For once in my career as a medical student, I have absolute faith that my patients will be taken care of regardless of how much money they have in their pocket. Entering the Misión Barrio Adentro clinic in San Rafael de Tabay, a town in Merida, Venezuela amazes even the most jaded visitor. The local community hospital, Centro de Diagnostico Integral (CDI) brings alive Venezuela’s social revolution in health care.
The premise of Misión Barrio Adentro is simple: doctors live and work in communities providing health services free of charge to anyone.(1) In the span of four years, Barrio Adentro added 1612 modules (with 4618 under construction) to the 4,800 existing public ambulatory clinics.(2) The national goal is to have one primary care doctor for every 1250 to 2500 habitants. While Cuban doctors currently cover a large portion of this health need, new medical schools are training over 17,000 Venezuelan youth to become doctors. A corollary training program has around 3,000 Venezuelan doctors in a postgraduate residency community medicine. It’s one thing to look at the numbers, but does this massive expansion of primary health through Misión Barrio Adentro actually work? To gain perspective, I have been studying as a medical student under Venezuelan and Cuban physicians in both the traditional and revolutionary Barrio Adentro public health clinics. Beyond the reports and statistics, I carry back with me the experience of participating in egalitarian medicine, a goal I can keep in my mind’s eye.
Many who view the new health care programs as a radical departure, may not know that even before the Chavez government, all people had a right to health care, education, social protection provided free from the state. However, access was limited. A report of the Panamerican Health Organization and World Health Organization, "Barrio Adentro: the right to health and social inclusion in Venezuela" documents the history of health care in Venezuela. Before Chavez, there was an underinvestment in social programs, increased orientation to the private sector. When Chavez was first elected president in 1998, over 35 percent of the poorest 20 percent of the population indicated that they didn’t go to see a medical for their health problem because they didn’t have the money to pay for a consult, medicine, or exam.(3)
Since the 1970s until Chavez’s Administration, investment in public health did not match the expanding population’s needs. During the 80s and 90s, only 50 new public clinics were built. Meanwhile, 400 new private clinics were constructed. From the 70s to Chavez’s election, there was only one public hospital built. A 1985 study revealed that Venezuelans had trouble getting care in Caracas, even in spite of the fact that the capital had disproportionately more physicians than the rest of the country. This is for many reasons. Clinics were too far away and badly organized for the communities needs. They also lacked appropriate referral systems, and were focused on curing instead of preventing disease. In poor and rural communities, care was provided by recently graduated inexperienced physicians.(4) These results match the stories I am told by my patients.
Misión Barrio Adentro was founded in 2003 as a part of 17 Misións, or comprehensive national social service programs, that together have similar explicit objectives to overturn decades of growing social inequalities. By recognizing the social rights of health, education, nutrition, housing, and employment, the Misións create sustainable new power relations based on democratic and participative ideals.
How does a country with a per-capita gross domestic product 1/6th that of the United States fund this massive expansion of primary clinics? In an example of South-South economic cooperation, bypassing neoliberal economic trade models, Venezuela sends up to 50 thousand barrels of oil per day in exchange for the services of Cuban health workers and related medical supplies. A ‘petrol for physicians’ trade agreement brings over 23,500 Cuban health professionals including nearly 15,500 doctors to serve the community. Importantly, new medical schools led by these doctors are training Venezuelan medical students, youth who would never otherwise have had access to advanced formal education.(5)
Like their counterparts in Cuba, doctors spend mornings attending to patients in neighborhood walk-in clinics. In the afternoon, doctors walk "terreno" where they make house calls and facilitate community classes. Doctors census person by person, family by family, recording the prevalence of disease and issues like lack of housing or clean water. Initially, the most frequent problems that doctors encountered were malnutrition and illiteracy.(6)
Entering the Community Hospital
The intelligent and friendly Cuban hospital director, Doctora Jaquiline greets me at the CDI’s door. She is interested in letting the world in to see the successes of her hospital. While she readily acknowledges that, like any hospital, there is room for improvement at the CDI, she says in general things are going well. I concur.
Doctora Jaquiline and her advisor, Julio Sanchez, introduced me to patients and the community. The atmosphere was honest and frank; I felt no guardedness on the part of families, staff or patients. Patients were told they were free to answer positively or negatively about any topic, to raise any of their concerns, and it would not change the level of services they are receiving. Additionally, we let patients know that they can share opinions away from hospital staff, allowing private discussion. All patients agreed to be interviewed.
Some articles about Misión Barrio Adentro, written by leaders of the Venezuelan Medical Federation (the AMA of Venezuela,) state that doctors "give health care to those with red shirts," imply that political allegiance to the Chavez administration is a requisite to access health care.(7) In my months as a participant observer of the Misión, I have never heard any worker ask any patient about partisan politics. Moreover, a Cuban medical journal publishes that the goal of Cuban doctors working abroad is to provide "attention to all of the population without distinction to race, creed, ideology without mixing in internal politics and respecting the law and customs of the countries where they work."(8)
A Venezuelan doctor working in the Misión, who did not identify as Chavista, explained to me, "I serve everyone regardless of their politics, if I agree with them, if I disagree, if I like them, if I don’t like them, I doctor everyone. Above everything, I am a doctor. We don’t wear political colors in my clinic." This was reflected in my conversations at the CDI. People shared negatives and positives of the programs openly, and discussions were more health care based than overtly political.
Patient Experiences
Gregorio Sulbaran, a much loved grandfather from the pueblo of Pedgregal high in the Andes Mountains, came to the hospital. He felt very weak, dizzy, and had trouble breathing: an exacerbation of his chronic heart failure made worse by pneumonia. Before Chavez administration, Mr Sulbaran "never" had received medical attention because it was "impossible" for him to pay for medical services. His first encounter with a thorough medical exam occurred during a Misión campaign in which patients from his community were brought to the CDI for EKGs, Chest X Rays, ultrasounds, dentist and eye exams, as well as a complete blood tests. These exams, as well as transportation, are provided for free to all. The goal of this health campaign is to create a health census, in which 100% of the community receives preventive health work up, diagnosis and referrals to services if needed.
Mr Sulbaran’s enlargement of his heart was first identified during this initial community health screening. Also this screen diagnosed his chronic obstructive lung disease and chronic heart failure. He says that in this hospital there has been "enormous attention" to his health. He says here, the doctors treat wealthy and poor patients equally. He has had continuous access to health services. The food is good, too. Everything– from his initial health check up, to his now-three day hospitalization (including medications) to treat his acute bout of pneumonia, to the plate of spaghetti with meat sauce for lunch—is free of charge.
I see Mr Sulbaran’s family waiting in the hallway, and stop to talk. They explain there was nothing in the way of accessible health services before Misión Barrio Adentro. If the CDI were not present, they would have brought Mr Sulbaran to an academic hospital an hour and half away where the family believes that "the staff would send us away with an appointment for next week or next month." Jose Gorns, Gregorio’s son in-law, believes that "in the time and money spent coming and going to the academic hospital, my father in law would have died before receiving care."
"Some people are political," continues Jose, "but not here." The politicization of missions has been hotly debated. Some believe that the Chavez’s Misións were strategically located to "buy votes" from poor communities. Other people believe that the evaluation of the Misións impacts or outcomes have not been completely or transparently reported, due to of political reasons. Those claims look dubious here. "If things were going badly, I would say that. But things are good here," Jose concludes.
Participation of the Community in Health
Ender Quintero, a local community activist and member of "Comite de Salud," meets me in the hallway of the CDI. The "Comite de Salud" a participatory local health committee identifies and priorities community health needs. They also donate space for clinics and lunches for doctors and us medical students. (Thanks for the rice and chicken today!) Ender describes the origin and history of the CDI. "During the 90s, the population of this municipality grew greatly. We only had three public ambulatory clinics to serve the entire region. These saw about 15-20 patients a day. There weren’t enough resources, and I’m talking about both technology and doctors." He recounts that previously, for example, there was only one functioning X ray machine for the entire municipality, and no overnight hospitalization capabilities.
For these reasons, two years ago Ender Quintero began to meet with nearly two dozen other community members to help coordinate the planning of a local hospital. Today he is proud of the CDI, and knows its capacity off the top of his head. It has a "24 hour laboratory, 2 overnight doctors, 2 overnight nurses, an observation room and trauma room, rehabilitation center, EKG machine, and X ray machine" he recounts accurately. "Now, we serve around 250 patients a day." Not only does this improve trauma care, but it increases the preventive services available to the community. There are now 600 CDIs built across Venezuela. For every 10 to 15 neighborhood walk-in clinics, there is one local hospital CDI providing a more intense level of health care.
Before the Misión, there were preventive community health services but the schedule was arraigned by centralized health workers, resulting in top-down single issue projects like a vaccination campaign. Ender is excited that health information at the Misión is now better organized, so that the community can be sure that everyone is receiving appropriate care.
More Than A Treatment: Holistic Rehabilitation
After meeting with Ender, I pass the free dental clinic, speech therapists, and physical therapists to enter the rehabilitation room. Perhaps the most impressive and emotionally charged part of health care, rehabilitation services are often first service to be slashed in budget cuts. Rehabilitation is a key part of any recovery process, often ignored by physicians in the United States. Inside we find Idalba Castillo who is struggling to stand from a sitting position. At her side is her son, Richard Rangel Castillo, who brings her to rehabilitation 90 minutes every day Monday through Friday.
Richard is a bright industrial design student in his early twenties. His family’s life changed suddenly when his mother fell from a motorcycle the day following Chavez’s electoral victory. She suffered a blunt force injury to the right temporal lobe of her brain, and spent 10 days in a coma. Surgeons thought she would never regain the ability to communicate or walk. Richard says that his mother was the "heart of the family," and the whole family has suffered tremendously from her injury. However, he believes that she has much improved thanks to the CDI rehabilitation program.
At first the family attempted to bring Ms Castillo to the distant IVSS (social security) hospital for physical therapy, but they were sorely disappointed when therapists implemented a ‘one size fits all’ generic program for their mother. The hospital "couldn’t provide a therapy program in the way she needed it" reported her son. Additionally, the family preferred that she receive daily services instead of every-other-day therapy, and the hour and a half commute made it difficult to transport her to the clinic. The family decided to give the CDI a try. Now, after months of daily sessions, Idalba can raise herself from her wheelchair to a standing position, far surpassing her original surgical team’s assessment.
Impressions and a look to the future
As I said goodbye, I was impressed by the dedication of the staff to the program. From my perspective working within the program, I find an atmosphere that is open to continual growth. Mostly things are going well, but critiques aren’t ignored or brushed under the rug. For example at times we lack certain medications and ask our patients to buy them at local pharmacies or go to another clinic site. But, mechanisms are in place to figure out what medications we are running out of faster than initially planned.
On a broader level, both Cubans and Venezuelans alike are excited for the day when the Misión becomes operated and fully run by Venezuelans. Doctors are doctors regardless of nationality, but there is well deserved pride when a clinic staffed and run by doctors from the community they serve. Many Cuban doctors have been separated from their families for a few years while working in Venezuela. On the whole, Cuban and Venezuelan doctors work well together. But, both groups do things slightly differently, having subtle management and educational style variations. The heavy reliance on Cubans is seen as a short term solution.
Misión Barrio Adentro is currently run in parallel to the traditional ambulatory clinics, under both Cuban and Venezuelan administration. In the long run, there are plans to create a unified Venezuelan public health system bringing the management of older public clinics together with the new clinics. However each public health system (military hospitals, social security hospitals, older public health clinics from the 70s, Misión Barrio Adentro clinics) has its own style of management and independent administration. The logistics to unify will be challenging, even though well intentioned.
If the clinics appear to fail, it will be a blow against Chavez. Though the opposition bemoans quality of care in Barrio Adentro, going so far as to claim that the Cubans are not ‘real’ doctors, this is not my experience. I see the positive results of well qualified physicians working long hours on behalf of our patients. It is unfortunate that some want to discredit the clinics and doctors for political motivations.
I am heartened to see an ethic of continual improvement being built into this Misión Barrio Adentro’s infrastructure. Hot off the press monograph, "Consultorio por la salud del barrio: moviemento por la excelencia de los servicios de salud en el consultorio popular" ("Clinics for the health of the barrio: a movement for the excellence in health services in the popular clinics"), confirms the attention to quality health services by giving health workers specific survey tools to measure their impact and evaluate patient satisfaction. Instead of being satisfied with merely expanding services, seeing more patients, there is an active effort to make sure quality of care remains high.
I leave the hospital energized. Though I have been a participant-observer in the local consultarios for a while, at the end of the day I remain unable to sufficiently describe the emotional impact of seeing the national transformation of health care from a commodity to a human right.
Rebecca Trotzky Sirr is a 3rd year medical student at the University of Minnesota. She is a 2006/07 Fulbright Scholar studying the impact of Misión Barrio Adentro in Venezuela. Rebecca also studies in the postgraduate public health program at the Universidad de Los Andes through the Departmento de Medicina Preventiva y Social. She is a single mom to her Zev, who studies 2nd grade at the Escuela Bolivariana de la Mucuy Alta. He asks that you send him macaroni and cheese.
Notes:
1. República Bolivariana de Venezuela (2004) Decreto Presidencial de creación
de la Misión Barrio Adentro. Gaceta Oficial No. 37.865, de 26 de Enero de 2004.
2. Misión Médica Cubana (2006) Información Semanal del 21 al 27 de mayo.
Caracas: Ministerio de Salud.
3. Instituto Nacional de Estadística (1998) Encuesta Social. Disponible en internet
4. Rakowski CA, Kastner G Dificultéis envolved in taking health services to the people: The example of a public health care center in a poor Caracas barrio. Social Science & Medicine 21:67-75
5. CONVENIO INTEGRAL DE COOPERACIÓN ENTRE LA REPÚBLICA DE CUBA Y LA REPÚBLICA BOLIVARIANA DE VENEZUELA
6. Misión Médica Cubana (2006) Informe Misión Médica Cubana. Caracas:
Misión Médica Cubana.
7. 2005 Que Tal.
8. "La colaboracion Medica Cubana en el siglo XXI: Una propuesta para la sostenibilidad en Guiea Bissau" trabajo para optar por el titulo de master en salud publica en Haban 2006 autor Dr Nestor Marimon Torres