Remedies for Democratizing Health in Venezuela

Halfway up the hill, in a semi-finished, rustic house, a sheet divides the consulting room from the treatment room. Rarely is there a need to identify oneself upon arrival. “How are you Mr. Antonio, has your pressure decreased?” says the 53 year-old Venezuelan nurse Carlota Núñez. Antonio goes in and, little by little, the inhabitants of the neighborhood Las Terrazas de Oropeza Castillo, municipality Sucre, Caracas move through the waiting room.

In the consultation room, one of the 11,000 Cuban physicians that make up the Barrio Adentro (Into the Neighborhood) [1]] health program gives basic medical attention to the public. Measuring blood pressure, calming asthma attacks; vaccinating the children and even delivering babies are some of the tasks of Dr. Carlos Cordeiro, who attends an average of 25 patients per day.

“We do preventive medicine. The idea is that if the people learn to live better, they will not need medicines”, he explains. When it is necessary, more than 100 varieties of medicines, brought from Cuba, are available to patients free of charge.

The 31 year-old doctor, who left his family in Cuba eleven months ago, recounts that the land for building the clinic was donated by a neighborhood resident. “We had to finish building the house. All the community helped. A neighbor brought a table, another made the stretcher, and another donated the chairs, blocks and cement. We are used to working with little”, says Cordeiro, who lives in one of the three rooms of the house. “I am on call 24 hours a day. If someone needs attention, Carlota (the nurse) calls me and we go immediately.”
This is one stage of the health program born of a cooperative agreement between Cuba and Venezuela that began in 2001.

Venezuela, the fourth largest exporter of petroleum in the world, sends 53,000 barrels daily to the island. In addition to aiding in the literacy campaign of Hugo Chávez’ government, Cuba sends medical aid and medicines to Venezuela.

Due to the lack of technology and adequate infrastructure in the public hospitals, nearly 17,000 Venezuelans have traveled to Cuba to complete treatment and for orthopedic and ophthalmologic surgeries.

Privatization and health

Exclusion and elitism are among the recurrent illnesses from past decades. Venezuela is an example of the dismantling of the public health system promoted by the neo-liberal avalanche that was applied to Latin America in the 1990’s. Privatization and decentralization annihilated the possibility of maintaining public hospitals, which were substituted by for-profit, private clinics.

For those of limited financial resources, two alternatives remained: the payment of medical consultations (which cost an average of 35,000 bolívares, or US$18), or waiting in queues for days at a public hospital, in hopes of receiving attention. Privatization was so complete, that even in the public hospitals, the patients were “accustomed” to paying small fees for attention and to pay for the supplies utilized by the physicians.

“Before we had to leave early in the morning, risking our lives, waiting in line all day and many times returning home without being seen” 77 year- old Paula Páez recalls. She now receives a daily visit from the physician to control her blood pressure. “Here many people have died for lack of attention. If someone had hypertension, by the time they were able to get aid, it was already too late, the person had a heart attack”, she comments.

Illness of the rich

Access to the barrios is not easy. To get there it is necessary to take old, large jeeps that wind around the narrow and solitary roads up the hills. At night, the streets are deserted and there is no transportation of any kind.

Venezuelan physicians, “educated” in the logic of private health care, did not dare to go up the hills to attend the needs of the population in this panorama of exclusion, precarious life conditions, and difficult access. The president of the Venezuelan Medical Federation (FMV), Douglas Léon Natera explains: “The government says that it cannot guarantee our safety. How are we then going to go into the hills where there are all kinds of marginalized people?” For him it is not possible to practice his profession under precarious conditions. “It is fiction that one can save a life with just a stethoscope”, he says.

According to Ministry of Health data, from April 2003 to July 2004, 16,485 lives were saved and 808 childbirths were attended in a total of more than 43 million medical visits under the Barrio Adentro Program.
One of the arguments the FMV used to justify its opposition to the government program was that supposedly it fails to employ 11,000 unemployed or under-employed physicians, as Natera called them, in order to employ Cubans that, according to him, earn US$750 per month for “dispensing ideology”. At the start of the program, the main argument for the opposition’s campaign to throw the Cuban physicians out of the country was that the Cubans came to “inject communism” into the veins of the population.

As to the payment of the Barrio Adentro physicians, according to the Ministry of Health, the Cuban government pays the salaries of the professionals, which are handed over to their families in Cuba and the Venezuelan government provides a monthly remuneration around 420,000 bolívares (US$ 210) for food and transport expenses.

The preference that Venezuelan physicians have for unemployment rather than working in the government program is justified by the FMV president with a simple argument. “We will not submit to those conditions. The government should equip the hospitals and clinics”, Natera affirmed.

The population also feels the absence of the state in the public hospitals. Even though the presence of the Cuban physicians reduced regular hospital visits by 25%, when patients are in serious condition they are sent to hospitals, and there they are confronted with uncertain conditions. There is a lack of physicians and of medicines.

Gustavo Salas, director of the Gestión Ciudad (City Action) program that forms part of the Barrio Adentro program in Caracas, admits that many hospitals continue to be abandoned. According to him, one of the barriers to state efficiency has been the intense political dispute in the country. He affirms that, “In the states where governors and mayors are in opposition, we find resistance and sabotage towards the reform of the hospitals.”

Meanwhile, hospital reform and refitting are not yet a priority for the health program. The main strategy of the Barrio Adentro program is to create small consulting offices and so-called popular clinics in the centers of peripheral areas. “The hospitals are far from these communities and that is why we give preference to clinics that are at the bottom of the hills”, explains Salas.

Change of course

The great majority of Venezuelan physicians’ rejection of the preventative medicine concept, which is expanding throughout the nation, is justified through a neo-liberal lens. To re-educate the public in order to prevent illness is to go directly against the interests of pharmaceutical companies and private clinics.
“We are confronting the resistance of the doctors that control the health market. If we reach excellence in attention, we will no longer need their services,” explained Diana Verdi of the Health Committee Coordination, an organization made up of 800 Venezuelan doctors participating in the Barrio Adentro program.

Hundreds of Health Committee volunteers circulate through the barrios staffing afternoon shifts at the clinics while resident physicians visit patients at home. “We need health education. This includes family planning, nutrition and exercise. It is part of community building,” says Diana Verdi.

At the heart of the peripheral barrios, the health program is more organized and homogenous. “This is Barrio is Adentro with make-up,” comments Victor Navas, one of the volunteers who serves as a guide for curious visitors who come to see the achievements of the “Bolivarian Revolution”. Although different from the semi-finished, community-built clinic on the hill, this clinic, also in Sucre (a municipality of 1 million inhabitants), has the official face and colors. It was built and equipped by the government.

In the middle of the patio, surrounded by hills, a group of handicapped people exercise using weights made of containers filled with sand, led by a doctor who coordinates the activity three times a week. A few meters away from this group of new “athletes”, a small line of men, women, and children wait to see the dentist. “We began this treatment two months ago when the dentist arrived. Previously we had no dental treatment. An appointment elsewhere would be too expensive,” commented Maria Albaron, mother of two boys. A visit to a cheap, private dentist costs around 20.000 bolivares (US$10)

Prescription of the World Bank

Even if the 11,000 physicians who refuse to work in the poor barrios would participate in the health program, barely half of the country’s health problem would be resolved. According to the former minister of higher education, Héctor Navarro, the country has a 20,000 physician deficit. Nearly 70% of the population lacks basic attention. “We have a humanitarian crisis on our hands,” says Navarro, justifying the need for the medical aid offered by Cuba.

As is also true for other social aspects, the problem of health care cannot be separated from the economic development structure adopted by the country. In the 70’s, the petroleum bonanza years, the logic of importing consumer goods prevailed. Industrial and technological development became “dispensable” and consequently it was seen as unnecessary to advance the educational level of the population.

“At that time, the view of the World Bank was that the country should spend resources that should have been destined for technical training, at the universities. It was what we needed most,” explained Navarro.
With the lack of investment and incentives for higher education, only a small class of privileged people was able to attend university. The great majority of the current Venezuelan physicians are products of that period.

One of the alternatives proposed by the Department of Higher Education that has generated much controversy within the faculties of medicine at the public universities, has been the adoption of a new teaching model to qualify medical professionals in a shorter time.

Héctor Navarro believes that in little more than three years it is possible to train a physician for emergency primary care in the areas of surgery and first aid. “The current situation requires the presence of trained doctors. If someone needs emergency attention, and a physician does not have six years of training, he is going to opt for letting that person die, as already has happened”, Navarro says.

The sectors that are opposed to the proposal argue that it is necessary to safeguard the quality of teaching. “This concept of quality is completely divorced from reality and in this case is hypocrisy. Juxtaposed to quality is justice. Without justice there is no quality”, affirms Navarro.

Another medium-term solution constitute the graduates of the Latin-American School of Medicine in Havana, which has more than 7,000 students from all over the continent. The first group of 500 new doctors will return to Venezuela at the end of this year. “As new doctors are formed, we will replace the Cubans. We know that we cannot count on their aid forever”, the former minister affirms.

Translated by Dawn Gable and Maria Paez Victor