Abstract

Introduction

Lack of healthcare for the rural population, a secular problem of the territories that formed the Kingdom of Spain(^c(c)However, the existing difficulties did not imply a total absence of professionals in rural areas. Several studies have shown that the healthcare needs of small and medium-sized towns were covered by a dense network of health professionals, especially surgeons trained through a guild system outside the university.), was not solved with the implementation of the Compulsory Health Insurance (SOE, according to its Spanish acronym)¹1 España. Decreto de 11 de Noviembre de 1943, por el que se aprueba el Reglamento para la aplicación de la Ley del Seguro de Enfermedad. Boletín Oficial del Estado. 28 Nov 1943. in 1944(^d(d)The SOE was established in 1944, although the law creating it was published at the end of 1942.), after the Spanish Civil War (1936–1939). It was a Bismarck-like healthcare system that, for the first time in the country, it socialized the fascist healthcare provided by the dictatorial regime established by General Francisco Franco²2 Vilar-Rodríguez M, Pons-Pons J. The Introduction of sickness insurance in Spain in the first decades of the Franco Dictatorship (1939-1962). Soc Hist Med. 2012; 26(2):267-87.

3 Pons Pons J, Vilar Rodríguez M. El seguro de salud privado y público en España: su análisis en perspectiva histórica. Zaragoza: Prensas de la Universidad de Zaragoza; 2014.^-44 Bueno Vergara E, Perdiguero Gil E. Mejor curar que prevenir: dispositivos asistenciales y actividades preventivas en el primer franquismo. En: Moreno Seco M, Fernández Sirvent R, Gutiérrez Lloret RA, editores. Del siglo XIX al XXI Tendencias y debates. Alicante: Biblioteca Virtual Miguel de Cervantes; 2019. p. 1972-83.. Thus, the assistance of the SOE was under the Ministry of Labor, although it was managed through an autonomous body, the National Welfare Institute (INP, according to its Spanish acronym). However, it wasn’t until the Special Agrarian Social Security Regime, implemented in (1966)⁵5 España. Ley nº 38, de 31 de Mayo de 1966. Sobre régimen especial agrario de la seguridad social. Boletín Oficial del Estado. 2 Jun 1966., and its successive modifications, implemented in (1970-71)⁶6 España. Ley nº 41, de 22 de Diciembre de 1970. Por la que se perfecciona la acción protectora y se modifica la financiación del Régimen Especial Agrario de la Seguridad Social. Boletín Oficial del Estado. 31 Dic 1970.^,77 España. Decreto nº 2123, de 23 de Julio de 1971, por el que se aprueba el texto refundido de las Leyes nº 38, de 31 de Mayo de 1966, y nº 41, de 22 de Diciembre de 1970, por las que se establece y regula el Régimen Especial Agrario de la Seguridad Social. Boletín Oficial del Estado. 21 Sep 1971., that the welfare situation of rural workers began to improve, although not without serious financing problems⁸8 Vilar Rodríguez M, Pons Pons J. La cobertura social de los trabajadores en el campo español durante la dictadura franquista. Hist Agrar. 2015; (66):177-210.. Healthcare inequalities between the rural and urban areas did not improve ostensibly until the General Health Law was approved in 1986, during the democratic period. Despite this law, many inequalities remained⁹9 Otero García L. Campos de soledad. Atención primaria y procesos asistenciales en pueblos de Segovia [tesis]. Tarragona: Universitat Rovira i Virgili; 2012..

The implementation of the SOE significantly changed the professional situation of the physicians, due to varying employers and the demand of the population. Both aspects influenced the medical practice, resulting in changes that not always were well accepted by doctors.

The objective of this article is to analyze the limitations of the assistance provided in the rural areas at the time, and the doctors’ resistance against its extension in the second period of the Dictatorship (1959-1975)(^e(e)Identifying the different periods within a long dictatorship (1939-1975), such as that of General Franco after his victory in the Civil War, is problematic. However, there is certain consensus regarding the second period, which started after the autarkic economic model was dissolved and Spain joined the liberal economy.), in which there was a strong exodus from the rural areas to the cities. The sources used for the analysis have been the vast governmental publications –that sheds light on the unsuccessful attempts to ensure the availability of doctors and other healthcare workers in rural areas–, publications from official professional associations, such as the Boletín del Consejo General de Colegios de Médicos de España (Boletín), the regular press focused on medical practice (Profesión Médica, Tribuna Médica), documents from the municipal archives of the province of Alicante regarding the performance of healthcare workers and, lastly, reports on the situation of rural assistance throughout the nation.

To understand the changes experienced by the rural population and physicians under the gradual extension of healthcare insurance to incorporate the rural population, it is necessary to briefly describe the situation before the SOE was implemented. The access to healthcare of the Spanish population was extremely unequal due to socioeconomic and geographical reasons¹⁰10 Perdiguero-Gil E, Comelles JM. The roots of the health Reform in Spain. In: Abreu L, editor. Health care and government policy. Évora: Publicações do Cidehus; 2019.. Private healthcare, with payment per medical act, was only available to the predominantly urban middle and upper classes. For physicians, this meant the idealisation of the medical practice, forged throughout the nineteenth century, although for most it was a wish rather than a reality¹¹11 Valenzuela Calendario J. El espejismo del ejercicio libre. La ordenación de la asistencia médica en la España decimonónica. Dynamis. 1994; 14:269-304.. In the urban industrial settings, the available option was the associations of mutual assistance, the successor of the brotherhoods and of other types of mutual aid societies, which provided medical and pharmaceutical assistance, among other services³3 Pons Pons J, Vilar Rodríguez M. El seguro de salud privado y público en España: su análisis en perspectiva histórica. Zaragoza: Prensas de la Universidad de Zaragoza; 2014.^,1212 León Sanz P. Professional responsibility and the welfare system in Spain at the turn of the 19th century. Hygiea Internationalis. 2006; 1(5):75-90.. According to the Health Law of 1849¹³13 Reglamento general para la ejecución de la ley de beneficencia de 20 de junio de 1849. Gaceta de Madrid. 16 Mayo 1952., charity hospitals in provincial capitals and other municipal charitable bodies provided healthcare to the poor communities. In the rural areas, district practitioners were responsible for the healthcare of these populations. Their official title with roots in the late Middle Ages¹⁴14 Ferragud Domingo C. Medicina i promoció social a la Baixa Edat Mitjana (Corona d’Aragó, 1350-1410). Madrid: Consejo Superior de Investigaciones Científicas; 2005. was médicos titulares, and it evolved to a governmental body, the Public Home-based Care (APD), which was accessed by nation-wide merit competition¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124.. Thanks to the municipal charities, these physicians were the only option in many rural municipalities, a role that was not relevant in urban areas. Because of this, they attended to those in need as well as the rest of the inhabitants of these municipalities under different payment systems that covered all possible issues (annual, quarterly, etc.), called the iguala. The SOE overlapped with the network of workers’ mutual system, the charitable institutions, the APD practitioners, and the iguala. There were many consequences of this process in rural areas.

The implementation of the SOE and its limitations in rural areas

The creation and implementation of the SOE was the materialization of the most ambitious assistance project developed by the Dictatorship. Its objective was to provide healthcare to industrial workers with low incomes, called “financially weak”, which, according to the estimates by Pons and Vilar³3 Pons Pons J, Vilar Rodríguez M. El seguro de salud privado y público en España: su análisis en perspectiva histórica. Zaragoza: Prensas de la Universidad de Zaragoza; 2014., constituted a quarter of the Spanish population. The healthcare network for the newly insured (contributing workers) and beneficiaries (their relatives), was articulated in two ways. On the one hand, a total of 17.000 doctors were hired, on a part-time basis, to care the insured employees. On the other hand, the pre-existing and well-established charity network, which comprised practitioners, midwives, pharmacists, and healthcare assistants took on a more relevant role(^f(f)For the present study, we will focus on the physicians). Thus, from 1948, the APDs were also designated as SOE practitioners. In urban areas, and from an economic point of view, combining the free exercise of the profession and the exercise under the SOE was well received, as it offered another source of income in a labor context marked by multiple employment¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124.^,1616 González Madrid DA. Apuntes para un análisis crítico sobre la asistencia médica general y ambulatoria de la Seguridad Social del tardofranquismo a la Transición. En: González Madrid DA, Ortiz Heras M, editores. El estado del bienestar: entre el franquismo y la transición. Madrid: Sílex; 2020. p. 199-230.. Despite this, physicians greatly disagreed with the socialization of medicine, as we have analyzed in other works, especially when the salary thresholds for affiliation to the SOE gradually increased and, therefore, a greater number of workers were included in the system¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124..

Although field workers were not explicitly excluded from the healthcare provided by the SOE, they were unable to access it due to their status as temporary workers. As a result, the limited implementation of the SOE in rural areas did not result in remarkable changes in the medical care of the rural community, as the organization remained under the scope of the traditional charitable system and the aforementioned iguala. The legislation echoed the differences between the services offered in the urban areas to the detriment of the rural communities, as reflected in the preamble to the Law on the Bases of National Health, enacted in 1944¹⁷17 España. Ley de 25 de Noviembre de 1944, de Bases de Sanidad Nacional. Boletín Oficial del Estado. 26 Nov 1944..

Issues of medical practice in rural areas according to its protagonists

In this context, APD doctors clearly and repeatedly marked the differences that existed between professionals who practiced in urban areas versus rural areas. The rural/urban rift affected the entire population, as evidenced by the massive and generalized migration flow from the countryside to the city that took place during this period. However, given that the district doctors followed the reversed path –from university to the rural community– and enjoyed a certain status that allowed them to express their concerns, we are now able to understand the issues from their perspective¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124..

The most notorious characteristic of the medical practice in the field during this period was the personal and professional estrangement from the urban practice. Professionally, scientific-experimental medicine was linked to hospitals¹⁸18 Vilar-Rodríguez M, Pons-Pons M. El sistema hospitalario público y privado en España en las primeras décadas del Franquismo (1942-1963). En: Vilar-Rodríguez M, Pons Pons M, editores. Un siglo de hospitales entre lo público y lo privado (1886-1986). Madrid: Marcial Pons; 2018. p. 179-261., institutions necessarily located in urban areas. Meanwhile, the healthcare provided in the rural areas was mainly general medicine, which took place in the home, in small dispensaries, or in the doctor’s own home, who had an office specifically for this purpose. Thus, the gradually expanding “hyper specialty” was not usual practice in smaller communities, where it was practically anecdotal¹⁹19 España. Ministerio de Trabajo. Libro blanco de la Seguridad Social. Madrid: Ministerio de Trabajo, Subsecretaria de la Seguridad Social; 1977.. This remoteness was also evidenced in the impossibility of maintaining contact with other colleagues and learning about the latest medical news at the scientific congresses since they could hardly attend. During training, only the journals from the pharmaceutical laboratories and, over the years, the visitors, were the link between rural practice and the advances in medical knowledge and practices²⁰20 Mayor Domingo F, editor. La asistencia sanitaria en las zonas rurales. Madrid: Centro de Estudios de Asistencia Sanitaria; 1979..

Personally, staying in small towns was perceived as an exile, a palpable feeling widely reflected in the sources. Given the university training of doctors and their social aspirations, participating in the social and cultural life in rural communities was difficult. As per the request of the professional journal Tribuna Médica, writer Ángel María de Lera reported wrote a series of reports regarding professional life in the rural communities, that appeared during 1965 and were later collected and published in a single volume. These articles intended to convey, through interviews, the lives of the district doctors in the exercise of their profession in isolated rural areas. The interviewees repeatedly conveyed the feeling of abandonment, as Francisco Javier Vadell Miranda, practicing in Salomó (Tarragona), highlighted:

This loneliness that they expressed through different means also involved their wives, who sometimes worked as assistants in their practice without receiving any type of institutional recognition. It was frequently mentioned that their offspring were sent away after primary school to continue with their studies.

Sometimes, the arrival of a foreign practitioner to a municipality with its own social dynamics gave rise to open or hidden conflicts with the residents, other practicing physicians, and non-regulated health workers. Occasionally they would also feel misunderstood by part of a population clinging to what they considered atavistic beliefs. In one of the articles published in the Boletín, Mariano Jiménez Ruiz, APD in Urda (Toledo), a town of about 5.500 inhabitants, expressed in a story how “the concepts of the minds of the villagers” were imposed on medical science²²22 Jiménez Ruiz M. La última inyección. Boletín. 1948; (18).. The narrative –centered on a case of typhoid fever– showed the delicate balance of hegemony and subordination between the patients and the doctor, who could tilt in favor of the former.

In the opinion of the physicians, this situation hindered their practice, of similar importance as of the apostles, who were supposed to bring the light of scientific knowledge to the profane territory. In these terms, Santiago Ibarz Grao, APD in Peralta de Alcofea (Huesca), described in fiery words the different disagreements that arose upon his arrival in the municipality, which he had faced as part of “that army of ‘medicine missionaries’ that was to carry the banner of science and charity to all corners of our nation”²³23 Ibarz Grao S. Carta Abierta a Don Antonio Alarcón Peñafiel. Boletín. 1948; (16):48-9.(p. 49). We have dealt extensively with this missional conception of the rural doctor in previous works¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124.^,2424 Perdiguero Gil E, Bueno Vergara E. “Hay una diferencia entre la medicina social y la socializada”: las resistencias de los médicos españoles a la colectivización de la asistencia sanitaria y la ampliación de la cobertura sanitaria (1944-1963). En: González Madrid DA, Ortiz Heras M, editores. El estado del bienestar: entre el franquismo y la transición. Madrid: Sílex; 2020. p. 95-124..

In addition to the professional and personal exile of the practitioners in rural areas, the most frequent complaints found in the medical press referred to their fees. Determining their average income is not easy, as there are numerous variables involved such as the size of the community, the number of neighbors under the iguala, the clientele that paid per act, and multiple employment, that in any case, did not reach the level of the cities. Also, the General Health Board (DGS, according to its Spanish acronym) updated their salaries at different times during this period, making it difficult to draw general conclusions. According to the information gathered in Por los caminos de la medicina rural (Along the Paths of Rural Medicine), salaries ranged between 1.650 and 11.000 pesetas per month²¹21 De Lera ÁM. Por los caminos de la medicina rural. Salamanca: Graficesa; 1966.. It’s worth noting that in 1965, the minimum interprofessional monthly income was 2.520 pesetas per month²⁵25 Maluquer de Motes i Bernet J, Llonch M. Trabajo y relaciones laborales. En: Tafunell Sambola X, Carreras i Odriozola A, editores. Estadísticas históricas de España: siglo XIX-XX. Bilbao: Fundación BBVA; 2005. p. 1155-246.. Despite this amount, an overwhelming majority considered that their income was insufficient, as –according to their testimonies– they were available twenty-four hours a day, seven days a week, 365 days of the year, and were not legally entitled to vacation days.

Regulatory attempts to improve rural assistance

On top of the issues that directly affected the medical profession in rural areas, there were also organizational deficits that the Francoist authorities tried to address. To this end, exhaustive legislative work was carried out to centralize, rationalize, and control the practice of the APD physicians.

Apart from very specific measures that regulated rural healthcare¹⁵15 Comelles JM, Perdiguero-Gil E, Bueno E, Barceló-Prats J. Por caminos y veredas: la práctica médica rural bajo el franquismo (1939-1979). En: Martínez-Pérez J, Perdiguero-Gil E, editores. Genealogías de la reforma sanitaria en España. Madrid: Los Libros de la Catarata; 2020. p. 63-124., the most important milestone was that the government assumed payment of the fees of the district doctors. Until then, the municipalities or provincial administrations (Diputaciones) were responsible for paying the salaries of the physicians but, due to financial difficulties, they accumulated considerable debts with the healthcare workers. Because of this, the DGS(^g(g)The DGS was under the Ministry of the Interior, and it dealt with public health, district doctors and other healthcare workers.) took over the payment of salaries to the APDs. In 1941²⁶26 España. Ley de 31 de Diciembre de 1941, por la que se dispone que los haberes correspondientes a los Médicos Titulares de Asistencia Pública Domiciliaria. Boletín Oficial del Estado. 14 Ene 1942., included the smallest municipalities and, by 1961²⁷27 España. Ley nº 4, de 19 de Abril de 1961, por la que se dispone que los haberes correspondientes a los Médicos titulares de primera y segunda categoría se hagan efectivos con cargo al Presupuesto General del Estado. Boletín Oficial del Estado. 21 Abr 1961., it was already extended to include all district doctors regardless of the size of the locality in which they worked, thus culminating the centralizing process.

The authorities also attempted to control and put an end to one of the main ills afflicting rural healthcare: absenteeism of village doctors without previous notice. The preamble of the regulation approved focused on putting an end to this situation described it as an “anomalous and chaotic government”²⁸28 España. Orden de 27 de Junio de 1945 por la que se dan normas a las que habrán de ajustarse los Médicos de APD para ausentarse del lugar de su destino. Boletín Oficial del Estado. 2 Jul 1945.. This situation tried to be remedied by requiring the practitioners to notify any absence of more than twentyfour hours. For this purpose, two record books under the control of the municipalities were created, one for introductions and one for terminations. These books contained information regarding their permits, the duration of the permits, the granting authority (Provincial Healthcare Headquarters or DGS), and the destination. At the same time, a disciplinary regime was established to punish the unjustified abandonment of the work post with financial and administrative fines.

Understanding the actual degree of implementation of these measures is challenging, given the fragmentation and dispersion of historical sources in small municipalities. In the cases where these record books have been kept, such as, for example, in the Alicante town of Onil(^h(h)A town located in the province of Alicante, with a population of 2.919 inhabitants in 1950, which was home to significant industrial activity.), we can verify that absences were effectively controlled as the medical absences’ entries match the return to the workplace(ⁱ(i)Municipal Archive of Onil, Libro-registro de presentaciones de médicos, 884/1, and Libro-registro de salidas de médicos, 884/2.). However, only two years are recorded, 1952 and 1953, which prevents us from drawing any broader conclusions in this regard. Despite the long period of time recorded, the existing data for the municipality of Hondón de Los Frailes(^j(j)Also located in the province of Alicante, with a population of about 600 inhabitants in 1950, it had a predominantly agricultural activity), provides information limited to the designation of the practitioner and his subsequent termination, with hardly any data on temporary absences(^K(k)Municipal Archive of Hondón de los Frailes, Libro-registro de salidas de médicos, 227/17, and Libro-registro de presentaciones de médicos, 227/18).

The documentation, however, allows us to confirm the high degree of intermittency that characterized the practitioners of rural areas. Thus, in Hondón de los Frailes, between 1947 and 1965, fifteen different regular physicians were appointed, some of them occupying the position in several different periods. This was a problem that persisted throughout the entire period covered by this study, evidencing an unsuccessful legislative action by the Dictatorship. The district doctor positions in smaller towns were particularly unattractive due to the low income and the greater isolation so that they were generally fulfilled by young recent graduates who abandoned their assignment as soon as they had the chance²⁰20 Mayor Domingo F, editor. La asistencia sanitaria en las zonas rurales. Madrid: Centro de Estudios de Asistencia Sanitaria; 1979..

About the rationalization, the reorganization of healthcare constituted one of the issues most mentioned in the professional press. The rural healthcare was organized based on “medical districts”, a territorial demarcation comprising one or more municipalities, whose population had to be assisted by the practitioner. These districts could be “open” if other physicians could practice freely, or “closed” if only the APD practitioner was allowed to practice, something that sought to guarantee to the latter the economic income generated by the work outside the care of the poor. The long-awaited reform was to establish a rational system that would avoid work overload for rural physicians, limiting as much as possible the constant travel within and outside the district, and ensuring the economic income of the district doctors. This reform, which was delayed, took place in a rural world increasingly depopulated by migration to the cities. The reorganization of the districts began in 1967²⁹29 España. Decreto nº 188, de 2 de Febrero de 1967, por el que se adoptan medidas preliminares en orden a la revisión de plantillas de los Cuerpos Sanitarios Locales. Boletín Oficial del Estado. 13 Ene 1967. and it was approved the following year. This reorganization entailed the elimination of four hundred and sixty-four positions that were added to another nearby district with a larger population³⁰30 España. Decreto nº 3279, de 26 de Diciembre de 1968, por el que se aprueba una reestructuración parcial de partidos médicos farmacéuticos y veterinarios. Boletín Oficial del Estado. 17 Ene 1969.. The objective of this modification was to ensure the presence of physicians in the municipalities and that the income of the professionals would increase by increasing the number of insured persons, peers, and potential private patients, on a pay-per-doctor basis. Although these measures led to a decrease in the number of available healthcare positions in small municipalities, these positions often remained unfilled for long periods and when they were filled, it was only for short periods of time.

This reform gave rise to conflicts, such as the one that occurred in the town of Onil. In May 1967, the Preliminary Draft for the restructuring of the medical districts³¹31 Anteproyecto de la subcomisión provincial de reestructuración de partidos sanitarios. Boletín Oficial de la Provincia de Alicante. 13 Mayo 1967. was published, eliminating one of the two positions in the municipality. In this and other surrounding municipalities, such as Ibi, a flourishing industry based on the manufacture of toys had developed, which led to a demographic increase. Thus, unlike so many other places in rural Spain, Onil had seen an increase in its population, which went from 3,202 in 1960 to 3,838 in 1966, according to the municipal census. The City Council pleaded to the restructuring project before the Provincial Healthcare Headquarters, intending to maintain the two designated positions(^l(l)Municipal Archive of Onil, Expediente de reclamación instruido por la amortización de una plaza de médico titular, 884/4.). Along with the demographic defense, the plea emphasized on the “many work-related accidents” caused by the outstanding manufacturing activity and the specific care they required. The industrial economic sector also offered their support, which was recorded through the adhesion that was signed and sealed by up to thirty-eight companies, almost all of them dedicated to the manufacture of dolls. Two fundamental pillars of the Franco regime also joined the request: the Spanish Syndical Organization and the Falange, the only trade union and party allowed by the Dictatorship. Likewise, the General Association of Household Heads expressed its disagreement with losing a practitioner and the resulting economic loss. They argued that each doctor saw about eighty or ninety patients a day, causing long waits at the dispensary, a circumstance that would worsen if the reform were to persist.

All the problems related to the medical exercise in rural areas we have mentioned contrasted with the notable local status that doctors held during the period under study. Despite the constant complaints in the professional press about the loss of authority, at the beginning of the democratic transition, physicians enjoyed the greatest prestige among the community, far ahead of other recognized professionals such as teachers, veterinarians, pharmacists, priests, the city council secretary, and healthcare assistants. This distinguished position, based on their education and the importance of healthcare for the community, was the counterpoint to the shortcomings of life in rural areas.

It was not uncommon for district doctors who settled in a town to end up holding positions of responsibility, such as mayor, or receiving varied honors such as naming streets or squares. The latter is the case of José Sanmiguel Tarazona in the town of Sant Joan d’Alacant(^m(m)Town located in the province of Alicante, with about 3.912 inhabitants in 1950.), who worked in this town from 1946 until his retirement in 1968. Upon unanimously granting the title in 1975, the City Council emphasized the traits of the ideal type of rural doctor, highlighting their “great work, not only in healthcare, but also as a human” as the “legendary figure of the family doctor” and their role as a “friendly, loved and respected doctor” offering the community “understanding, science, affection and, above all, unreserved dedication to their profession”(ⁿ(n)Municipal Archive of Sant Joan d’Alacant, Nombramiento de hijo adoptivo a José Sanmiguel Tarazona, 1115-07.).

The tributes paid to rural doctors by municipal corporations or medical associations were, to a certain extent commonplace and contrasted with the complex situation of an activity carried out in an agrarian environment in obvious decline. The ambitious project of the “great” national monument to the rural doctor (1964) was an example of that situation. The Medical Association of Guadalajara had the initiative and found the enthusiastic support of the whole profession through the General Council of Medical Associations, the Ministry of Labor, and the DGS. The monument was a big equestrian figure (the sculpture measured 55 feet) located in one of the typical rural areas of Spain, the province of Guadalajara, and it attempted to display the attributes that adorned the image of the rural practitioners³²32 Visea Bustamante JM. Un grandioso monumento al médico rural. Tribuna Med. 1964; 24:4-5.. The endeavor received considerable media coverage in the general and press dealing with medical practice but soon fell into oblivion. At the end of 1966 the Dictatorship decreed a salary increase for the district doctors, and the monument, which was conceived as recognition and a labor claim, became meaningless.

Expansion of healthcare to farm workers

There were many attempts to extend healthcare to rural areas, but all were faced with technical or logistical problems, as well as the seasonal nature of farm labor, the resistance of agricultural employers, contribution fraud, and systemic financing deficits. As a result, the agricultural sector joined the insurance system later than the industry and service sectors. The implementation of the National Agricultural Welfare Service of 1958 and the National Agrarian Welfare³³33 España. Decreto nº 613, de 23 de Abril, por el que se crea la Mutualidad Nacional de Previsión Agraria. Boletín Oficial del Estado. 27 Abr 1959. the year later, was delayed and failed to improve the situation, even reducing the number of contributors⁸8 Vilar Rodríguez M, Pons Pons J. La cobertura social de los trabajadores en el campo español durante la dictadura franquista. Hist Agrar. 2015; (66):177-210..

It was not until 1966, with the approval of the law on the Special Agrarian Social Security Regime, that an attempt was made to provide healthcare to farmworkers “as similar as possible” to the healthcare provided to workers in the industry and the service sector, according to the Law on the Bases of Social Security³⁴34 España. Ley nº 193, de 28 de Diciembre de 1963, sobre Bases de la Seguridad Social. Boletín Oficial del Estado. 30 Dic 1963.. The preamble to the regulation on the Special Agrarian Social Security Regime expressly manifested the need to maintain an agricultural labor force presently at risk of being compromised because of the current migratory flow:

This measure –which had been in the making since the approval of the Law of Bases–, was closely followed by the medical profession, especially by the district doctors, who saw the payments under the iguala reduced –their main source of income– as the result of the greater national coverage.

Numerous examples clearly illustrate this resistance. For example, in the column of Tribuna Médica dedicated to interviewing presidents of Regional Medical Associations, the interviewees stated their disagreement with the advances of Social Security in rural areas. Marcelino Martín Luelmo, president of the Zamora Medical Association, pointed out how they had “raised the alarm” before the General Council of Medical Associations due to the plans to extend healthcare coverage in the country³⁵35 Robles S. Al habla con el presidente del Colegio de médicos de Zamora, Dr. D. Marcelino Martín Luelmo. Tribuna Med. 10 Abr 1965.. We can also find statements along the same lines in the Boletín, for example, in an unsigned article: “Difficult times for the rural doctor: Social Security advances relentlessly”³⁶36 Momentos graves para el médico rural: la Seguridad Social avanza implacable. Boletín. 1965; 2(9):17-9.(p. 17). This text analyzed the repercussions of extending healthcare to rural areas, a policy that was the culmination of previous attempts to implement a system of rural protection. We found similar thoughts in Profesión Médica, such as that of the president of the College of Physicians of Cuenca, E. Valero, who predicted the conversion of the rural doctor into just another migrant who moved from the country to the city, in search of better job opportunities³⁷37 Valero E. La situación del médico rural en nuestra provincia es angustiosa para muchos. Profesión Med. 30 Ago 1966..

Antonio Salamanca Rodríguez, national representative of the APD Medical Corps in the General Council of Medical Associations of Spain, noted that these attempts dated back to the entry into force of the SOE in 1944, which reduced the income from the iguala to a quarter. These estimates are not very credible and must be considered with the intention to safeguard the income generated by the iguala. It is worth noting how in the late Franco era, district doctors still considered the Insurance as the beginning of the end of their profession as they knew it. They felt it threatened the archetypal that they themselves had built and that Antonio Salamanca summarized as “human, intimate, cordial medicine of direct contact, which the rural doctor or the district doctor can provide as opposed to the scientific medicine applied to the masses, at fixed and scheduled times” and that the socialized medicine represented³⁸38 González Yañez R. Con el Dr. D. Antonio Salamanca Rodríguez, de Valladolid, vocal por los médicos titulares. Tribuna Med. 12 Feb 1965..

Conclusion

As demonstrated, healthcare in rural areas was neglected in within the healthcare structure during the Dictatorship. Thus, while in urban areas the most ambitious social policy project of the early Franco regime –the SOE– was deployed, although not without difficulties, the structures of charitable assistance were still fundamental in the country. At the same time, the situation was exacerbated by an important migration flow from the countryside to the city, which progressively emptied the rural world.

The study of the different realities that emerged as a result of this process is inevitably burdened by the absence of patients’ voices. However, after reviewing other sources, we have been able to approach the perspective of the medical personnel responsible for providing care in small communities and, also, the legislation enacted by the Government to try to reorganize the district doctors and include agricultural workers in the healthcare coverage. Thus, physicians who practiced in the rural sector were lavish in their accounts of the increasing distance that separated them from the physicians in urban areas. Rural medicine was foreign to the knowledge learned in universities, progressively based on medical specialties and with hospitals as the epicenter. Daily practice in rural Spain was characterized by precarious resources, endless working days, low wages, and lack of rest. Moreover, the professionals perceived their life as an exile in a foreign and often hostile environment.

The national policy and regulations sought to centralize the organizational structures of rural healthcare and to pursue the neglect detected in many medical districts and reorganize them. While the centralization process was completed –although it was a secular transformation–, the new classification of the medical districts was limited to the elimination of practitioner positions, provoking the objection of some of the population. At the same time, the neglect of care in the country remained a reality until the end of the Dictatorship. This situation contrasted with the attempts to extend healthcare coverage to the rural areas, especially through the Special Agrarian Social Security Regime. The district doctors perceived these attempts as the final blow to their profession, which decline had begun with the timid implementation of the SOE in the rural areas and which had been severely affected by the process of depopulation and the advance of Social Security, limiting the income they received from the iguala.

Acknowledgments

The authors thank the Tordesillas Doctoral Schools of Public Health and History of Science for the institutional support provided. We also appreciate the considerations made by our colleagues Josep M. Comelles and Josep Barceló, with whom we have been maintaining a fruitful academic and personal dialogue over the last years.

References

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