Adentro Barrio Adentro: An American Medical Student in Venezuela

By
the time I finished my second year of medical school in a large
Midwestern university, I genuinely feared that I was losing the passion
that had led me to choose medicine as a career. As medical students
quickly discover, the focus in our medical education system is on the
hard sciences rather than on any integrated critical analysis of issues
related to social justice or the larger societal context in which we
will ultimately practice. Lamenting that we no longer had time to
volunteer, let alone read anything beyond required text books, we
placed a part of our souls on a shelf, agreeing that after board exams,
we'd return and dust off our interests in social justice, women's
health, and our international community. Throughout my pre-clinical
years, that choice nagged and pulled at me, a voice constantly asking:
was I selling out?

In
my medical school in the North, I reluctantly accepted the presumption
that medicine best-served the lucky few with resources and health
insurance. Labeled ‘naïvely optimistic' if I earnestly proposed
universal health care, I longed to live in a country where
comprehensive health care was a right of all citizens. Most
importantly, I wanted to hear firsthand the stories of transformations
from a marketbased health care system to one in which medical services,
regardless of the level of complexity, are universally guaranteed and
provided at no cost to the patient. During 2004, I began reading
articles about Venezuela's political changes and notably the redesign
of their health and education systems. The government of socialist
president Hugo Chavez created a new public health initiative called
Barrio Adentro and, through a cooperative agreement between Venezuela
and Cuba, was able to bring thousands of Cuban primary care doctors to
underserved Venezuelan neighborhoods. Bottom line: a six-fold increase
in free clinic visits in six months. Critics asserted that, while
hundreds of free clinics opened in just a few years, there were
problems with the quality of services. "This is too crazy to be real",
I thought to myself, simultaneously discrediting while secretly
yearning to believe in Barrio Adentro.

I
decided I had to see it for myself. Had Barrio Adentro been
successfully implemented so quickly in such a large and diverse
geographic setting? Surely there would be important lessons learned for
health care providers across the globe. What worked well? What should
be done differently? Applying for a Fulbright grant to study medicine
in Venezuela was like sending a message in a bottle to my future self:
"Dear Jaded Future-Self, do not give up your dreams of social justice
in medicine. Check out the health care system transformations in South
America. Love, Idealistic Former-Self." I wanted to gain direct
exposure to the Barrio Adentro program, interview Cuban physicians, and
understand the perspective of Venezuelan physicians who often saw
Barrio Adentro as a threat to professional organized medicine.
Gratefully, I received my Fulbright award in 2006-07 and headed for
South America after completing my first clinical clerkships at my
medical school.

In
spite of good intentions, traveling to Venezuelan as a citizen of the
United States presented a number of complications. "Venezuela's most
senior leaders, including President Chavez, regularly express
anti-American sentiment. The Venezuelan government's rhetoric against
the U.S. government, its American culture and institutions, has
affected attitudes in what used to be one of the most pro-American
countries in the hemisphere," writes the US State Department holding up
their side of the international ping-pong game between the US and
Venezuela. Understanding the conflicts between the United States and
Venezuela meant not only wrestling with economic and historical
discourses, but also carefully planning to accurately access both sides
of the heated Venezuelan debates about the merits of the new health
care policies. Venezuela's professional class-including many, but not
all, physicians-tend to be highly critical of the Chavez government's
reforms and often, their criticisms are repeated in the rhetoric of the
US government and mainstream media. Because of assumptions made based
on the fact that I was from the United States, those who opposed the
Chavez government perceived me as a natural ally. Yet, due to my
community-service background and visible interest in public health and
preventive medicine, pro-Chavez physicians spoke candidly with me about
their fears and hopes for the new policies.

Accepting
funds from the United States State Department to travel and study in
Venezuela during a time of intense international polarization provided
unique access to multiple perspectives. Additionally, studying public
health at the local university facilitated introductions to healthcare
professionals from broad backgrounds. My classmates included directors
of hospitals, physicians, nurses, nutritionists, and accountants. These
individuals represented the spectrum of political beliefs in
Venezuela-from very pro-Chavez to vehemently anti-Chavez. Finally and
perhaps most importantly, by bringing my elementary school-aged child
to live and attend school in Venezuela, I unintentionally opened many
doors normally shut to outsiders. I was able to network with families
in my child's public school and in our neighborhood, effortlessly
creating a base to reality check my ideas with an economically and
politically diverse cross-section of Venezuelans.

I
divided my time between the Universidad de Los Andes and clinical
practicums through Barrio Adentro. At the University, I studied in the
department of Community and Preventive Medicine earning a public health
certification at one of the oldest and most traditional universities in
South America. This provided a substantive and structured counterpart
to my community-based clinical work in Barrio Adentro. Although my
formal studies inspired me, my everyday interactions within the rural
Andean community where I lived and worked effectively contextualized
the impact of the new clinics and health policies of the Chavez
government.

When
Barrio Adentro began in December 2003, few could have foreseen the
broad changes ahead for the small villages that are scattered
throughout Venezuela. Within months of the proclamation that launched
the initiative, more doctors arrived from Cuba and began living in
spare rooms within Venezuela's poorest and most underserved
communities. Neighborhoods and villages throughout the country opened
their doors to Cuban doctors providing room and board as a way of
collaborating with and supporting the community-based initiative.
People in the community reported that, initially, the Cuban doctors
were viewed with caution as foreigners without critical cultural
understanding. However, the initiative continued to grow rapidly, with
Cuban health professionals providing community-based primary care as
they do in their own country and across the world. Over a period of a
few months, Cuban doctors earned the village's respect by consistently
comprehensive services regardless of political affiliation.

In
addition to providing direct services in thousands of neighborhood
clinics, Cuban physicians are engaged in training Venezuelans in
community-based, social medicine. While one of the Cuban doctors I met
fell in love with a Venezuelan and intends to raise their family in
Venezuela, most of the physicians have families in Cuba and are looking
forward to handing over the clinical infrastructure to Venezuelans and
returning to their home. Within the first year, Barrio Adentro began
training Venezuelan students to take over these community based
consultarios. At first, qualified Venezuelan students were sent (free
of charge) to study medicine in Cuba. By the time I arrived in
Venezuela in September of 2006, local medical schools partnered with
community consultorios to train their second year of students. Like
many countries across Europe and Latin America, Venezuelan medical
schools start immediately after high-school and last for 6 years, as
opposed to the United States where medical school requires four years
of study that begin after four years of undergraduate college work. A
postgraduate fellowship track was initiated within the Barrio Adentro
initiative to train Venezuelan physicians in community medicine. This
two-year program includes epidemiology, advanced practice in resource
poor areas, and community organization. Upon completion, these doctors
are equipped to run municipal health care systems. Currently,
Venezuelan graduates of this program have also begun training
Venezuelan medical students. The object is to create a self-sufficient
system that no longer depends on importing human resources from Cuba.
The medical students in Barrio Adentro are my kind of people-they are
drawn from a crosssection of Venezuelan society and include single moms
and youth organizers from underserved communities. They have witnessed
the complete transformation of the Venezuelan health system. "We never
had a clinic… growing up, if we got sick we waited until we were on our
deathbeds before heading down to the city. Even then we had to wait all
day to be seen." More than increased accessibility, there is the
perception of heightened understanding, "The doctors in Barrio Adentro
didn't make me feel stupid for not having clean water, and they know
what my neighborhood is like because they live here too."

My
day would typically begin by getting my 7-year-old son off to our
town's two room school house. Waiting on the side of the road, we would
often meet a respected village resident, Señora Rafaela. Her son Martin
attended the same neighborhood school with my son in a mixed
second-third-fourth grade classroom that had recently opened as a
result of the government's commitment to provide all day elementary
school in rural communities. During these trips to and from school and
town, she discussed the positive impact on community health of the new
Barrio Adentro ambulatory centers, explaining how the local preventive
health care program emerged from years of community organizing work.

As
a key organizer of the community council, Señora Rafaela works closely
with Cuban and Venezuelan political leaders and doctors to coordinate
health fair events. Given her impressive competency in managing
budgets, transportation, and logistics, it's hard for me to imagine
that she was unable to finish high school and only recently obtained
her high school equivalency through one of = st1 ns =
"urn:schemas-microsoft-com:office:smarttags" />Venezuela's new
universal adult educational programs. "Before, no one listened,
actually listened, to our community," she explained to me, "Our
neighbors who come from the upper classes, who are college educated and
professional, they don't understand how much has actually changed."

I
would arrive at the one room consultorio (ambulatory clinic) in the
morning where my Cuban preceptor and Venezuelan post-graduate fellow
would see patients on a walk-in basis until noon. Often we were joined
by two Venezuelan medical students who had worked in the clinic as a
continuity experience over the previous two years and will continue to
work in the clinic throughout their training. Over the course of a
typical morning we would evaluate and treat a dozen patients with
common complaints such as diarrhea and respiratory illnesses. In our
small one-room clinic, a glass display case stood stocked with dozens
of commonlyused medicines that were dispensed free of charge and
included medicines for hypertension, viral, parasitic, and fungal
infections, antibiotics, NSAIDs, prenatal vitamins, and birth control.
The staff and students explained to me how previously people in the
community would wait to see a doctor until seriously ill. A lack of
preventive care, relatively expensive treatment, and clinics
inaccessible to those without transportation fueled a disparity of
access between rich and poor. When the clinic opened in the
neighborhood, the nature of disease changed as more families had access
to preventive medicine and attended clinics earlier in the course of a
disease. A subtle shift in the sense of security in the community
developed as people felt secure in having nearby a clinic, a doctor,
and an accessible pharmacy.

After
seeing patients, we would spend the afternoon engaged either in
follow-up home visits or canvassing the neighborhood to actively seek
out our homebound ill neighbors. At other times we would work with
community leaders to design and implement simple, but effective, health
education projects.

For
example, during the spring, our goal was for 100% of the neighbors to
obtain a well-person physical. Everyone in our small village received
preventive care exams. For many, this visit to the doctor was the first
in decades. Families could walk to the local Bolivarian school situated
on top of a mountain, where the classroom was temporarily converted to
a mobile ambulatory clinic. On the other side of the valley, the two
room community center had been transformed into a makeshift clinic
intake center. In spite of the non-traditional locations, Misión Barrio
Adentro staff provided a very traditional physical exam. The Venezuelan
medical students asked about medical history under the guidance of the
Cuban physicians, performing a standard 12-point review of systems with
the same precision as their medical student counterparts in the United
States. With this virtually universal community outreach project, we
facilitated wellperson health evaluations and created a community
health census.

Although
similar in quality to a well-person check up, the spring health census
highlighted some of the differences between Venezuelan medical students
in Misión Barrio Adentro and their North American peers. By also
obtaining a detailed socioeconomic history, Venezuelan students in
Barrio Adentro made the significant connections between poverty and
health. How many people share each bedroom? Is there enough food and
cooking fuel?

Socioeconomic
information is charted in personal files and was later aggregated at
the district level. In this way, a child's case of diarrhea becomes an
issue that can be tracked to the lack of clean drinking water. Health
issues coalesce into projects that the municipality and community can
change-wells dug, pipes placed. The community can hold elected leaders
responsible for what previously was attributed purely to an individual
family's problem.

After
the health census in the spring, we next organized a summertime
‘graduation' for all of the community infants and their mothers who had
successfully completed at least six months of exclusive lactation. It
was a very Venezuelan event, with graduation gown, diplomas, and
presents for mom and baby. Our public health messages (family spacing,
reproductive health, and the benefits of lactation) were featured
throughout the day. The celebration provided a successful excuse to canvass
our neighborhood for pregnant women who otherwise would not have
initiated early prenatal care. Also, we created a safe place to discuss
reproductive health care without preaching or further marginalizing
young, poor families.

The
year I spent in Venezuela greatly contributed to my professional
development. Just as important, through my interactions with
Venezuelans and Cubans, I realized there was a much wider breadth of
people working and studying to be doctors from the community and for
the people. My interest in community-based social medicine had
unexpectedly led me to one of the most fascinating social experiments
in healthcare systems during recent times: Barrio Adentro. Though
initially reluctant, Venezuelans seem to be accepting both the new
socialized structure of their public health system as well as the
fundamental tenets of social medicine that form its practical and
philosophical foundations. Private consultation firm Arthur D. Little
and polling organization Datanalisis recently reported that over 80 %
of Venezuelans surveyed benefited from Barrio Adentro's services. While
I was pleased to improve my own practice of community-based medicine
under the tutelage of Barrio Adentro, importantly I was able to access
the critiques of socialized health care reforms to create a broader
understanding. Walking between two polarized worlds-21st century
socialized medicine and the traditional faculty of medicine, pro-Chavez
& anti-Chavez, I learned more than any clerkship or class about the
successes and failures of a national health system transformation.

I
believe that the United States medical system is at a crisis point, our
current practices are unsustainable. The question we need to ask
ourselves is "How can we build a sustainable and just health care
system for the 21st century?" Looking internationally, Venezuela
provides one example of expansive and rapid health care reform that
seeks to answer that question. The most critical lesson I witnessed was
not about managing a clinic, although that was important. Rather, it
was about the need to involve community and professionals in building a
new system that is based on shared values, the recognition of
underserved and marginalized communities and the importance of not
alienating wellresourced professionals. When physicians, medical
students, professionals and patients collaborate, we design our own
innovative solutions to improve the welfare of our entire community.

Rebecca
Trotzky-Sirr graduates medical school December 2009, and will start the
best ever Family Medicine residency program (location TBA.) She has
weekly Thursday potlucks in Minneapolis, you are invited. Rebecca is
the co-founder of a non-existant revolutionary movement, Weather
Overground which has higher aims than before. If she could, she would
make universally free dignified health care a part of the four basic
food groups. Tell her what you are bringing to her next potluck: [email protected]