Mission Barrio Adentro

The Barrio Adentro program is an example of Latin American Social Medicine (LASM), which became prominent in the 1960s and 1970s. Among others in Latin America, both Salvador Allende in Chile in the early 1970s and Tabaré Vázquez in Uruguay since 2005 have implemented LASM principles.[14] LASM's roots can be traced back to 19th-century European social medicine (particularly the work of social medicine pioneer Rudolf Virchow), which was exported to Latin America in the early 20th century.[14]

LASM emphasises a collective and holistic approach to healthcare, rather than merely treating the particular symptoms of an individual. Thus the importance of health promotion and disease prevention is stressed—informed by the political, economic, and social determinants of health—over a merely reactive treatment of health problems as they occur.[14] LASM incorporates the concept of primary health care (as defined by the 1978 Alma Ata Declaration), of which the "simplified healthcare" adopted in rural Venezuela in the 1960s and 1970s was one form.[15][16] More recently, in 2006, Barrio Adentro was described by the Director of the PAHO as "the culmination of 25 years of experience in Latin America and the rest of the world in transforming health systems through the primary health care strategy."[6]

When Hugo Chávez became President in 1999, he sought to implement LASM principles, beginning with their incorporation into the new 1999 Venezuelan Constitution, in articles 83–85 of Title III. These articles enshrine free and high quality healthcare as a human right guaranteed to all Venezuelan citizens.[17] Notably, Article 84 of Title III follows LASM principles in declaring health promotion and disease prevention a priority; it also describes the healthcare system as "decentralized and participative" and declares that the community has "the right and the duty" to be involved in policy decisions regarding the public health system. In addition, Article 85 mandates that the government provide adequate funding for the public healthcare system, while Article 84 explicitly proscribes its privatization.[17]

Initial attempts to transform the Ministry of Health to LASM principles (from 1999–2003) were met with little success. The Venezuelan Medical Federation was aligned with the Punto Fijo parties, and many of its members that worked in private health care opposed the new emphasis on the public sector. During the period the new policies failed to make much ground within the healthcare system, the traditional top-down way in which the policies were developed and carried out prevented a strong connection between the healthcare system and the concerns of the poor.[14]

The origins of a different approach for carrying out LASM lay in the Libertador Municipality of Caracas,[18] which in 2003 (under a pro-Chávez mayor, Freddy Bernal) set up an Institute for Endogenous Development (IED), broadly intended to improve living conditions through the active participation of the local population. Following a series of discussions between the IED and local residents, a proposal was formulated to set up "Plan Barrio Adentro" using small local clinics to provide free healthcare "inside the neighborhood" where previously there was none, and to involve residents in the management of the scheme. Bernal then issued a call for doctors, but the Venezuelan Medical Federation put pressure on its members not to apply.[6] Of the 50 Venezuelan doctors who did apply, 30 left on hearing that they would need to live in the barrios; the remaining 20 were specialists and therefore employed in specialist centers and not required to work in the primary health care centers in the barrios.[6] Faced with a lack of willing doctors, Bernal recalled the Cuban doctors who had provided emergency aid following the 1999 mud slides, and discussion with the Cuban Embassy in February 2003 ultimately led to a contingent of 58 Cuban doctors starting the program in April 2003.[14] In the interim, three Cuban physicians spent a month visiting the barrios, examining the homes and clinical spaces offered in the community.[6] By May 2003, another 100 Cuban doctors arrived, and were sent to other parts of Libertador and to other municipalities in and around Caracas.[6] Besides diagnosis and treatment, including the provision of free prescription drugs, the doctors carried out a health census of the barrios, which provided a complete health survey of the Caracas barrios for the first time.[6]

Despite some obstacles (including the refusal by public hospitals to accept referrals for diagnosis and treatment, which was gradually and only partially overcome in 2003), "Plan Barrio Adentro" became very popular with its constituents.[6] By December 2003, "Plan Barrio Adentro"—having seen over 9 million patient consultations and 4 million health interventions[6]—was so popular that it was attracting national attention, and President Chávez transformed it into a national program, named "Mission Barrio Adentro" (MBA). It became the first of a series of popular "missions" that bypassed existing public institutions.[14]

"The key aspect of these centers is that they are located within the neighborhood and in the marginalized zones of the large cities,"[13] although some facilities were located in higher income areas.[14] "Placement of Barrio Adentro health posts within those neighborhoods that had been most excluded was undertaken at the request of the neighborhood health committees and taking into consideration preexisting health care facilities."[13]

A key part of the national Barrio Adentro scheme, as in the original local plan, is the participation of the local community. This takes place through health committees (an assembly of 10 or so appointed citizens). By 2006, some 8,951 health committees had been registered, one for each primary care post.[13] (The total was already 6,241 in 2004).[6] A total of 41,639 community health assemblies were held in the first quarter of 2006, with the participation of 1,423,815 people.[6]

The issue of participation goes beyond mere management. As one academic study put it, "the observed role of positive, egalitarian clinical interactions between Cuban physicians and Venezuelan patients and other residents suggests that doctor–patient interactions model power relations between communities and institutions and affect local perceptions and participation." It concluded that developing more positive and egalitarian physician-patient and professional-community relationships "may be one of the easiest, most effective ways" the medical profession can contribute to overcoming health disparities.[14]

Each primary care post covered 250 to 300 families.[13] By 2003, primary medical care coverage was made available to 70% of the Venezuelan population for whom primary care was previously unavailable, representing over 18 million people. By 2007, 3,717 primary care posts had been built and equipped, and a total of 8,633 posts were operational (including those still located in community centers and homes). There were also 4,800 dentists. In 1998, Venezuela had only 1,628 staffed primary care posts, and 800 dentists. Between 1998 and 2007, this represented an increase of 530% and 600%, respectively.[13]

In addition to the new infrastructure, there were also new outreach programs. For example, in addition to the drug module for the popular medical dispensaries (which provided free access to 106 essential medicines designed to cover the needs at this level of care), a family drug module was launched in 2005. This program reached 40 selected municipalities in 17 states, and every three months delivered drugs and vitamin supplements tailored to the family's needs. Hundreds of thousands of infants, children, and pregnant and elderly women have benefited.[6] Over 150,000 health promoters from local communities were trained in 2004–2006 to spread messages relating to ways of improving health.[6]

After the Barrio Adentro's primary care network went nationwide in 2004, moves to expand beyond primary care soon followed. What became known as "Barrio Adentro I" focused on primary health care. "Barrio Adentro II" focused on secondary care, in three main areas: Comprehensive Diagnosis Centers (for more advanced diagnoses), Comprehensive Rehabilitation Centers (for people with disabilities, another social deficit uncovered by Barrio Adentro I—there were only 78 public sector centers in 1998), and Advanced Technology Centers (for more advanced treatment). Plans were made for 600 each of the first two facilities (each serving a population of approximately 40,000 to 50,000) and 35 of the latter (with at least one in each state).[13]

As of 2007, Barrio Adentro II included 417 Comprehensive Diagnostic Centers (of the 600 planned), 576 Comprehensive Rehabilitation Centers (of the 600 planned), and 22 Advanced Technology Centers (of the 35 planned). Key modern technology is split between CDCs and ATCs (by 2007 CDCs had 13 of the 19 public sector MRI machines, ATCs 15 of the 26 CT scanners). In 1998, there was only one MRI machine and five CT scanners in the public sector.[13]

Barrio Adentro III provides care for those cases which cannot be resolved at the two lower levels—major illnesses, palliative and specialist care. Care is available 24 hours a day.[13] Barrio Adentro IV is responsible for the most complicated and specialized medical and surgical needs. These are national and referral facilities where teaching and research is carried out.[13] The Dr. Gilberto Rodríguez Ochoa Latin American Children's Cardiology Hospital, inaugurated in 2007,[19] is the most notable example,[14] being one of the largest centers of its kind in the world, with 142 hospital beds and 33 intensive care beds.[6]

As the work of the first primary health care program Barrio Adentro proceeded, censuses began to reveal "the depth of the social deficits accumulated in these communities."[13] The response was to expand into a number of new areas, creating new missions. Thus under Misión Mercal, efforts are made to ensure that the vulnerable (children, elderly, etc.) receive at least two meals a day. Misión Robinson was created to address illiteracy, which in turn led to Misión Milagro to deal with deficiencies in ophthalmological care.

In July 2007, Douglas León Natera, chairman of The Venezuelan Medical Federation, reported that up to 70% of the Barrio Adentro modules had been either abandoned or were left unfinished.[21] In some cases the Venezuelan government accused elected opposition officials of trying to impede or close existing Missions. In 2006 Chávez accused the governor of Zulia State of impeding Barrio Adentro there.[22] According to investigative journalist Patricia Marcano, in 2010 the Venezuelan government promised to start 357 clinics of which 148 were completed. In 2012, 298 clinics were promised and 175 were completed, and in 2013, 62 were promised with 35 completed.[20]

In December 2014, it was estimated that 80% of Barrio Adentro establishments were abandoned with reports of some structures being filled with trash or becoming unintentional shelters for the homeless.[9] The majority of Cuban medical personnel had left Venezuela as of 2016.[10]

In August 2006, the George W. Bush administration of the United States created the Cuban Medical Professional Parole program, specifically targeting Cuban medical personnel and encouraging them to defect when working in a country outside of Cuba.[23] According to a 2007 paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the United States".[24][25] Cuban doctors working abroad are reported to be monitored by "minders" and are subject to curfew.[24]

In February 2010, seven Cuban doctors who defected to the US introduced an indictment against the governments of Cuba and Venezuela and the oil company PDVSA for what they considered was a conspiracy to force them to work under conditions of "modern-day slaves" as payment for the Cuban government's debt.[26] In 2014, it was reported by a Miami NGO, Solidarity Without Borders, that at least 700 Cuban medical personnel had left Venezuela in the past year and that hundreds of Cuban personnel had asked for advice on how to escape from Venezuela weekly.[27] Solidarity Without Borders also stated that Cuban personnel cannot refuse to work, cannot express complaints, may be blackmailed, and suffer threats against their family in Cuba.[27]

The Venezuelan Medical Federation, the largest association of medical doctors in Venezuela, lobbied vigorously against the use of Cuban doctors in Mission Barrio Adentro, and was in a legal dispute with the Chávez administration over the legitimacy of the Cuban doctors' licensure and practice. In 2003, they obtained a court order preventing Cuban doctors from practicing in Venezuela, on the basis that they were not properly licensed according to the Venezuelan system; a compromise was reached enabling them to continue working in Barrio Adentro.[28][29][30]

In 2014, the Comptroller General of the Republic "found serious irregularities in the ... repair, modernization, and extension of eight national referral hospitals". In 2006, the Venezuelan government funded companies without reason and without certain regulations. The Comptroller said that the project was "marked by weakness and improvisations" and that "[t]his authorization does not imply commitment to the Foundation or the MPPS (Ministry of Health)".[31]

In 2017, The Miami Herald reported that groups of Cuban health care workers who had defected from the program stated that due to the daily quotas of patients, they would often feel pressured to fake paperwork and throw away medicine, since regular audits of their supplies meant they needed them to match their patient count. If Cuban medical personnel did not meet their quotas, they were threatened with having their pay cut or being sent back to Cuba.[12]

The New York Times interviewed sixteen Cuban medical professionals in 2019 who had worked for Barrio Adentro prior to the 2018 Venezuelan presidential elections; all sixteen revealed that they were required to participate in voting fraud.[32] Some of the Cubans said that "command centers" for elections were placed near clinics to facilitate "dispatching doctors to pressure residents".[32] Some tactics reported by the Cubans were unrelated to their profession: they were given counterfeit cards to vote even though they were not eligible voters, they witnessed vote tampering with officials opening ballot boxes and destroyed ballots, and they were told to instruct easily manipulated elderly patients in how to vote.[32]

But they also "described a system of deliberate political manipulation"; their services as medical professionals "were wielded to secure votes for the governing Socialist Party, often through coercion," they told The New York Times.[32] Facing a shortage of supplies and medicine, they were instructed to withhold treatment – even for emergencies – so supplies and treatment could be "doled out closer to the election, part of a national strategy to compel patients to vote for the government".[32] They reported that life-saving treatment was denied to patients who supported the opposition. As the election neared, they were sent door-to-door, on house visits with a political purpose: "to hand out medicine and enlist voters for Venezuela's Socialist Party".[32] Patients were warned that they could lose their medical care if they did not vote for the Socialist Party, and that, if Maduro lost, ties would be broken with Cuba, and Venezuelans would lose all medical care. Patients with chronic conditions and those at risk of death if they couldn't get medicine, were a particular focus of these tactics. One said that government officials were posing as doctors to make these house calls before elections; "We, the doctors, were asked to give our extra robes to people. The fake doctors were even giving out medicines, without knowing what they were or how to use them," he said.[32]