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ORIGINAL CONTRIBUTIONS

Received: December 9^th 2014

Accepted: March 5^th 2015

Historical and social perspective from the 64-65 Mexican Medical Movement

Alejandro Cabello-López,^a Rodrigo Gopar-Nieto,^b Guadalupe Aguilar-Madrid,^a Cuauhtémoc Arturo Juárez-Pérez,^a Luis Cuauhtémoc Haro-García^a

^aUnidad de Investigación de Salud en el Trabajo, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social

^bServicio de Medicina Interna, Hospital Regional “Lic. Adolfo López Mateos”, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado

Distrito Federal, México

Communication with: Guadalupe Aguilar-Madrid

Telephone: (55) 5761 0725

Email: gpeaguilarm@gmail.com

The Mexican Medical Movement from 1964-1965 constitutes an important event from the rising urban middle-class, besides it was the first time medical doctors claimed for fair working conditions. The background of this movement is the so-called Crisis of 1958, which included the Movements from the educators union, oil workers union, telegraph workers union and the railroad workers union. The conflict began because interns and residents from the “Hospital 20 de Noviembre” would not get a payment at the end of the year, so on November 26th, 1964, the movement started. The Asociación Mexicana de Médicos Residentes e Internos (AMMRI) was created and their demands were the following: 1) Full working site restitution without retaliations, 2) Legal examination of the scholarship-contract terms, in order to get annual, renewable and progressive contracts, and a fixed salary with the usual working-hours and characteristics of each institution, 3) To have preference to get an adscription at the hospital where the resident studied, 4) Active participation from the resident in the elaboration of the academic plans, and 5) Resolution of each hospital’s problems. This movement had social impact for Mexico’s contemporary life, nevertheless some of the demands are still unchanged among medical residents.

Keywords: Mexico; History of medicine; Government

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2014 marked the 50th anniversary of the appearance of the medical movement 1964-1965, one of the most representative of the modernity of post-revolutionary Mexico, and although this labor dispute was not the first for public workers in the country,¹ the movement constituted an essential part of the confluence which occurred in 1965, which was marked by three simultaneous processes: the attempt to reform Article 59 of the Constitution which sought to establish the continuous re-election of deputies, the democracy movement within the Partido Revolucionario Institucional (PRI) by Carlos Madrazo, and the emergence of the guerrilla movement in Ciudad Madera in Chihuahua.²

On the other hand, the setting of this urban movement also started in the crisis of 1958, delineated by the mobilization of four state labor sectors: the Magisterio, the Sindicato de Trabajadores Petroleros, the Alianza de Telegrafistas, and the Sindicato de Trabajadores Ferrocarrileros, which generated 740 strikes,^3,4 and which coincided in their struggle against the regime of the time, proclaiming revolutionary values ​​and achievements but giving no solution to the social problems of the emerging bureaucracy, such as wage increases, the granting of social benefits, and the lack of identification of the unions with the interests of their workers.3 The pressure exerted by workers forced a change in labor policy, promoting the expansion of social security benefits to the population, and consolidating the Mexican government as the main source of medical care and social security.^4,5

As a result of the above facts, on December 7, 1959, by proposal of President Adolfo Lopez Mateos, the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) was officially founded, to provide medical care to public employees and academic and administrative staff of educational institutions.5,6 Starting January 1, 1960, when the Diario Oficial de la Federación announced the creation of ISSSTE, the merger and reorganization of public services for state workers began.^3,6 The first was education, which already had infrastructure, which was added to the new institution. By 1965, the ISSSTE, located mainly in the Federal District, had 366 419 beneficiaries, 27 hospitals and clinics and 4128 doctors. Meanwhile, the Instituto Mexicano del Seguro Social (IMSS), which came into function in 1944 had 6,815,685 beneficiaries, 27 hospitals, and 7894 doctors around the country.³

Economic, academic and medical-social context of post-revolutionary Mexico

During the "Mexican economic miracle" (in the 1940s and 1950s) the gross domestic product grew at a rate of 5.8% per year during the first decade and 6.3% in the second, stimulating urban development, reaching the highest rate of urbanization of the twentieth century between 1940 and 1950: 3.3%. Additionally, the increase of the urban population by 3.3 million inhabitants accounted for 53.5% of the total growth, and for the first time in Mexico, the population was predominantly urban, which meant an increase in demand for medical care and services to respond to this urban growth.^7,8

Thanks to the liquidity provided by the oil boom, the health care services of IMSS and ISSSTE grew significantly: big hospitals like the Centro Médico Nacional and the Hospital La Raza in Mexico City were built, and services for their members and their families expanded, addressing culture, recreation, and athletics.5 Public policies in health at that time focused mainly on the prevention of infectious diseases and attention to children.^6,9

Against this backdrop of apparent prosperity and in accordance with the presidential reports of Adolfo Lopez Mateos and his successor, Gustavo Diaz Ordaz, there was a major expansion in health infrastructure, with the creation of hospitals and health centers in urban areas, but also efforts directed towards the rural population, which in those years was the majority of the Mexican population. Moreover, smallpox, malaria, typhoid, yellow fever and vitiligo were fought by vaccination and eradication of disease vectors.^6,9

Despite this progress framework, expanding coverage in health care created a quantitative mismatch that could not meet the demand for doctors in the health care system.⁴ Admission to the Faculty of Medicine of the Universidad Nacional Autónoma de México (UNAM) remained constant during the period 1959-1967, and only two medical schools were created,⁴ so that the supply of medical graduates could not to cover the demand for care due to the unprecedented expansion of the health care system. This slow increase in physicians was offset by the work of undergraduate interns and residents, as well as the expansion of medical internship to one year in 1962. In addition to this, the welfare requirements were covered by current spending, including doctors’ salaries.⁴

Nevertheless, thanks to sustained economic growth during the years following World War II, cities became important centers for professional and economic development. The emerging urban middle classes had characteristics very different from that of the society that emerged from the Mexican Revolution, which had been characterized mostly by the military, agricultural, and labor sectors. This class was identified with Western democratic values, had access to national and international media, and possessed university academic preparation. These attributes, combined with the social and political determinants mentioned above, favored the emergence of a labor complaint by Mexican physicians in 1964.

Development of the medical movement 1964-1965

The beginning of the conflict was because residents and interns at the ISSSTE facility Hospital 20 de Noviembre based in Mexico City were not to receive the three months' salary that had been given as a bonus over the last three years, so on November 26, 1964 they began a work stoppage. Claims had resonance among the Juarez, Colonia, San Fernando and General de Mexico hospitals. The protesters formed the Asociación Mexicana de Médicos Residentes e Internos (AMMRI), independent of any labor organization, whose collective demands,3 were: 1) Dismissed doctors to be returned to their posts without retaliation of any kind; 2) Legal review and change of the terms and clauses of the contract- scholarship signed by doctors before entering upon their duties, in order to achieve annual work contracts, renewable and progressive in the ranks of residences, besides determining base salaries; 3) Preference for doctors’ positions to be given to resident graduates of the institutions; 4) Active participation of residents in the preparation of curricula; 5) satisfactory resolution of the problems of each hospital.^1,3

Starting November 26, 1964, several hospitals reduced their operating capacity, so the directors were forced to negotiate sometimes and threaten other times. On 18 December the same year, after dialogue with the authorities and having confidence that they would fulfill the aforementioned demands, it was decided to end the strike. Despite this, the promises were fulfilled partially and unevenly by the institutions, so that on January 13, 1965 another stoppage began.^3,10

It should be noted that the organization of the movement was closely followed by the General Directorate of Security; this is proven by is recently declassified reports,¹¹ including disclosing that meetings were attended by 100-200 physicians, and that these were conducted in hospitals and classrooms with the leaders present. In one of these reports we read how the ISSSTE Director General himself, Romulo Sanchez Mireles, went to one in the Hospital 20 de Noviembre for talks with members of the movement,¹¹ although the policy of the Diaz Ordaz government dictated not personally addressing problems that arise for any reason, but rather subordinating the response capacity of the relevant bureaucratic bodies; though in some cases, driven by social pressure, he met personally with leaders, he largely left it in the hands of the directors of the various hospitals to resolve the conflict.

This little contact with the strikers and their leaders, his limited knowledge of the causes of the movement, based only on information from third parties, accompanied by his lack of sensibility for solution and direct participation in the conflict, and his policy of subordination of functions, generated greater problems.^1,3,11

On January 15, 1965, the authorities of the Distrito Federal reported that they would raise proceedings of abandonment of office against the fellows who were serving in emergency hospitals and had not shown up for work in recent days. In addition, official trade unions and various government officials initiated a media attack against the movement, declaring the demands disproportionate and the motives of the movement distorted by external interference.³

This outright repression against the residents and interns awakened solidarity of the medical societies of the hospitals belonging to the social security institutions. Nurses from various hospitals openly showed their support for the demands of young doctors.^1,3,10 On January 16, when authorities ordered the firing of the doctors who were on strike, the hospital director of Huipulco (now known as the Instituto Nacional de Enfermedades Respiratorias), Dr. Ismael Cosio Villegas, presented his resignation to the Technical Advisory Council of the hospital, because he refused to dismiss the striking doctors within his jurisdiction, and he publicly expressed sympathy for the movement.^1,3 Dr. Cosio Villegas said: "I am disappointed by the things that happen in Mexican medicine, but I accept that perhaps many were disappointed in me"¹² This individual firmly believed that the conditions of physicians in training could be improved through public complaints. However, several people showed disagreement with the position taken by Dr. Cosio, as he held a position of prestige as an academic authority and probably could have brought claims through institutional channels of protest and not just symbolically, as happened with Carlos Madrazo.^2,12  Although the events occurred fundamentally in Mexico City, the movement succeeded in uniting medical residents and interns across the country about their demands. Moreover, after meeting with the Director de la Facultad de Medicina of the UNAM, Dr. Donato Alarcon, young doctors got sympathy from the students, who supported the proposals and even got to hold public demonstrations with members of the AMMRI.^3,11

In addition to this, the Sociedad Médica del Hospital General de México appointed a committee to draft a declaration of principles for medical societies to invite the country to form a national health alliance, which was established on January 19 under the name Alianza de Médicos Mexicanos (AMM). This organization supported AMMRI’s demands and their decision to continue the stoppage.^3,10

Given all these facts the federal government promised solutions, and after a direct meeting with President Diaz Ordaz, members of the AMM were satisfied with such promises. As a result, before a statement of approval from the AMMRI, on January 30 the young doctors returned to their work.^3,10

During the months of February and April 1965 a greater number of members joined the AMM, consisting mostly of staff doctors 10 because despite the fact that on February 18, 1965 President Diaz Ordaz announced a decree that would solve the economic and labor problems of the doctors, the AMMRI denounced the lack of implementation of the decree in hospitals. The list of demands was expanded to request an independent civil organization and non-membership by physicians to collective unions, in addition to replacing the contract-scholarship with individual contracts.^1,3,10 The members of the movement promoted a third strike on April 20 of that year, as they felt that the points of the presidential agreement were not put into practice by certain members of the ruling coalition, although residents and interns in the hospitals of Cardiology, Nutrition and Huipulco did not sympathize with the new strike called by the AMMRI, arguing that they "had resolved all their demands." In this context, on April 24, the AMM was legally constituted, and the decision was legally supported in a study by the lawyer Mario de la Cueva.³

Before this situation, the federal government issued a statement in which they warned the striking doctors that failing to report to work on May 17, they would be fired.^1,3 At the end of this period, authorities charged against doctors: they ceased conversations, opened vacancies to replace the strikers, raised charges of dereliction of duty, and even came to physical aggression by workers of the Servicio de Limpia y Transporte of DF in a series of public demonstrations that took place from May 18-26.^3,10 This caused dissent by some of the doctors on strike, which marked the beginning of the disintegration of the movement.

The June 3, 1965, 4900 doctors belonging to AMMRI returned to work. On June 25 a new meeting was held with the then President of the Republic and, as a result of this, on July 9 of that year a decree was announced to perform tabulations for medical graduates and graduates who provide their services to the government. However, 80% of doctors in the service of the state had no position, so they were not covered by this agreement. Thus, on July 25, 1965 the AMM proposed presenting a mass resignation, with divided opinions among members of the alliance.^1,3,10

Between July and August of that year protests erupted across the country and the repression was more severe.10 On August 26 police forces evicted resident doctors and interns from Hospital de 20 Noviembre.³ On September 1, the President declared "... Since steps are being taken in relation to the various crimes that are possibly being committed and that fundamentally could be injuries and even murder by omission, criminal association, collusion by officials, job abandonment, neglect of persons, personal resistance, poor service delivery, professional liability and entrapment ... "9 Faced with these threats, on September 5 the alliance decided to end a strike that had begun fourteen days prior. However, on returning to work on September 7, doctors were victims of retaliation by the hospital authorities. Following this last strike, the orthopedic surgery hospitals at La Villa, Xoco and Balbuena, based in Mexico City, were closed, and more than 500 medical residents and interns were dismissed, and arrest warrants brought against 60 of them.³

On return to their hospitals, young doctors found the same situation that had given rise to the conflict: they were forced to sign a contract-scholarship, lacking all kinds of benefits and job security. In addition, three of the leaders were persecuted: Norberto Trevino, Jose Castro Villagrana and Faustino Perez Tinajero, who were forced to emigrate from the country.³

Discussion

The Mexican medical movement stands as perhaps the first awakening of modern Mexican society, emerging from the rising urban middle classes who aspired to social recognition and professional status within the working class and thus marked an unprecedented story in the life of post-revolutionary Mexico, in which the representation of the state, a provider of labor rights and constitutional freedoms, was identified with the struggles emanating from the workers, peasants, and popular classes that emerged from the armed Mexican Revolution.

This brand emerged from the paternalistic social policies pursued by General Lazaro Cardenas del Rio, who, in his quest to represent the demands of the working class through the part of the State, fought for the articulation between labor union leaders and authorities, ¹³ creating, however, a myth for many years in the collective imagination of Mexicans: the unions are spokesmen for the working classes, in particular of the state bureaucracy, and mediators between it and the authorities directing the course of the country, which has been called state corporatism.³

It is important to note this given the nature of the medical movement: a social reaction that aims to call attention to the patronage of the unions with the state, the political career ambitions of these leaders, acting in coordination with the authorities to resolve to labor problems through neglect, threats and repression, and it represents the first attempt to establish a labor organization not established or recognized by the state, which were outdated in its operative problems and social methods.¹

Unlike the democracy movement led by Carlos Madrazo, doctors were one of the first non-partisan public sectors who demanded forms of collective organization through channels parallel to state corporatism. As a liberal profession, doctors feigned to distinguish themselves from the working class, mainly consisting of laborers and agriculturalists, and sought recognition and social prestige given their economic and educational status. Doctors did not consider themselves wage workers, and had no political tradition, much less a class consciousness or ideological support that would cohere them as a social agency. This political "innocence" was probably one of the factors that most influenced the quick disappearance of the movement.

Claims made by medical interns and residents in 1964 were as legitimate as fair; they did not intend to rise as higher caste, or nor did they have intentions beyond economic and labor protection, much less a "communist tinge", as deputy Everardo Gamiz Fernandez would say then, 3 by contrast, they were based on principles and values ​​inherent in the human condition: salary increases, individual contracts with legal benefits, and better working conditions.

Despite having started as an "isolated" protest in the ISSSTE Hospital 20 Noviembre, it gained cohesion given the conditions of the medical interns and residents of the nascent health system, which were common to all hospitals, offices, and all forms of social security.

Not being considered a worker means not enjoying social security, not receiving bonuses and other financial benefits, and - very singularly- not being entitled to demand anything. These arguments, though simplified, are very similar to those employed by the hospital executives at the time of the movement. President Lopez Mateos said: "... the social security system is one of the essential purposes of our democratic institutions, one of the best instruments for the realization of the principles of social justice established by the Mexican Revolution ..."⁶ It is true that the creation of ISSSTE and the strengthening of IMSS responded to the social needs of our country and are consistent with the ideals of the Mexican Revolution, however, the working conditions of the residents and interns belied this discourse.

Something unheard of, achieved by these young doctors, was the support of their superiors, and not just medical specialists or staff doctors, but directors of health centers and renowned hospitals, as the case of Dr. Ismael Cosio Villegas, director of the Sanatorio de Huipulco.

Following the medical movement of 1964 and 1965, urban groups became more aware of the role they should play in society; the level of organization reached by the students in 1968 to achieve their demands marked a continuation of the struggles of the urban working class to crystallize the democratization of union policy and the opening of a reciprocal dialogue between authorities and citizens.

From the 1964-1965 physician movement ideas have emerged that were implemented in later years: public universities are no longer elite circles, but rather universities of the people, and the middle class, forgotten until then, became focus of politicians in their campaigns.

The impact of this movement in academia are also evident. While the demands of the medical movement did not reach medical schools, they reflected the lack of coordination between academic and labor institutions in the health field: with the expansion in infrastructure of health care services, there was no parallel increase in the number of medical graduates who could cover tuition.4 This is why medical interns and residents endured workloads that solved that lack of human resources. Paradoxically, in the decade after the medical movement, the labor market could not absorb the large number of young people seeking employment, because the number of graduates from medical schools increased unprecedentedly as a result of the unregulated opening of public universities.^4,5

Finally, the employment situation is no more encouraging. 50 years ago, moonlighting was a common practice among doctors, in part because a single job did not allow them to cover their financial needs. This behavior prevailed in the decades after, as Frenk Mora et al. noted 25 years after the conflict, with the existence of unemployment and underemployment in a large proportion of physicians as well as the existence of doctors working several jobs.4 More recent reports show a similar trend to that of 1990, with general practitioners the most affected by these phenomena.¹⁴

The elements that shaped the medical movement 1964-1965, although currently in a different social setting, dominated by the free market, hiring through systems of outsourcing, the impoverishment of the health institutions and higher education,^15,16 and general job insecurity (which has led to burnout and an increase in malpractice suits)^17,18 far from dead, seem to be, lacking real national transformation, at the point of rebirth.

References

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17. Fajardo-Dolci GE, Hernández-Torres F, Santacruz-Varela J, Hernández-Ávila M, Kuri-Morales P, Gómez-Bernal E. Perfil epidemiológico general de las quejas médicas atendidas en la Comisión Nacional de Arbitraje Médico 1996-2007. Salud Publica Mex 2009;51:119-125.
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