[News] Attending Need, Not Profit: Venezuela’s Experiment with Community Medicine

[Anti-Imperialist News]

  Attending Need, Not Profit: Venezuela’s Experiment with Community Medicine

<http://venezuelanalysis.com/printmail/10092>http://venezuelanalysis.com/analysis/10092
<http://venezuelanalysis.com/print/10092>

By Ewan Robertson - Venezuelanalysis.com, October 14th 2013

/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 
<http://www.alianzabolivariana.org/modules.php?name=News&file=article&sid=1823> 
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 
<http://www.counterpunch.org/2012/12/14/the-achievements-of-hugo-chavez/> to 
have administered over 500 million consultations and saved over 1.4 
million lives since its founding.[i] 
<http://venezuelanalysis.com/analysis/10092#_edn1>

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 
<http://www.cepr.net/documents/publications/venezuela-2009-02.pdf> 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 
<http://www.counterpunch.org/2012/12/14/the-achievements-of-hugo-chavez/> 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 
<http://www.avn.info.ve/contenido/60000-m%C3%A9dicos-integrales-comunitarios-ser%C3%A1n-graduados-per%C3%ADodo-2013-2019> 
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] <http://venezuelanalysis.com/analysis/10092#_edn2> 
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] 
<http://venezuelanalysis.com/analysis/10092#_edn3> 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 
<http://www.mpps.gob.ve/index.php?option=com_content&view=article&id=1015:presidente-chavez-graduo-1215-medicas-y-medicos-integrales-comunitarios&catid=1:ultimas-noticas&Itemid=18> 
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 
<http://www.vive.gob.ve/actualidad/noticias/elam-forma-j%C3%B3venes-luchadores-revolucionarios-como-parte-de-un-ej%C3%A9rcito-de-batas>, 
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] 
<http://venezuelanalysis.com/analysis/10092#_edn4>

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 
<http://www.embajadacuba.com.ve/noticias/primera-graduacion-de-medicos-integrales-comunitarios-de-venezuela/> 
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 
<http://www.noticias24.com/venezuela/noticia/91709/se-tiene-previsto-que-el-presidente-chavez-encabece-un-acto-de-graduacion-de-medicos-comunitarios/> 
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 
<http://www.eluniversal.com/caracas/121227/medicos-integrales-reprobados> 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 
<http://www.eluniversal.com/nacional-y-politica/111030/8300-medicos-comunitarios-jamas-han-pisado-un-quirofano> 
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 
<http://www.ohdios.net/view/Comics/55268> 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 
<http://eltiempo.com.ve/locales/regionales/entrevista/medicos-integrales-comunitarios-diagnostican-tratando-de-acertar/71664> 
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 
<http://www.noticias24.com/venezuela/noticia/92576/medicina-integral-comunitaria-%C2%BFuna-solucion-o-un-problema-%C2%BFque-opinas-fotos-videos-y-audio/> 
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 
<http://www.ultimasnoticias.com.ve/noticias/ciudad/salud/no-existen-denuncias-contra-medicos-comunitarios.aspx> 
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 
<http://articles.sun-sentinel.com/2001-04-05/news/0104050207_1_cuban-doctors-medical-care-foreign-trained-doctors> 
Cuban medicine[v] <http://venezuelanalysis.com/analysis/10092#_edn5>, 
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 <http://venezuelanalysis.com/news/10069> 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 
<http://venezuelanalysis.com/analysis/7664> 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.

*Concluding Thoughts*

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] 
<http://venezuelanalysis.com/analysis/10092#_edn6> 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] <http://venezuelanalysis.com/analysis/10092#_ednref1> 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] <http://venezuelanalysis.com/analysis/10092#_ednref2> Brouwer, 
Steve, (2011). /Revolutionary Doctors: How Venezuela and Cuba are 
Changing the World’s Conception of Healthcare/, Monthly Review Press, 
New, York, p112

[iii] <http://venezuelanalysis.com/analysis/10092#_ednref3> Ibid, p120 - 121

[iv] <http://venezuelanalysis.com/analysis/10092#_ednref4> Ibid, p122 - 125

[v] <http://venezuelanalysis.com/analysis/10092#_ednref5> 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] <http://venezuelanalysis.com/analysis/10092#_ednref6> Borroto Cruz 
& Salas Perea (2008), The National Training Program for Comprehensive 
Community Physicians, Venezuela, /Social Medicine/, Vol. 3 No. 4

-- 
Freedom Archives 522 Valencia Street San Francisco, CA 94110 415 
863.9977 www.freedomarchives.org
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://freedomarchives.org/pipermail/news_freedomarchives.org/attachments/20131015/835ebfd7/attachment.htm>