Caracas Chronicles

At the end of March, before the latest protests blew up in the government’s face, Nicolás Maduro made a surprising announcement. Having rejected offers of help from NGOs and national governments over and over again, he suddenly said Venezuela would finally ask the United Nations for medicine to help solve the grave health crisis the country has faced since oil prices fell. It was a tardy acknowledgment of a crisis that all his ministers have denied, and became a ray of hope for long-suffering patients and their families.

That was almost two months ago. No actual aid has been delivered, and the situation patients face is just as dire now as it was then. In fact, the opposition’s protest today is centered on demanding the opening of “a humanitarian channel.”

As a doctor and a doctor-in-training, we deal with the problems of the Venezuelan health system each and every day. People have unrealistic expectations about what humanitarian aid can achieve. Thinking you can put the solution to Venezuela’s health crisis in a shipping container and send it to Puerto Cabello shows you haven’t really digested how bad things are, and what’s driving the crisis.

A Hospital Network that can’t cope

Back in March, the National Assembly-pushed National Hospital Poll revealed that 78% of the hospitals in the country face shortages of basic medicines, and 81% lack enough medical or surgical materials to treat patients regularly.

But that’s just on the surface: the Venezuelan health crisis goes far beyond the lack of basic supplies. The idea that “humanitarian aid” can be a quick fix is a pipe dream. Unless radical changes are made to the health system and major investment goes into our current hospital network, no international aid will make a dent in the health crisis.

Venezuela’s first proper modern health center was the iconic Hospital Vargas, which dates back to July 5th, 1891. It was followed by several other hospitals built at the dawn of the 20th century, one in each of the then state capitals. As population and demand grew, so did the network. Most of the currently active hospitals were built in the 1970s and 80s. Not much more has been done since then though. A Children’s Heart Hospital was built in Caracas in 2009, but that’s about it. For the most part, the revolution focused on out-clinics, which have their uses, but can’t substitute for a working hospital network.

People have unrealistic expectations about what a humanitarian aid can achieve.

And so the hospital network lagged… and lagged and lagged. According to the Venezuelan Network of Medical-Scientific Societies (RSCMV for its Spanish acronym), in 2007 there were 300 public hospitals and 457 private clinics around the country. By 2011 those 757 centers could theoretically provide care to 40,675 patients:14 beds per 10,000 population. That’s less than half the Latin American average of 30 beds per 10,000 population.

That’s not the kind of deficit you can make up overnight with “humanitarian aid.”

The hospital bed shortage gave rise to an administrative mess: most of the hospitals built in the last 40 years were intended to treat people exclusively from nearby. Designated Regional Reference Hospitals, which received patients from nearby states, too, received bigger budget allocations. As the population overwhelmed the health system, many local hospitals started receiving many more patients than they were designed for. Patients started coming from other states, too, because their hospitals couldn’t cope. Many local hospitals ended up becoming Regional Reference centers in practice. But that reality was never officially acknowledged, and it has certainly never been reflected in their budgets.

This die was cast years ago, but our recent economic collapse added a whole new layer of stress on an already overwhelmed system, especially in the public sector, which depends exclusively on the government’s chronically mismanaged systems.

The impact has been so severe that —according to Jose Manuel Olivares— even at a time when family budgets are under unprecedented strains, 55% of the healthcare demand in Venezuela is being covered by private providers. But this is insane: clinics only have (5-10%) of the hospital beds in the country. And most clinics are small-to-tiny: 90% of them have a capacity of 60 beds or less. The private health network definitely can’t cope — but it’s being forced to.  

Another important reason that might help explain this asymmetry between the public and private sectors is the fact that of those 38,375 beds that the public sector should theoretically have, only 19,911 remained operational in 2012. We don’t have newer data than that, but it’s hard to imagine the number is higher now.

Off Their Meds

OK, ok, so the hospital network is FUBAR. Still medicine shortages are certainly the most immediate issue, right? Humanitarian aid can solve that part of it, can’t it?

No, it can’t. Dealing with shortages means so much more than putting some medicine on a boat.

Can humanitarian aid guarantee daily treatment and food for almost 18,000 patients until the economy stabilizes again?

Managing the pharmacy for a modern hospital is no simple task. It takes infrastructure and administrative chops and medical know-how to distribute, store and administer the hundreds of antibiotics, analgesics, antihypertensives, electrolytic solutions and dozens more types of medicines a hospital needs to run day in and day out.

The existing system has broken down badly for the same reason every distribution system for price controlled goods breaks down. Price controls create enormous incentives for people to break the rules. Medicines are, in this sense, not that different from Harina PAN: if people are willing to pay X for them and the system forces you to sell them for a quarter of X, demand will inevitably exceed supply and a black market will arise. If Venezuelans haven’t learned this much after 17 years of revolution, we haven’t learned anything.

This is an aspect the advocates of humanitarian aid as a quick fix never seem to stop to consider: thinking Venezuela’s existing medical distribution network would work if you just put in more medicines is like thinking you can fill up a bucket with no bottom by just adding more water.

So what is the solution? Do we need to bring peacekeeping troops from other countries to watch over hospitals’ drug stocks? Can you imagine a corrupt military officer being deprived by some UN blue helmet of his “right” to divert to himself some of the boxes his men unload from a container?

Let’s be serious.

The proximate cause of medicine shortages are mainly due to the government’s massive built-up debt with pharmaceutical companies, which escalated to $6 billion last year. That’s nine zeros of debt, and more than three times the annual budget of the International Red Cross Committee. It’s not just that we’re pouring water into a bucket with no bottom, is that we haven’t paid for that water in years and the utility is minded to cut us off.

We see the impact of this chaotic mismanagement of medicine stocks every day at the hospitals where we work.

A wheezing child quickly turns into a nightmare: something as simple as an asthma crisis is pretty much unmanageable if you don’t have salbutamol, which hasn’t been generally available for years to us.  IV steroids —the cornerstone of treatment for this and other common conditions such as allergic reactions that sometimes can compromise a patient’s life— are not available at public hospitals and a single vial of hydrocortisone might cost up to BsF.50,000 — a month’s wages for many people.

Desperate mothers are an everyday thing now: they walk for miles to find the drugs their children with asthma need, as they’d go hours coughing, wheezing, trying desperately to get air into their lungs.

Medicine shortages are mainly due to the government’s massive built-up debt with pharmaceutical companies.

Even IV solutions with glucose used to treat low sugar levels have disappeared from some places, forcing doctors to improvise and sometimes spend their own money so they can carry life saving drugs like epinephrine (used to provide advanced cardiovascular resuscitation) in their coat pockets.

The antibiotics’ situation is also critical. Most antibiotic therapies in admitted patients must last at least a couple weeks in order to be effective. A vial of meropenem, imipenem or similar high-spectrum drugs (useful in infections produced by different types of bacteria) can cost between BsF.60,000 and 80,000. Patients sometimes need two or three of these vials daily. Do the math and you’ll quickly see that an infection can quickly bankrupt a middle class family.

Even if you are able to find the drug you need, there’s yet another obstacle: to do something as simple as put in an IV drip, you need equipment: catheters, gloves, alcohol, cotton, syringes, saline solution, and proper hygienic conditions to prepare it all in. Lots of hospitals lack all of the above, and the system it takes to get them there has broken down for the same reason the medicine distribution system has.

The nightmare does not end there. Sometimes we even lack resources to actually make a diagnosis: we’ll figure the patient has cancer but he won’t be able to get an MRI or CT scan to figure out what kind of cancer it is. Even a basic hemogram is impossible to get at many public hospitals, because the chemical reagents are not available. Diagnosing dengue fever and even the most common illnesses becomes impossible.

Let’s say a hospitalized patient requires an emergency CT scan, can’t get it done at the hospital but the patient’s family can afford getting it done at a private clinic. They’ll still need a way to transport him or her there. Some of the biggest hospitals (type III/IV) don’t have a single ambulance to provide transport for patients in critical condition. An external ambulance service can cost as much as BsF400,000 depending on how long the ride is. Most patients prefer to be taken by taxi, but when their situation is delicate, that’s obviously not an option.

On top of all this madness, there’s the brain drain. Hundreds of experienced, specialized physicians have chosen to leave the country, for reasons too obvious to go into here. In some states, you won’t even find a single oncologist working in the public health system. Infectologists needed to treat HIV+ patients are thin on the ground almost everywhere. Highly specialized physicians are rushing to foreign hospitals, as what remains of the Venezuelan health system drifts into the abyss. How is humanitarian aid supposed to address that?

We are not dismissing the importance of humanitarian aid. It’s badly needed, and every minute Venezuela goes without it, lives are lost needlessly. But thinking the U.N. can magically end the crisis amounts to magical thinking. The system needs top-to-bottom reform, and that’s something you just can’t put in a shipping container.