In Venezuela there’s a popular saying: ‘Opinion pollsters don’t climb hills.’ Their results never reflect the views of the people who, as far as the mainstream media are concerned, have neither voices nor faces, living as they do in their tens of thousands piled high on the hillsides. Until three years ago, the same might equally well have been said of doctors as of pollsters. The poorest regions of the country had to do without anyone to attend to their healthcare needs, from the simplest of worries to the most desperate of infirmities.
The Barrio Adentro (‘Inside the Barrio’) ‘mission’ passed its third anniversary in April 2006. It began as a plan for people who live in poor communities to receive free medical care and medicines. Now it has been transformed into an initiative to change the model of healthcare that has prevailed in Venezuela for the past 40 years.
Before, if her baby ran up a fever in mid-morning, Señora Pérez first had to find a way to get out of her barrio. Barrio roads are mountainous and public transport has to be provided by rural vehicles or jeeps, which don’t always offer a service mid-morning. Then she had to reach the nearest hospital. Finding a hospital was as difficult as winning an obstacle race – in the absence of public transport she needed $5 or $10 for any alternative, and she had to cope with the insecurity that prevails on the city streets as well.
Venezuelan healthcare was dismembered by its supposed decentralization. In 17 of the 24 States there was a sort of healthcare fiefdom, at the margins of national policy. Hospital care was privileged over the network of primary care, which was left to die of neglect. Doctors might study for 10 years or more, then be offered a basic wage of less than $1,000 a month in the public sector. Their only other option was to work in the strong but very expensive and exclusive system of private healthcare.
The first Barrio Adentro medical team arrived in the municipality of Libertador, Caracas – one of the most impoverished in the country – in April 2003. There were 58 Cuban doctors, specialists in Integrated General Medicine, with previous experience of humanitarian missions in Africa and Central America.
Immediately, the board of the Venezuelan Medical Federation (controlled by the opposition Acción Democrática party), with the support of the mass media, labelled the doctors ‘agents of Fidel Castro’ who were dedicated to ‘political indoctrination’ and ‘espionage’. The Federation organized demonstrations and hostile commentaries – but its members did not offer to take the place of the Cuban doctors in the ranchos (slums made from cardboard, wood, corrugated iron and other cheap materials).
The Federation repeatedly rehearsed the claim that the issue was not about doctors, but about impostors – even after the Venezuelan and Cuban authorities, and a commission of the Metropolitan District Medical College, had discredited this notion and checked all the doctors’ qualifications. Elements of the political opposition insisted that the doctors were practising illegally, since they had not complied with the requirements of the (Venezuelan) Law on the Practice of Medicine. These opponents turned up at the Tribunal of the Supreme Justice to stop the Cubans from working. Their case was rejected. The official response still is that the doctors are on a humanitarian mission – and that there are precedents in Venezuelan history for receiving help from ‘outsiders’.
In 2003 some alleged cases of medical malpractice, blamed on the Cubans, made banner headlines. This in a nation where reports of medical malpractice usually receive little or no coverage from the private radio and television networks. Close links between the private healthcare system and the owners of the mass media ensure that.
In August 2003 there were quite specific accusations of malpractice against a Cuban professional in a very impoverished part of Caracas. The response of the local inhabitants was a vigorous defence of the doctor, expressed on a demonstration with the slogan: ‘Uh! Ah! The Cuban stays!’
Eventually, since opinion polls invariably revealed a big majority in favour of Barrio Adentro, its chief critics changed their strategy. In the campaign for the presidential referendum in August 2004, opposition leaders gave firm reassurances that Barrio Adentro would continue no matter who won.
Tibisay is just one of the many thousands of reasons why they had to do so. She is hardly into the fourth decade of her life. But the weight of need – many years of need – shows on her face. She sells underwear at workplaces. Alone she cares, economically and physically, for her elderly father and uncle. Naturally, her own health has suffered from the immense effort.
A back pain struck her one night in February 2006. Before, she would have had to endure the pain until morning, or relieve it with some sort of household remedy. But this time the neighbourhood Cuban doctor visited Tibisay at home during the night and injected drugs to alleviate her condition. And not just that. Tibisay’s uncle, who suffers from a neurological complaint and has difficulty moving, was also treated in his own bed, along with the bed sores that had resulted from his long hours of immobility.
The concept is that these professionals, properly equipped with the tools of preventive healthcare, must be at the disposal of the people at the time and place they are needed – thereby resolving the causes of 8 out of every 10 medical consultations.
According to the Ministry of Health, this year the target of building 4,000 popular clinics across the country should be reached – there are currently 8,500 ‘attention points’, though not all can be classified as clinics.
The daily routine in one such place begins early – at about 7.00am. The length of the queue of patients varies with the number of medical emergencies during the previous night. There are elderly people with high blood pressure; children with asthmatic crises, skin complaints; individuals with fever or flu. One of the most important stages in the consultation is dialogue between doctor and patient, followed by blood-pressure tests, a physical examination, strict instructions, and free medication. In the afternoon the doctors visit the neighbourhood where they live. They take health censuses or have informal chats about current health problems in the community. During the night people are free to knock on their doors at any time.
So why are the Barrio Adentro doctors Cuban, not Venezuelan? First, because you have to live ‘barrio adentro’ – inside the barrio. You have to be prepared to suffer the scarcity of services and the violence; to share the misery and the want that have characterized daily life in these places for decades. Few indeed were the Venezuelan doctors disposed to make such a sacrifice. Change has been slow, though Venezuelan doctors, dentists and medical students are now being successfully recruited. By August 2005 there were just over 6,000 of them.
Second, words also heal. One of the treatments used by Cuban medics is, precisely, to talk, listen, console. Their patients assure you that the Cubans ‘always have a smile for you’. Venezuelan medicine, which is very advanced when it comes to expensive technology and the latest discoveries from the US, has forgotten this, the very first ‘medicine’ of all.
Barrio Adentro is now, according to the research group Datanálisis (which is linked to the opposition), one of the most popular of all the social programmes in Venezuela. Official figures show that 17 million people (out of a 25 million population) have benefited from its services. According to President Chávez there have been 163 million consultations. Add to this Misión Milagro, in which Cuba has helped restore clear sight to thousands of Venezuelans suffering from cataracts; and the Cuba-Venezuela Convention, through which thousands more have travelled to Cuba to be treated for a wide variety of ailments.
Barrio Adentro is now one of the building blocks shaping a new public healthcare system. In 2004 the then Minister of Health, Roger Capella, said that Barrio Adentro had become a ‘structural’ response to the problem of healthcare – though he admitted that it began as a parallel system, ‘because the Venezuelan State is backward and anchored in the Fourth Republic [before 2000], and we could not wait for the whole Ministry to be transformed before guaranteeing healthcare’.
The completed system will be based on popular clinics, integrated diagnostic and rehabilitation centres and about 300 rejuvenated, reorganized hospitals. It’s a safe bet that, when and if this comes about, it will be good news for the thousands of Tibisays who have had to wait so long already.
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