A Review of Health in Ruins: The Capitalist Destruction of Medical Care at a Colombian Maternity Hospital

Health in Ruins: The Capitalist Destruction of Medical Care at a Colombian Maternity Hospital by César Ernesto Abadía-Barrero (Durham and London: Duke University Press 2022. 287 pages)

I should say at the outset that I was involved in the “neoliberal” reform described by César Ernesto Abadía-Barrero in his book Health in Ruins: The Capitalist Destruction of Medical Care at a Colombian Maternity Hospital. The argument he makes attributes the closing of a historic Colombian maternity hospital to the “neoliberal” market-oriented reform embodied in Law 100 in 1993.  

Shortly after that reform law was passed, a Harvard School of Public Health team headed by Professor William Hsiao, and for which I was the project Director, helped develop the implementation plan for that health reform.  This reform, following other initiatives in the United States and elsewhere, applied a theory of “managed competition,” a heavily regulated way to improve access, quality and efficiency of health systems in countries that had serious problems with very limited access to often poor quality and very inefficient public services. We were involved in the initial implementation of the reform but not in the subsequent governmental decisions and did not anticipate the economic crisis and growing implementation problems that occurred in the 2000’s and have been described here and in other works on the impact of the reforms.

Abadía-Barrero tries to make the case that the maternity hospital, El Materno, was a victim of this “neo liberal” health reform.  He presents a neo-Marxist analysis of neoliberalism that is currently enjoying a resurgent interest in academia, especially in Latin America.  His approach to exploring this critical view is to use a political-oriented form of ethnographic anthropological methodsa deep gestalt plunge into the hospital’s history and recent workforce with the incorporation of the subjects in the research and in political action in an ethnographic approach similar to currently accepted methods of participant observation and “community-engaged research.”  Abadía-Barrero’s painstaking descriptions and deep interviewing are evocative, but they do not prove his point. This approach makes it difficult for him to actually demonstrate that neoliberalism was the culprit in part because a single relatively unique case of one hospital is a weak reed to rest such a large critique. There are also some clear limitations in the application of the ethnographic methods.  The story could be told easily with other perspectives that better capture the causes of the difficulties faced by El Materno.

The most important chapters focus on the impact of the health reforms of the 1990’s and the clumsy way the authorities and hospital managers reacted to those reforms.  This narrative actually shows that many of the problems attributed to the neoliberal reform were in evidence prior to the reforms.  In many countries with similar historic tertiary hospitals, the unique situation of these hospitals makes it hard to attribute their problems to any single type of change or reform. The financing problems and conflicts with unions were apparent before the 1993 reforms.  While these problems remained after the neoliberal reforms in many countries, most of the hospitals were able to survive. Even the El Materno, and other hospitals mentioned in this work, were adopting management strategies that initially were coping relatively well with the transition to a more market-oriented insurance-based system, suggesting that the eventual collapse of El Materno was due to something else.  

Indeed, the narrative of the chapters shows that the eventual collapse of the hospital and the egregious treatment of the health workforce was more due to unique competing conflicts among different bureaucracies of the national Ministry of Health, the provincial governor and the Bogotá municipal government and a confusion of competing laws which made even reasonable compromises and commitments almost impossible to enforce.  This story is more about the political, administrative and legal life unique to Colombia than to the neoliberal reforms of the 1990’s.  One feels, as do some of the participants in the story, that it should have been possible for the hospital to do well under the reforms, had it been able to apply the managerial skills that the leadership was learning in the face of both the competitive pressures and of the new rules governing subsidies for the poor. Indeed, these chapters would be very useful in a course on management problems were it not for the neo-Marxist language that would be off putting in most business schools.

A sub-theme is also a critical attack on the biomedical approach to medicine, driven, he claims, by commodification of medical care implicit in capitalism.  He describes the maternity hospital’s attempt to overcome this type of clinical practice as informed by an “epistemology of care” based on feminist and anticolonial perspectives which are more patient-oriented.  This approach is used to present highly readable cases of student and faculty perspectives of a premier medical school and teaching hospital that was committed to social medicine and a more holistic approach to care and specifically prenatal and maternity care.  This approach is now offered in programs in family medicine common in advanced medical schools in most countries and similar in some respects to the approach advocated by the late Paul Farmer of Harvard.  

This discussion is followed by a thoughtful chapter on the Kangaroo Mother innovation for premature babies that was developed in the maternity hospital and has become a prevalent international model endorsed by UNICEF and WHO.   The least interesting chapter is one on religion which rightly shows the importance of Catholic nuns and clergy in the hospital but uncritically endorses anti-abortion dogma and endorses an unnecessary critique of the growing popularity of Protestantism in Latin America, while attributing a “miracle” recovery to the Virgin Mary.

There are other problems with the scholarship in the book. There is a selectivity problem in the ethnographic sections with many of the stories of individual members of the staff uncritically asserting their perspectives without also presenting other views that might contradict the presented themes of the narrative.  In addition, despite a plethora of useful endnotes, many important assertions in the text are not supported by evidence or citations of other literature.

Perhaps most disappointing is the failure to find a realistic alternative to the neoliberal approach that we attempted to implement in Colombia.  Given the many problems of the health system before the 1990’s reform and the inherent dysfunction of the government bureaucracies illustrated in the book, it is hard to think that a public monopoly national health system like that of the UK and other European countries, or even the Latin American partial public systems held up in this book as possible options, could have been implemented in Colombia in the 1990’s.   It is telling of the sectarianism that plagues neo-Marxists that the Latin American cases include Venezuela and Nicaragua (hardly paragons of good health policy) and not Cuba.

Overall, there seems to be a tendency to view the past of El Materno and of the public- dominated systems in other countries through rose-colored glasses, not recognizing the many problems and failures of that past and those systems.   Even Chile with a stronger bureaucracy and which had a system close to the NHS of UK before their neoliberal reforms, is only considering a single payer alternative to replace their competitive insurance companies but not one that removes competitive private providers from the system.

This book is a reminder of my younger days as an academic when I was a harsh critic of capitalism.  However, by the 1990s I had abandoned that perspective in order to participate in feasible ways to try to help improve the health of disadvantaged people rather than just criticize a system with little hope of making changes.  Although I remained (and still remain) skeptical of the theories of neoliberalism, I was open to trying to make feasible changes that might mitigate some of the problems of the current capitalist dominated systems.  Health in Ruins shows that some of the elements of the approach might have worked given the efforts of key individuals in the hospital, but they were stymied by bad political and management decisions outside of their control.  It was a conglomeration of many unique failures that led to tragic results. Even without the neo Marxist approach, many of us recognize the serious problems the reforms created and the need to seek realistic reforms to attempt to solve them. 

However, it should be recognized that most attempts to find how political, economic or even cultural aspects predict health outcomes have not been very successful.  It appears that the technical policy choices that have proven to improve health outcomes occur in many different political economic and cultural contexts.  An illustration of this is that the authoritarian regime of Augusto Pinochet in Chile was more effective in reducing infant mortality than any democratic regime before or after, because it chose to prioritize funding for an effective package primary care rather than in hospitals. 

There are several interesting more comprehensive evaluations of the Colombian health reform, which provide a more balanced assessment of the impacts of the reform, not a carefully selected single case to uncritically illustrate an ideology.  They show that despite some serious problems, even neoliberals recognize, the Colombian system is now more equitable and has better quality maternity services over all.