On 20 April 2012, the Spanish government passed the Law by Royal Decree 16/2012, which took urgent measures to, as President Mariano Rajoy’s administration put it, “guarantee the sustainability of the National Health Service and improve the quality and security of health care benefits.” Yet with a per capita health care cost that ran at about a third of the US’s per capita costs, Spain’s public health care system had long been considered one of the world’s most efficient, and it proved so while guaranteeing truly universal coverage on the basis that every human being has a right to health.

What the new measures did, however, was curtail that universal human right, restricting it to Spanish citizens and immigrants with their documents in order. Due to Spain’s massive unemployment and the fact that the legality of one’s residential status requires an employment contract, the measures effectively exclude roughly 800,000 people from basic medical attention, according to Doctors of the World. In his appearance in front of the Congressional Health Committee, that NGO’s president, Álvaro González, explained that the Spanish government had enacted a policy of “apartheid” against those people, most of whom had seen their documents expire when they were unable to find work after the collapse of the country’s housing bubble and the construction sector. He also cited several studies indicating that the measure could actually serve to raise costs, in addition to putting public health and peoples’ very lives at risk.

Fortunately, the Rajoy government’s policy has been met with resistance and civil disobedience. From campaigns such as Madrid’s Yo Sí, Sanidad Universal and the Catalan Platform for Universal Health Care (PASUCat), to smaller, neighborhood-level collectives and Companion Groups, health care users and professionals are standing up together to abolish the apartheid being imposed on their communities. One such group is the Espacio del Inmigrante in Barcelona’s largely immigrant Raval neighborhood. In contrast to the aforementioned campaigns, this autonomous collective goes beyond the single issue of health care exclusion to address the full spectrum of apartheid experienced by undocumented residents. By providing free legal assistance to undocumented immigrants, free meals, and facilitating housing and organizational solutions for people (including the now evicted Mount Zion community), they work to obtain peoples’ basic needs through mutual aid, solidarity and civil disobedience. I recently sat down with one of their members at a small clinic they opened, and we discussed their methods, their philosophy and the challenges they currently face.

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ROAR: So, what exactly is the Espacio del Inmigrante? How and when did it come about?

Manuel (M): The Espacio del Inmigrante is a neighborhood-level citizen initiative started by a group of immigrant professionals here in the Raval, in response to the Law by Royal Decree passed by the Spanish government in 2012. We assessed the situation and, considering that we live in a neighborhood where over 40% of the residents are immigrants, we came to the conclusion that this is likely to have an especially large, degrading effect on our community. We were seeing that a lot of our neighbors were not going to the doctor because they didn’t have enough money, because their public health insurance cards were no longer valid and because they thought that, if they went, there was some sort of link between that institutional setting and the police. Considering that they were undocumented, this kept them from going.

Through face-to-face contact, our neighbors learned that there was a doctor on our street. Whenever she went to buy bread or groceries or go to the pharmacy, the shopkeepers would mention that someone they knew was ill but could not go to the primary care center. She would often end up doing check-ups on the spot. This doctor happened to be in contact with the neighborhood assembly a lot of us were in, and she mentioned this there. We then decided to open up a space where we could carry out free, basic medical attention. So in January of this year, we went to a building block where there was already an assembly established and asked them for a space. They gave us an entire floor, and we fixed it up, making it fit for providing basic medical attention and stocking it with basic medical supplies.

The original idea was that people might feel less at-risk coming to us than if they went to hospitals they distrusted. What we found was that there is a large group of people and an important voice that is being cast aside. Many of them do not fit our traditional class categories, but are being forced to live “under the underclass”, so to speak. They tended to remain out of sight and were hesitant to be identified for fear that they could be sent to an Immigrant Internment Center or deported.

What types of health problems have you encountered? What measures do you take in order to guarantee that the patients’ rights are guaranteed?

We follow a very specific action protocol and we limit ourselves to providing consultation, primary care and treating superficial pains and circumstances that a doctor can alleviate or cure with first aid or prescription drugs. All of our doctors work in the public hospital system and they are trained to treat these kinds of issues. The problem is that the majority of the people who come to us have more serious and complicated health problems, precisely because they stopped using the health system as a result of the Law by Royal Decree. When they finally reach us, that small stomach pain they were suffering has turned into peritonitis or something more serious. That’s when the doctor lets us know that the Companion Groups have to take action.

A Companion Group is a group of citizens who accompany the affected person to a primary care center or walk-in clinic and try to reach the health care professionals on a personal level, to encourage them to disobey on the grounds of conscientious objection. We ask that they honor their oaths and give their professional ethics priority over whatever law or doctrine the party in power has chosen to promote.

What sort of response do you tend to get from health professionals? Do most end up disobeying and treating the patient, or does only a small minority do so?

When the Companion Group gets to the hospital, the first person they encounter is a hospital administrator, who is neither a nurse nor a doctor. Whether or not the patient has access to hospital care usually depends on this person. We often find people who are racist, burned out and just want to clock out or people who are simply obedient and insist that if they don’t have a health card, they will not receive treatment and that if they do, they will be charged beforehand. So, you can see that the idea is that whoever doesn’t have money doesn’t have access to the health care system.

That’s where the hardest work begins. First we have to sensitize the administrator. If we get past the administrator, we then have to talk to a nurse and gain access to the doctor. In terms of their response, honestly, most doctors are uncertain: on the one hand, they see themselves as morally and ethically obligated to care for the patient, but on the other, they are afraid of losing their job or being reprimanded in some way. What we have found, though, is that a very conscientious minority disobeys. They often say, “The ill are neither right- nor left-wing, foreign or native, but human beings that must be treated”. With their help, we have set up a network across Barcelona of doctors who are willing to treat people after-hours, so as not to impact the other patients. But while this assures that people with serious health problems are treated by a professional, if it were not for their solidarity, they wouldn’t receive any care at all.

How many people are involved in the health care work carried out by the Espacio del Inmigrante? How many health care users do you care for in an average week?

In January we were one doctor, one community organizer and an auxiliary worker. Now, we have three doctors, two nurses, an auxiliary worker, three community organizers, one social worker and three neighbors who work every day. The number of users we care for varies. Last week, 15 people had to come to us to get TB skin tests, for example. But this week, it was only 4 or so. The problem we have is that there are still too few of us, and people with a serious problem on Monday can’t wait until Wednesday to be treated. So we are trying to open more days per week, because right now the clinic is only open two days per week, and we’re trying to expand to three. As it stands, I’d say that in an average week, we get 5 or 6 visits that are usually serious cases.

Do you encounter a lot of people who are openly hostile to what you do?

Yes, we do. The racist ideology promoted by politicians and the media, this rhetoric about “the enemy within”, has really permeated society. There is a considerable part of the population that I wouldn’t call “fascist”, but who perceive an intense competition for scarce resources.

There are also some people who are actually racist. Over 100 languages are spoken in this neighborhood, and none of the integration programs promoted by the city put any work or emphasis towards economic or material inequalities. They’re not only absurd, but hypocritical. How can you promote coexistence when people don’t have a place to live? How can you promote coexistence when people don’t have enough to eat? How can you promote coexistence when most of the violence exerted in this neighborhood is by the system, the state, and the police, who are constantly monitoring us? All of these issues cultivate the tensions in our neighborhood.

We have, however, been able to engage in dialogues with people ourselves. We present them with evidence, with data and hard facts that show that it’s not we, the immigrants, who are responsible for this situation, but the policies carried out by politicians. We don’t get rid of racism when we do this, but people do open themselves up a bit to the real issues raised by immigration. In a lot of cases, some of the people who were blaming immigrants for everything when we talked to them ended up donating medicine to us. What’s important is to realize that the people who are being impoverished look beyond political ideologies. And that’s where you see the importance of seeing ourselves as equals, the importance of what he have in common. That it’s not just immigrants, for example, who are being cast aside from the public health system, but that it will be the locals themselves next: the unemployed, the chronically ill, the elderly and so on. This is where they realize the importance of weaving a social fabric together.

Does the Espacio del Inmigrante focus on other issues besides health care exclusion? What other activities do you engage in?

As the Companion Groups started to grow and we gained more experience, people came to us with different situations and different demands. We reached the conclusion that the cornerstone of the administration’s efforts to strip immigrants of their rights is institutional racism. They’ve made municipal registration procedures much more complex; there is a bureaucratic maze that impedes an everyday person from another country from accessing his or her fundamental rights. So we set up the Migrants’ Rights Office with a compañero who is very well-versed in immigration law and offers people legal assistance.

There’s also a group we call the Street Brigade, which goes directly to the stores, fruit stands, cybercafés and so on, all those spaces in which immigrants work, come together and interact in our neighbourhood. We just inform them that many of them lost their health cards when they lost their jobs and, with those, their right to free public health care. A surprising number of people are simply not aware of this situation yet. We also try to make the native population aware of the fact that, in Catalonia, undocumented immigrants do not currently have access to free public health care. We have to do this because the city and regional government, as well as the mainstream media, have created this myth that Catalonia grants all human beings the right to quality health care.

Do you think this local practice you all are undertaking is applicable beyond the Raval, Barcelona, Catalonia or Spain? If so, what can be done to extend it?

That is what we consider to be our political project. What we’ve been talking about until now is a social health intervention, with a set of technical tasks carried out by the professionals we work with. But there is another dimension, a social one, which consists of weaving a social fabric and a network of common people who are marginalized or excluded. With humility, we try to align ourselves in this task with the autonomy of the Zapatistas. We have two main principles. The first is to walk while questioning. We decided that we needed to stop theorizing at some point and put the ideas we were talking about into practice, to avoid getting caught up in a permanent analysis, waiting for a great conjuncture that will never come. Our current context and moment, in this neighbourhood, obligated us to take these steps, with all of their difficulties and mistakes, and we accept our limitations.

We also believe that we are not in a position to promote or make people believe that we have a finished, alternative model. We believe that, if this is working in the Raval, it doesn’t necessarily have to work in other places. The conditions here obligated us to construct this, not reflection. It’s a process that’s kind of the opposite of the traditional left’s.

Our second principle is that we do not work with political parties or institutions. We understand that we are an important link that is trusted by people who have been segregated or excluded. The moment we become an arm of the government or the wing of a political party, we lose that trust. When people come to us, they know we won’t ID them or ask them for their documents.

We also make it a point to educate people about who is responsible for their current situation, and that is where our solidarity goes beyond the concept of “solidarity” so favoured by religious institutions. For us solidarity is based on social justice. To build it, we must understand human beings from the standpoint of their living conditions. We consider that the people affected must understand who is responsible for their current situation, not just depend on charity groups or handouts. We explain what policies created the situation, who passed those policies and who has a vested interest in those policies. For instance, in this neighbourhood, City Hall has been cutting back on all support to social services and transferring responsibility to religious organizations or NGOs. This is a complication, because the vast majority of the organizations that exist in this neighbourhood belong either to Opus Dei, Caritas or private groups receiving state subsidies.

What would you say is the ultimate goal of Espacio del Inmigrante?

We emphasize the need to build solutions without the aid of professional politicians, by which I mean politicians or technocrats who don’t tend to understand the specificities of our communities and the importance of being grounded in them. Beyond abolishing apartheid in the health care system, our ultimate goal is to generate autonomous processes among the people affected by this situation, processes of empowerment, so that it’s not just us doing this all the time. What’s most interesting to us is how the health professionals who work with us and had no previous experience in political mobilization are starting to feel more and more empowered and convinced that they can disobey on ethical grounds. What we want to do is remove barriers to solidarity, such as fear, and strengthen the links between equals.

And it’s not that we want to substitute the state with what we do. What we want to show is that the existence of spaces like ours is the result of the gaps and the shame of the state. In this case, it’s a way of breaking through the official rhetoric that says that everyone who needs it has access to quality health care here. All of our patients are proof of the fact that this is not the case, that there is a very real apartheid. So we are a mirror that reflects the shame that the state thinks it is hiding.