Betty Martinez remembers how a baby boy died in her arms in 2003, during the bosses' oil lockout against President Hugo Chavez, because his mother couldn't get him in time to the hospital where she was a junior doctor. “My world changed, and the medicine I practiced changed.” She has just been taking me round as she visits some of her patients in Buenavista, a low-income neighborhood in the west of Caracas.
Betty had been trained in the old school of hospital-based health care, where the aim of young doctors was to get a job in a big private clinic and then never leave the four walls of their office. “Yet when I attended an emergency during my rural placement, I'd have to send the patient or their family to buy all the supplies I needed, the drugs, the syringes, the cotton swabs. Without that I couldn't treat them.” That's what Venezuelan health care was like before the Bolivarian revolution.
My politics then were “revolutionary light,” I voted for Chavez but I avoided talking about it, Betty says. All that changed. A few months later, she became one of the first group of 113 Venezuelans to sign up with the Cuban-run Barrio Adentro program, for a postgrad in Integral Community Medicine. It was a completely different approach. She recalls how at one of her first classes she'd forgotten her stethoscope. She asked the Cuban instructor if she could pop back and get it. “No,” said the teacher, “You don't need it. Put you ear to the patient's chest and listen carefully.”
Barrio Adentro mission in Buenaventura, Catia | Photo: teleSUR
"And she was right, they taught me real medicine," Betty says. “If we don't have an ointment, we make it. All we need is the active ingredient. We are war doctors, social doctors.”
She then spent nine years living and working in one of the tiny modules, or primary health care clinics, that Barrio Adentro set up in almost every poor community across Venezuela. “It was unheard of, doctors based in the shanty towns, available for the community 24 hours a day.”
Those are the two big gains, she says. Firstly that health care is available where people need it, right by where they live. It's not just the community clinics, they go to people's homes to treat them, and they have "home admissions" too, which is like being in hospital, but in your own home. Secondly, both the care and the medicines are entirely free.
There is little doubt that the Barrio Adentro health mission was one of the most successful initiatives of the Bolivarian revolution in its first decade. It was a major factor in building the popularity of the revolution. So much so that in successive electoral campaigns the opposition found it necessary to claim they would not get rid of it.
It's also true that in recent years the front-line modules or community clinics were sometimes neglected. This one where Betty worked for so many years, in the western Caracas neighborhood of Buenaventura, Catia, closed for two years. It's just reopened as part of the government's push to reinvigorate the program, known as “Barrio Adentro 100 per cent.”
Part of the reason was that the Barrio Adentro mission grew. After 2006 and 2007, it came to include bigger neighborhood clinics, known as CDIs, the Spanish acronym for Integral Diagnostic Clinics, or Barrio Adentro II, and then a smaller number of CATs, High Technology Centres, or Barrio Adentro III, with more specializations and more sophisticated equipment for MRI scans and the like. Patients often thought, well I need such and such a test, so I'll go straight to the CDI. And since Barrio Adentro has always had a policy of never turning a patient away, the original modules were often bypassed.
As a doctor for Barrio Adentro, Betty sees patients both in the clinic and at their homes. | Photo: teleSUR
But this trend itself seems to reflect a deeper, structural and cultural clash, between two very different approaches to health care. When Barrio Adentro was first set up, it operated outside the framework of Venezuela's existing health service, as part of a direct cooperation agreement with Cuba. There were several reasons. The vast majority of Venezuelan doctors, represented by the powerful and very conservative Doctors' Federation of Venezuela, were deeply hostile to the innovations of the Bolivarian government and to their Cuban counterparts.
They would never dream of going to work in a barrio themselves. The bureaucracy of the Health Ministry, largely inherited from the pre-Chavez years of the 4th Republic, shared much the same outlook. Setting up Barrio Adentro as a parallel structure also allowed Chavez to encourage community participation in running the new service. Local health committees, alongside urban land committees, water boards, became a key expression of the participatory democracy that the Bolivarian revolution was seeking to promote.
Venezuela's Health Mission Turns 12
As the Barrio Adentro mission was consolidated and grew, several attempts were made to bring it back under the auspices of the Ministry of Health. In the end, it became part of a new, integrated service, the Single National Health System. But, as Betty points out, the old, pre-Chavez health system and its culture has not gone away. It continues to dominate not only the private sector but much of the public hospital system as well. “That's a real obstacle to integration,” she says.
More than 90 per cent of doctors in the public hospitals, trained in the old system, have a double life. “They work three hours a day in the public sector,” says Betty, “and siphon patients off to the private sector. They ask their patients if they have insurance. If they do, the money bells start ringing and they refer them to their private clinic. They whisper, 'you need such-and-such a test, and I have it at my clinic'. For them, patients are commodities.”
Some, perhaps most, of the often hysterical attacks over the crisis in Venezuelan health care and the shortages of some medicines, can be traced to this underlying contradiction between two opposing visions of medicine. “It's a battle,” says Betty, “it really is a battle. They'll always hate us, because we're taking away their patients, their money.”
Betty tells Iain Bruce private doctors see Barrio Adentro as a threat to business. | Photo: teleSUR
“Some directors of public hospitals even contribute to the sabotage,” she alleges. “They have the drugs under lock and key, but they choose not to release them.” Why? Because they don't want the new system with Barrio Adentro to work, according to Betty. “They want to get rid of Maduro and go back to the 4th Republic, so they can take the patients to the private sector.”
This “battle” is complicated by the fact that many of the habits of the old, commercial health service have become ingrained in the Venezuelan lifestyle. There is a tendency for people to expect a pill to deal with just about any ailment, even when it would probably do them better to take nothing.
And it's not just any old pill they want. They expect such-and-such a brand name. Those are precisely the ones that are most likely to be in short supply, because the transnational companies that control their supply have cut production or stopped importing. So a perfectly adequate alternative or generic drug may be to hand, but people don't want it and the perception is that “there are no medicines.”
From Betty, I hear the same thing I have now heard repeatedly from doctors on her side of Venezuela's health battle: “It simply isn't true that patients are dying for lack of supplies.”
Another example of how old habits die hard is the issue of health insurance. Almost any Venezuelan in a stable job expects private health insurance to be included in their basic benefits. Even the most radical, Chavista union leaders have the terms of their members' insurance policies high up their list of priorities when they are negotiating a new collective contract. That's what their members expect, in both the public and private sectors. The result is the state pays millions, billions of dollars to prop up the private clinics, which could have been spent on the public hospitals and Barrio Adentro.
Betty is certainly a fighter. As I take my leave of her at the community clinic that has just reopened, I can't help thinking that this battle she talks of, between two visions of medicine, is a nice metaphor for the contradictions and challenges running through the Bolivarian revolution itself.