Adentro Barrio Adentro: An American Medical Student in Venezuela

When Barrio Adentro began in December 2003, few could have foreseen the broad changes ahead for the small villages that are scattered throughout Venezuela. Within months of the proclamation that launched the initiative, more doctors arrived from Cuba and began living in spare rooms within Venezuela’s poorest and most underserved communities.

Source: Social Medicine Vol 3 No 4 (2008)

By the time I finished my second year of medical school in a large Midwestern university, I genuinely feared that I was losing the passion that had led me to choose medicine as a career. As medical students quickly discover, the focus in our medical education system is on the hard sciences rather than on any integrated critical analysis of issues related to social justice or the larger societal context in which we will ultimately practice. Lamenting that we no longer had time to volunteer, let alone read anything beyond required text books, we placed a part of our souls on a shelf, agreeing that after board exams, we’d return and dust off our interests in social justice, women’s health, and our international community. Throughout my pre-clinical years, that choice nagged and pulled at me, a voice constantly asking: was I selling out?

In my medical school in the North, I reluctantly accepted the presumption that medicine best-served the lucky few with resources and health insurance. Labeled ‘naïvely optimistic’ if I earnestly proposed universal health care, I longed to live in a country where comprehensive health care was a right of all citizens. Most importantly, I wanted to hear firsthand the stories of transformations from a marketbased health care system to one in which medical services, regardless of the level of complexity, are universally guaranteed and provided at no cost to the patient. During 2004, I began reading articles about Venezuela’s political changes and notably the redesign of their health and education systems. The government of socialist president Hugo Chavez created a new public health initiative called Barrio Adentro and, through a cooperative agreement between Venezuela and Cuba, was able to bring thousands of Cuban primary care doctors to underserved Venezuelan neighborhoods. Bottom line: a six-fold increase in free clinic visits in six months. Critics asserted that, while hundreds of free clinics opened in just a few years, there were problems with the quality of services. "This is too crazy to be real", I thought to myself, simultaneously discrediting while secretly yearning to believe in Barrio Adentro.

I decided I had to see it for myself. Had Barrio Adentro been successfully implemented so quickly in such a large and diverse geographic setting? Surely there would be important lessons learned for health care providers across the globe. What worked well? What should be done differently? Applying for a Fulbright grant to study medicine in Venezuela was like sending a message in a bottle to my future self: "Dear Jaded Future-Self, do not give up your dreams of social justice in medicine. Check out the health care system transformations in South America. Love, Idealistic Former-Self." I wanted to gain direct exposure to the Barrio Adentro program, interview Cuban physicians, and understand the perspective of Venezuelan physicians who often saw Barrio Adentro as a threat to professional organized medicine. Gratefully, I received my Fulbright award in 2006-07 and headed for South America after completing my first clinical clerkships at my medical school.

In spite of good intentions, traveling to Venezuelan as a citizen of the United States presented a number of complications. "Venezuela’s most senior leaders, including President Chavez, regularly express anti-American sentiment. The Venezuelan government’s rhetoric against the U.S. government, its American culture and institutions, has affected attitudes in what used to be one of the most pro-American countries in the hemisphere," writes the US State Department holding up their side of the international ping-pong game between the US and Venezuela. Understanding the conflicts between the United States and Venezuela meant not only wrestling with economic and historical discourses, but also carefully planning to accurately access both sides of the heated Venezuelan debates about the merits of the new health care policies. Venezuela’s professional class—including many, but not all, physicians—tend to be highly critical of the Chavez government’s reforms and often, their criticisms are repeated in the rhetoric of the US government and mainstream media. Because of assumptions made based on the fact that I was from the United States, those who opposed the Chavez government perceived me as a natural ally. Yet, due to my community-service background and visible interest in public health and preventive medicine, pro-Chavez physicians spoke candidly with me about their fears and hopes for the new policies.

Accepting funds from the United States State Department to travel and study in Venezuela during a time of intense international polarization provided unique access to multiple perspectives. Additionally, studying public health at the local university facilitated introductions to healthcare professionals from broad backgrounds. My classmates included directors of hospitals, physicians, nurses, nutritionists, and accountants. These individuals represented the spectrum of political beliefs in Venezuela—from very pro-Chavez to vehemently anti-Chavez. Finally and perhaps most importantly, by bringing my elementary school-aged child to live and attend school in Venezuela, I unintentionally opened many doors normally shut to outsiders. I was able to network with families in my child’s public school and in our neighborhood, effortlessly creating a base to reality check my ideas with an economically and politically diverse cross-section of Venezuelans.

ImageI divided my time between the Universidad de Los Andes and clinical practicums through Barrio Adentro. At the University, I studied in the department of Community and Preventive Medicine earning a public health certification at one of the oldest and most traditional universities in South America. This provided a substantive and structured counterpart to my community-based clinical work in Barrio Adentro. Although my formal studies inspired me, my everyday interactions within the rural Andean community where I lived and worked effectively contextualized the impact of the new clinics and health policies of the Chavez government.

When Barrio Adentro began in December 2003, few could have foreseen the broad changes ahead for the small villages that are scattered throughout Venezuela. Within months of the proclamation that launched the initiative, more doctors arrived from Cuba and began living in spare rooms within Venezuela’s poorest and most underserved communities. Neighborhoods and villages throughout the country opened their doors to Cuban doctors providing room and board as a way of collaborating with and supporting the community-based initiative. People in the community reported that, initially, the Cuban doctors were viewed with caution as foreigners without critical cultural understanding. However, the initiative continued to grow rapidly, with Cuban health professionals providing community-based primary care as they do in their own country and across the world. Over a period of a few months, Cuban doctors earned the village’s respect by consistently comprehensive services regardless of political affiliation.

In addition to providing direct services in thousands of neighborhood clinics, Cuban physicians are engaged in training Venezuelans in community-based, social medicine. While one of the Cuban doctors I met fell in love with a Venezuelan and intends to raise their family in Venezuela, most of the physicians have families in Cuba and are looking forward to handing over the clinical infrastructure to Venezuelans and returning to their home. Within the first year, Barrio Adentro began training Venezuelan students to take over these community based consultarios. At first, qualified Venezuelan students were sent (free of charge) to study medicine in Cuba. By the time I arrived in Venezuela in September of 2006, local medical schools partnered with community consultorios to train their second year of students. Like many countries across Europe and Latin America, Venezuelan medical schools start immediately after high-school and last for 6 years, as opposed to the United States where medical school requires four years of study that begin after four years of undergraduate college work. A postgraduate fellowship track was initiated within the Barrio Adentro initiative to train Venezuelan physicians in community medicine. This two-year program includes epidemiology, advanced practice in resource poor areas, and community organization. Upon completion, these doctors are equipped to run municipal health care systems. Currently, Venezuelan graduates of this program have also begun training Venezuelan medical students. The object is to create a self-sufficient system that no longer depends on importing human resources from Cuba. The medical students in Barrio Adentro are my kind of people—they are drawn from a crosssection of Venezuelan society and include single moms and youth organizers from underserved communities. They have witnessed the complete transformation of the Venezuelan health system. "We never had a clinic… growing up, if we got sick we waited until we were on our deathbeds before heading down to the city. Even then we had to wait all day to be seen." More than increased accessibility, there is the perception of heightened understanding, "The doctors in Barrio Adentro didn’t make me feel stupid for not having clean water, and they know what my neighborhood is like because they live here too."

My day would typically begin by getting my 7-year-old son off to our town’s two room school house. Waiting on the side of the road, we would often meet a respected village resident, Señora Rafaela. Her son Martin attended the same neighborhood school with my son in a mixed second-third-fourth grade classroom that had recently opened as a result of the government’s commitment to provide all day elementary school in rural communities. During these trips to and from school and town, she discussed the positive impact on community health of the new Barrio Adentro ambulatory centers, explaining how the local preventive health care program emerged from years of community organizing work.

As a key organizer of the community council, Señora Rafaela works closely with Cuban and Venezuelan political leaders and doctors to coordinate health fair events. Given her impressive competency in managing budgets, transportation, and logistics, it’s hard for me to imagine that she was unable to finish high school and only recently obtained her high school equivalency through one of = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Venezuela’s new universal adult educational programs. "Before, no one listened, actually listened, to our community," she explained to me, "Our neighbors who come from the upper classes, who are college educated and professional, they don’t understand how much has actually changed."

I would arrive at the one room consultorio (ambulatory clinic) in the morning where my Cuban preceptor and Venezuelan post-graduate fellow would see patients on a walk-in basis until noon. Often we were joined by two Venezuelan medical students who had worked in the clinic as a continuity experience over the previous two years and will continue to work in the clinic throughout their training. Over the course of a typical morning we would evaluate and treat a dozen patients with common complaints such as diarrhea and respiratory illnesses. In our small one-room clinic, a glass display case stood stocked with dozens of commonlyused medicines that were dispensed free of charge and included medicines for hypertension, viral, parasitic, and fungal infections, antibiotics, NSAIDs, prenatal vitamins, and birth control. The staff and students explained to me how previously people in the community would wait to see a doctor until seriously ill. A lack of preventive care, relatively expensive treatment, and clinics inaccessible to those without transportation fueled a disparity of access between rich and poor. When the clinic opened in the neighborhood, the nature of disease changed as more families had access to preventive medicine and attended clinics earlier in the course of a disease. A subtle shift in the sense of security in the community developed as people felt secure in having nearby a clinic, a doctor, and an accessible pharmacy.

After seeing patients, we would spend the afternoon engaged either in follow-up home visits or canvassing the neighborhood to actively seek out our homebound ill neighbors. At other times we would work with community leaders to design and implement simple, but effective, health education projects.

For example, during the spring, our goal was for 100% of the neighbors to obtain a well-person physical. Everyone in our small village received preventive care exams. For many, this visit to the doctor was the first in decades. Families could walk to the local Bolivarian school situated on top of a mountain, where the classroom was temporarily converted to a mobile ambulatory clinic. On the other side of the valley, the two room community center had been transformed into a makeshift clinic intake center. In spite of the non-traditional locations, Misión Barrio Adentro staff provided a very traditional physical exam. The Venezuelan medical students asked about medical history under the guidance of the Cuban physicians, performing a standard 12-point review of systems with the same precision as their medical student counterparts in the United States. With this virtually universal community outreach project, we facilitated wellperson health evaluations and created a community health census.

Although similar in quality to a well-person check up, the spring health census highlighted some of the differences between Venezuelan medical students in Misión Barrio Adentro and their North American peers. By also obtaining a detailed socioeconomic history, Venezuelan students in Barrio Adentro made the significant connections between poverty and health. How many people share each bedroom? Is there enough food and cooking fuel?

Socioeconomic information is charted in personal files and was later aggregated at the district level. In this way, a child’s case of diarrhea becomes an issue that can be tracked to the lack of clean drinking water. Health issues coalesce into projects that the municipality and community can change—wells dug, pipes placed. The community can hold elected leaders responsible for what previously was attributed purely to an individual family’s problem.

ImageAfter the health census in the spring, we next organized a summertime ‘graduation’ for all of the community infants and their mothers who had successfully completed at least six months of exclusive lactation. It was a very Venezuelan event, with graduation gown, diplomas, and presents for mom and baby. Our public health messages (family spacing, reproductive health, and the benefits of lactation) were featured throughout the day. The celebration provided a successful excuse to Imagecanvass our neighborhood for pregnant women who otherwise would not have initiated early prenatal care. Also, we created a safe place to discuss reproductive health care without preaching or further marginalizing young, poor families.

The year I spent in Venezuela greatly contributed to my professional development. Just as important, through my interactions with Venezuelans and Cubans, I realized there was a much wider breadth of people working and studying to be doctors from the community and for the people. My interest in community-based social medicine had unexpectedly led me to one of the most fascinating social experiments in healthcare systems during recent times: Barrio Adentro. Though initially reluctant, Venezuelans seem to be accepting both the new socialized structure of their public health system as well as the fundamental tenets of social medicine that form its practical and philosophical foundations. Private consultation firm Arthur D. Little and polling organization Datanalisis recently reported that over 80 % of Venezuelans surveyed benefited from Barrio Adentro’s services. While I was pleased to improve my own practice of community-based medicine under the tutelage of Barrio Adentro, importantly I was able to access the critiques of socialized health care reforms to create a broader understanding. Walking between two polarized worlds—21st century socialized medicine and the traditional faculty of medicine, pro-Chavez & anti-Chavez, I learned more than any clerkship or class about the successes and failures of a national health system transformation.

I believe that the United States medical system is at a crisis point, our current practices are unsustainable. The question we need to ask ourselves is "How can we build a sustainable and just health care system for the 21st century?" Looking internationally, Venezuela provides one example of expansive and rapid health care reform that seeks to answer that question. The most critical lesson I witnessed was not about managing a clinic, although that was important. Rather, it was about the need to involve community and professionals in building a new system that is based on shared values, the recognition of underserved and marginalized communities and the importance of not alienating wellresourced professionals. When physicians, medical students, professionals and patients collaborate, we design our own innovative solutions to improve the welfare of our entire community.

Rebecca Trotzky-Sirr graduates medical school December 2009, and will start the best ever Family Medicine residency program (location TBA.) She has weekly Thursday potlucks in Minneapolis, you are invited. Rebecca is the co-founder of a non-existant revolutionary movement, Weather Overground which has higher aims than before. If she could, she would make universally free dignified health care a part of the four basic food groups. Tell her what you are bringing to her next potluck: