On Sunday 19 February, Ecuador held what turned out to be the first round of  its presidential election. It was the first time in ten years that the current president, Rafael Correa, wasn’t on the electoral ballot. The Correa government is part of the so called “Latin American pink tide”, but Correa is considered somewhat more pragmatic than other leaders in the movement. This pragmatism was clear when his government shifted from an initial socialist agenda, investing in social development, towards a more moderate center-left approach. The presidential elections of early 2017 are quite important because they will define whether Ecuador continues with the pink tide legacy or, instead, turns (again) towards a neoliberal government like Argentina and Brazil did recently. The two main candidates represent opposing poles:

• Lenin (!) Moreno from the government party Alianza Pais was the vice-president of Ecuador under the first government of President Rafael Correa. He wants to continue with the social goals of the citizen revolution but is also haunted by allegations of corruption against his accompanying vice president candidate, Jorge Glass.
• At the other end of the spectrum, you find Guillermo Lasso, a prosperous banker and ex-minister of finance. He was part of a government in the late 90’s which led Ecuador to the worst economic crisis of its history. He aims to boost economic growth through the privatization of the state and tax cuts – fairly standard neoliberal recipes.

It is clear that after ten years of the current government there is a need for change. We need fresh ideas and approaches to our (still numerous) problems. Against that backdrop, however, it is just sad that we still find the same political figures in “progressive” ranks and the same neoliberal mummies of the last 30 years on the other side. In spite of the new global SDG agenda, we also still hear the same discourses of economic growth. (Side remark: I am all for sustainable development, but new leadership doesn’t need to come in the form of recycled political material )

Around the globe, people are dissatisfied with governments for many reasons – good ones and some not so good. That is no different in Ecuador. I would say the good reasons in my country (for dissatisfaction) are the high level of corruption, an autocratic government, lack of self-reflection on the part of the governing party and a loss of connection with civil society. The not so good reasons are perhaps those based in hatred, increased (but often very sterile) polarisation and ill-informed and uncritical thinking – conditions not quite unique to Ecuador, as you can tell from global headlines.

It is troublesome to see the impact of poor critical thinking on policy and political activity. In Ecuador, these days conversations between friends tend to end up in discussions on the “terrible” condition of the country, but many of these conversations are just based on (often unchecked or downright wrong) assumptions. By way of example, I recently had a conversation with a (middle-class, well-educated & fierce opponent of the Correa government) friend who believes the public health system is completely broken. Just a quote from that conversation, focusing on the use of generics, to give you an idea of some of the baffling assumptions people have:

Friend: “The Ecuadorian health system is a complete mess, imagine the whole thing with generics, they don’t do anything to you, my mother is still ill and plus you can never compare generics with the originals”.

Me: “- Yes, but does your mother go to the public hospitals?”

Friend:  “- No, but her doctor who also works in the public sector prescribed her generics…”

This conversation made me laugh (wryly), but mostly worry because my friend’s opinion was clearly based on a poor understanding of the issue, for the most part originating in rumors generated by unreliable sources of information. “Fake news” isn’t just made (up) in America. Generics are, as most of you will know, far from evil, and quality generics have actually improved access to medicines for a large number of people. It is worrying that this way of coming to a “judgment”, based on gut feelings often inspired by the “camp” one belongs to, and without much critical analysis of an issue, is becoming the new norm globally.

Certainly in Ecuador, these opposed political identities have become the norm. Around the world, polarized points of view leave no common ground for debate and imagining a better world –   maybe it’s because of human nature, or maybe it’s our ruthless global economic system … and certainly social media hasn’t exactly helped.

In any case, one cannot deny that the Ecuadorian government has achieved quite a bit over the past decade, including the transformation of a very instable country (that went from having eight different presidents in less than a decade) into a State with a clear model of governance. I am not based in Ecuador and I haven’t been in a public hospital there for years, but I can speak from what I know, which is policy analysis: the health system in Ecuador is not what it used to be; it’s substantially improved and for the first time in decades there was a comprehensive body of reforms which now provide a structure to work with. So, yes, now we have a public system where generic medication is common and  therefore provides medication to people who in the past were actually dying due to the lack of access to medicines.

Having said that, in spite of undeniable progress, the country continues to face significant challenges, including those related to the environment. I am critical of the lack of commitment of the current government towards protecting the environment, the militarization of indigenous lands, the mining negotiations with big companies which often lead to the imprisonment and persecution of environmental activists, … All these worrying trends are jeopardizing our water, our land and livelihoods.  We continue to be challenged by corruption, an increasing sense of authoritarianism and lack of freedom of speech.

Anyway…

As said before, no government is perfect, but we need to find a balance and acknowledge and nurture the positive, not just the negative.  Ecuador has a good health system model, but imperfect implementation. So, what if, instead of dismantling the work undertaken over the last ten years we focus on improving the model by making it more functional? This can be achieved if we reflect rationally and critically on our successes and failures and stop basing our opinions on hate and irrational “analysis”.

I don’t really have a straightforward conclusion to this story. After the results became clear in February, it turned out a second round of presidential elections would be necessary.  On 2 April, Moreno and Lasso will thus face each other in the second and final round. Initial polls indicate Lasso is in the lead, so it looks as if Ecuador will be following Argentina and Brazil’s example in bringing back to power a conservative and neoliberal government. The (dire) consequences of such a shift are already visible in these countries and one would hope that we learn from that – in time.

If not, we can perhaps still think of the wise words of Dussel, an Argentinean/Mexican philosopher who said that the gains of progressive movements surfing on the pink tide wave have allowed us to take two steps forward, and that a neoliberal backlash will only lead to a temporary setback (i.e. one step backwards). He’s certainly hoping for a progressive rebound in the medium term. However, if progressive governments are to rebound they will need to become more humble about their gains and engage in a deep process of critical questioning of their models of governance, which includes acknowledging their mistakes. We, the people who are at the center of these processes also play a role in not letting ourselves be deceived by false illusions. I personally think that whatever the result in the elections, we’re heading for a period of civil unrest. Grassroots movements will be pivotal in holding the government accountable and ensuring that the social gains of the last ten years are not lost. Or in the words of social movements in Ecuador: “If you want to choose, then choose to fight!”

Although these recent events in South America do not explicitly have the word health inscribed in them, there is in fact an important space for reflection for health systems. The last decade has indeed brought great gains in health. Increasing attention has been given to the achievement of universal health coverage; there has been the recognition of intercultural health systems, and in many countries people are now able to access free health care. My grandfather for instance receives dialysis three times a week without incurring any out-of pocket payment.  So then, what is going to happen with these gains now that the revolutionary project of socialism in the Americas is failing to keep up its promise and is now taken over once again by neoliberal “values”? How do we, as individuals and health professionals, contribute towards the protection of these important gains? How do we engage with these political conversations?

I have been thinking about these questions in the last few days and the Zapatista phrase, “Otro mundo es posible” came to my mind.  I think that yes, we have the obligation to protect and foster the achievements in health care from the past few decades! However, to do so we also need to go through a process of deep deconstruction of our beliefs and the parameters in which we think about the world. The events of this year are pushing us all over the line and the only possible solution in my opinion is to dream! To dream and create! I think a time begins were creativity will be essential. We need to destroy ideological dichotomies. I firmly believe that another world is possible; there must be a third or fourth or fifth direction to take and it’s time we create those options for ourselves.

We as societies are dealing with complex global issues that require a lot of joint effort and collaboration. Yet, in the spirit of the Zapatista phrase used in this reflection, I also think that more and more we need to move towards local solutions to global problems – I know this has been said before but I think it’s relevant to remind ourselves of the importance and significance of local contexts. I am not talking about local in terms of national government. I think the idea of locality needs to provide people in neighborhoods, small towns, and organizations, the opportunity to generate solutions to their problems, including health systems issues.  It is in light of this reflection that I’m looking forward to the possibilities that next year might bring.  I invite us all to talk with people who might not be health researchers or who might have nothing to do with health at all and find intersections between problems and disciplines. Let us start designing a new system for the world and our communities.

Next year in Ecuador we will be hosting the Latin American congress of Cultural Viva Comunitaria, which is a regional movement trying to foster local expressions of community organization based on cultural contexts and built on the idea of sharing experiences across regions. This congress engages multiple areas of social organization across culture, popular education, arts expressions and economy… however there is not yet a space for health. So! We have proposed the inclusion of health in their agenda, which is exciting. We hope that we can think about health from a cultural lens and beyond the idea of traditional medicine. How do we talk about health within the organizational culture of our communities? I am excited to find ways in which I can start thinking about health systems and its intersections with other social processes, looking forward to building new, stronger systems.

On that note, have a great end of the year!