Attending Need, Not Profit: Venezuela’s Experiment with Community Medicine
How should the healthcare needs of a society be met? Conspicuously absent from international media coverage and under fire from conservative critics at home, Venezuela is developing a public healthcare system distinct from both U.S. market-driven and European welfare-state models. Perhaps nothing makes this system more unique than the kind of doctors being trained to run it.
The first remarkable thing to note about Venezuela’s comprehensive community medicine program is how little is known about it outside of Venezuela. The attempt to train tens of thousands of aspiring doctors in Cuban-style preventative community medicine, the majority of these new physicians from lower-income backgrounds, has merited next to no attention from the international mass media. Compared to issues of crime, inflation and sporadic shortages in the economy, for these outlets the effort to create an “army of white jackets” to make the vision of a free, universal healthcare service with clinics in every neighbourhood a reality is seemingly not of importance for understanding Venezuela today.
Yet Venezuela’s new community doctors are now central to the performance and future shape of the country’s revitalised public healthcare system. Further, at a time when medicine is usually a vocation only open to elites and public healthcare services are being increasingly fractured and privatised by anti-popular governments, the Venezuelan example of constructing a robust public healthcare system in often difficult circumstances is demonstrative on a global level.
In progressive and independent media important work has already been done to open the world’s eyes to new programs offering free public healthcare in Venezuela. This article focuses on the next stage of this project: the training of tens of thousands of new doctors under the Cuban-supported comprehensive community medicine program. With the first wave of community doctors graduating in December 2011, these are the professionals who are now developing the country’s new national public healthcare system, from local community clinics to hospital level. Between the following article and direct interviews with graduates, this investigation aims to shine a light on Venezuela’s, and indeed Latin America’s, new type of doctor: their quality, their values, and their future vision for healthcare in Venezuela and the wider world.
The Origins of Medicina Integral Comunitaria (MIC) in Venezuela
Comprehensive community medicine (MIC in its Spanish acronym) in Venezuela was born out of a health accord signed in 2005 between presidents Hugo Chavez and Fidel Castro. As part of the agreement, in exchange for oil shipments Cuba would help Venezuela train 30,000 community doctors to staff Venezuela’s “Barrio Adentro”(Inside the Barrio) public health program.
Established with Cuban assistance and staffed by thousands of Cuban doctors, Barrio Adentro grew rapidly from 2003 and forms a key part of Venezuela’s expanded public healthcare system. The Barrio Adentro network has four stages, delivering free healthcare from 7,000 local community clinics up to hospital level. The program is measured to have administered over 500 million consultations and saved over 1.4 million lives since its founding.[i]
In conjunction with other government social programs, Barrio Adentro has been an important factor in the improvement of health indicators in the South American nation over the previous decade. This was highlighted in a study by the Council for Social and Economic Research which found that among other indicators, between 2003 – 2006 alone infant mortality fell in Venezuela from 18.5 per 1000 births to 14.2 per 1000 births.
Of course the expansion of Venezuela’s public healthcare system over the previous decade has required the influx of thousands of extra doctors, with the number of doctors per 10,000 inhabitants rising from 18 to 58 from 1998 - 2012. However the great majority of these new doctors could not be drawn from within Venezuela’s traditional medical profession. When the Chavez administration first sought to increase public healthcare provision in the early 2000s it found the country’s elite medical schools reluctant to open their doors to more students, especially those from poorer backgrounds. Meanwhile, with honourable exceptions, few aspiring young doctors or established specialists from the traditional system had much interest in going to work in the urban barrios (poorer neighbourhoods) or remote rural practices, preferring to seek high paid jobs in up-market private clinics.
Instead the Chavez government turned to its ally Cuba for help, not just to send doctors from Cuba, but also for assistance in training a new type of doctor in Venezuela prepared to serve the healthcare needs of the whole Venezuelan population. Thus in 2005 the National Training Program in Comprehensive Community Medicine (MIC) was born. Under the initiative, the Cuban doctors working in Barrio Adentro would double up as teachers, training their Venezuelan replacements to gradually take over the running of the country’s public healthcare system.
By 2013 this plan is bearing fruit. Over 14,000 community doctors are now working in public clinics and hospitals throughout the country (8,160 graduated in December 2011 and 6,200 in December 2012) as part of an obligatory two-year urban / rural residency which all community doctors must complete after graduating. In fact the program is now being extended, with the Venezuelan government aiming to train a total of 60,000 community doctors by 2019. Meanwhile postgraduate programs are being prepared for those who are completing their residency and want to become specialists in a given area of medicine.
Aspects and Goals of Comprehensive Community Medicine
Beyond supplying new doctors for Venezuela’s public healthcare system, a second aim of MIC is to implement a new model of medical education and healthcare delivery in Venezuela based on the preventative, community-based model utilised in Cuba. Supported by the state’s new academic institutions such as the Bolivarian University of Venezuela (UBV), the comprehensive community medicine degree program lasts a total of six years plus a pre-medical preparatory training course. Unlike traditional medical degrees, from the first year students are brought into direct contact with patients by assisting doctors in local clinics and accompanying them on house to house community visits. As described by author Steve Brouwer, who has written extensively on the MIC program, Cuban doctors thus assume the role of “demonstrating, by their comportment and attention to preventative healthcare in the barrios, how a revolutionary doctor promotes trust among his or her patients in the community, and then involves them in creating a healthier society”.[ii] Students also undertake hospital and rural internships during their final two years of study, increasing patient contact and practical experience.
Another difference with the traditional model of medical education taught in Venezuela is that the MIC program is more interdisciplinary in nature. In the classroom, rather than introducing the individual medical sciences in isolated components, the same material is delivered in a “sophisticated curriculum” through interdisciplinary courses weaving together subjects from anatomy to immunology. Advocates argue this methodology better applies scientific knowledge for a holistic understanding of the human body and complex morphology.[iii] Classes are generally held in the health centres of the Barrio Adentro network, with students grouped geographically into different study groups, or nuclei.
A third aim of the program is to create doctors with values different from those of the market-driven model of healthcare prevalent in the United States and the wealthier echelons of Venezuelan society. Community doctors are expected to be both rigorously trained and socially-conscious; committed to public healthcare and focused on the needs of their patients and communities rather than seeking lucrative careers in private clinics. Hugo Chavez urged community doctors in training to become “doctors of socialism”, and declared to newly graduated community doctors during a ceremony in February 2012 that “The doctor should be a social leader; a true doctor doesn’t only stay in the clinic, but goes out to the community”.
The MIC program forms part of the more inclusive higher education model developed under the Chavez administration. Those studying comprehensive community medicine do not pay tuition and receive a small stipend (currently around 40% of the minimum wage) toward living costs, with a great number of students coming from less well off backgrounds. The program has thus given an opportunity to thousands of aspiring medical students who would not have been able to enter the country’s traditional medical schools, either because they could not afford it or because of concealed class discrimination in these schools’ admittance processes. Further, the majority of MIC students are women: 77% of the community doctors who graduated in December 2012 were female.
Venezuela has also spread comprehensive community medicine to Latin America and the wider world through the “Salvador Allende” Latin American School of Medicine (ELAM) in Caracas. Through this institution, 2,200 students from 42 countries are currently being trained, courtesy of the Venezuelan government, in comprehensive community medicine. Once they finish their studies they are expected to return to their home countries to strengthen public healthcare systems there and serve the healthcare needs of their peoples.
Evaluating the Program
Writing in 2010, U.S. journalist Steve Brouwer suggested that it would likely take several years before the quality, professionalism and values of community doctors could be fully assessed. Indeed, with the first wave of community doctors graduating in December 2011, only now that these new physicians have begun to work in the national public healthcare system is it possible to begin to do so with any definitive basis.
Nevertheless, based on his own research and observation of MIC’s curriculum and training, Brouwer gave a positive assessment of the program. He reported on the work of the National Academic Coordinating Committee of Barrio Adentro in recommending improvements to the program and reported that “initial shortcomings of the program were rapidly overcome”, which was reflected in a rising pass and retention rate for new students between 2006 and 2008. Further, he reported that studies by Cuban and Venezuelan medical researchers “indicate that Medicina Integral Comunitaria (MIC) is headed in the right direction”.[iv]
Government ministers have also given a positive appraisal of community doctors, who of course are the product of one of the government’s own educational programs. During the first graduation ceremony of community doctors in February 2012, late President Hugo Chavez told graduates, “I have the first reports of your extraordinarily positive work. You are serving the people”, while the minister for university education, Yadira Cordova, said that community doctors would be “the best doctors this country has given birth to”.
However, the quality of the MIC program and its graduates have been criticised by members of the conservative opposition, sectors of the pro-opposition private media, and most virulently, by Venezuela’s traditional medical establishment. These voices argue that students of comprehensive community medicine lack practical training in hospital settings and with technology. They also claim that the program lacks infrastructure, teaching is poor and evaluation lax.
The National Academy of Medicine, the organisation representing traditional doctors in Venezuela, appears to have led criticism of MIC. In a 2012 National Academy report gauging traditional medical specialists’ opinion of new community doctors undertaking hospital placements, eighty percent of the specialists consulted described community doctors’ performance as “bad”, and none as “excellent”. The report went on to describe the comprehensive community medicine program as a “true educational fraud”.
The National Academy also opposed the entry of community doctors into the public hospital system, arguing against a change to Venezuela’s law on the exercise of medicine in 2011 to allow the first MIC graduates to legally practice. In an interview with flagship conservative paper El Universal in October 2011, the president of the National Academy, Claudio Aoun Soulie, launched a series of criticisms against the program to justify this stance. However almost all of the criticisms cited were factually incorrect; for example that MIC students are ignorant of the main pathologies affecting Venezuelans, that they never enter surgeries or perform births, and that they don’t undertake rural or accident and emergency placements. The representative of Venezuela’s medical elite went on to argue, “If we don’t stop healthcare being put into the hands of non-qualified personnel, the complaints of malpractice will multiply minute by minute”.
As the first wave of community doctors graduated in December 2011 these criticisms took on the characteristics of a campaign to discredit the MIC program. Blog “exposés” of supposed malpractice by MIC students and mocking memes and other online jokes depicting community doctors as incompetent and stupid proliferated, while criticisms from the traditional medical system appeared disproportionate, harsh, and at times outright false. In an interview with Venezuelan newspaper El Tiempo in November 2012, the head of the College of Doctors in Anzoátegui state, Asdrúbal González, went as far as to claim that Cuban doctors in Venezuela have a “60 – 70% diagnostic error rate”, and said of the community doctors they were training, “I don’t know for what it is they are being trained, but it’s definitely not to be doctors”.
The campaign against comprehensive community medicine created misunderstandings among many citizens as to the nature of the program and the quality of its graduates. This misinformation was highlighted in a street survey by Venezuelan media outlet Noticias 24 in February 2012 of citizen opinion of community doctors. While there were many positive responses, one respondent said that she would only see a doctor from the traditional medical establishment and not a community doctor, declaring, “If to study medicine you have to train for five years and then do postgraduates, it doesn’t make sense to me to go to a doctor that’s studied the degree for less time”. Trainee community doctors in fact study for six years, including rural and hospital internships, before undertaking a two year residency and then moving on to postgraduate study, as with other doctors.
For practitioners and supporters of comprehensive community medicine, this campaign has represented more than just the attacking of a government program or raising any possible legitimate criticisms of MIC. It also indicates the hostile reaction of Venezuela’s medical elite and those defending a market-based model of medical care toward of a perceived threat to this sector’s privileges and interests. To Venezuela’s traditional medical sector, the influx of thousands of Cuban-trained doctors from low-income backgrounds, who are now working in public hospitals directly alongside doctors from the traditional sector, is at once a political and class affront. It is quite possible that some traditional doctors also perceive community doctors as a source of competition for entry into postgraduate programs and jobs, further increasing hostility towards them.
Advocates of comprehensive community medicine have responded to criticisms and disinformation by explaining the program’s content and nature while pointing to community doctors’ practical performance. For example, six months after the National Academy president’s warning of “minute by minute” malpractice by MIC graduates, the Ministry of Health reported that it had not received one single complaint of malpractice by a community doctor. Defenders of the program also highlight that students receive a comprehensive curriculum by doctors trained in world-recognised Cuban medicine[v], gain extensive practical experience in the Barrio Adentro health network, and during their fifth and sixth years of study undertake demanding rural and hospital internships. In addition to this, many graduates of the program feel proud of the unique characteristics community medicine teaches them as doctors, such as playing an active role in community healthcare and supporting public over private healthcare.
Authorities also highlight that the comprehensive community medicine program has been constantly improved since its inception. Recent changes include implementing a series of specialist workshops for students in their final two years, supplying students with more teaching equipment, and having MIC students begin hospital internships from their third year of study.
As such, French journalist Jean Araud has drawn a parallel between the campaign against community doctors and the opposition’s campaign in 2003 against incoming Cuban doctors of the Barrio Adentro system, who were painted either as Cuban spies or medically incompetent. Araud predicted that as in 2003, criticisms against MIC graduates will fail to deter the population from seeking out their care, as community doctors “are no longer “infiltrating Cuban agents” but instead are graduated Venezuelan doctors,” offering humane and quality healthcare to society as a whole.
The Venezuelan government’s effort to establish a new medical education program from the ground up and train tens of thousands of doctors for the country’s revitalised public health system has been a bold initiative, and one whose benefit is now being seen the length and breadth of the country. Of course the program has had to confront many obstacles and difficulties, such as an initial lack of infrastructure, the requirement for practicing Cuban doctors to take on the demanding task of teaching a new curriculum, and a hostile attitude from the traditional medical establishment. Further, given the experimental nature of comprehensive community medicine in its early phases and the expectation for students to engage in a great amount of independent study, there are likely some graduates who are not fully up to standard; something which such individuals will have to confront in their two years of residency. Nevertheless, the same could also likely be said of some graduates from the country’s traditional medical schools.
However based on the information available and in concordance with the anecdotal findings of this investigation, the great majority of Venezuela’s new community doctors appear to be humane, well trained, and professionally competent. The evidence suggests that it is now falling on the traditional sector to accept that many of their comprehensive community colleagues are far better trained than they had originally imagined, and that much of the criticism aimed at the MIC program has proven to be unfair at best, and deliberately misleading at worst. Many conventional doctors will have been shocked when in a recent competition to enter postgraduate study in the prestigious University of the Andes in Mérida, three of the four community doctors who applied were accepted to the forty-something places offered, while up to two hundred graduates from traditional universities were not.
By 2019 it is possible that around 60,000 community doctors will be working in Venezuela’s free public healthcare system, following what Social Medicine Journal describes as “the most ambitious example of scaling up of physician training in a single country”.[vi] This is a huge investment of resources for a country that, despite its oil income, is regarded as belonging to the “third world” with multiple challenges to its development. While in many nations the political class informs the population that the resources do not exist to support public healthcare and that the private sector must play an ever greater role in healthcare delivery, Venezuela’s experiment with community medicine offers a different path. With the political will it is indeed possible to guarantee all members of society the right to free healthcare, and it is also possible to train the doctors needed to ensure this service is humane, professional, and public. Perhaps that’s why not a squeak about comprehensive community medicine has been heard from in the international mainstream media up to now.
Beyond what the Venezuelan government, the traditional medical establishment and foreign observers have concluded about comprehensive community medicine, this investigation invites readers to look at what recently-graduated community doctors themselves think about the program. In the second part of this study, to be published this week, these new professionals from all walks of life give their first-hand accounts of their training and their experiences working alongside conventional doctors in the nation’s public hospitals. The interviews also reveal a lot about the values and future aspirations of Venezuela’s “army in white jackets”.
[i] Venezuela’s public healthcare system is split into two different networks, both of which are free to use and open to the public, and which to some extent overlap and collaborate. One of these is the new Barrio Adentro network, which is staffed by Cuban doctors and Venezuelan community medicine students and graduates. This network focuses on primary and community level care, and service is completely free, including medicines. This network also offers higher level care and technology in Comprehensive Diagnostic Centres (CDIs), Comprehensive Rehabilitation Centres (CRIs), and mid-level clinics called ambulatories.
The second network is the traditional public hospital system, in which conventional Venezuelan doctors work, many of whom also work in the private sector. These professionals are trained in the country’s traditional medical schools and politically are considered to be generally favourable to the conservative opposition.
In their first years of study, students of comprehensive community doctors are trained by Cuban doctors and gain their practical experience within the Barrio Adentro network. However in their final years of study, trainee community doctors also undertake placements in the public hospital system, and work alongside traditional sector doctors. After graduating, community doctors also undertake an obligatory two year residency which can include placements in both public health networks, thus continuing to work in public hospitals alongside conventional doctors. The working relationship between these two groups is explored in more depth in the interviews conducted with graduates of comprehensive community medicine in a separate article.
[ii] Brouwer, Steve, (2011). Revolutionary Doctors: How Venezuela and Cuba are Changing the World’s Conception of Healthcare, Monthly Review Press, New, York, p112
[iii] Ibid, p120 - 121
[iv] Ibid, p122 - 125
[v] Further, according to a MEDICC Review report in 2008, 68.5% of teachers on the program hold the rank of Instructor or Assistant Professor under requirements established by Cuba’s Ministry of High Education. By 2013 this percentage may well be higher, as Cuban doctors on the program also continue to develop their teaching capacities.
[vi] Borroto Cruz & Salas Perea (2008), The National Training Program for Comprehensive Community Physicians, Venezuela, Social Medicine, Vol. 3 No. 4