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Letter from Spain: Inside The Maternity Ward

At Barcelona Maternity, obstetric nurses are considered the backbone of one of Spain's most beloved institutions. Today they are weathering longer shifts and dramatic cutbacks. How austerity is about much more than money.
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Barecelon featurea

Barcelona — Of the European movies that aren’t available with English subtitles, Bienvenido Mister Marshall is among the most frustrating. A brutal 1952 satire by Luis Garcia Berlangathe film tells the story of a small town suffering under the Franco dictatorship. Someone invents a story that the Americans are coming to town, bringing their Marshall Plan and prosperity. The town’s residents hold an ecstatic, ridiculous welcome for the Yanks, singing in expectation:

Americans, they’re coming to Spain!

Handsome and healthy!

Long live the wealth of this great and powerful people!

Ole Virginia, and Michigan, and Texas, which isn’t so bad!

Americans, we greet you with joy!

Neither the Americans nor the Marshall Plan ever arrive, of course. And the rest of the real story isn’t in the movie. As most of Europe rebuilds, Spain suffers forty more years of dictatorship. Only by the 1980s can the country, now home to 40 million, start to catch up.

I mention Bienvenido Mister Marshall by way of explaining how the argument over Europe’s economic future feels so different here—in Europe—than it does either in the US, or when reading headlines about this week’s meeting of the G-20 in Mexico. Here, the discussions of austerity and debt don’t play as debates over responsibility and discipline. Nor do they play as a defense of large European social safety nets—free hospitals, public pre-school, retirements many years earlier than in America.

The talk of austerity makes Spaniards worry about their most beloved institutions, and fear for the health of their democracy should they be damaged, so far as I can detect. In America, courts and polling booths are sacrosanct. In Spain, for many, it’s the public hospital.

I say this with a key disclosure: I am married to a local, and she is nine months pregnant, and we have been receiving free health care through her entire pregnancy.

That the quality of our health care may be dependent on the domestic politics of Germany, or the mood at a dinner in Cabo tomorrow, is vexing, but isn’t primary in our minds. What’s primary is that Spain doesn’t think about austerity as a rollback—temporary or permanent—of a nanny state

Here, austerity is a discussion about actual nannies.

Americans are so annoyed by their own health system that it’s easy to forget that in other parts of the world, the medical establishment is still seen as a positive part of society. People in Barcelona talk about the city maternity hospital the way Americans used to talk about the space shuttle. The hospital is spectacularly well-regarded by its patients, and the credit usually goes to the hospital’s corps of comadronas, which means obstetrics nurses. They pretty much run the place, and while I speak from great ignorance in the medical field, as a client they are awe-inspiring.

Having spent much time at Barcelona Maternity this year, Nuria and I have been handed around through several comadronas. We have found that two types exist, based on seniority; in my foreigner’s head I distinguish them as the Great Aunt and the Dependable Younger Sister. The difference is that the less-senior Sisters are my peers or younger, use gentler verbs, and occasionally coo at the preemies.

The Great Aunts do not coo. The Great Aunts insist on describing the work of their watch via the stockyard verb parir (“To birth”) rather than the frillier dar luz (“To give light”). It’s an article of faith at Barcelona Maternity’s old yellow building that while the Sisters are cheerier, you want a Great Aunt on station when the proper rending starts.

These women, and their outsized reputation for stalwartness and grace, are also consciously part of a system that has become one of the most envied in Europe — built from the ruins of the Franco dictatorship. Spanish health care is so low cost and so good that people from elsewhere in the EU would take advantage of relaxed border rules, and have a check up, or intestinal surgery, or perhaps a baby, while on vacation in Spain. Locally, no one minded this “medical tourism,” for awhile, the way you don’t really mind if a guest eats all your food, but takes care to compliment your cooking. In the back of everyone’s mind, Barcelona’s hospitals were not just medical centers, but were also their Smithsonian, their National Park Service, their Oak Ridge Laboratory.

The result was a medical system that also serves as a monument. To offer an awkward American parallel, to be born at Barcelona Maternity is to say you were born on the Fourth of July; to say your grandmother worked there is to say she shot rivets in the Richmond shipyards.

But now, to be a nurse there is to face not only daily cutbacks, but the creeping feeling that Spain’s democracy is losing ground too. If the hospitals finally start to slip, to many here that will represent Spain itself slipping.

What is missing from the reports from Mexico this week is a sense that people outside Spain understand what the country’s social safety-net institutions represent—beyond the size of their budgets. The cuts don’t read as necessary pain to safeguard the future—even if the math shows that’s what they are; they read as aggression against the fundamental pillars of a still-young democracy. The comadronas at Barcelona Maternity aren’t just excellent nurses. Here, they’re The Troops. As at home, one supports them, regardless of what you may think of the war.

What does this have to do with Berlanga? The Americans weren’t the only target of his script. Franco’s propaganda system, a gullible Spanish public, and Europe’s postwar abandonment of Spain all ends up on the screen – hilariously, but bitterly.

Those themes are still in the air, and you can feel them arriving to the hospital for free care. When criticism of “siestas” and long lunches comes over the television from Berlin or Washington, they sound reasonable on CNN – Spain really does do things with frustrating slowness at times. But when we pay nothing for dazzling technology and centuries of cumulative institutional memory, it doesn’t feel wasteful, or grabby. The social contract is different than in the US, where public services are often held as luxuries, to be reduced in hard times. Here, public services are conceived of as most important in hard times, and the luxury would be to reduce them. The social contract, the one that austerity is forcing Spaniards to defend, is that if you walk through the hospital door, you are cared for until you get better. The hospitals are the place where that contract gets enforced.

And they do enforce it, despite the cuts. The comadronas are all working longer shifts, often dramatically longer, to cover staff shortages. Yet the level of care stays enviably high. Medical tourism persists here (Spain just had to announce, reluctantly, that it would no longer treat illegal aliens or nationals who have not paid their tax into the system; they used to swallow that cost).

Increasingly, they do this amid criticism from abroad. Once a week or so we go to the hospital, and meet with a comadrona or a doctor, who is plainly killing herself for our sake. Then we go home, and on the BBC, a finance minister is calling them lazy.

Our baby is due in three weeks and I still have not yet fully accepted that no bill is coming. The reports from the G-20 get ever more shrill; the bond market isn’t responding to the latest cuts as everyone would hope; the medicine isn’t working. And Berlanga keeps crossing my mind. The world seems to be patting Europeans on the head and telling them to take their medicine, without quite understanding just how much medicine costs here—even when it’s free.