By Amparo Iraola, family doctor and oncologist

In a few days I will be a year old in my current job; a contract as an adjunct doctor of Oncology at the Valencian Institute of Oncology. The work journey to get here would give to write several texts, but ultimately the summary is that of the job options that were proposed to me in June 2019, it was the most stable.

And it was.

Giving up Public Health was an important ethical dilemma for me, which cost me several nights of sleep. Neither eat with the ideals nor pay the mortgage. But you sleep better with a clear conscience. Still, there was no color. The job options available on the table were accepting multiple summer replacement offers, some longer replacement offer with the flimsy promise of then trying to combine contracts to make a full workday (more than full, since they went from hours) to get a living wage.

Assuming that the patients are patients regardless of the management systems, with a work project and also a personal one that was more attractive to me in the end, I opted for the IVO.

A year and a pandemic later, I reach the month of June with a call to the Valencian Public Health job bank. At one time, it is supposed, due to a shortage of personnel, that I am still penalized in the stock market for having rejected precarious job offers. Precarious contracts continue to be offered, which today cannot even be considered patches, since the pandemic tsunami has been such that the way it has been tricked to keep health afloat until 2020 is no longer useful. It falls by its own weight.

In my department they have had the idea of ​​blocking summer contracts. Or that has transcended. The idea seems to be to offer longer contracts of six months, compared to chained fortnightly contracts or substitutions of a month and a half, two months or, at most, three that were offered until now, especially in the services that need it most. : Primary Care and Emergencies. Until now, each hospital, each service and each health center, looked for its substitutes. As a kind of “professional soccer league summer market”, but in seedy.

This year no.

Everything is centralized in the Ministry so that the Ministry decides what services to reinforce and where. Meanwhile, the other source of regular staffing supplies at this time, this is: the entry of new residents after the election of MIR positions, has been standing still waiting for how the election of these positions should be resolved. , whether online or in person. Because we can de-escalate to go en masse to the beach, cover the bars and discos and go to the shopping centers without problems, but we cannot organize face-to-face shifts to choose places for those who have spent more than a year studying like mad, have They did a hellish exam in which their professional future was played to a card and they were recruited as a “fifth bottle” to face COVID.

Let’s continue with the story.

Six months of work. It doesn’t seem like a bad thing. We make sure to have people in the summer (another thing is where and not taking into account the preferences of the contracted person) and to have them subject until the end of the year, anticipating the next peak or regrowth that, hopefully, we’ll see if we succeed this time, will occur in October .

And then what?

Looking at the Community of Madrid it is easy to deduce it: on the street. Among other things because these semi-annual contracts, “accumulations of tasks” of all the life of God, the law establishes that if they last beyond a year or a year and a half, they can no longer be considered a punctual reinforcement necessary to cover the needs of a certain period. If more than a year passes, that position is considered a necessary position and must become an interim position. Let’s be done! Impossible!. There is no money. Termination of the contract. And in a few months we will call you back. In the meantime “To the fridge”, euphemism invented to refer to unemployment that is used in some centers.

This is so for doctors, nurses, assistants and other health personnel.

There are other traps that the administration uses as well. At least in Medicine. They are the “continuous care” contracts. In short: guards contracts. They serve for Primary, Emergency and also for Hospital Care. And they can be done for days and months, skipping the legality of the job exchange, depending on the period for which you hire. What’s more, any medical specialist can be hired in this way, offering the contract for a category that does not need to be yours.

Let me explain: I, an oncologist, can be hired with a continuous care contract for hospital emergencies or for ward guards, but I will not work in emergencies nor will I make ward guards, instead I will work with a regular day in Oncology. Economically, the hours will be prorated to match the salary of my colleagues, but seniority, the score for the time worked in my category to compete, and many other similar details, will be worse or directly non-existent compared to those of my colleagues. In conclusion: you have several people working in the same way but hired in a different way and that, on the ground, very ethical (not to say legal) is not.

When we talk about job insecurity in Public Health, we refer to things like these

Every year Spain trains thousands of residents from multiple specialties in a training program that is one of the best things we have, the MIR system. The training of a specialist costs the State around 300,000 euros. None, I repeat, NO staff from any service of any public state hospital, could work if all residents went on strike. NONE. And this should not be so, since the resident should be a support (he is a doctor in training), but he cannot carry out (or legally assume) the tasks of an assistant. In recent years, due to the impossibility of hiring new attachments (which is equivalent to creating new positions or cheating as explained above), the services have managed to demand more places from residents. Residents who, once trained, go to unemployment, hiring in precarious or abroad.

Can anyone even imagine starting to rebuild anything with these working conditions?

The ninguneo

“Primary health care is essential health care accessible to all individuals and families in the community through means acceptable to them, with their full participation and at an affordable cost to the community and the country. It is the nucleus of the country’s health system and is an integral part of the general socioeconomic development of the community ”. WHO definition. Primary health care.

“Primary Health Care is part of the political, social and economic development of each country. The proper development of the health system needs the integration of the two essential sectors that comprise it: Primary Care and Hospital Care. A health system essentially focused on technological applications is not efficient in terms of population health ”. Armando Martín Zurro. Primary care. Concepts, organization and clinical practice.

The fundamental services in this pandemic have been largely forgotten for many years.

While the media spotlight was on the ICU respirators and beds available in every community, the battle, the real battle, was fought in the mud.

That is, in Primary Care.

Yes, that specialty considered a minor specialty or not even considered a specialty. Denounced, assaulted, ignored and beaten for decades.

Those comrades who have the sad record of being the lowest (dead, to understand us) they have had. If the hospital collapse has not been greater, it has been thanks to the colleagues in Primary Care. The same people who are now being asked to assume the role of trackers, in addition to the multiple functions that they have as a base, and who are attacked for having organized telematic assistance in the harsh weeks of the pandemic, because apparently the Coronavirus has a predilection for infecting hospitals, but it perfectly distinguishes health centers and it does not go to those centers (understand the irony of the comment).

Today these comrades are asked to again contain the masses who, once the fear is over, furiously demand that “theirs” be resumed, without distinguishing between whether theirs is the diagnosis of a constitutional syndrome that smells of something evil, or a minor operation, postponed for months on those phantom waiting lists that the autonomous communities refuse to provide to those who ask for them.

Without means, without enough personnel and with hospital colleagues who are supported by their management because they have to restructure the schedules to attend to patients in a safer way (in short, work in the evenings, with no expiration date in this new normality and at cost zero).

That is to say: squashed companions like ham and cheese in the center of the sandwich that makes up the population and the hospitals.

The forgotten. The none.

Also the essentials.

Without primary care, no health system is sustained.

Does anyone believe that we can rebuild anything if we do not reinforce the entrance doors to the system, the Primary Care, guarantor of ensuring stability in the chronicity of the patients and the health of the healthy?

The vulnerables

“Modernization has not degraded the elderly. He has played down the family. It has given people – young and old – a way to live with more freedom and control, including the freedom to be less indebted to other generations. The veneration of elders may have disappeared, but not because it has been replaced by the veneration of youth. It has been replaced by the veneration of the independent individual. (…) And then a new question arises: if we live to have independence, what do we do when it is no longer possible to maintain it? (…) “The consequence of a society facing the final phase of people’s life cycle through the procedure of trying not to think about it is that we end up having institutions that fulfill all kinds of tasks for society – from releasing hospital beds to remove a burden from families, or face poverty among the elderly – but never the task that matters most to the people who live in them: how to make life worthwhile when one is weak and fragile and already is not able to cope alone “

I recommend reading Ser Mortal by Atul Gawande, from which I have extracted the text with which this section starts. This book brings to the table a pressing problem in the United States. of the 90s: care for the elderly. Of all the elders. Dependents and non-dependents.

The pandemic has cruelly exposed the weaknesses and miseries of a care system that has been running for water since ancient times. Anyone who has made guards in Primary Care can tell various stories of patients

cared for in residences. Calls at so many at night, the distressed voice of an assistant who is alone in the care of too many beds and patients who arrive at the emergency doors in very sad conditions. And the difficulty of sending them back to what their homes are, due to the lack of adequate assistance and means (except in those cases of medical residences, which are not all far).

Seriously … What are we surprised now ?. This situation has been dramatic for years, with too many economic interests at stake and with something much worse as a basis: the separation to infinity of two facets that cannot be independent if we want to create a system that is cost-effective: social assistance and healthcare.

Assistance cannot be generalized because not all residents are the same, nor are they in the same conditions. Nor is the lack of it, for the same reasons. Ideally, in a situation such as that experienced, care should be tailored to each case, to each patient. And refer to a higher level of assistance according to the characteristics, expectations and needs of each one. It has undoubtedly been a time of extreme difficulty and of making dramatic decisions in extraordinarily stressful and difficult conditions. But a question does not stop running through my head … How much suffering could have been avoided if, with the same indication of not mobilizing the hospitals, the assistance of these patients had been reinforced in their homes, in their habitat, in this case , the residences ?.

We will never know.

The images of dozens of toilets come to mind waiting idly for someone to tell them what to do in the IFEMA waiting room. Lined up, by the way. Yes, Madrid has unfortunately been the visible tip of the Iceberg. But it is not just a problem in Madrid.

We have failed the weakest, the most fragile.

And with or without coronavirus, the problem of aging, dependency and the need for care will continue to “in crescendo” for years to come.

We must bet on policies that enhance community health, protect care and caregivers. And look for solutions to guarantee the assistance of the elderly, without collapsing the system.

As Rafael Bengoa says: “We have a wonderful opportunity to improve the health system. The integration of health and social services, or their close collaboration, will be essential in the future welfare model ”.

I would add more: it will be the only way out to maintain the welfare state. If we do not put this in our heads, we can already build twenty hospitals like IFEMA every month throughout the Spanish geography, which will be useless.

Can we even propose a reconstruction turning our backs on dependency and old age assistance?

He we”

Abandon the ‘I’ to practice the ‘we’. No one can know if at any time in his life, whether due to an economic setback or a health problem, he will be in a vulnerable situation.

Altruism should have a higher social consideration. On the other hand, those who with their actions and behaviors harm or harm the community should be penalized. We need to visualize exemplary accomplishments of social behavior. We lack references of solidarity and we have plenty of selfishness ». Albert Jovell. ‘The Social Doctor’

We were not even in phase 2 when on the way back from work home, the ten terraces (well, counted by eye) of bars and cafes that I found in my path were full of people with the mask placed in multiple and colorful places, but never in place. Every day news came out of big bottles made in different parts of the country. As we advanced in time, the irresponsibility of people was confirmed by having to close the capacity on the beaches for excess of people, Twitter echoed the stupid conspiranoic statements of a well-known singer more than the advice of scientists and emergencies were again filled with consultations that make the livers of those who have to take care of them bleed (foot blister, muscle strain months ago, sunburn, overwhelm by the mask and make me a report not to wear it, etc …).

They are just a few examples.

We happily relax assuming that the new normality is equivalent to saying that the danger has passed, that the virus has disappeared, that it is weakened and that we can return to life as we had before at zero cost, understanding by zero cost not to assume any of the indications given to us.

The authorities have missed a unique opportunity to do a little health pedagogy. For years many of us have claimed to create something similar to health education or health education. Among other things, for example, to take care of ourselves so as not to get sick or delay the appearance of the most prevalent diseases, in our environment, cardiovascular diseases.


And today, in this situation that we currently live in, I think: with the fear in our bodies that got into us at the beginning of the pandemic, in addition to leaving the clear message of not collapsing hospitals, could we not have taken the opportunity to, in the style of that mythical television program It is better to prevent, to emphasize the idea that maintaining health is everyone’s responsibility and that the way to do it is by maintaining habits that last, whether or not there is a pandemic. And by the way (to ask that it not remain), educate in the use of resources beyond the real problem of saturation of the ICUs with COVID, to achieve the sustainability of the system in the long term.

It does not seem very politically correct to appeal to individual responsibility in these times. And less if what you are trying to do is protect collective health. A few days ago, a friend jokingly called me “Bolivarian” for asking her about this. But we are not going to be able to get out of this pandemic if we do not begin to take individual responsibility for what we have in our hands to save ourselves all.

There will be no sanitary exit, but neither will it be economic.

As it says Beatriz Gonzalez López-Valcarcel in this presentation in front of the forum for the social and economic reconstruction of the Congress that I advise not only to listen, but to memorize from beginning to end, This is the first time that healthcare has been invoked to save the economy.

And what’s more … Maybe for the moment the situation in our country is contained, but in this globalized world, it’s going to give a bit the same to contain the pandemic at one point if the rest of the world continues to be infected. Either we help the least favored countries contain the pandemic, or we will have a pandemic until the day of the final judgment.

Can we think of rebuilding anything if, as the great Albert Jovell said, we are not ready to “abandon the self to build the we”?

Let’s rebuild

“Fate weighs on our generation. That is our historical responsibility (…) Who can guide us today? (…) We cannot forget that in these old times already spent on their values, there are those who believe in nothing, but there are also multitudes of human beings who work and are still waiting as sentinels … Yes, instead of feeding the broths of the despair and anguish, we turned passionate, revealing an enthusiasm for the new that expresses the confidence that man can have in life itself !. Stop walling off, long for a human world and be on your way. ” Ernesto Sábato. ‘The resistance’.

There is so much, so much to do! The work is so enormous and we are so tired that we see the mountain and, within days, we despair.

What if it was just the mountain! .

Added to the mountain are the politicians, their war of accusations, their throwing balls out, their irresponsibility with the future and a long etcetera.

Much to do and many stones along the way.


I want, rather I need, to think that we are also facing a unique opportunity. The opportunity to rearm the system once we have seen the failures that we were dragging and that the pandemic has exposed. Once the masks and masks were removed in front of society and the clappers who sold us that of the “best health in the world and such” and aware (I also want to believe, I also need to believe) society

that there are things that cannot be played with, such as health, health care and those who help us when we lose it.

We are very tired and discouraged. But I don’t think anybody wants to lose the spirit that started us in these past months.

That spirit of collaboration, of teamwork, of piecework against adversity.

As i said Big Fani in his post Applause and Broncas, if all the health workers in this country have been able to park our respective specialties and fold ourselves to a new one: The Coronavirus Specialty, each forgetting about ‘his or her own’ to do ‘ours’, what less than asking society and its highest representatives in Congress a little collaboration to do exactly the same.

Out of respect for the memory of those who have left. Out of respect for those who have fallen ill and those infected. For you. For me. For us. For those who come behind.

And for the future.

Paco Blasco, the day he was released | Amparo Iraola

Keith Jarret can transport me to states of deep melancholy and reflection, and to places that are just the opposite. Like this ‘In Your Quiet Place‘, Who says something like:” Come on, don’t complain so much !. Roll up your sleeves again, get out there and fight, there is still a lot to do ”. There can be no better final pairing for this text …