Caracas Chronicles

It’s been twenty years since Hugo Chávez won his first election, and fifteen since one of his government’s banners was launched, Barrio Adentro, the first of many social programs (misiones) that helped build his popularity. The program, initially praised for its focus on primary care and accessibility, wound up compounding the current health crisis: not only did it fail to address the problems it was designed to solve, it also channeled investment away from the parts of the system that did, sorta, work: the hospital network.

Today, long forgotten infectious diseases are back in Venezuela, more than ten years after Cuban doctors first came “to lend us a hand.”

Barrio Adentro can be traced back as far as 1999, when a group of Cuban doctors was brought to Venezuela following that year’s catastrophic landslides in Vargas State, which killed tens of thousands. A year later, Chávez signed the first cooperation agreement with Cuba. In 2002, a series of strikes were called by the Venezuelan Medical Federation, demanding the payment of a $100 million-debt the Ministry of Health held with the medical guild. Chávez, true to his soul, ignored that, and instead started negotiations with Cuba for more doctors.

By May, 2003, some 150 Cuban doctors had been deployed in Caracas. That December, Chávez made the Barrio Adentro Mission official, and expanded it to the whole country. After that he added the first group of Venezuelan integral doctors, later known as Integral Community Doctors (MIC, for its Spanish acronym).

Had Barrio Adentro remained a primary care program, it may have been a valuable complement to the existing ambulatory network, whose reform had been under discussion since the late 80s, at least. But the program quickly encompassed more and more curative functions traditionally limited to the Venezuelan hospital network. By 2005, the government announced Barrio Adentro 2, an expansion based on the construction of 600 Centers of Integral Diagnosis (CDIs), rehabilitation rooms and 35 high-technology centers that would supposedly provide CAT and MRI scans to the population for free.

Not only did it fail to address the problems it was designed to solve, it also channeled investment away from the parts of the system that did.

By the time Barrio Adentro 3 started, meant for studying the condition of the current hospital network and developing a modernization plan, the program was a massive source of corruption. Even though millions of dollars were invested, all hospitalary interventions, from surgeries to laboratory tests where reduced in about 75%, between 2005 and 2011. In 2006, after the Caracas Cardiology Hospital was inaugurated, the government announced a further expansion, Barrio Adentro 4, aimed at building another 15 highly specialized hospitals throughout the country, none of which has been finished as of 2018.

All of these expansions meant a staggering amount of money was invested. The exact figures are virtually impossible to find, but according to estimates from NGO Transparencia Venezuela, at least $29,7 billion were spent between 2005 and 2014. The vast majority of this money came from PDVSA, representing 51,3% of the money spent in all social programs until 2014, and more than thrice the value of Venezuela’s international reserves, as of June 2018.

But this huge investment hasn’t been reflected in the quality of Venezuela’s healthcare. According to official sources, 609,704,922 medical consultations had been reported by the Barrio Adentro program until 2014, numbers that to many have been greatly exaggerated. The Universidad Católica Andrés Bello’s ENCOVI 2017 poll suggests that some 200,000 patients benefited from Barrio Adentro that year, a sharp contrast with the more than 118 million consultations reported by the government. For this number to match, each patient should’ve consulted around 600 times in 2017.

The ENCOVI data matches with off the record reports that claim that over 80% of the 13,496 popular clinics acknowledged by the government in 2017 were closed. The remaining centers would be managed by some of the 14,000 MICs, with some reports saying that only 1,094 of the 30,000 Cuban doctors in Barrio Adentro remain in Venezuela, as of 2017.

The Cuban medical mission managed popular clinics and CDIs for years, independent from the Health Ministry, which made it impossible to coordinate actions inside the health system.

But beyond these assumptions, Barrio Adentro’s failure is unequivocally reflected in the evolution of sanitary indicators in Venezuela, as presented in this report from Transparencia Venezuela. Family planning, one of the key areas where primary care programs are expected to act, is non-existent: between 2010 and 2015, Venezuela presented the highest teenage pregnancy rate in South America. According to the last available data from the Health Ministry, 756 maternal deaths were registered in 2016, compared to 346 in 2010. The maternal mortality rate is estimated to be around 110 maternal deaths per/100,000 registered newborns, a number not seen since the late 50s and almost twice as that registered throughout the 90s and early 00s. Child mortality, another key indicator of human development, increased 92% compared to 2010, with an estimated rate of 19 deaths per 1,000 registered newborns.

Another key activity, vaccination, also had a sharp reduction since Barrio Adentro came about. Coverage with the vaccine against poliomyelitis fell from 86% in 2000 to 58% in 2008. On the other hand, after an initial increase between 2004 and 2006, coverage against diphtheria, whooping cough and tetanus, fell to just 22% in 2008. Nine years later, we saw the consequences.

Mind you, Barrio Adentro doubled as something less often discussed: a massive, state-sponsored human trafficking program, where Cuban doctors’ working conditions bordered on slavery. It’s been estimated that out of every $100 Venezuela paid for their services, the Cuban regime kept as much as $96. Doctors were not allowed to bring their families — a kind of hostage guarantee system that smacked of medievalism. But we digress.

The hospital network today must cover more patients than before, with an extremely damaged and outdated infrastructure. The Cuban medical mission managed popular clinics and CDIs for years, independent from the Health Ministry, which made it impossible to coordinate actions inside the health system, rendering epidemiologic vigilance networks useless, and paving the way for the re-emergence of long-eradicated infectious diseases.

But the program did work to bolster the government’s interests. Chávez sold Barrio Adentro to both Venezuelans and foreigners, as proof of his interest in the people’s welfare, and it was key for his victory in the 2004 referendum. Even today, a quick search in Google Scholar will show hundreds of papers, from Venezuela and abroad, analysing Barrio Adentro’s role as a “tool to fight exclusion and strengthen democracy”.

It was also the project that cemented the relationship between Venezuela and Cuba, paving the way for the pervasive penetration of the Cuban government into the Venezuelan State.