"The right to health requires a more egalitarian society" – Interview with Sofie Merckx (PTB)

LVSL - What is the 'Medicine for the People' (MPLP) programme?

Sofie Merckx - "Medicine for the people" is first and foremost a network of eleven medical centres that can be found all over Belgium, but especially in working-class regions or cities.

On the one hand, we offer primary care, with general practitioners, nurses, dieticians, but also social workers, reception and administrative staff, etc. On the other hand, we are also an organisation that fights, as our slogan states, for the right to health in a healthy society.

Since the opening of the first medical centre in 1971, we have always combined medical work with political actions, such as accessibility to health care or lower drug prices. We believe that the realization of the right to health requires a more egalitarian society. Health is much more than accessibility to care, it also means having decent housing, having a job and good working conditions.

A lot of diseases are caused by people's living and working conditions. Just think of stress, even burn-out. For example, in Hoboken, one of the first towns where MPLP set up shop, there was a lot of lead pollution and we fought against the factory that was the source of it. We were also very active in the city of Antwerp against the construction of a new highway that would bring much more dust, bad for the lungs and causing hypertension. So we have always been active in building a healthy society.

LVSL - Are the patients you receive at Medicine for the People people who would normally forego certain care and are reintegrated into the health care system through your activities?

S.M. - At the outset our health system is fully functional. We did not create our centres to address a systemic problem of exclusion. We believe that Social Security, which is the major conquest of the labour movement after the Second World War, is the answer to this problem. This is still our working principle.

Having said that, it is true that we have, in our centres, a higher proportion than elsewhere of people who are either excluded or poor workers. Most of our patients fall into the latter category. We get a lot of cleaning women, postmen, supermarket employees, care assistants, people working in low-paying jobs. During containment, it was these low income people who had to continue working to keep the society going.

LVSL - Can you tell us about the specific health claims you are making? For example, the campaign on drug prices?

S.M. - The fight for cheaper medicines has been one of our major campaigns for more than 10 years. Last year in Belgium a little girl was prescribed a new drug, Zolgensma, which costs 1.9 million euros per injection! It was the most expensive drug in the world. This drug must be administered fairly quickly because it provides a one-time cure for PSA (proximal spinal muscular atrophy), a disease that affects children and leaves them completely paralyzed.

The story made a lot of noise because the research on this revolutionary drug was partly financed thanks to the Telethon (TV crowdfunding programme, translator's note) in France. It was a French woman who found the working mechanism of this gene therapy, before the firm Avexis marketed it. In recent years, there has been increasing evidence that patents obtained through public research are being bought up by pharmaceutical companies, which then carry out clinical studies and market treatments at relatively high prices, which we pay back a second time with our social security. In fact, we pay at the beginning as well as at the end, and the pharmaceutical companies make a lot of profit in the process. It's a phenomenon that can be found everywhere.

 

"In recent years, there has been increasing evidence that patents obtained through public research are being bought up by pharmaceutical companies, which then carry out clinical studies and market treatments at relatively high prices,
which we pay back a second time with our social security."

 

We are fighting to change the way drugs are reimbursed by organising tenders for drugs. Many new drugs are indeed variants of older drugs. You can definitely put them in competition with each other by making larger, more grouped purchases, and thus lower prices. That applies in New Zealand, for example, and that's what we call the kiwi model. In the Netherlands, some private insurers make use of these tenders and some medicines are at one tenth of the Belgian price. We even have patients who go to the Netherlands to get the drugs there: even if they don't get a refund, it still comes back to them cheaper.

This tendering principle not only lowers the price but also removes the influence of marketing on the prescription of the drug.  Doctors often prescribe the most expensive drugs and not necessarily the best. We want to break with this logic and prescribe only the drugs we really need, based only on scientific criteria.

LVSL - What was the Belgian government's response?

S.M. - We have had, and still have, quite an influence on these debates. More generic drugs are now being prescribed, which was not the case before. Nevertheless, our government is very liberal and works hand in hand with the pharmaceutical companies. For example, these firms send medical sales representatives to doctors' offices to present their studies and have their product prescribed. For some years, Belgium had been implementing a programme to send neutral representatives to general practitioners. This was beginning to work well, as one in two physicians was receiving these representatives, and one study even showed that physicians who had received visits from these neutral representatives were generally prescribing cheaper and better drugs. But this program was stopped by Health Minister Maggie De Block three years ago! Then we saw huge spikes in the price of drugs. On the other hand, we are facing a new problem: secret agreements with firms on price. The price remains a secret, and no one knows how much we pay for these drugs with our social security.

Free health care

LVSL - Since we are talking about financial issues, when people go to your centres, they can receive care free of charge. Concretely, how is that possible?

S.M. - In Belgium, when you go to see the doctor, you pay about € 27 and you are reimbursed part of this amount by your mutual insurance company. In our centres, we only ask for the part reimbursed by the social security, we do not charge more than the fee. So it's free for the patient.

After a few years, we also introduced flat-rate systems. This consists of being paid a fixed amount per month and per registered patient by the Social Security System. The patient comes to register with us and can benefit from nursing care and general medicine free of charge, without paying for it. It is another system of financing which is no longer based on a fee-for-service basis but on a fixed price, and 300,000 Belgians use it, including outside MPLP. Certainly, there are criteria for adjusting the cost in relation to the workload, for example if the person is diabetic. This was practical at the beginning of the health crisis, when we could no longer consult patients due to a lack of protective equipment: unlike the pay-per-service liberal doctors, we have not had a drop in income. And because we have the contact information for the patients who are registered with us, we called all those who were in at-risk groups to find out if they were okay, if they needed medication, and to offer them the services of our network of volunteers, for example, to do their shopping.

LVSL - This flat-rate pricing system has led to a very long conflict with the Belgian Order of Physicians. Why did the Order of Physicians reject this system? How was this conflict resolved?

S.M. - Medicine for the people was born in 1971, in the middle of the post-May '68 period. The initiators of MPLP (including Sofie Merckx's father, Dr. Kris Merckx, editor's note) came from this movement and wanted to link up with the working class. As these were people who took part in the protest movements, this way of doing medicine was frowned upon by the caste of doctors who had a paternalistic vision of their profession, considering themselves superior to their patients.

Furthermore, at MPLP, there was no question of making people pay. At the time, there weren't a lot of fee overruns. But starting in the 1980s, when they started cutting back on health care, that difference became more significant. For the medical association, we were therefore unfair competition. So there were court cases.

Another criticism of MPLP by the Order of Physicians was our proactive flu vaccination campaign. We were supposedly recruiting patients for vaccinations! Today, on the contrary, there is a consensus on this preventive policy. There was no vision of public health, the doctor was seen as a businessman.

So from the outset, the Order of Physicians did not accept our way of working. For our part, we were beginning to find that the way in which the Order of Physicians represented the interests of independent physicians who sought more to enrich themselves than to serve the people was not correct. So we refused to join the Order and refused to contribute for 40 years.

But in the meantime, there have been advances at the state level, including the recognition of lump-sum medicine in the 1990s. And then the mentality changed: people saw that we had a vision of public health that everyone in the health world should have. Now, a lot of water passed under the bridge: Generally speaking, many physicians and even within the Order felt that we had a good way of doing medicine and that we had been pioneers in certain areas. Since our way of working has been recognized, we have decided to bury the hatchet between us and the Order of Physicians, even though we continue to fight on the legislative level to reform this Order of Physicians.

LVSL - You mentioned the right to health and its link with the work environment, with the air we breathe... In concrete terms, how do you talk about the right to health to the people who come to your centres and how do you approach your other political struggles? Isn't that a way to abuse patient distress?

S. M. - We approach it spontaneously. We listen to patients and their problems. We do not look at health in a narrow way, but we also talk about their living and working conditions. Then we come to talking about things we could fight about together, with the patients. In fact, we don't have a paternalistic view of medicine. As doctors or caregivers, we try to have an equal relationship with patients, rather than standing above them.

 

"We listen to patients and their problems. We do not look at health in a narrow way,
but we also talk about their living and working conditions."

 

For example, three years ago, when Maggie De Block decided to increase the price of antibiotics and other drugs, thus making it harder to reimburse patients, patients were directly affected and they knew it. So we approached this question spontaneously. We did a campaign with Christmas postcards on which people were expressing themselves to send a message to the minister. We then organized an action in front of her cabinet in Brussels to drop off these cards, and were received by the minister.

We also encourage our patients to join a trade union in their company, to go and talk to union representatives when they have a problem with working conditions, etc. If we really want to make a difference in this world, it's through collective mobilization.

It should be remembered that we have a link with the PTB and we are very open on this. We did a survey that showed that more than 90 % of our patients know that we have a link with a political party. Similarly, more than 90 % had expressed positive views on the fact that we are mobilizing for their problems. Most of my patients (Sofie Merckx continues to practice her profession as a doctor, editor's note) are happy that I defend their rights in Parliament, and before that in the local council in Charleroi.

Of course, not everyone comes to demonstrate with us, it is done on a voluntary basis. We don't propose a demonstration to a patient who has a fever of 40.... Of course, some of our patients are members of other parties and have other opinions and we are very attentive to that. In short, we act with respect for everyone's opinions, but with the idea that we must mobilize to make things change. It's called community heath care: trying to get people moving, trying to empower people.

The answer to the covid-19 crisis

LVSL - During the health crisis, how did you mobilize, both with Medicine for the People and with the PTB?

S. M. - For the demonstrations, it was complicated, even if we tried to make virtual demonstrations. But above all, together with Medicine for the People and our local PTB groups, we are trying to help in a practical way. On the one hand we contacted our patients to organize solidarity as I explained. As schools remained closed for a long time, groups organized laptop collections for children who did not have laptops at home. Other groups made cloth masks for the population. Furthermore, we did not have protective equipment to receive patients. So we made a group purchase ourselves, along with other doctors, to bring in masks from China, because the government wouldn't deliver.

And then there was also a lack of testing. In Belgium, we had one of the highest death rates in the world in nursing homes, where the virus arrived because the nursing staff were not equipped. It was clear that all staff and residents in nursing homes needed to be tested, but the government was slow to find those who were asymptomatic so that they could be ruled out. Together with other general practitioners, we were the first to go and do testings in retirement homes. We have been at the forefront and have organized ourselves to show the government that these tests need to be done. Similarly, a few weeks ago, two workers found themselves in a coma after being contaminated at their workplace at AB InBev (world leader in beer, editor's note). So Medicine for the People tested the staff. Despite the poor management of the epidemic by our government, this solidarity between health care personnel and within the population itself has made it possible to deal with this pandemic.

Secondly, we have started to organize events with social distancing, including a large demonstration with health workers (La santé en lutte) on September 13. The Belgian health workers were sent directly to the front and then there was enormous anger at the government's inaction. During a hospital visit by Sophie Wilmès, our Prime Minister, the staff turned their backs. It was a very important symbol. As a result, the government had to negotiate with the trade unions, which obtained an additional 400 million euros per year to improve working conditions and increase salaries in public hospitals. So people still mobilized despite the health crisis, and they got some victories.

The health crisis has been mishandled because our government only trusts the free market. It's been a big problem: masks were ordered late instead of making sure from the outset that there was a production in Belgium. The government took months before asking firms to produce them in Belgium. In addition, there are nine ministers of health (due to the country's very strong decentralization. The unity of the country is an essential point of the PTB programme, editor's note) ! When we ask them a question in Parliament, they explain the meetings they are going to have with the other ministers without explaining what they are going to do or the decisions they are going to make. It's a disaster.

The second problem is that they put a lot of responsibility on individuals. As soon as the first wave passed, we knew we needed a lot of staff to do contact tracing of positive cases. This system of collective protection is completely ineffective, which has meant that today, instead of taking care of others, everyone takes care of themselves. It's a complete failure. Since the reopening of the schools, we have had an explosion in demand for tests, particularly in Brussels. It can take two days before you can find a place to get tested and then another two days minimum to get the result, so the test is almost useless because the person is contagious for seven days. In the meantime they could have infected other people. This system is completely ineffective. We are now paying for all the savings we have made over the past few years. And yet we are not investing heavily in health care. Winter is going to be very complicated...

Challenging the new 'Vivaldi' government

LVSL - Legislative elections were held in Belgium just over a year ago. The PTB-PVDA has made good progress, going from 2 MPs to 12, including you. For a few months, there was no government, then Sophie Wilmès was appointed Prime Minister. Recently, on 1 October, a new government named "  Vivaldi coalition" was put in place. What is your analysis of the situation? Do you think that the health crisis and the economic crisis will change the political game in Belgium?

S. M. - The question everyone is asking is "who will pay for this crisis? " All over the world, people say that we should tax big fortunes. This does not exist in Belgium and we have been fighting for this for years. We have proposed an exceptional "corona tax" on fortunes of more than 3 million euros. But, in view of the government agreement, this is not on the order. So the issue is not resolved. 

Another important point that seems essential is the minimum wage. We saw it during the crisis: all these essential jobs that had to continue working (care assistants, postmen, garbage collectors, cashiers...) are very badly paid, only € 11 per hour! Wages are frozen, and the government agreement does not go back on that either.

This grand coalition of seven parties remains along the same lines as the previous government of making the world of work more flexible. The PTB has become the only left-wing opposition, the other opponents are either separatists (the Nieuw-Vlaamse Alliantie, a right-wing party that claims independence from Flanders, editor's note) or fascists (the Vlaams Belang, an extreme right-wing party that also claims independence from Flanders, editor's note). Apparently, we are going to break the record for the number of ministers once again. And that does not improve citizens' confidence in politics. We don't see any difference between before and after coronavirus.

LVSL - You have a great responsibility as the only left-wing opposition. Can we hope that the voters will be aware of this next time?

S. M. - Yes. With the PTB, we've already got a big win this year with the so-called "white coat fund". I told you about the victory they got after turning their backs on the Prime Minister, but you should know that the health care workers were already on the street in past years. Under the provisional government that was in place, there was no annual budget but a budget voted every three months in Parliament to enable the State to function. This vote took place on an action day for white coats in Belgium. With the PTB, we had already proposed to increase health resources, but this had not been approved. However, this action on the day of the second vote enabled us to obtain, all of a sudden, this white coat fund of 400 million euros a year, which will be able to create 5 000 jobs in Belgium. This is the biggest win for the PTB so far. This shows that the PTB is nothing without the mobilization of people on the ground.