BOGOTA - In the middle of July, as the Colombian government was presenting a bundle of measures to reform the health-care industry, 5,000 people congregated in the Plaza de Bolivar in Bogota to hold a “White March.”
One block away from the president’s office, the protest was led by a group of women in black, to symbolize the death of the health care system in Colombia.
The public demonstration came after months of press reports of a nation's medical care in crisis: an elderly man in chains in an assisted living facility, asking for his medicine; 36 doctors resigning in the city of Quibdo, in eastern Colombia, after months without pay; a young man dying after waiting for hours to be admitted to the hospital.
Since 1993 the government has regulated health care through the Ministry of Health and Social Protection. There are two types of standing in the health-care system - contributive or subsidized. The first is for people who have some kind of income, the second for the unemployed.
Benefits for the first group are financed with a percentage of their monthly salary, while benefits for the second group come from government contributions. At the moment, both types of membership, which affect 96% of the population, are in question.
The contributive regime is delegated to the private sector and managed by the Healthcare Services Promotion Companies (HSPC). All working Colombians pay 12.5% of their monthly salary in contributions to the health care system. Freelancers and independent contractors pay the whole 12.5%; employees pay 4% of their salary into the health-care pot, while their employer picks up the rest. The loot that the HSPC networks must have is incredible.
The National Audit Office has opened cases totaling $683 million against the various HSPCs. Half of the HSPCs are suspected of corruption; the government has imposed precautionary anti-corruption measures on 36 out of 76 of them, and one has been taken over completely by the government. In all, the Colombian government and the HSPCs owe hospitals and clinics $2.243 billion, and 775,102 lawsuits have been filed by citizens against the government concerning access to medical care.
The corruption problem has raised the question of whether private companies should continue to control public money for what is considered a social right, or whether the government should control the system once more, as it did prior to 1993. At the same time, there are also critics of the government’s cases against the HSPCs. “There hasn’t been a single guilty sentence, everything is just investigations,” says Colombian congresswoman Gloria Diaz.
There are also problems with the subsidized health plans, which also involve HSPCs. The companies are accused of fictitious accounts, inflated prices for drugs and medical procedures, double-billed supplies and medicine that is never used, as well as of the use of state money for political campaigns. The National Audit Office insists that if the money were all invested in health care, there would be enough. A study by the same office discovered that in 2010, 75% of the $840 million meant for health care in 74 municipalities was lost.
As the government studies the workings of the HSPCs, it is taken for granted that more than half of them will disappear. The measures announced by Colombian President Juan Manuel Santos include an injection of $672 million to ease the budget pressure on hospitals and clinics, as well as the creation of a guarantee fund to save HSPCs in crisis. It would also restructure the system and combine the contributive and subsidized membership options.
The president affirmed that the current model will continue. This did not exactly please the many people who want a change. “It’s a slap in the face to think that after the HSPCs robbed us, we now have to give them money,” said Francisco Yepes, a public health professor at the University of Javeriana.
Several associations of scientists and doctors have presented Congress with proposals for the government to regain control. “In saying that there needs to be a structural change, we are not saying that the private companies need to disappear, but that the government should be the dominant representative of the public good,” Yepes explained.
For their part, the HSPCs say that federal and municipal governments owe them more than $2.243 billion, and that they are being unfairly accused of causing a crisis that has been 10 years in the making and has many more contributing factors. “Unpaid bills among the various parties have made the financial costs unmanageable. Resources that are supposed to be used for everyday operations are being used for financial leverage,” explained Alvaro Cobo, president of the Asocajas association, a group of HSPCs.
For Juan Carlos Giraldo, director of the Colombian Association of Hospitals and Clinics, the most important reform is to change who has possession of the money. Right now, the HSPCs get the money in advance. “That is the source of all the problems, because every time someone needs a service, it means that the insurers have to get money out of their pockets. If we change that, we will make everything easier,” he said.
The government says that the current regime has increased health coverage, but the detractors ask whether or not that matters if no one is able to access health services at all. The increase in the number of tuberculosis patients is one argument detractors use, saying the government is not addressing prevention. “The situation in Colombia should be a warning for other countries that have tried to imitate us. It should also be a warning for the World Bank and the Inter-American Development Bank, which have both been promoting the Colombian model,” Yepes said.
The debate is on the table, and advocates of change have said that they will take the issue to a referendum, if necessary. Hopefully the government’s new measures will keep the system alive, even if they are not enough to get it out of intensive care.
In San Diego, California, a researcher tracked how in the city's low-income neighborhoods that have traditionally lacked dining options, when interesting eateries arrive the gentrification of white, affluent and college-educated people has begun.
SAN DIEGO — Everybody, it seems, welcomes the arrival of new restaurants, cafés, food trucks and farmers markets.
What could be the downside of fresh veggies, homemade empanadas and a pop-up restaurant specializing in banh mis?
But when they appear in unexpected places – think inner-city areas populated by immigrants – they're often the first salvo in a broader effort to rebrand and remake the community. As a result, these neighborhoods can quickly become unaffordable and unrecognizable to longtime residents.
An appetite for gentrification
I live in San Diego, where I teach courses on urban and food geographies and conduct research on the relationship between food and ethnicity in urban contexts.
In recent years, I started to notice a pattern playing out in the city's low-income neighborhoods that have traditionally lacked food options. More ethnic restaurants, street vendors, community gardens and farmers markets were cropping up. These, in turn, spurred growing numbers of white, affluent and college-educated people to venture into areas they had long avoided.
This observation inspired me to write a book, titled The $16 Taco, about how food – including what's seen as "ethnic," "authentic" or "alternative" – often serves as a spearhead for gentrification.
Take City Heights, a large multi-ethnic San Diego neighborhood where successive waves of refugees from places as far away as Vietnam and Somalia have resettled. In 2016, a dusty vacant lot on the busiest boulevard was converted into an outdoor international marketplace called Fair@44. There, food vendors gather in semi-permanent stalls to sell pupusas, lechon (roasted pig), single-sourced cold-brewed coffee, cupcakes and tamarind raspado (crushed ice) to neighborhood residents, along with tourists and visitors from other parts of the city.
Informal street vendors are casualties.
A public-private partnership called the City Heights Community Development Corporation, together with several nonprofits, launched the initiative to increase "access to healthy and culturally appropriate food" and serve as "a business incubator for local micro-entrepreneurs," including immigrants and refugees who live in the neighborhood.
On paper, this all sounds great.
But just a few blocks outside the gates, informal street vendors – who have long sold goods such as fruit, tamales and ice cream to residents who can't easily access supermarkets – now face heightened harassment. They've become causalities in a citywide crackdown on sidewalk vending spurred by complaints from business owners and residents in more affluent areas.
This isn't just happening in San Diego. The same tensions have been playing out in rapidly gentrifying areas like Los Angeles' Boyle Heights neighborhood, Chicago's Pilsen neighborhood, New York's Queens borough and East Austin, Texas.
In all of these places, because "ethnic," "authentic" and "exotic" foods are seen as cultural assets, they've become magnets for development.
A call for food justice
Cities and neighborhoods have long sought to attract educated and affluent residents – people whom sociologist Richard Florida dubbed "the creative class." The thinking goes that these newcomers will spend their dollars and presumably contribute to economic growth and job creation.
Food, it seems, has become the perfect lure.
It's uncontroversial and has broad appeal. It taps into the American Dream and appeals to the multicultural values of many educated, wealthy foodies. Small food businesses, with their relatively low cost of entry, have been a cornerstone of ethnic entrepreneurship in American cities. And initiatives like farmers markets and street fairs don't require much in the way of public investment; instead, they rely on entrepreneurs and community-based organizations to do the heavy lifting.
In City Heights, the Community Development Corporation hosted its first annual City Heights Street Food Festival in 2019 to "get people together around table and food stalls to celebrate another year of community building." Other recent events have included African Restaurant Week, Dia de Los Muertos, New Year Lunar Festival, Soul Food Fest and Brazilian Carnival, all of which rely on food and drink to attract visitors and support local businesses.
Meanwhile, initiatives such as the New Roots Community Farm and the City Heights Farmers' Market have been launched by nonprofits with philanthropic support in the name of "food justice," with the goal of reducing racial disparities in access to healthy food and empowering residents – projects that are particularly appealing to highly educated people who value diversity and democracy.
Upending an existing foodscape
In media coverage of changing foodscapes in low-income neighborhoods like City Heights, you'll rarely find any complaints.
San Diego Magazine's neighborhood guide for City Heights, for example, emphasizes its "claim to authentic international eats, along with live music venues, craft beer, coffee, and outdoor fun." It recommends several ethnic restaurants and warns readers not to be fooled by appearances.
Longtime residents find themselves forced to compete against the "urban food machine"
But that doesn't mean objections don't exist.
Many longtime residents and small-business owners – mostly people of color and immigrants – have, for decades, lived, worked and struggled to feed their families in these neighborhoods. To do so, they've run convenience stores, opened ethnic restaurants, sold food in parks and alleys and created spaces to grow their own food.
All represent strategies to meet community needs in a place mostly ignored by mainstream retailers.
So what happens when new competitors come to town?
Starting at a disadvantage
As I document in my book, these ethnic food businesses, because of a lack of financial and technical support, often struggle to compete with new enterprises that feature fresh façades, celebrity chefs, flashy marketing, bogus claims of authenticity and disproportionate media attention. Furthermore, following the arrival of more-affluent residents, existing ones find it increasingly difficult to stay.
My analysis of real estate ads for properties listed in City Heights and other gentrifying San Diego neighborhoods found that access to restaurants, cafés, farmers markets and outdoor dining is a common selling point. The listings I studied from 2019 often enticed potential buyers with lines like "shop at the local farmers' market," "join food truck festivals" and "participate in community food drives!"
San Diego Magazine's home buyer guide for the same year identified City Heights as an "up-and-coming neighborhood," attributing its appeal to its diverse population and eclectic "culinary landscape," including several restaurants and Fair@44.
When I see that City Heights' home prices rose 58% over the past three years, I'm not surprised.
Going up against the urban food machine
Longtime residents find themselves forced to compete against what I call the "urban food machine," a play on sociologist Harvey Molotch's "urban growth machine" – a term he coined more than 50 years ago to explain how cities were being shaped by a loose coalition of powerful elites who sought to profit off urban growth.
I argue that investors and developers use food as a tool for achieving the same ends.
When their work is done, what's left is a rather insipid and tasteless neighborhood, where foodscapes become more of a marketable mishmash of cultures than an ethnic enclave that's evolved organically to meet the needs of residents. The distinctions of time and place start to blur: An "ethnic food district" in San Diego looks no different than one in Chicago or Austin.
Meanwhile, the routines and rhythms of everyday life have changed so much that longtime residents no longer feel like they belong. Their stories and culture reduced to a selling point, they're forced to either recede to the shadows or leave altogether.
It's hard to see how that's a form of inclusion or empowerment.
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