Face to Face with People’s Health in Caracas, Venezuela
- Padma
Comrade Surya and I were in Venezuela in December 2005 when we were inspired by the inroads the Bolivarian revolutionary process was making in the areas of health, education and workers rights. At that time we were unable to obtain a first hand experience of the remarkable free public health care system (Barrio Adentro). Mission Barrio Adentro also called Inside the Neighbourhood programme was founded in 2003 by the government headed by Hugo Chavez with the help of Cuban health care professionals. In May 2008, we were able to get permission and help from Ministry of the Popular Power of Health and National Direction of Indigenous Health in Caracas, Venezuela. They arranged an extensive tour for us of the Barrio Adentro levels 2 and 3 over a period of 3 days.
Brief History of Health Care in Venezuela before Barrio Adentro
After the Second World War, Latin American countries in general used government interventions and protection to promote national development and industrialization. Welfare state policies were developed throughout the 1950s and 1960s. Venezuela in particular with its large petroleum and gas reserves helped to develop a decent health care system. The health expenditure which accounted for 13.3% of the national budget in 1970 fell to 9.3% in 1990 and a mere 7.8% in 1996. Decreased oil revenues in the 1980s contributed to the socioeconomic crisis (1). In 1989 figures indicate close to 54% of Venezuelans living in extreme poverty. Health care reforms dictated by World Bank and Inter American Development Bank in the 1990s led to expansion of the private health care sector and erosion of public health services. 50 new public health facilities were established in the 1980s and 1990s in contrast to 400 private clinics. A 1985 study revealed that in the capital city Caracas, inspite of the large number of doctors practising there, people had difficulty accessing medical care. In rural communities medical care was being provided by inexperienced doctors.
Barrio Adentro Programme – Inception and Results
After the victory of Hugo Chavez in the 1998 elections which was fought on an anti neo liberal platform, a new Bolivarian constitution was drafted by a special constituent assembly. Article 83 views health as a fundamental human right that the state is obligated to guarantee. Articles 84 and 85 expand on the duty of the state to create and manage a universal public health system providing free services and financed through taxes and oil revenues.
The concept of Barrio Adentro emerged in 1999 when torrential rains caused havoc in the state of Vargas. Poor people living in crowded barrios (neighbourhoods located in the hilly peripheries of urban centers) were affected. Several thousand people were killed by mud slides, 8000 homes were destroyed and up to 100,000 people displaced. The Cuban government responded in its usual humanitarian fashion by sending 454 Cuban health care workers. Based on this experience, the government in Caracas requested the help of the Venezuelan medical community to work with the underserved poor in the barrios. Little more than 50 Venezuelan doctors responded to the advertisement. The Venezuelan Medical Association has been a vociferous adversary of the free health care system enshrined in the Bolivarian constitution, not surprising as the vast majority of its doctors are from the elite and upper middle class families.
In April 2003, 58 Cuban doctors specialising in integrated family medicine started to see patients in various barrios in Caracas and its periphery (2). Within 2 months of launching the program named Mission Barrio Adentro by President Hugo Chavez, 1000 Cuban doctors were working in the working class neighbourhoods. 4 months later in 2003 their numbers doubled and Cuban health professionals were going into areas in Venezuela which had not sighted medicos for decades. By the end of 2003, more than 10,000 health care professionals were dispensing free health care all over Venezuela. So began the heart warming relationship between Cuba and Venezuela based on solidarity and human needs.
Barrio Adentro I provides basic primary and preventive health care. There were 4,800 health clinics in Venezuela in 1998. 6,569 new basic health clinics have been set up since then through the Barrio Adentro I programme. The clinics in the barrios have a characteristic hexagonal structure, the patients are seen below and the doctor and the nurse have living quarters upstairs. Health care committees have formed in the barrios with women largely heading the committees and they work hand in hand with the health professionals.
Barrio Adentro II was launched in 2005 to provide more sophisticated care. The Barrio Adentro II programme which consists of Integral Diagnostic Centers (CDI), Integral Rehabilitation Centers (SRI), and High Technology Centers (CAT) now has a total of 1,235 installations in the whole country which give free medical treatment to all Venezuelans. CDIs provide emergency services, intensive care treatment, diagnostic and laboratory procedures including cat scans, ECG and endoscopy. The CDIs and the SRIs represent four components of health care- prevention, promotion, treatment and rehabilitation.
Barrio Adentro III was launched in 2005 initially to upgrade 42 existing hospitals in the country which has now included 90 hospitals. The goal would be to upgrade all the existing 300 or so hospitals in the country. Barrio Adentro IV will involve construction of new hospitals in the country.
The facts are there for everyone to see. In 1998 there were 1628 primary care physicians for a population of 23.4 million, now there are 19,571 for a population of 27 million. In the Barrio Adentro program, per the statistics released by the Ministry of Health in 2007, there are 12,272 Cuban doctors and 1,935 Venezuelan doctors. With the other personnel included there are a total of 25,561 Cubans and 10,614 Venezuelans working for the health of the population. In 1998, the life expectancy was 71 years, now it is 73. The infant mortality rate has dropped from 21 to 13 per 1000 live births. The maternal mortality rate has dropped from 67 per 1000 to less than half that number.
The SUMED (Distribution of Medicine) programme works with the Barrio Adentro wherein subsidized prescription drugs are sold to patients. The community clinics offer 129 essential drugs and treat over 97% of the common illnesses (3).
Interaction with the Barrio Adentro Programme
We spent three busy and memorable days observing and talking to health care professionals in Barrio Adentro levels II and III. The first day we were taken to a busy clinic in the neighbourhood of Catia which has a population of about 300,000 people and mostly working class. (Of note during the military coup in April 2003 when Chavez was illegally held as a prisoner many young people from Catia organized and surrounded the presidential palace). I interviewed a nurse and the doctor who were on duty at the clinic. The doctor and the nurse were both from Venezuela, they were happy to be able to deliver care to patients completely free of charge. I was informed that the clinic treated about 200 patients a day for various ailments that ranged from trauma to patients with diabetes, hypertension and related complications like heart attacks and cerebrovascular events. In addition, the clinic treated patients with gynaecological problems and also had a paediatric unit to treat children. The clinic was spotlessly clean and provided x-rays, electrocardiography and other radiology services. It provided 24 hour services, which were accessible to everyone and was in keeping with articles 83-85 of the Bolivarian constitution that enshrine free and quality health care to all citizens. There was a textile cooperative run by women located next to the clinic in the sprawling grounds. It had 103 women working in a spirit of togetherness sharing the profits made from sewing T shirts, uniforms for schools and the military. There was also a playground and a crèche in the same area.
The second day we were taken to a CDI and SRI in a middle class neighbourhood called Los Dos Caminos in Caracas. The CDI and SRI have Cuban professionals from doctors and nurses to podiatrists, occupational therapists and speech therapists. The CDI had a well stocked emergency room, an ICU with 4 beds, a general ward with several beds to treat illnesses from pneumonia to diabetic emergencies. I interviewed a patient a truck driver with diabetes and cellulitis (skin infection) who was touched by the loving and dedicated care he had received. He said it was fortunate to have Barrio Adentro to help poor patients like him who cannot afford treatment in private clinics. Patients were booked for endoscopic procedures on a routine basis. There are state of the art interventions available to treat patients with conditions like heart attacks, sepsis, asthma and heart failure.
I talked to the physician in charge whose responsibilities included seeing patients, teaching and some administration. She arrived with the first group of Cuban professionals in 2003 and has seen the growth of the Barrio Adentro programme. She said the Barrio Adentro program was saving lives and promoting health care to communities which previously had very little access. However, she was equally honest about the need to fight infectious diseases like dengue, malaria and diarrheal illnesses in Venezuela. Cuba of note has eradicated malaria since 1968, there have been no cases of diphtheria since 1971 and there are very few cases of gastroenteritis. Every Cuban professional that I met, exuded compassion and a passion to help their fellow human beings regardless of their colour, nationality or political affiliation. They felt that serving the health care needs of people was of utmost importance and they would stay as long as they were needed. However, there was general optimism that Venezuela under the Bolivarian process is training enough medical professionals whose presence in the Barrio Adentro program will be increasingly seen in the future. After a three year program of studies, 1,013 Venezuelan doctors graduated in General Integral Medicine in 2007 in the Cuban-developed system of preventative health care.
I was able to meet with a team of highly dedicated health care professionals mostly women in the Barrio Adentro III programme. The director was a woman nephrologist who heads the programme that oversees buying state of the art equipment and upgrading facilities in the hospitals in the country. I was able to meet the Director of the University Hospital in Caracas, a very well known doctor, who has trained medical students for more than 3 decades. The University hospital which is a beneficiary of the Barrio Adentro III programme is a famed centre for cardiac by pass and valve surgeries and also for cardiac transplants and kidney transplants. The medical community in the hospitals is highly polarised politically with some supporting the Bolivarian revolutionary process and others violently opposed to the changes and the involvement of the Cuban doctors. However, the director reassured me that the doctors are trying to put politics aside and work toward the common goal of providing optimal treatment to patients. Many hospitals in the country now have peoples’ committees to protect the new equipment purchased under the Barrio Adentro III programme from sabotage by those antagonistic to the new changes.
Cuba-Venezuela partnership-Putting People First
The solidarity and friendship that we witnessed between the Cuban and Venezuelan health professionals was an inspiring and moving experience. While the Venezuelan Barrio Adentro program is being compared to the celebrated Cuban health care system, there are differences in addition to the similarities. Cuba after the triumph of the revolution in 1959 expropriated land and private property and within a year nationalised all U.S and foreign property. The revolutionary government in Cuba believed that a band aid approach will not eliminate disease either real or metaphorical. Along with health care agrarian reform, housing, employment and education were instituted. The Bolivarian process has to be credited for investing money and resources on social programs like health care, education and subsidized food (Mission Mercal); 90% of PDVSA’s (government owned oil company) contributions last year went to Barrio Adentro programs and the subsidized food market. Having said that, in Venezuela, there has not been a rupture with the bourgeois state and the old structures are still in place. Private national and foreign banks earned over 30% rate of returns in 2005-2007. Some of the key industries such as media, communications, and food are still in private hands. Less than 1% of the landed estates have been appropriated and turned over to the landless. There is overcrowding in cities, areas with indigenous peoples are underdeveloped and there are many infectious diseases that need to be controlled and eradicated.
In conclusion, the creation of the free quality peoples’ health care system by the Bolivarian process indeed is a progressive measure and is a cause for celebration but it cannot reach its full potential until the community councils, the working class movement and the fight against imperialism get strengthened in Venezuela.
References:
1. World Health Organization http://www.who.int/nha/country/ven/en
2. Venezuela’s Barrio Adentro: An alternative to Neoliberalism in Health Care: International Journal of Health Services, Volume 36, Number 4, Pages 803-811, 2006
3. Ministry of Popular Power for Health. “There is medicine for HIV patients.” 14 March 2007.Acknowledgement: I would like to thank venezuelanalysis.com for providing a lot of useful information