Friends of Labournet.tv filmed a short interview with a striking hospital worker from Leipzig, which you can watch with English subtitles <a href="https://en.labournet.tv/strike-university-hospital-leipzig-2023">here</a>.
Frauke is a nurse at the university hospital in Leipzig, Germany. She talks about what has happened during the strike in 2023 and about how the strike gave her hope. The hospital workers were able to enforce a reduction of working time from 40 to 38.5 hours and a wage increase between 9 and 16%.
After the strike, Frauke and her colleagues founded a hospital workers&#8217; group. They are preparing themselves to enforce a collective relief agreement for better staffing levels.
We have featured articles that look more critically at the relief agreements and the strikes around them, you can read them <a href="https://www.vitalsignsmag.org/posts/current-and-past-hospital-movements-in-germany-conversation-with-a-friend-and-fellow-worker">here </a>and <a href="https://www.vitalsignsmag.org/posts/strikes-have-to-be-able-to-emancipate-what-are-the-results-of-the-berlin-health-workers-strikes-of-2021">here</a>.
The video was created as part of the workshop series &#8220;How to labournet.tv?&#8221;.

Film – Strike at the university hospital in Leipzig

We spoke to fellow health workers in Sao Paulo about their initiative to defend public access to health services and good conditions for workers and patients. You can follow the activities of Viva SUS on Instagram: vivasus_
We are a health workers group from Sao Paulo, most of us working in mental health care. We started our group in 2022. Sao Paolo is a large city, we already had a group of health workers in the northern part of the city, which formed around a so-called ‘health reform’ introduced by the local health secretary. This legal reform for the Sao Paulo area obliged us to adhere to fixed productivity rates. The law was a kind of prototype or model that might also be applied in other regions in the future. Before the law, consultations should be no longer than 20 minutes. The reform further reduced this to 15 minutes, so four patients an hour. This means we have even less time to understand what our patient’s life is like, beyond the symptom, e.g. what their daily routine is like, what their social relationships are like, what kind of food they have access to. We organised a bigger meeting to discuss the reform and around 100 workers attended. From this initial meeting smaller local groups formed. 
The public health system
There are some particularities regarding the health system of Brazil. The public health system, called SUS, was established with the national constitution of 1988, after the end of the military dictatorship. During the struggle against the dictatorship in the 1980s many independent health initiatives developed in industrial and working class areas. In 1988 these initiatives were institutionalised in the SUS. But actually, this health system was never really implemented nationally, its implementation depends on municipal or city laws. We have three governmental levels in Brazil: cities, states and federal government. In Sao Paulo, Brazil’s largest city, the SUS is actually not public, it is primarily run by so-called ‘non-profit’ or third-party organisations that get a lot of money. These third-party organisations have been set up by private corporations to get contracts from the public health system. Other organisations were initially set up by medical professional associations and the university of medicine, but they also have turned into important private players. This process of privatisation is also supported by the Lula government. Another aspect is that if you use services of the SUS with a private health insurance cover, which only richer people have, the money that is paid for the treatment by the insurance is supposed to stay within the SUS. But actually, all this money goes into the pockets of the third-party organisations. The Lula government now says that if you don’t pay the insurance money into the public system, then at least provide additional services, such as examinations or surgeries. We fear that this is an even more obvious form of privatisation than the establishment of the third-party organisations themselves. 
The outsourced sector
In our area there are four or five major organisations and they employ more than 80% of all health workers. Only a few public hospitals are left that are owned by the city. These are the only workplaces where the unions are still present, but due to their minoritarian position within the wider health sector they have lost influence. They continue their symbolic protests or appeals to the law makers, but this type of struggle doesn’t work anymore. In contrast, nearly all primary health care in Sao Paulo is run through third-party organisations. We have more than 600 primary health care units in Sao Paulo alone. These organisations have become majoritarian in the health system from about 2012. From 2012 onwards vacancies for civil servants in the local public health care administration have not been filled anymore. This means that there is no municipal public body that would organise or plan local public health. All this is left to these allegedly non-profit organisations in collaboration with the governing political parties. They control the health system. This opens the door for the intensification of corruption. In terms of numbers, the largest of these organisations in Sao Paulo is paid nearly 1 billion USD every year. The disastrous state management during the COVID pandemic demonstrated to which extent public administration and the integration of health services had been undermined by this process. Health workers don’t see themselves as public sector workers anymore, but as employees of individual corporations. Or they see themselves and fight only as an individual profession, like the doctors. This makes it more difficult to create a unity, also because the labour contracts with the organizations are precarious and workers can be fired relatively easily, as they are not covered by the CLT (Consolidated Labour Laws).
The current &#8216;productivity reform&#8217;
The recent law concerning productivity targets created a lot of anger amongst health workers, but it was difficult to turn that anger into organised resistance. On paper the SUS gives workers and the wider population a lot of rights of participating in the decision making process, but in reality these rights don’t exist. The mayor and the owners of the organisations decide. The reform doesn’t specify any ‘positive’ parameters, for example, the reduction of child mortality or the reduction of certain illnesses in the area &#8211; they just create productivity parameters for each category of treatment. Time is allocated only for direct treatments, not, for example, for conversations within your team how to organise and improve care. The logic is not anymore one of prevention of disease, but of productivity management. There is no logic of universal free health care anymore, but a business logic. There are no parameters for the organisations or the governing bodies themselves, e.g. you have to provide x number of doctors for a population of size y. The parameters of the reform just target the workers. All governments support this attack, the right wing government in Sao Paulo city, but also the left wing government of the federal system.
The resistance
At the beginning, at the first meetings to discuss the new laws, there were many workers and patients. The majority of workers are from these multi professional teams like physiotherapist psychologists, occupational therapists, some are doctors. Initially we were very much focussed on addressing the institutions, e.g. we organised a meeting with the mayor about the new law. We wrote a lot of letters. All this was not effective and it was very frustrating for us. We referred to legal rights, but nothing happens if we don&#8217;t have political power to implement or enforce them. People who referred to their constitutional rights were actually fired. So then we started to turn around and look for another way of acting. We put the word out on social media, and we start to go to areas where there are other forms of movements, struggles or initiatives happening, mainly in the neighbourhoods. For example, we linked up with an initiative to defend access to a local accident and emergency department that was threatened with closure. We went on protest marches with them and joined meetings primarily with local women and children. We are also in touch with other independent groups that focus on workers’ struggles in other sectors, for example in public transport and education. These public services are also affected by the proliferation of these third-sector organisations, as a means of privatisation. The unions there are still stronger than in the health sector. We organised two wider assemblies for workers and the local population, where we talked about the logic of public health and the current attack on it. We explained our idea that everyone should be hired by the municipality directly. We are still at the beginning of our struggle, we haven’t built the power yet, for a strike for example. 
There was a public health workers strike in Rio de Janeiro recently, but it happened because the city wasn&#8217;t paying them. It was a defensive struggle, it was not about the logic of our work. So we are getting paid. In Campinas, the mental health workers went on strike, too, after the local government wanted to shift work from a cooperative to a private business. It was a powerful movement because it wasn&#8217;t just about nonpayment of wages. It was a struggle to maintain the logic of public health. In Sao Paulo, we don&#8217;t have this kind of power and union between workers yet. We are still building that power. We are producing a magazine that promotes self-organization and self-defense. We spread them in health clinics. We propose that workers make public the situation they are facing. People are angry, but they don’t believe that they can change something. That’s why we organise assemblies. We also go to universities and speak to medical students there, mainly psychology and physiotherapy students.
Historically the best organised group of patients in terms of resistance are mental health patients. Like in many other countries they organised struggles 50 years ago against the conditions in mental asylums, which were like prisons, and for the implementation of a public health system in the community. This was similar to the anti-psychiatric movement in Italy. Another group that organised recent protests are mothers of children with autism. They advocate for specific care for their children. Then there are movements from the LGBT community for better HIV treatment and by women groups for better access to abortion services. There are many struggles on the level of neighbourhoods for better local health provisions, which question the so-called third-party organisations. One of the big issues are lack of appointments and long waiting times. This is devastating for us as workers, too. At the end of the day, you decide who will have access to healthcare today and who will not, who will have to go home without treatment and continue living a half life. 
We are preparing for our third independent workers’ assembly and the launch of our magazine. We talk about taking back the SUS, but throughout our reflections we have concluded that it was never really ours. Perhaps we have to raise awareness, to equip ourselves, to collectivise, to organise in order to transform the system and propose access to healthcare that makes sense for society in general.
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Viva SUS! – Struggle and self-organisation of health workers in Sao Paulo

Conversation with a striking nurse from New York

The figure of the doctor has been an awkward one. In a market society, the privilege and alienation of years of specialised training produces a certain monopoly that allows doctors to climb up the social ladder. In some cases the social ladder consists in managerial functions, e.g.  within the hospital hierarchy, in other cases it expresses itself in becoming a small employer, e.g. as co-owners of clinics or medical enterprises. When pushed by revolutionary working class movements, many doctors sided with the old regime, while others became ardent allies of the cause. You can find more thoughts on the figure of the doctor in <a href="https://www.vitalsignsmag.org/posts/what-is-a-doctor-a-book-review">this book review</a>. 
In this sense the material class position of doctors is often arbitrary, which makes the struggle around political positions even more important. One association that takes this political struggle seriously is the<a href="https://www.vdaeae.de/"> Vdää* &#8211; Verein Demokratischer Aerzt*innen</a> (Association of Democratic Doctors) from Germany. Although new organisations, such as MedAct, have recently emerged, there is no real equivalent in the UK. We therefore spoke to some members of the association and summarised its history and development.
The association recently released a substantial booklet about the threat of militarisation of the health sector. We have previously<a href="https://www.vitalsignsmag.org/posts/interview-the-militarisation-of-the-health-sector"> translated an article by one of their members</a> on the issue. The association is a progressive force amongst the professional group of doctors, who, at least in Germany, tend to be both conservative and more interested in private business opportunities.
The current organisation
Currently Vdää has 900 members, out of a total of about 350,000 registered doctors in Germany. The organisation has local chapters and it works closely with organisations of critical medical students, amongst other towns in<a href="https://berlin.kritmed.de/"> Berlin</a> and<a href="https://krit-med.uni-koeln.de/"> Cologne</a>. Similar to many groups, the problem is to maintain momentum after people leave university, as work and family obligations take up a lot of capacity. The Vdää has a steering committee of 40 people. Despite the fact that also in Germany there are many international doctors employed in the health system, most members of the Vdää are ‘local’ doctors. Many international doctors come to Germany primarily for educational purposes, an exception are doctors from Syria, but they tend to be sent into small towns where most of the doctors don’t wants to work.
The origins 
The association Vdää was founded in November 1986 in Frankfurt, at a meeting of around 150 doctors who wanted to form a left slate in the election of the official and conservative doctors&#8217; associations, the doctors chambers of the federal states (Landesärztekammern) and the Deutsche Ärztetage. The criticism of the traditional doctors’ association was that they were too closely involved with the right-wing parties, the Ministry of Defence and with both the pharmaceutical and medical equipment industry. The internal structure of the official doctors associations was deemed as undemocratic and it never dealt with the problematic role that doctors’ associations played during the Nazi regime. The Vdää* saw itself close to the historic &#8216;Association of Socialist Doctors&#8217; of the Weimar Republic, but due to the contemporary Cold War witch hunts avoided the term socialism. At the time even the trade unions were dominated by anti-communist social democrats. Nevertheless, the association’s understanding of &#8216;democracy&#8217; referred to a process of social and economic democratisation which goes beyond parliamentary democracy.
A critique of capitalist damage to health
In the 1980s the association took up the work of ‘sociology of health’, meaning, they looked into the day-to-day and class-specific reasons why people become ill. These debates were led openly on the so-called ‘Gesundheitstage’ (health convention), which attracted thousands of people and were an alternative to the official Ärztetage. The debate evolved around the contemporary issues of smog and the risks of nuclear power, in particular after the accident in Chernobyl. They helped coining the term Umweltmedizin (‘environmental medicine’), which tried to analyse the connection between illness and industrial pollution. They also participated in the critique of research into genetic modification. They organised a campaign for the boycott of the pharmaceutical companies Sandoz and Ciba Geigy after the disastrous pollution of the river Rhein following an industrial accident in November 1986. They put a focus on the question of women’s health and reproductive rights.
International solidarity
The association works with other progressive doctors’ associations around the globe. In the 1980s they supported doctors’ associations in South Africa (National Medical and Dental Association &#8211; NAMDA) that struggled against the Apartheid system and called for an exclusion of racist official medical associations. More recently they participated in health conferences in Greece that discussed the impact of EU-enforced austerity measures on the local health system. 
Doctors of today
Early on, Vdää spoke for a general system of primary care for all, which would employ doctors as wage workers, rather than the predominant system of GP surgeries that are run as small enterprises. They notice that currently, most medical students would rather be employed than becoming small entrepreneurs, which is a shift from the traditional aspirations of doctors in Germany. They also see more support by doctors for strikes of other hospital workers, at least in symbolic terms. This has become an apparent change <a href="https://www.vitalsignsmag.org/posts/strikes-have-to-be-able-to-emancipate-what-are-the-results-of-the-berlin-health-workers-strikes-of-2021">since the 2015 struggle at the Charité in Berlin</a>, Europe’s biggest university hospital. This shift might also be due to the fact that doctors, too, became victims of the &#8216;flat rate per case&#8217; hospital DRG system. Politicians and hospital managers had  tried to integrate doctors in the management of the DRG system, which was successful for some. But most of the hospital doctors were becoming disillusioned with the system. Currently they see that due to a lack of workforce it becomes possible that doctors change jobs more often and there are more opportunities for further education. Overall though, research and scientific work are still very disjointed, there is less &#8216;practical research&#8217; work done by doctors themselves, compared to some decades ago. Research happens more and more within medical industries (‘lab science’). 
Resistance against reforms and austerity measures
The association criticises the stark division between hospital and community care and the dominance by pharma and tech-companies. In Germany, we see payments for individual treatments on one side (individualisation) and the power of health insurances on the other (bureaucracy), there seems to be no space for alternatives. Currently, there are experiments with cooperatively managed polyclinics in Berlin, Hamburg and Frankfurt which Vdää members are involved with. The organisation also criticises the current structure of doctors’ training, with an unfruitful separation of theoretical and practical elements. There is not enough patient engagement and engagement with their social conditions. The association has published a thorough analysis and critique of the &#8216;flat-rate per case system&#8217; / DRG system and of the wider health reform. They talk about the difficulties to agree on a common position, for example about the state lock-down strategy during Covid, which the association might perhaps have supported too uncritically. They are part of the alliance &#8216;Krankenhaus statt Fabrik&#8217;, which support local disputes of health workers.

Film – Strike at the university hospital in Leipzig

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