Trying to save a health care system: Colombian residents go on strike.

Go on Strike It was mid morning on Tuesday, October 29. We had just finished rounds at the Hospital Universitario del Valle (HUV) in Cali, Colombia. To my surprise, the resident, Diego, turned to me and said, “I have to go now— the strike is beginning.” He grabbed a rolled-up hand-painted banner and, along with nearly every resident in the hospital, headed out to the street. At the same moment, thousands of residents all over Colombia, from Cali to Bogotá to Medellı́n, stepped away from morning rounds to begin a nationwide strike. Unlike many resident strikes that have happened globally, this strike was not in protest of poor working conditions. Instead, the residents were protesting Colombia’s new health care legislation, which meant to privatize the management of the country’s public health care system. If enacted, it could restrict access to diagnostics, treatment, and funding for medical education at public institutions. In response to the proposed law, the Asociación Nacional de Internos y Residentes called for a strike. The evening news showed throngs of doctors in scrubs and white coats marching down main boulevards and gathering in major plazas around the country, demanding that the legislation be revoked. They sang songs and carried huge banners shaped like white coats and signs declaring, “Health is not everything, but without it, everything else is nothing.” The strike was not sudden. The debate about the proposed legislation had been building for some time. As the law neared final approval, those who opposed it organized. At HUV, the largest public tertiary care center and teaching hospital in the region, the preparations were visible. Legions of all types of hospital employees wore matching T-shirts declaring in Spanish, “I am the hospital.” They hung banners and posters opposing third-party management of the hospital. One poster showed a cartoon skeleton visiting a doctor and being denied treatment. A few days before the strike began, a rally took place inside the lobby of the hospital itself. The shouting could be heard from many floors above. The new law intended to privatize the government’s public health care system overseer, Entidades Promotoras de Salud, in an effort to keep health care costs down and public hospitals open. However, doctors and patients feared that the overseer would restrict access to life-saving diagnostics and therapies. Although the country’s public hospitals are tertiary care centers of academic excellence and residency training, their resources are severely limited. They serve the poorest patients in the country, those who cannot afford to buy private insurance. These limited resources also restrict the salaries of faculty and specialists at public hospitals. Most earn a pittance working part-time teaching and attending to patients at these hospitals and spend the rest of their professional time at profitable private institutions. Residents, who must pay to do a residency, have felt the effects of these compromises on their education. A few days after the walkout, I texted Diego to find out whether he would be returning to work. He replied in English, “We don’t have work ‘cause we are in strike.” Despite his absence, I walked over to the hospital to assess the situation. The changes in the hospital were striking. Inpatient wards were half-empty, with a small group of supportive attendings agreeing to care for the remaining patients while the residents were away. The one attending on the women’s ward, Dr. D, sat at a nearly abandoned workstation with a tall pile of patient charts to one side and a line of nurses on the other, collecting his written orders. He barely had time to look up from his rapid scrawling of notes to speak with me. Many other attendings went along with the strike, making elective procedures and consults essentially unavailable. Wards in the ED were overcrowded, with a backlog of admitted patients waiting for beds. I saw a 19-year-old man in the ED with a seemingly straightforward asthma exacerbation on the first day of the strike still sitting on the same stretcher in the same location 3 days later. He recognized me and beckoned me over. “How are you?” I asked. “I’m not getting any better,” he declared, looking slightly winded through his nonrebreather mask. “How is the strike?” I could tell him only that I didn’t know because I was struggling to understand it myself. In the next room sat a woman with swollen legs who had heart failure with a ruptured mitral chorda tendinea. Under normal circumstances, she would have had her heart surgery several days ago, but she still waited to be seen by a cardiothoracic surgeon. When I asked the ED attendings about it, they shrugged sadly. With Dr. D working solo on the medicine ward and the residents gone, I was unsure of my role. To me, it was clear that patients were suffering. Even my home cleaning lady declared, “People are dying at the hospital!” How could I allow that? Would I seem like a scab if I helped out? As a guest in Colombia, I was not sure whether the debate was my struggle to fight. Yet, I was being hosted and supported by the very residents who chose to take up the cause. They remained adamant that the results of their actions would justify the means and that the few Annals of Internal Medicine On Being a Doctor