Studying Other Memories

The Tensions of a Complex Health System

In the early twentieth century, Chile had one of the highest childhood mortality rates in the world, and illnesses such as typhus, cholera, tuberculosis, and syphilis took a heavy toll on the population. The change in this dramatic situation over the course of the century has been attributed to what Illanes (2010: 65; Murdock, 1995) has called “greater organizational responsibility toward charitable assistance,” culminating in a genuine public health policy overseen by the state, and physicians have been perceived (and have perceived themselves) as important actors in that process. Through the establishment of the Sociedad Médica de Santiago in 1869, the foundation of medical schools, and participation in official hygiene and public health initiatives, physicians exercised significant influence over public officials as a sort of “fourth branch of government” concerning those issues (Illanes, 2010: 89).

Their professional organizations, such as the Sindicato de Médicos de Chile (founded in 1924), the Asociación Médica de Chile (founded in 1931), and the Colegio Médico de Chile (founded in 1948), all supported and worked toward wider medical coverage financed by the government (B. Molina, 2010: 74). One of their major accomplishments was the Estatuto de Médicos Funcionarios (Medical Functionaries Law) in 1951, which established salaries and conditions for government doctors that were significantly better than other public employees enjoyed (Vargas, 2002: 6). The following year saw the creation of the Servicio Nacional de Salud (National Health Service—SNS), charged with “the protection of [public] health through sanitary and social assistance actions and through preventative and curative medicine.” ² The SNS replaced and assumed the roles of previously existing public health agencies. By the 1950s three health care systems existed side by side in Chile. In the private sector, physicians freely set their rates in a direct relationship with patients, while the SNS and its public-sector physicians attended to the working class and the poor; in addition, the Servicio Médico Nacional de Empleados (National Medical Service for Employees—SERMENA) was a mixed system mostly covering public employees in which participants could freely choose their physicians (in contrast to the public system) and pay with a voucher.

During the 1950s and 1960s editorials and analyses of the Colegio Médico’s publications highlighted the tension, as they saw it, between public and private health care. While the Colegio had supported the creation of the SNS as a necessary public instrument of health care, it worried about turning physicians into “functionaries” whose professional values and prerogatives were subordinated to the interests of the state. In 1959 the Colegio’s Cuadernos Médico Sociales warned that “changing attitudes about physicians” would impact both their economic well-being and the internal cohesion of the medical fraternity, as physicians debated these changes and how they might change the doctor-patient relationship (Díaz et al., 1959: 5; Fricke, 1960: 22; Sepúlveda, 1959: 12).

This tension between the free and essentially private (or bilateral, doctor-patient) exercise of medicine and the growing role of the state and its “social medicine” was central to the conflict that would arise during the Popular Unity regime between the government and the Colegio. By the end of the 1960s we find a professional association that embraced its role in the construction of public-sector medicine and defined it as positive for the country but at the same time defended the economic interests of physicians, displaying a wary attitude toward political changes that might impact those interests or their role in determining public health policy.

The Popular Unity Government

The election of Salvador Allende, candidate of the leftist Popular Unity alliance, in 1970 represented the high point of the state’s role in the Chilean economy (Pinto and Salazar, 2002; Winn, 2013). Allende’s program of “revolution by institutional means” generated enthusiasm and high expectations in the Chilean and foreign left and serious doubt and worry in the political center and right. Would Chile become a second Cuba? How far would the socialist government go in “statizing” Chilean economy and society?

For its part, the Colegio Médico initially welcomed Allende’s election, noting that he was the first physician to reach the Chilean presidency, after a long career as legislator supported in part by the Colegio: “We can trust Allende,” the Colegio’s journal noted in 1970 (Vida Médica, 1970a). However, this friendly attitude did not last long. The Colegio hoped for “sufficient financing to carry out its work” and for “a substantial improvement in the socioeconomic and cultural level of the population,” areas in which the previous three administrations had been “hostile,” inefficient, and sectarian (G. Molina, 1970). These labels were soon attached to the new regime, as the Colegio’s president Emilio Villarroel González criticized Allende’s plan to unify health care into a single service ³ as “the complete funcionarización of the profession”—turning doctors into mere employees. If the Colegio was to support the plan, it would be under certain conditions: “realistic financing, technical and administrative decentralization, and the effective and responsible participation of those who provide and receive services” (Vida Médica, 1970b). The Colegio feared the “statizing” of health care, in which doctors would lose control over compensation and working conditions.

By 1971 the conflict was out in the open, as the Colegio rejected the government’s proposal and was in turn criticized by the minister of health, Juan Carlos Concha, and by Allende himself. The government alleged that doctors were a privileged social class that opposed (through the Colegio) the interests of the working class. The Colegio’s president publicly complained after Concha, in a speech in Antofagasta, said that doctors were born into a golden cradle while workers were born into straw. Concha later explained his remarks, noting that he had sometimes gone hungry as a medical student (Vida Médica, 1971d):

I don’t mean to say that we doctors were born with a golden calf in our hands. No. When I was a student, my pants were patched and my shoes had holes and sometimes I would do other students’ homework to get a bit of bread that I didn’t get at home. I’m not ashamed to say it. But while my parents weren’t wealthy, we did manage to get ahead because we had culture and family bonds.

The conflict, however, was not just between the leaders of the Popular Unity government and the Colegio but within the medical profession itself. As in other professions, there was a profound division between defenders of professional and economic autonomy and the so-called leftist doctors who supported the government’s reform plan. Hernán Romero, a former president of the Colegio, lamented in a 1971 interview the divisions within the profession about the role of medicine and of doctors. He dismissed the notion that most doctors lived “opulently,” but he did acknowledge the contradiction between their vocation of service and the defense of their upper-middle-class status: “We have had semisocialized medicine in a consumer society, so to speak, and we have therefore been the square peg in the round hole. But we are headed toward a socialist regime in which many of these paradoxes will be corrected” (Vida Médica, 1971a).

The government’s discourse in this regard was clear: for Allende, the doctor with social responsibility “ha[d] to become a revolutionary doctor,” and a doctor who identified with the left had “the obligation to become a dynamic factor in the revolutionary process.” Allende (1971: 21) acknowledged the important role of doctors in expanding medical care through 1970, but the next step under Popular Unity was the “socialization” of care so that all social classes would receive the same attention. This was the task of “leftist doctors,” and the Colegio stood in the way:

If we look at the trajectory of the Colegio Médico over the past few years, we must conclude that its work has been dark, concerned with its own rights rather than those of society. In general it has played catch-up rather than displaying any creative imagination. . . . Its most noteworthy actions have been economic ones, justified at the time but having an external and internal whiff of pettiness.

The responses of the leadership of the Colegio were numerous and laid the foundation for a strong mobilization against the government. Its president, Emilio Villarroel, accused Popular Unity’s “doctors’ convention” of organizing a campaign against the Colegio, insulting its democratically elected leaders (Vida Médica, 1971b). In late 1971 and early 1972 there were efforts to improve the relationship (Vida Médica, 1971c), but confrontations between doctors of different political persuasions, government officials, and even patients increased (Vida Médica, 1972a). The Colegio’s headquarters in Santiago and a branch in Concepción were attacked in June and July of 1973, probably by the Movimiento de Izquierda Revolucionaria (Revolutionary Left Movement—MIR) (Vida Médica, 1973a; 1973b).

It is difficult to determine how many doctors were in favor of the Popular Unity reforms instead of the official position of the Colegio. One of my interview subjects said that “by 1973, before the coup, those of us on the left represented about a third, and the rest were Pinochet supporters.” Juan Carlos Concha said in a recent interview,

The leadership of the Colegio had its social roots in the bourgeoisie, and its political sympathies were with the right. Several times they called strikes and protests to destabilize the Allende government. . . . About 20 percent [of the membership] were progressives or, as Allende said, “they were Marxists, lay and Christian”; 8 or 10 percent were reactionary enemies, the ones who set fire to my house. Later on they killed many people, since the Colegio Médico even administered a concentration camp during the coup. . . But most of the membership was what we called the “ideological swamp,” around 70 percent. They didn’t know where to situate themselves, on one side or the other.

While I cannot come up with exact figures, it is worth noting that the provincial and national leadership of the Colegio was elected by direct vote of the membership, and until the reforms of the early 1980s membership in the Colegio was obligatory for the exercise of the medical profession in Chile. We can therefore assume that the leadership was highly representative of the membership as a whole.

As Concha noted, the Colegio joined the mobilizations and strikes organized by various business and professional organizations in August through October of 1972 (Vida Médica, 1972b). It also used its regulatory power over medical credentials to veto the government’s plan to bring in Cuban doctors and graduates of Patrice Lumumba University in the Soviet Union. In August 1973 the Colegio called for Allende’s resignation in the following terms (Vida Médica, 1973c):

The anarchy and collapse of the principal health institutions (National Health Service, SERMENA, etc.) has ruined to an unimaginable degree the health of our people through shortages, childhood malnutrition, labor indiscipline, political meddling, and sectarian politics. . . . We believe, Dr. Allende, that it is pointless to persist in the error of imposing programmatic goals that only lead to serfdom. This would only ignore and negate the virtues of our race and our noble, good and hard-working people who seek only to live in peace and liberty.

On September 11, 1973, a coup carried out by the military with the support of the right (and part of the center) overthrew the Allende government. Allende committed suicide in the presidential palace, La Moncada, which was attacked by the air force. A military junta took charge of the country for the next 16 years.

Support For The New Government

The coup was applauded and embraced by the national leadership of the Colegio Médico, which adopted the new government’s discourse of “national reconstruction” and publicly offered its support. The Colegio noted the change in approach between the two regimes, contrasting a note from the prior minister of health accusing the Colegio of infantile attitudes and rejecting its strikes and petitions with one from the new authorities politely requesting the use of the Colegio’s headquarters to house the Ministry (to which the Colegio gladly consented). The new minister told the Colegio, only partly in jest, that ideologically suspect doctors should be “exported” to other countries (Vida Médica, 1973d; 1973e). Meanwhile the Colegio’s national leadership called upon doctors and their spouses to join the government’s “national reconstruction” campaigns by donating money and jewelry and upon public-sector doctors to donate 5 percent of their salaries. In a ceremony on October 13, 1973, doctors’ wives turned over more than 1,000,000 escudos and US$139, along with wedding rings and other jewelry (Vida Médica, 1973f; 1973g).

The Colegio’s representatives attended numerous professional meetings and conventions throughout Chile and abroad, where they defended the new government and rejected what they called a defamation campaign against a change that they considered fully justified given the chaos and institutional crisis the country faced prior to the coup. They asked the Church, among others, to spread the truth about what was happening in Chile, which they characterized as an effort to save the country from anarchy, radicalism, and Marxist enslavement (Vida Médica, 1973h). The leadership expressed confidence that the Popular Unity period would soon be a distant memory in a country entering a new era of normality: “The days of tenacious resistance to the Popular Unity government that sought to enslave us are past. Nothing is left but their memory, and by a very natural mental process this memory tends to lose its emotional baggage—and when it is gone, it will leave a mere historical episode in the life of the Chilean people” (Vida Médica, 1973i).

The Colegio thus ignored the military’s persecution and repression of many of its own members, the “leftist doctors.” Later investigations revealed that at least 21 doctors had been detained-disappeared or killed outright between 1973 and 1990 and many more fired from their jobs, jailed, or exiled during military rule. Among the detained-disappeared were well-known political figures from the medical profession such as Enrique Paris Roa of the Communist Party, a personal adviser to Allende, and Bautista Von Schouwen, one of the founders and principal leaders of the MIR (Comisión de Solidaridad, 1993).

From Collaboration To Opposition

Toward the end of the 1970s the harmonious relationship between the Colegio Médico and the dictatorship began to come undone. The first disputes were about money, as the low salaries of public sector doctors were further eroded by high inflation (Vida Médica, 1977: 16–18). In 1979 the Colegio criticized the government for declaring, through the Ministry of Finance, that the Colegio’s published price list (arancel) for medical services was merely a guide rather than an obligation. This declaration threatened younger doctors starting out in the profession, and its consequences extended to other professional associations ( Vida Médica , 1979: 12).

The dictatorship’s aggressive neoliberal policies did not spare the health care sector, and the Colegio criticized the privatization of public hospitals, the termination of the government’s employment guarantee for medical school graduates, and the creation of private health insurers, previously unknown in Chile. ⁴ For the Colegio, these companies threatened the free exercise of medicine and its social character (Bravo, 1979: 2); it cited the U.S. experience, of private hospitals and insurers, as evidence that the poorer sectors of the population would be marginalized (Vida Médica, 1981a). In 1981 the Colegio reminded the government that since it had opposed the socialist project of the Popular Unity regime and its politicized “unified health system,” it was unjust to accuse the Colegio of blocking the government’s push for a mixed private-public system.

But it was the 1981 decree converting Chile’s professional associations into lesser interest groups (gremios) that marked the definitive rupture between Colegio and the government. This change meant in practice that Colegio membership was no longer required for the practice of medicine, and the Colegio lost the power to discipline or suspend doctors who violated professional standards. It accepted this change but warned that it would have negative consequences (Vida Médica, 1981b) and even organized a national doctors’ referendum against the new law, which the government harshly criticized and repressed.

From that point on the Colegio was clearly identified with the opposition to the military regime. While its monthly magazine Vida Médica criticized the private insurance reform and the emphasis on curative medicine over public health, the Colegio played down its clear support for the 1973 coup and sought to backdate its opposition (Vida Médica, 1983):

After September 11, 1973, the Colegio Médico by virtue of its antagonistic relationship with the former regime became the temporary seat of the Ministry of Health and and a willing [obsecuente] participant in the government’s reform proposals. In particular, the Colegio accepted smaller salary increases [for public-sector doctors] than inflation justified, a sacrifice made, it was said, in favor of “national reconstruction.” Already in 1974 the first disagreements between the government and the Colegio arose, over the government’s privatizing reforms which were contrary to the social spirit of Chilean medicine.

The Colegio maintained its oppositional stance through the return to democracy in 1990. In 1984, after 11 years of silence, the theme of repression of doctors and the population in general appeared in its publications. Vida Médica covered the situation of doctors in foreign exile, praised Salvador Allende, and described the historical role of doctors in developing the now-threatened model of social medicine. In 1985 the Colegio received the annual award of the American Association for the Advancement of Science for its work in denouncing torture and defending human rights (Vida Médica, 1986).

In the Colegio’s current discourse the memory of having actively supported the dictatorship both domestically and outside the country is either strongly relativized or omitted entirely. For example, the Colegio’s web site sums up its recent history as follows:

After 1973, the [Colegio] progressively lost its role in health policy until it was reduced to a trade association in 1981, thus losing the essential attributes it had enjoyed as a legally established corporation (such as the moral oversight of its members). The return to democracy restored its leading role, but since it was practically paralyzed for 16 years changes were needed. The system of internal elections was restructured, and in 1993 the first direct elections were won by Dr. Ricardo Vacarezza, whose first task was to recoup the Colegio’s status as a governing body of the profession [corporación de derecho público] and initiate the first proposals for reforming the national health system. ⁵

It is worth noting more generally that the Colegio Médico was not the only professional organization to support the coup only to join the opposition years later in response to neoliberal reforms that impacted its members’ well-being. This was also the trajectory of the Agrupación Nacional de Empleados Fiscales (ANEF), the principal union of Chilean public employees (Candina, 2013).

The Complexities of Memory

Given recent advances in the study of historical memory in Latin America and specifically in Chile, it is perhaps unnecessary to provide an extensive discussion of what is essential to social memories and constitutes them as such: that they are not about the past or memories in general but interpretations constructed in the present that serve as the framework for reading the past and interpreting it for others (Jelin, 2002; Loveman and Lira, 2001; Portelli, 2004). Memory, as individual and collective craftsmanship, is both Virgil and Beatrice as depicted in the Divine Comedy, both the traveler and the moralizing guide. Beatriz Sarlo (2005: 9) notes that “attempting not to remember is like attempting not to smell something, because memory, like smell, is present even when not invited.” What happens in the public realm is not remembering but selecting which memories (our own and those of others) will be spoken and shared and how they will be used. Memory is thus not a resource but a recourse.

With respect to the Colegio Médico, my investigation demonstrates that starting in the 1980s the leadership selected and categorized the past events and processes that would form the basis of its recent history. The Colegio’s opposition to the dictatorship would be a “strong” or dominant memory, while its prior conflicts with the Popular Unity government and initial collaboration with the dictatorship would be “weak,” according to the definitions of Traverso (2007: 48). From this perspective, the adaptation of the discourses of memory to present circumstances is well known and in itself unsurprising to students of social memory. What interests us is the reasons behind those adaptations. Throughout the period studied, the Colegio supported or opposed various political projects according to its sectoral interests, starting with the defense of physicians’ autonomy in the exercise of their profession (and the review of their performance), their compensation, and their veto over policies and reforms that concerned them. All told, their positions were governed not by pure political ideology but by the consequences of that ideology for the exercise of their profession and their collective power as a professional association.

This case is therefore a good example of the importance of considering class and professional identities and not just party-political or ideological ones when analyzing narratives of memory. The Colegio’s support for the 1973 coup and the subsequent military regime was not a function of its identity as a right-wing golpista organization—which it was not—but a narrower response to Popular Unity reforms that imperiled the autonomy and well-being of its members. The military regime was welcomed for its promises to return doctors, more than the country as a whole, to a situation of “normality.” Likewise, the radical change in the Colegio’s position on the regime in the 1980s represented not a sudden discovery of its democratic vocation but a reaction to neoliberal reforms that impacted it and its members negatively. With the return to democracy and increasing public rejection of the abuses committed under the dictatorship, the Colegio emphasized its role in the opposition and the memory of the doctors who were killed, detained-disappeared, exiled, or fired during that period.

This situation has interesting theoretical and political aspects. One of these is the importance of analyzing social memories as tools not only for denouncing conflict and making it visible but also for manipulating conflict and making it invisible. While the literature on memory accepts that all processes of construction of memory (“memory undertakings,” in the phrase of Jelin [2002]) involve a selection process, typically we focus on what is highlighted, not on what is omitted or silenced or the motives behind those omissions and silencings. A memory can be used to denounce abuses and pay homage to victims, while it renders another memory invisible; for instance, the publicity barrage about the Colegio’s role in the democratization struggle of the 1980s not only exalts its ethical and political leadership in more recent years but also serves to cover up the memory of its support for the dictatorship during the previous decade. Another interesting aspect is that the memory of the Colegio’s active participation in the construction and expansion of the public health sector during the twentieth century was used at various political moments to criticize the dangers of “socializing” medicine under Salvador Allende or privatizing it under Pinochet.

This use of the same memories at different points in different political contexts leads us to reflect upon the fact that public memories are much more mobile and pragmatic and less principled than they first appear. Although they are presented as unimpeachable and almost ahistorical truth, they are profoundly historical and political in that they emphasize certain events or situations according to the debates, threats, or judgments that are currently considered pertinent. This somewhat bare-knuckles analysis of political or professional organizations’ “memory work” has not been absent from social theory and the study of political discourse, but it has not been sufficiently central to memory studies. As Sarlo (2005) has observed, “the ‘sacredness of testimony’ and the need to denounce the undeniable horrors of repression led memory studies to avoid analyzing the instrumentality of memory as a tool in political struggle” ; the scholar who confronted the question risked being accused of justifying, however indirectly, human rights violations or questioning the legitimacy of victims.

This underlines the importance of incorporating the categories of social class and professional or corporate identity into analyses of the discourse of memory. These are, however, not the only categories that merit greater attention; differences of gender, nationality, and ethnicity are also particularly relevant to an understanding of what is remembered and how, as demonstrated by recent studies on how diverse populations (urban, “white,” indigenous) remember war and repression in Andean communities in the 1980s (Sastre, 2015). This incorporation is especially important when it comes to understanding the political activity of groups or organizations that, as we have seen, do not rebel against authoritarian initiatives and sometimes even support them. These processes can be difficult to document, because often these groups do not defend their social and economic interests directly; as we have seen in this case, one of the Popular Unity (and “leftist doctors”) attacks that most irritated the Colegio was the observation that doctors as a group were better-off than Chilean society as a whole, which the Colegio refuted by noting the lower-class origins of many doctors, the precarious situation of new and retired doctors, and (perhaps most of all) the social vocation of the profession. Of course, doctors’ relatively high socioeconomic status was real, and it influenced the Colegio’s positions and self-image. Therefore we must pay attention to those class and corporate interests to get beyond a victims/victimizers dichotomy that does not sufficiently explain the decisions made at the time or the subsequent construction of discourses of memory about those decisions. Along these lines, we must also keep in mind the prevalence in crisis situations of “situational ethics” (Rees, 2009: 204)—the adaptation of individuals and groups to the realities of the situation rather than mere cynicism.

While the study of specific cases such as the Colegio can be a large and sometimes difficult project, it is necessary to a better understanding of the experience of authoritarianism, at least in Latin America, and the subsequent democratic transition.