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Colombian scientific medicine began with José Celestino Mutis, a Spanish botanist, mathematician, physician, and professor of anatomy who arrived in Bogota in 1761 as the viceroy‟s personal physician. In 1802 medical teaching started in the Our Lady of the Rosary Major College223 (Rosselli, H., 1960) and later the Central Faculty of Medicine was created in 1826 by Francisco de Paula Santander, the Colombian War of Independence hero who laid the political, administrative and legal foundations of the young republic. However, the political instability of the time affected the continuity of this faculty. By the 1840s anyone who wanted to be a physician could either become a student of a qualified doctor in a system of „free teaching‟ or go abroad to study, for instance, in Europe and particularly in France (Miranda, 1993, p. 20).

In 1873 a group of a few doctors in Bogota created the National Academy of Medicine that later would be officially recognised by Law 71 of 1891 and, as ratified by Law 02 of 1979, was made the national government‟s consultant and advisor regarding public health and medical education (Miranda, 1993, p. 110). This Academy played an important role in the creation of Law 23 of 1981, best known in Colombia as the „medical ethics law‟ (Otero, 2003, p. 81). In 1935 the Colombian Medical Federation224 hereafter CMF was created. This association was “interested in promoting the progress of Colombian medicine and in safeguarding the profession‟s moral principles” (A. Jaramillo, 1968). In 1962 the CMF promoted the legal regulation of the medical profession through Law 14 of 1962 and previously was also involved in the promulgation of a “magnificent code of medical morality”225

(A. Jaramillo, 1968).

In the early 1900s, Colombia experienced a first wave of modernisation which went hand in hand with an increase of foreign investment, particularly from American companies. The industrialised world wanted to „open the tropics‟. In this new economic environment philanthropic organisations like the Rockefeller Foundation played an important role in improving social conditions that affected the new [American] economic projects (Quevedo, et al., 1993, p. 213). In 1931 a French medical mission visited the country emphasised that

223

Colegio Mayor de Nuestra Señora del Rosario.

224

Federación Médica Colombiana.

225

This code was not very well received by many Colombian doctors and it discriminated those who were not practicing Catholics.

155 medical schools should be a source of professionalism, with high standards in teaching and research, and an early contact of students with patients was advised. By the 1940s the concept of social security came into being as a result of new insights into health and social welfare. Then the first institutions to provide healthcare to workers were created, for instance, the

Institute for Social Security in 1946 (Redondo & Guzmán, 2000, p. 69). At the end of the

1940s and early 1950s two American missions visited the country to promote structural and ideological shifts in healthcare and medical education: The Unitary (or Humphrey) Mission in 1948, and the Tulaine (or Lapham) Mission, in 1953.

According to the Unitary Mission it was necessary to strengthen basic pre-clinical sciences, cut the number of students, increase the number of full-time teachers and spend more time on students‟ supervision. In short, this mission “recommended a reorganisation of training following the Flexner226 programme, consisting of two years of basic sciences and four years of clinical studies, followed by one year of internship” (Marston & Ospina, 2004). In 1949 a compulsory social service year was introduced. Thus newly graduated doctors were to go to a remote area or part of the country with high demand for medical services where they would work for one year while being paid by the state (Quevedo, et al., 1993, p. 263). With the Tulaine Mission, internal medicine became the model for medical education and the length of the programme increased to six years. At the beginning of the 1950s, Colombia had four faculties of medicine, three public227 and one private.228 In the following ten years, three more were created. It has been argued that these new medical schools would provide cheap medical labour for the US (Miranda, 1993, p. 146) and during the 1960s the exodus of Colombian doctors to the US was a public concern (Calibán, 1967; Galindo, 1968). The Tulaine Mission also suggested the creation of an association of medical schools. In 1959 the National Association of Faculties of Medicine, ASCOFAME was created.229

The mid-twentieth century thus marked a turning point for the Colombian medical ethos from the „classic‟ French style of practice to the „pragmatic‟ American one. Since the second half of the nineteenth century, France had been a favourite destination for Colombians to

226

For a whole picture of the impact of A. Flexner‟s medical education reform in the USA at the beginning of the twentieth century, see: Cooke, M., Irby, D. M., Sullivan, W. & Ludmerer, K. M. (2006). American Medical Education 100 Years after the Flexner Report. New England Journal of Medicine, 355(13), 1339-1344.

227

National University, University of Antioquia, and University of Cartagena.

228

Javeriana University.

229

See ASCOFAME‟s webpage:

http://www.ascofame.org.co/index.php?option=com_content&view=article&id=1&Itemid=2, accessed 28 August 2011.

156 study medicine. However, throughout the first half of the twentieth century more and more doctors would travel to the US for two reasons. First, because of the leading role of American medicine, and second the Second World War prevented people from going to Europe (Otero, 1994). By the 1950s there were clashes between junior doctors who had recently returned from the US and senior teachers who had remained bound to the style of French medical practice. It became clear that “the poetic inspiration of French medicine [had given way to the] one hundred per cent positivist [American] mentality” (Miranda, 1993, p. 133).

In the 1960s doctors were concerned about becoming salaried workers of socialised medicine institutions and the bad effects of this change on their profession as they would be subjected to external rules. Doctors feared the end of medicine as a liberal profession (Redondo & Guzmán, 2000, pp. 63, 86), i.e. the end of medical autonomy. As a result, medical unions became relevant,230 which were seen as necessary to defend medics‟ rights and promote the welfare of the new „medical proletariat‟ (Galindo, 1968; A. Jaramillo, 1968). Medical strikes had a great impact in the 1970s, and they became a „daily bread‟ for Colombian society (El Tiempo, 1970, 1973b, 1976a, 1976b). During these medical strikes some accused doctors of careless and selfish behaviour (El Tiempo, 1963a, 1966, 1973a). Although doctors were still described as “respectable, worthy […] educated and patriotic people” in the newspapers (El Tiempo, 1963a) and were honoured and greatly appreciated (El Tiempo, 1963b), their behaviour and various aspects related to their profession were now under scrutiny in the mass media. By the mid-1970s doctors would be condemned for forgetting their profession‟s “humanist side, deontology, and apostolate” (Castelblanco, 1973), depicted as “bad managers” (El Tiempo, 1974b), and, along with lawyers, seen as “morally deficient” (Lerner, 1975). Some non-medical voices started to become louder, arguing that medical unions should be more committed to renovating society rather than with doctors‟ salaries (Escribano, 1974), that citizens‟ opinion should be taken into account and not only doctors‟ requests for privileges (El Tiempo, 1974a), and that the medical profession should be legally regulated, similarly to how it was in the US (Mora, 1976).

How many and what kind of physicians the country required also became an issue that doctors and non-doctors would discuss more and more. Critical medical lecturers argued that Colombia conformed to American demands of medical education too much, for example, by

230

For instance, the Colombian Medical Union [Asociación Médica Sindical de Colombia, ASMEDAS) that was created in 1958 (Calibán, 1967).

157 promoting among doctors „super-specialisation‟, but failed to train GPs fit to practise within the country‟s particular socio-political and economic conditions (El Tiempo, 1971; Fergusson, 1964). Even tropical diseases were removed from the medical curriculum in a tropical country like Colombia and doctors became better trained to treat people in France or US than in Colombia (De Zubiría, R., 1972). By the early 1960s a minister of health said that “it was necessary to inundate the country with doctors” (El Tiempo, 1963c) as in many areas there was none. By the mid-1970s it was said that half a country lacked a doctor, with a worse situation in rural areas (Castelblanco, 1975; Turbay, 1974). New medical faculties were opened to deal with this problem (El Tiempo, 1978). By the early 1980s the debate about suitable medical education for the country had not ceased, but the focus shifted as some began to warn about a surplus of physicians and that it was therefore not advisable to create more faculties of medicine (Campo, 1981; El Tiempo, 1983).231 Moreover, there were concerns about a decrease in the quality of medical education as a phenomenon linked to the creation of new medical schools and also about the geographical distribution of doctors since they tended to remain in the major cities of the country, while the number of health professionals in small cities and rural areas remained insufficient (Moanack, 1983; Sánchez, 1981).

In the 1970s private healthcare insurance companies started to manage a significant part of the Colombian healthcare market. Many doctors deplored the price competition imposed by these companies and their detrimental influence on doctors‟ private practice. Nevertheless, many doctors ended up working for them (Redondo & Guzmán, 2000, pp. 63, 86). In 1975 a National Health System was created (Vega, 1999, p. 36), but this system was by no means similar to the UK‟s NHS. Rather, it was a non-unitary system that included many autonomous institutions, and although in 1975 the government had embraced the World Health Organisation‟s campaign Health for All by the Year 2000, its commitment was limited to simple actions regarding health promotion, prevention and the improvement of very basic medical services (de Currea-Lugo, 2003, pp. 77, 79). By the end of the 1970s the impact of socialised/corporative medicine and the increase in medical lawsuits led to a discussion about the nature of medicine and doctors‟ legal and ethical duties. By the end of this decade a group of doctors in the Academy organised workshops to discuss the creation of a code of medical

231

158 ethics. In 1981 the Congress passed a bill that became Law 23 of 1981, or the national Code of Medical Ethics.