A Strange form of Declaring a Health Emergency: The case of Venezuela - World Medical Journal

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A Strange form of Declaring a Health Emergency:
The case of Venezuela

International, Regional and NMA news

Introduction
The declaration of a national health emergency in any country in the world is a decision that is adopted by the authorities in the face of unexpected or unusual events that produce a situation that is considered a public health emergency [1] of national or international concern. Th ese diverse events go from natural disasters, armed confl icts, to disease outbreaks or potentially pathogenic events that constitute a threat to the public health of a country and of other States.This type of declaration is usually accompanied by decisions of a legal and administrative nature, that allow the authorities to adopt dispositions that, amongst other things, temporarily restrict liberties, as in the case of quarantines, and/or temporarily eliminate certain requisites demanded of the national public administrations for the acquisition of the goods and services necessary to protect the health of the population affected by the events that produced the emergency.

The case we are concerned with, the declaration of emergency recently announced by
the President of the Bolivarian Republic of Venezuela, Hugo Chavez [2], is sui generis. On one hand, it is not the result of an unexpected or unusual event of a kind that is frequently invoked to adopt such a decision; on the other hand, it is not supported by any administrative act. Other kinds of facts are clearly at play here, and revealing their meaning is the purpose of this article, which draws heavily on an open letter addressed to President Chavez by Venezuelan ex-Ministers of Health Blas Bruni Celli, Jose FelixOletta, Rafael Orihuela, Pablo Pulido and Carlos Walter.

The announcement of the emergency declaration and a question that warrants a
different response "In the social area, we have an emergency at this time: health.
Let us state that we are all in a state of emergency (…) Two thousand Barrio
Adentro* primary health care units have been closed. What happened there? We have all been negligent" [3]. Thus was this declaration of emergency announced to the Venezuelans in an extended Cabinet Meeting held on 19 September.

Venezuelans were surprised that President Chavez asked himself "What happened
there?" Th e president seems to have forgotten that both he and the Cuban Government
decided to start a progressive transfer of 4500 Cuban doctors from Venezuela to
Bolivia by 2006?

Since 2007, various studies as well as statements [4, 5] by the users of the parallel system of Barrio Adentro, have shown serious problems in access and quality of services. This dissatisfaction worsened when the personnel were reduced upon being transferred (without explanation to the Venezuelan people) to other countries.

Of the 8000 buildings scheduled to be built as popular clinics for the Barrio Adentro I network only 2000 have been built, and in the clinics and attention sites that are operative,the tasks of primary health attention * Barrio Adentro (BA) I is the name that the Venezuelan government uses to designate a network of primary attention in a health system that is parallel to the conventional one, that began operating in 2003. Th is system is managed by the Cuban Medical Mission in Venezuela outside the rectory of the Ministry of Health.had to be limited.

In addition, many of the "cooperantes" or Cuban health professionalsor technicians were moved to work at the "Comprehensive Diagnostic Centres"**.

Very soon the provision of services was discontinuous and irregular, the hours of
operation were reduced and many modules closed their doors. Th is resulted in discomfort and frustration among the users and among those that in good faith accepted to get involved in health activities. Finally, the infrastructure has deteriorated due to lack of maintenance and use. It seems that President Chavez has not found out that on January 2008, the President of Th e Metropolitan College of Physicians and representative of the National Bolivarian Physicians Front stated: "Unfortunately, I have to admit that the wonderful plan of Barrio Adentro has collapsed. Th e centres have been transformed into simple points of reception. Th e constitutional goal has not been met" [6].

The abandonment of the 2000 Barrio Adentro centres to which the President referred
is not the only problem this system faces. Barrio Adentro generated a new network
within the public subsystem, which deepened and broadened the segmentation and
fragmentation of the Venezuelan health system.

These characteristics were some of the flaws that the Ministry of Health and Social
Development (today the Ministry of Popular Power for Health) pointed out about the
health system existing in the country before 1999, and that needed to be corrected [7].

From a technical, administrative, and managerial perspective, Barrio Adentro was
never integrated into the Public Health System; on the contrary, it was a critical factor in debilitating the existing system. At the same time, this system did not achieve
** The Comprehensive Diagnostic Centers are part of the medical assistance establishments that constitutethe network for secondary attention in the parallel health system managed by the Cuban Medical Mission in Venezuela.

the expected coverage. Even though Barrio Adentro increased the coverage of the
primary care level, in practice it duplicated the existing coverage. Th e question is, how efficient, eff ective and sustainable has this policy been? How much has it contributed to reduce the regional inequities in terms of coverage? In addition, there has never been enough information to evaluate the results, nor transparency in the management and rendering of accounts by those who have led and managed this parallel health system.

For all these reasons, the dismantling of Barrio Adentro is not a "health emergency".
It is a fact known for over three years by the President, the health authorities and most Venezuelans, a fact that adds to other ills of the national health system. We regret that the President accepts it as true only when the Cuban Government corroborates this information. It would have been enough for him to listen to the Venezuelan people, those who support him, those who supported him, and those who do not agree with his administration, but particularly, to those people with scant resources that benefited from Barrio Adentro and who now feel deceived and cheated.

Responsibilities of the announced abandonment The responsibility of the President in this matter is not transferable. He cannot transfer blame to the rest of his Cabinet, his governors and his mayors. He and he alone is responsible for having delegated to a foreign government, the Cuban Government, through the Cuban Medical Mission, the management, supervision and evaluation of this Parallel Health System.

How can the President explain to the country that in January 2008 in his Annual Message to the Nation [8], he stated that 6531 primary health centres were in operation and seven months later, he said 2000 had been abandoned? How can he explain that on 25 January 2006, at the height of Barrio Adentro, 21 745 Cuban health "cooperantes" were working, and now with 24 000 "cooperantes", 2000 health centres have been closed?

It is the duty of the President and of the State Controller Agencies to promptly order investigations to establish responsibilities in the neglect and abandonment of Barrio Adentro Mission that gave rise to the aforementioned declaration of emergency,
and what share of the responsibility belongs to the Cuban Government.

A wrong answer The solution is not to bring more Cuban doctors and students to join those already here, and who are not showing results in improving the health care in our Nation. This will only compound the errors and will delay the actions to start a systematic approach to improve the Venezuelan health care system.

After 10 years in power, President Chavez does not seem to realise that the severe
problems of the Venezuelan health care system are not limited to the appalling
neglect of Barrio Adentro. During this decade of President Chavez's government,
many critical health system functions were abandoned, deteriorated or improvised. Debilitating policies, such as reorienting the objectives of health campaigns, fragmenting, segmenting and centralising health care services have produced inequity and exclusion, in addition to reducing the coverage and the quality of health care. Never before has so much money been spent in health, in a disorganised, uncontrollable, and nontransparent way. And never before have the results, as measured by health indicators,been so poor.

Fundamental health programs do not show results, epidemiological surveillance is weak
and the capacity to respond to endemic diseases, epidemics, emerging and re-emerging
diseases is poor and ineffi cient. There are no integrated plans against new social health threats such as violence, drug addiction and problems arising from population explosion.

Environmental sanitation and the quality of housing is poor. Public hospitals are in
ruins, Venezuelan mothers are giving birth on the street, health information has been
arbitrarily restricted, all of which weaken the response capacity of the system. In addition,there is a deliberate policy to destroy the national health manpower, which has morally damaged the health workers and their families.

To make matters worse, in these past 10 years of President Chavez and his ruling
party in government, despite having an ample majority in the National Assembly, he
has been unable to foster a broad debate to approve health legislation that would contribute to make the right to health an eff ective right for all Venezuelans.

The critical social reality
The problems related to the health sector affect other social policy areas, which in turn decisively aff ect the health of the population and their quality of life.

We are deeply concerned that the political environment, the democratic shift towards
an authoritarian regime, the fragile social peace, the loss of civil liberties and the recently approved unconstitutional laws that impose a national model stamped with the personal ideology of President Chavez, have all advanced simultaneously with repression and threats to the freedom of speech.The increasingly unsatisfied social demands stimulate conflict and have contributed to a disrupted social dialog, particularly with the public authorities. These conditions fertilise the way towards greater poverty, deeper conflicts, greater insecurity, more exclusion,less health, fewer opportunities for productive work and less development.

Thus, it is critical to enable a space for social dialogue in order to reach fundamental agreements. Amongst these, health is a critical condition for equitable development,and this value is the best drive in combating exclusion and poverty.

The necessary correction
The Venezuelan health system has serious deficiencies. Improving them requires making
political decisions sustained by sound technical and scientific criteria. Th is is a
hard reality for all Venezuelans, a reality from which we cannot escape. A shared
destiny forces us to humbly off er wise and timely responses.

The construction of Venezuela requires tolerance, respect for personal dignity, willingness to a civilised understanding within our society that cannot continue oscillating between extremes of endless and fruitless confrontation, and indiff erence or social autism, driven by hatred, resentment and thoughtlessness. Th ere is still time to rectify, to invoke more freedom and more democracy, and in this way call on all Venezuelans to share the dream of a more just and better country.

References
1. Organización Mundial de la Salud (2006). Reglamento Sanitario Internacional 2005, Ediciones de la OMS, Ginebra, Suiza.
2. Chávez declara en emergencia sistema de salud.
Avalaible from: http://www.eud.com/2009/09/19/pol_ava_chavez-declara-en-em_19A2760687.shtml
3. Chávez declaró en emergencia la salud en Venezuela.
Avalaible from: http://www.eluniversal.
com.ve/2009/09/20/pol_art_chavez-declaro-enem_
1574464.shtml
4. Rachel Jones, Hugo Chavez's health-care programme misses its goals. Lancet. 2008 Jun; 371( 9629):1988.
5. Aceptación de Barrio Adentro descendió pero sigue alta. Avalaible from: http://www.guia.com.ve/noti/50545/aceptacion-de-barrio-adentro-descendio-
pero-sigue-alta
6. Fernando Bianco: "La misión Barrio Adentro se vino abajo". Avalaible from: http://www.aporrea.org/misiones/n108067.html
7. Organización Panamericana de la Salud -OPS(2006). Barrio Adentro: derecho a la salud e inclusión social en Venezuela, Caracas, Venezuela
8. Mensaje Anual a la Nación del Presidente de la República. Avalaible from: www.abn.info.ve/mensaje_anual_2009.doc

Carlos Walter V.
Ex-Minister of Health of the
Bolivarian Republic of Venezuela
Ex- Institutional Development Advisor of
the Pan American Health Organization
Director of the Centre for Development
Studies (CENDES) of the Central
University of Venezuela.
Caracas. Venezuela