapon

Melissa Jameson reports on the state of health in El Salvador, where people are struggling to rebuild their lives after 12 years of brutal civil war

Twelve years of a brutal civil war, from 1980 to 1992, left the people of El Salvador, already familiar with the struggles of severe poverty, with acute health care needs and only pieces of a health care system, unable to provide more than marginal care for the majority. The Peace Accords signed in January 1992 have not put an end to either the increasing needs or the attacks on the health care system. Political and military factors continue to combine with economic ones to keep access to health coverage limited to a privileged few, while the majority suffer with few options for even minimal care.

One year ago, Frank Chalmers reported in healthmatters that the major causes of death in El Salvador were perinatal (11 per cent), intestinal infection (10 per cent) and murder or intentional injury (9.9 per cent). These statistics are telling both of the poverty and the widespread violence which have been prevalent. While these realities exist throughout the country, the situation is most acute where poverty and conflict have been most severe. In the countryside, where people are most poor and the conflict has been most intense, life expectancy is now 22 years less than the national average.¹

In addition to the physical disease and injury resulting from the violence, Salvadorean society is suffering in ways that are not so easily quantified. Civilians as well as former combatants are experiencing the post-traumatic stress syndrome common after periods of violence and displacement, especially characteristic of civil war. During interviews conducted throughout central El Salvador, reports of massive mental health needs, stemming from the conflict, were constant from both national and international health care workers. The fact that there are no accurate statistics on this indicates the lack both of cultural recognition and of resources to measure and treat the problem.

Post-traumatic stress syndrome also has resulted in social fragmentation, evident at family, community and national levels. This is manifest in increased violence in both private and public spheres. Domestic violence, already a problem, appears to be soaring in the post-war era. This represents a significant public health threat, both mental and physical — primarily for women and children. One international mental health volunteer estimates that over 80 per cent of the women in the villages in which she recently worked in the western region suffer from beatings and other abuse from their partners.

Common street crimes (muggings, physical attacks, etc.) are increasing in number and in violence. Aggravated by economic hardship and greater availability of weapons, increased street crime is both cause and effect of the general insecurity of the post-war transition.

Youth gangs, another symptom of the current psycho-social conditions, are growing. This complex phenomenon was imported from the US by children who fled the violence in El Salvador only to become involved in another kind of warfare in their often hostile host country and who now have returned as young adults.²

Both the family and the Church, traditionally the most available (if imperfect) sources of support, have been sharply divided by the violence and displacement consequent on the civil war. So not only are common social problems such as street and domestic violence increasingly prevalent and new ones such as gang violence taking root, but the social institutions traditionally in place to deal with such upheaval have themselves been ruptured. For most people this means greater vulnerability in physical, mental and spiritual terms, which contributes to the critical state of public health.

The current crisis in health care is not only an unfortunate symptom of underdevelopment or an accidental casualty of the war. Health care was an explicit target of the military during the war; health workers in rural areas were persecuted routinely and systematically. This was part of a larger ‘scorched earth’ policy in which the military attacked not only guerrillas or their specific sympathisers, but rather whole villages and regions. Intentionally targeting those who provided health care to rural villages was one of the more sophisticated and efficient ways of attacking entire populations.³

During this same period, the Farabundo Martí National Liberation (FMLN) guerrillas established an impressive network of health promoters who reached many in the rural areas. In many cases these were young people with little formal schooling, who learned their skills mostly by experience — from basic diagnoses of common village illnesses to field surgeries, often under extremely trying conditions. In addition to whatever genuine interest the FMLN may have had in the well-being of the poor majority, they also benefited as an organisation from the health promoters’ work. Rural health care was not only essential in order for their combatants to have access to treatment, but an effective way to win and maintain the loyalty of civilians.⁴

Health care in El Salvador has been a military weapon. In addition to diminishing its accessibility, this has distorted its very nature. In post-war El Salvador the lives of the people, especially the rural poor, remain pawns in a game of power as health care continues to be a weapon, now in the political rather than the military arena.

One of the most prominent examples is the fate of rural health promoters and the populations they have served. Many of these health workers were previously funded by international organisations, often through factions of the FMLN or other local non-governmental organisations (NGOs). Since the official end of the war in January 1992, international resources and attention have been diverted elsewhere to more apparently urgent needs.

Not only are there fewer resources on the left in general, but the FMLN has been directing those resources elsewhere. The transition from a military force of five factions to an opposition political coalition has unfortunately resulted in budget cuts in health while funds are concentrated in the establishment and maintenance of formal political organisations. Additionally, the left is being damaged by its own lack of unity. Recently defeated by the far-right ruling party ARENA (National Republican Alliance) in April’s contested presidential elections, disorganisation and in-fighting continue to plague the left, exacerbating the tendency to spend on bureaucratic demands, leaving fewer resources for health care and making co-operation in health work difficult if not impossible.

Meanwhile, dubiously-elected President Armando Calderón Sol has promised to expand the neo-liberal project begun by his predecessor. Central to this plan is reduction of social spending and privatisation of many basic services. The people of El Salvador cannot depend on the government to provide an increase in resources for health care. Strikes by workers in different sectors of the state health care system have been frequent in the past two years, most recently to protest the privatisation of the state social security institute.⁵

While there have been some isolated government attempts to train, certify and fund a few rural health promoters, thousands of those who were trained and funded during the war are having to leave health care work in order to be able to earn a living. Most of these will not qualify for either training or certification by the government, and therefore cannot be state-employed, nor is there funding for more than a tiny minority available through NGOs. As the new government continues to cut funding for the state system, the network of grassroots health workers dissolves, leaving millions with no access to even minimal regular care.

But health care in the post-war era is suffering not only neglect within broad economic policy. There are many who do not want good health care for the majority, especially in the rural areas where the tenure of the majority of land that was to be distributed under the Peace Accords has yet to be resolved. Providing decent health care in areas where property rights are still contested is seen as tantamount to legitimising the claims of the people currently living there, in many cases squatters who established communities on land abandoned by large land owners during the war. Given the potential for large profits on such lands in the ever more neo-liberal economy, there are many with wealth and power who continue to block any real investment in health care in the countryside.

Just as health care was previously denied to the majority for military motives, today health care is denied for political and economic motives. During the war the international community made the difference by supporting the work of health promoters in the countryside.

Given the current political and economic interests opposing expanded government investment in health care, and the crisis of unity in the left, international involvement is as crucial as ever — this time not simply to respond to immediate, war-induced crises but to support the construction of a sustainable, just health care system for the future.