Gutting Public Health
For years, Spain had one of the best healthcare systems in the world.
Not perfect—but fast, universal, and remarkably effective. You got sick, you were treated. No drama. No billing calculations. No quiet fear about what it might cost you. Getting sick wasn’t a death sentence.
And the data backed it up. Spain sits near the top globally for life expectancy, while studies in journals like The Lancet consistently show the same thing: strong public systems deliver better outcomes—and do so more efficiently—than privatized ones.
I’d seen what happens when that starts to change.
The UK and Canada got there first. Both built strong public systems—and then slowly eroded them. Underfunding. Outsourcing. “Efficiency.” More private involvement at the edges.
Nothing dramatic. Just a steady decline.
Longer waits. Worse access. Growing dependence on private alternatives.
Spain is now following the same path.
Not collapsing—digesting.
The system still stands. The doctors are still excellent. But something is shifting underneath. Waiting is becoming normal. Private insurance is creeping in—not out of belief, but out of desperation.
I wrote about this here in Spanish: (English translation below)
👉 https://www.elsaltodiario.com/sanidad-publica/te-va-costar-un-rinon-literalmente
It’s about what it feels like to watch something that worked… slowly hollow out.
An Arm, a Leg…or even a Kidney
On the quiet, respectable digestion of a civilization
The first rule of fully privatized healthcare is simple: don’t turn your back on it—and whatever you do, never go to sleep.
Not because of the operation. Not because of the pain. But because of the invoice—and what might quietly disappear from your body while you’re unconscious. Sleep is surrender. Sleep is consent. Sleep is the moment your body stops being yours and becomes, briefly, a poorly guarded warehouse.
“Whatever happens, don’t let them put me under.”
This was said to me in Yemen, in a hospital that felt less like a place of healing and more like a provisional abattoir for spare parts. The man gripping my arm wasn’t afraid of death—death, at least, is clean. What terrified him was waking up diminished. Edited. His insides rearranged by invisible accountants with scalpels. He had come for a burst appendix. What he didn’t want, was to lose a kidney like one of his cousins after a gunshot wound. A little “bonus extraction” for the informal market. A side hustle in human spare parts.
Because in the market, everything circulates. Money. Blood. Organs. Panic.
You start with fees. Then surcharges. Then “enhanced service tiers”—a phrase that should be tried at The Hague. Then someone notices there’s good money in scarcity. And before long, you are lying on a metal table, bargaining internally over which organs you can live without.
The Hippocratic oath doesn’t vanish. It just gets quietly outcompeted.
And the free market—this shrieking, insatiable organism we have decided to trust with everything from housing to water and oxygen—leans in, licks its lips, and asks what else you might be willing to part with.
A kidney? A lung? A little dignity?
This is, we tell ourselves, a long way from Spain.
That is what happens elsewhere. In broken places. In failed states. In countries where institutions have been chewed down to the bone and spat out.
And yet.
Because no country ever openly announces that it is about to dismantle its public healthcare system and replace it with a polite bazaar of suffering. There is no grand speech. No ribbon-cutting ceremony for the End of Collective Responsibility.
Instead, it happens gently. Respectably. With consultants in suits and ties.
Because collapse is theatrical, and what we are living through is not collapse. It is digestion.
There is a story—perhaps true, perhaps too good to be true—that the anthropologist Margaret Mead once said the first sign of civilization was a healed femur. A broken human being, carried, protected, fed, and allowed the time to recover. No invoice stapled to the leg. No “premium fracture package”. Just care.
Civilization begins the moment we decide the injured are not liabilities.
It ends when we start itemizing them.
Everything else—markets, flags, growth—is just decoration on top of that decision.
Spain, not so long ago, stood firmly on the right side of that line. From the moldering ruins of a 40-year dictatorship, it built a world-class public healthcare system that worked—not perfectly, not magically, but reliably. You got sick, you were treated. Quickly. Quietly. Without having to consider which internal organ might fetch the best price on the open market. Not fine “for what it is”—actually excellent. Life expectancy among the highest on Earth. Universal access. Outcomes that made richer nations quietly uncomfortable. This wasn’t football, but we were still the best.
It was, in the grand scheme of human history, an outrageous achievement.
And now it’s beginning to feel like a rumor. Like something you once imagined to be true, like Santa Claus.
Spain has the longest life expectancy in the EU—two and a half years above average—and is somehow managing to sabotage the very system that produced it. It has achieved this while spending below that same EU average on healthcare as a share of GDP. The country is basically running the most cost-effective life-extension program in the Western world. And it is methodically dismantling it with the quiet, bureaucratic diligence of a nation that has confused aspiration with self-harm.
Spain still spends a hefty slice of its wealth on healthcare—around a tenth of everything the country produces, depending on how creatively one does the accounting—and yet manages to produce waiting lists so long they have begun to develop their own ecosystems. The average wait to see a GP is nearing 10 days. For a specialist: over three months, with more than one in three patients waiting longer still. For non-urgent surgery, four months on average—and that is the average. Hundreds of thousands of people suspended in bureaucratic amber, ageing in place while their appointments creep towards them with the speed of continental drift.
And this in a country that, in the heady times of austerity, cut healthcare spending by 20% as a ‘necessary’ measure, slashing almost 30,000 health service positions, and has never fully rebuilt what it tore down. The country is measurably wealthier now than it was then. There has been no war. No natural disaster. No sudden national collapse. And yet, somehow, we have less. People pay the same taxes—or more—and receive less in return.
Time, in this system, is no longer linear. It is elastic. It stretches. It warps. It snaps.
You do not wait for care. You marinate in its absence.
We are living through what can only be described, in the most precise technical language available, as enshitification.
Everything looks better. The buildings shine. The logos have been redesigned. There are apps now—dozens of them—each one a brightly colored maze in which you can lose an afternoon trying to locate a human being.
And yet everything is worse.
Primary care, once the quiet triumph of the system, now routinely involves delays of a week or more. The doctors are still extraordinary. But the care is thinner. The time shorter. The outcomes fuzzier. It is healthcare that has been skimmed, like milk, until all that remains is something pale and vaguely nutritional. The idea of being seen tomorrow has become a nostalgic fantasy, like affordable housing or tomatoes that taste of anything at all.
Ahhh, tomatoes. It is the tomato problem.
There was a time when Spanish tomatoes tasted like an argument—sharp, messy, impossible to ignore. You bit into one and it fought back.
Now they sit there, aspirationally immaculate and expressionless, like wax replicas of themselves. Perfect on the outside. Dead on the inside. Prices crept up. Taste crept out. A triumph of appearance over substance. The neoliberal fantasy on a plate.
Healthcare followed the same trajectory.
Sleek. Efficient. Nutritionally void.
This did not happen by accident. Spain aspired to it.
Aspiration, in this context, means observing systems that are demonstrably worse—more expensive, less humane, openly predatory—and deciding to import their worst features like a cultural exchange programme for bad ideas. Privatize a little. Outsource a little. Introduce “efficiencies”, which translates roughly as “do more with less until something breaks, then call it reform”.
The public system absorbs the strain. The private system absorbs the profit. A neat arrangement, like a parasite that has convinced its host this is a mutually beneficial relationship.
And this is not the work of one political faction alone.
The right does it loudly, with ideological fervor and the subtlety of their cherished chainsaw. They don’t even try to hide it anymore—they proudly promise to liberate the system from the unbearable weight of actually functioning, and people not only go along with it, they buy the t-shirt and the illusion that this time it will be different. The left does it quietly, incrementally, like someone taking discreet nips from a hip flask on increasingly frequent bathroom breaks while insisting they are perfectly sober. Nothing to see here.
The end result is the same: a system that still stands, but only in the way a hollowed-out tree still stands—upright, impressive from a distance, and one strong wind away from collapse.
Into that hollow space creeps the market. Around a quarter of the population now carry private health insurance. Not because they believe in it. Not because they believe they are better than others, but because they no longer believe in waiting. Because waiting has become a condition in its own right, with symptoms that include anxiety, frustration, and the slow erosion of trust in the very thing keeping them alive longer than anyone else on the continent.
Which brings us to the strikes.
Today I had two appointments. Or rather, I had two theoretical appointments—Platonic ideals of appointments, existing somewhere in a higher realm of administrative intention.
The first at the health center: silence. Doctors on strike. The place felt like a museum exhibit titled Healthcare, Early 21st Century.
The next at the hospital: elderly patients who had travelled from surrounding villages, clutching their appointment slips like talismans, only to be told—again—that nothing would happen today. Or tomorrow. Or perhaps this week.
No prior notice. No warning. No explanation. Just the quiet, grinding humiliation of being processed and then discarded. A vague sense that something had gone wrong and that, somehow, it was everyone else’s fault.
The nurses apologized. The patients grew angry. The air thickened with that uniquely modern emotion: the suspicion that you are being failed, but in such a complex and distributed way that no one can be held responsible.
Here is the masterstroke.
The anger—raw, justified, overdue—lands not on the architects of this slow disassembly, but on the system itself. On the very idea of public healthcare. Because there is no narrative. No explanation. No attempt to draw a line between cause and effect—between the funding cut and the waiting list, between the political choice and the missed appointment, between the vote and the consequence. No information desk. No leaflet. No pedagogy of any kind. Just a vacuum into which frustration pours, pooling wherever it can.
And so people drift. Not because they are convinced. Because they are cornered.
Towards private providers. Towards monthly premiums. Towards a system that promises speed and delivers dependency and only occasionally reuses the catheter. Towards a world in which your health is no longer a right, but a subscription service with variable terms and conditions.
And then comes the final twist of the knife.
They vote for it.
They vote, in effect, for a system in which the healed femur—the anthropologist’s symbol of civilization—is replaced by a credit card. Towards, in short, Yemen. But sanitized. Regulated. Rebranded. A boutique version of the same underlying logic, where the body is a ledger and care is a transaction.
Yes, Spain is wealthier now than it was twenty years ago and yet we have less. Less access. Less trust. Less patience. Less of that quiet, radical idea that illness should not be a business opportunity.
Something fundamental has shifted.
The quiet, radical idea that we do not abandon the injured—that we carry them, that we mend them, that we absorb the cost as a collective—has been replaced by something colder. Something transactional. Something that looks at a broken femur and sees not a responsibility, but a billing opportunity.
Civilization is not lost all at once.
It is itemized.
It is deferred.
It is rescheduled.
Until one day you find yourself lying on a table, staring at the ceiling, running the numbers on your own body like a failing business.
And thinking, with perfect clarity:
Whatever happens, don’t let them put me under.
