This article was originally published on Red Pepper in November 2013 - By Rosalind Adams and Charlotte Sexauer.

Protests for better health care on an archipelago off the coast of Chile demonstrate the successes of local mobilizations in Chile, as well as the failures of the larger social movement.

Next Thursday, as many as 200,000 students will once again march through the streets of Santiago calling for reforms to Chile’s education system.

The demonstrations have been a regular affair since 2011, but as the education movement faces an impasse against an unresponsive government winding down its administration, the students’ influence on regional movements may be one of their greatest accomplishments. Across Chile, residents are taking their cue from the students and using the same organizing tactics to fight for better access to health care, increased job security and environmental concerns, among other issues.

But despite local victories, both regional movements as well as the larger, more visible student movement have so far failed to spark reforms to the country's larger structural problems inherent in a system built upon a former dictatorship.

The island of Chiloé

A movement for better access to health care services on the archipelago of Chiloé highlights both these successes and failures.

In response to months of demonstrations—including protests, occupations of the local health ministry and petitions listing demands—Chile’s Health Minister Jaime Mañalich wrapped up a three-day tour of Chiloé earlier this month, where he committed to a total investment of US$175 million that will improve funding for basic health services as well as hospital infrastructure.

“This is a concrete answer for residents, no more promises or speeches,” Mañalich told local media during his visit.

Chiloé is home to only about 150,000 residents scattered across 32 islands off the coast of Chile, though most are concentrated on the main island of the same name. A region that developed largely independently from the rest of the country, its landscape is radically different: Rolling green pastures boast flocks of sheep that produce the well- known wool common to the islands; vibrant colored houses called “palafitos” stand on stilts above the water, and bartering is common as the cost of living is high, though resources are slim.

Residents—they call themselves Chilotes—also have much poorer access to healthcare than their compatriots on the mainland. They often face long, expensive trips off the island for necessary health services; local hospitals lack the standards employed by the rest of the country, as well as critical specialists; and in cases of emergency it is time- consuming to transport patients to a location with the necessary facilities. Frequently, people here refer to the problem simply as one of the islands’ insularity.

“Our geography sets us apart,” said a midwife who works in the hospital in Ancud. “It is very expensive to live here and truly, a baby born here hasn’t got the same chances as one born in Santiago.”

Anatomy of a Local Movement

While this has long been the reality for Chilotes, a string of deaths over the past year brought new urgency to the issue, mobilizing local politicians, citizen action groups as well as labor unions to call the government’s attention to the issue.

Miriam Marcela Ojeda, who was 25 weeks pregnant, died of a brain hemorrhage in the hospital of Puerto Montt early in July after being shuttled back and forth between the hospitals in the municipalities of Ancud and Castro that lacked the specialists to handle the emergency, losing valuable response time.

In May, Verónica Cosme was misdiagnosed several times by doctors in her local hospital in the distant municipality of Quellón, before finally passing away due to complications from the H1N1 virus, also in the Puerto Montt hospital.

“She wasn’t given the attention she deserved and paid the price of death,” said Alejandra Guerrero, a friend of Cosme and spokesperson for the family.

These cases, among others, became important symbols of the health movement in Chiloé. They put faces to the cause, stirring a public debate across the archipelago about health care and compelling locals to express their grievances.

Citizen action groups, known as social assemblies began sprouting up across the main island of Chiloé two years ago, originally in support of the student movement that was gaining ground across the country. Leaders describe the assemblies as democratic spaces for debate and discussion. But as the groups continued meeting, the focus shifted to improving the quality of healthcare for its residents.

“The health care problem really hit us hard. People were dying from lack of care. We couldn’t ignore it any longer,” describes Claudio Vásquez, leader of the social assembly in Castro.

The assemblies have mobilized more than 3,000 citizens to action across seven different, yet related organizations. The strength of the movement is visible: in many towns across Chiloé, it is common to see signs calling for “salud digna” or “respectable health care” posted on front yards and in shop windows, or spray-painted on edifices.

In an interview, Mañalich disputed the fact that the insularity of the islands necessarily caused these deaths, saying that there were more than 40 fatalities across the country due to the H1N1 virus this past year, and that brain hemorrhages generally have low survival rates. But it is hard to challenge that these cases have been fundamental to mobilizing people across Chiloé.

The health minister did agree that Chiloé is in need of attention, describing it as one of the remote parts of the country that has lagged behind in its development.

“The health infrastructure is very precarious. Cities like Castro and Ancud—major urban centers of the island—have hospitals that are very inadequate,” he said.

The mayors of each of Chiloé’s ten municipalities have also been an active part of this movement, forming their own petition of demands, and appealing directly to Mañalich.

“This preoccupation for better health care has been a long time coming in Chiloé, but it’s really since last year that people have been wondering, ‘when are we going to get up and fight for our rights?’” said Paulina Reinoso, who serves as the Director of Health under the mayor of Castro. 

Of fundamental concern to the mayors has been the per capita amount that the government provides for primary healthcare services—it is the same in every region across the country—arguing it should be higher in Chiloé to account for its insularity. The social assemblies have largely focused on raising the standards of the hospitals and building a base hospital on the island with more specialists. But together, their joint efforts have successfully garnered attention from the government.

The Success of Chile’s Regional Movements

Chile—which from north to south runs the same distance as London to Tehran— encompasses a variety of climates, economies and needs. The sentiment that has developed across Chiloé’s islands is just one example of the country’s growing culture of collective action finding success at the regional scale.

In early 2011, protests broke out in the southern tip of Chile, after the government proposed a 17% hike in natural gas prices. Affordable fuel is essential to life in the blistery region and thousands created road blockades, leaving tourists stranded who were visiting the popular Torres del Paine National Park. Eventually, the government conceded and after negotiations, and chose to reduce the hike from 17% to 3%.

Last year, fisherman in the Aysén region protested a law that they said would hurt local fisherman in the interests of big fishing companies. After weeks of blockades that shut down the region, the government signed an agreement with the Aysén social movement to inject US$10 million into efforts to promote local fishing.

“Regional or local protests have been quite successful in that they make a lot of noise and basically the government, which is under siege by many other movements— particularly the student movement—is tempted to pour some money [into these issues] ... and basically buy the regional or local movement into staying quiet,” said Javier Couso, a constitutional law professor at Diego Portales University.

Andreas Feldmann, a political science professor at Chile’s Catholic University, sees the specificity of the demands, as well as their ability to shut down entire regions of the country, as the key to their effectiveness. 

“It creates panic in the government—in many ways it needs to act,” said Feldmann. “Otherwise it creates the message that the country is not governable.”

Local movements have also been key to blocking controversial mega dams and mining projects. In Chile’s arid northern region, where the country’s valuable minerals are concentrated, new energy projects that have been planned to support mining projects have faced heavy local opposition, though these victories are significantly more difficult to achieve.

Most recently, the coal plant Punta Alcalde has been stalled by an injunction filed by the marine conservation group Oceana on behalf of the activist group SOS Huasco. Local groups in the Huasco valley have been mobilizing against the controversial Pascua- Lama mine for a decade, which is currently stalled. And in Chile’s southern Patagonia region, the proposed mega dam project HidroAysen also remains stalled in a government committee against a backdrop of rampant local distaste for the project.

New Proposals for Chilotes by the Government

In Chiloé, the narrative is one of success, like many of these stories.

Mañalich first visited the archipelago in May, after heavy protests broke out in Quellón over Cosme’s death, and the social assembly of Castro occupied the health ministry for 30 hours demanding the minister visit the island. At the conclusion of meetings with both the mayors and social assemblies in Ancud, Castro and Quellón, he vowed to return in two months with answers for the islands.

The health minister discussed the importance of his visit, saying that in addition to his addressing the practicalities of the issues, the people want to know, is the government listening to us, as citizens?

“And of course we are listening,” said Mañalich. “This is the best way to understand the necessities of the people. We can’t meet every demand, but we are willing to listen.”

During his most recent visit—in a meeting with the Mayors Council of Chiloé Province early in August—Mañalich proposed an additional US$4 million to improve health services for 2014 that will go towards subsidizing the per capita fund. It is to be approved as part of the annual budget next month in Congress. It includes an emergency fund to inject new resources into the island’s health care needs for the remainder of the year.

Additionally, the hospital in Castro will be expanded, and new hospitals in Quellón and Ancud have been planned, said Mañalich. So far, the Ministry of Social Development has acquired the tracts of land for these projects and the minister confirmed they are moving forward. This will bring the total investment in health care services and infrastructure for the island to 90 billion pesos, or about $US175 million, according to his estimates. The commitment is stunning considering the island’s population, and reflects the success of the collective action movement.

Largely, Mañalich has been incredibly responsive to the mobilizations here, approving of the collective efforts of citizens and local politicians.

“What’s happening here, with the students and the health movement, is the citizens are going out and demanding their rights,” he said. “Culturally, Chile is changing quickly and what’s at stake here is the legitimacy of the democratic institutions: the ability to go out to your democratically elected representatives to express grievances,” added Mañalich.

Chile’s Wider Social Movement

Many of the themes of Chiloé’s movement for better access to health care are consistent with the wider social movement that continues to gain steam across the country, representative of the underlying frustrations that exist in Chile.

In the most recent national strike organized on July 11 by the Central Workers Union (CUT) in association with the umbrella student organization CONFECH, the social assemblies joined in local marches across Chiloé. Residents used the opportunity to march for their own cause of improving access to health care, while supporting the efforts of labor unions and students.

As Ruth Oyarzún describes, a leader of the labor union ASEMUCH in Ancud, the causes are like-minded.

“The trade unions joined the social assemblies in protest because our demands go across our areas of work and everyone is affected—from students to workers in both the public and private sectors," she said.

At the heart of these movements is outrage against the country’s growing socio- economic inequality. While Chile is often touted as one of the strongest economies in Latin America, its income inequality is the most severe among the Organization for Economic Co-operation and Development (OECD) countries.

Andrés Zahler, a professor of Public Policy at Diego Portales University and Harvard scholar, has conducted research showing that less than 20% of Chileans have incomes fitting for a developed country, while the rest live at a much lower level.

Sin lucro, or without profit, is frequently chanted in various protests across the country, or scribbled on buildings in Santiago, as excessive profiteering is often seen as a root cause of many these issues. For example, while it is illegal for schools in Chile to earn profits, a number of loopholes allow owners of private universities to skirt this regulation.

Similarly, labor unions often find fault with the privatized pension system known as the AFP, allowing fund managers to profit, while workers’ pensions are tied to market volatility. In Chiloé as well, stickers bearing the phrase sin lucro are plastered in the windows of the hospitals in Ancud and Castro. After the hospitals close, doctors may rent out rooms to see private clients that can afford to pay more for services, while most locals lack options for specialized care.

“For the past 40 years, Chile has implemented the idea that the public services are for the poor, and the private services are for the rich, and that they are better,” said Vásquez. He also sees the causes of the social movement as closely intertwined.

Much of this is rooted in the policies of Gen. Augusto Pinochet’s dictatorship, which prized privatization and aggressive market capitalism. Despite multiple democratic administrations since the end of Pinochet’s rule in 1990, the constitution remains intact with few amendments, as well as much of the legal infrastructure that allows these types of profiteering to continue.

Professor Couso is one of the authors of the recent book “The Other Model,” which delves deeper into the structural problems of Chile. He considers the neoliberal policies put into place by Pinochet as radical when considered on a global scale, pointing to examples like Chile’s privatized prison system and public transportation system run by private companies.

“There is not a public regime that governs when private entities develop public services,” he said.

Failure to find unity

While these regional movements have found success, they are not adding up to a movement that seeks to change these underlying problems in Chile, even though they are linked by the same themes.

“What is common to all is that they have realized how powerful the possibility of protest is,” said Couso.

But even if all 365 municipalities in Chile started protesting, he said, it does not necessarily add up to one greater movement.

“There is an idea that you only get respected if you protest. But that doesn’t necessarily mean it connects all the movements together,” he explained.

While in Turkey and Egypt for example, protesters have found centralized, physical locations of protest—the now well-known Gezi Park and Tahrir Square—Chile’s movement has suffered from the fractured nature of its protests. They are unified in ideology, but not always in their issues or location. This has allowed Piñera’s cabinet to solve several of these outcries one by one, rather than commit to the large structural changes the country demands.

The student movement is certainly the most prominent of Chile’s protests and one of the most sustained, successfully mobilizing hundred of thousands in regular marches and protests over the past several years. But it also has seen little movement in its goals, remaining committed to grandiose demands, which many see as unrealistic. And while it has been an influential force on these local movements, it has also failed to really become a true unifying force.

Chile’s flagging student movement

Part of the difficulty is the transitory nature of being a student. The leaders during the peak of Chile’s student uprisings in 2011 and 2012, which regularly engaged in talks with the government over specific demands, have graduated. Former leaders like Giorgio Jackson and Camila Vallejo (The Guardian’s person of the year in 2011) are now running for Congress, motivated to create structural change from within the political system.

Today’s student leaders have grown dogmatic, sticking to its anthem that copper should be nationalized in order to fund free education at all levels for students. Many lament this goal, saying even if education were free, it fails to get really address the problem of its quality.

Copper was nationalized under the former president Salvador Allende, who committed suicide during the coup d’etat that would install Pinochet as the future president. But even this happened over several stages, and there has been little talk among the student leaders of intermediary steps to reach this goal.

Sociology professor Manuel Antonio Garretón of the University of Chile, who studies social movements and experienced the student occupations on his own campus, says the lack of interaction between the government and student leaders is hurting the plight of the students.

“In 2011, the political system cared what was going on with the students and it was challenged, but today it doesn’t care,” he said. “Today, the student movement is not challenging the political system.” Instead, “you have two dynamics developing, isolated from each other.”

Indeed, the center-right businessman, President Sebastián Piñera remains largely unmoved by this aspect of the social movement. His most recent moves to push through several legislative bills against “encapuchados,” the hooded protesters that habitually appear at the end of student marches to wreak havoc, reflect his strategy to change the public conversation of education into one of law and order.

“In many ways the government and the political parties have reacted only rhetorically to their demands, so they are growing increasingly frustrated about it,” said Feldmann.

As Piñera’s administration comes to a close, it is also clear that there is no time to really solve the deeper structural problems that lie at the heart of this problem, he added.

Support for the movement is also eroding among Chileans. Shops in central Santiago are shuttered on the days of student protests, in anticipation of the inevitable destruction that transpires at their close. When you ask people here about the student movement, many groan or scoff. While education remains an important issue for Chileans, there is a sense of fatigue over the protests that regularly rock the country’s capital, where half of the country’s population is concentrated.

Professor Garretón verbalized this sentiment, saying that the student protests and occupations of schools are just becoming part of the fabric of Chile, rather than a means to achieve substantive progress.

“[These mobilizations] are not linked to some concrete goals but they have become some way of being a student, some way of living, some way of life,” he said. “And that is the main problem.”

New Solutions

The most important result of the student movement may be the trickle down effect it has had on these various regional movements across the country. Feldmann sees the development of these local protests as influenced by the students as well as other protests unfolding globally.

“Definitely there is a diffusion of other movements that have been going on elsewhere— in the region, in the world,” he described. “But this diffusion is also going on locally from the student movement.”

According to Couso, the deeper problems must be addressed with a new constitution for any effective change to happen. In his book, he and his co-authors call for this, among a range of policy shifts designed to bring greater control of the country's institutions back to the public. 

Michelle Bachelet, the former president and frontrunner in this year’s presidential election, has called for a new constitution as part of her campaign’s platform, but it is difficult to see how she will muster the political will to make this happen. After Pinochet’s dictatorship ended, one of the first points of order was changing the country’s privatized water system, but it took 12 years before even a modest amendment was approved by Congress.

There is also widespread distrust of Bachelet among activists and the student leaders, who believe much of her former administration was dedicated to upholding the policies of Pinochet.

Though it is unclear what exactly will engender the structural changes that Chile needs, until then these local protests are at least winning victories on a smaller scale, making impacts on the quality of life on a local level.

Ana Vera, the head of the social assembly in Quellón, conceded that their fight is not over, but she is pleased that their efforts had brought new proposals from the government.

“Our actions forced the government to respond,” Vera said, saying her group will continue to work toward the construction of the new hospital in Quellón.

“It is clear that had we not mobilized, nothing would have been achieved.”