Barrio Adentro (MBA; ‘‘Inside the Objectives

RESEARCH AND PRACTICE

Confronting Health Disparities: Latin American Social Medicine in Venezuela

Charles L. Briggs, PhD, and Clara Mantini-Briggs, MD, MPH

Misioń Barrio Adentro (MBA; ‘‘Inside the Objectives. We explored the emergence and effectiveness of Venezuela’s Neighborhood Mission’’) in Venezuela is one of Misio´ n Barrio Adentro, ‘‘Inside the Neighborhood Mission,’’ a program designed the most striking examples of Latin American to improve access to health care among underserved residents of the country, social medicine (LASM). With its origins in hoping to draw lessons to apply to future attempts to address acute health 19th-century European social medicine, par- disparities. ticularly the work of Rudolf Virchow, LASM Methods. We conducted our study in 3 capital-region neighborhoods, 2 small took root in Chile in the early 20th century and cities, and 2 rural areas, combining systematic observations with interviews of had become well established there by the 221 residents, 41 health professionals, and 28 government officials. We surveyed 1930s. LASM, which had also taken root in 177 female and 91 male heads of household. Argentina and Ecuador by that time, became Results. Interviews suggested that Misio´ n Barrio Adentro emerged from prominent in other areas of Latin America in creative interactions between policymakers, clinicians, community workers, and residents, adopting flexible, problem-solving strategies. In addition, data the 1960s and 1970s.1 LASM scholars and indicated that egalitarian physician–patient relationships and the direct involve- practitioners endorse collective rather than indi- ment of local health committees overcame distrust and generated popular vidual approaches to health care, stress the im- support for the program. Media and opposition antagonism complicated phy- portance of political–economic and social deter- sicians’ lives and clinical practices but heightened the program’s visibility. minants of health, and promote holistic Conclusions. Top-down and bottom-up efforts are less effective than ‘‘hori- approaches to health–disease–health care pro- zontal’’ collaborations between professionals and residents in underserved com- cesses.2 A related perspective that scrutinizes munities. Direct, local involvement can generate creative and dynamic efforts to epidemiological categories and measures—‘‘criti- address acute health disparities in these areas. (Am J Public Health. 2009;99: cal epidemiology’’3—stresses attention to the fac- 549–555. doi:10.2105/AJPH.2007.129130) tors that produce health inequities rather than descriptions and analyses of observed dispar- and 1980s, national health policies of the government enacted LASM-oriented policies ities.4 1990s decreased state investment in health based on equity and justice in health—deemed For example, rather than observing that care in favor of the private sector; growing to be a social right—and decentralized health rates of infant mortality are higher in a partic- social inequality negatively affected the ability institutions, integrating health services with ular minority group and analyzing individual of the poor to pay for services.8 In 2000, Asa local governments and fostering neighborhood risk factors, LASM and critical epidemiology Cristina Laurell,9 a leading critic of market-ori- participation.10 As an example of local-level scholars would document race- and class-based ented health policies, became secretary of health policies, LASM has been the dominant model in differences in access to health care, sanitary for Mexico City mayor Andre´s Manuel Lo´pez the Argentinean city of Rosario since 1995. In infrastructures, employment, and political rep- Obrador’s Party of the Democratic Revolution that city, local teams have worked with residents resentation and how they might produce government. At the same time that market-ori- ‘‘to guarantee that all decisions are made as higher levels of morbidity and mortality. These ented policies dominated nationally in Mexico, closely as possible to the level of the people scholars promote practices and policies that Obrador’spartyprioritizedhealthindeveloping directly affected.’’11(p233) treat health as a social and human right and strong social welfare institutions and providing We studied how access to health care was extend universal and equal health care access, free health care for the city’s 8.5 million inhab- extended to millions of formerly underserved oppose the privatization of health and its itants. The party defined health as a social right Venezuelans through the various programs transformation into a free-market commodity, and increased the health budget by 67% in its and policies instituted during the ‘‘Bolivarian and advocate strengthening the state’s role in first year in office.7 revolution’’ (named for Simoń Bolı´var, who led guaranteeing access to health services.5 A Similarly, in Uruguay, from the 1990s to Venezuela’s war of independence), initiated by number of researchers and policymakers have 2005, metropolitan and national governments the left-leaning government of President Hugo reported on their efforts to convert LASM prin- adopted health policies based on LASM and Cha´vez Frıás in 1999. In Venezuela, the public ciples into practice in administering municipal free-market principles, respectively. When health gains achieved in previous decades had and national public health systems.6,7 Broad Front leader and oncologist Tabare´ eroded during the 1980s and 1990s, as was In Mexico, although substantial gains in Va´zquez, mayor of Montevideo from 1990 evident in the falling percentage of the gross health services were made during the 1970s to 1995, became president in 2005, his domestic product spent on health and the

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decaying health infrastructure. When the ma- collaborated with community workers to sur- assumed active roles in fostering prevention, jority of health expenditures were transferred vey barrio residents on their perceptions of enhancing health infrastructures, and procur- to the private sector, the poor, whose economic problems in the areas of housing, health care, ing resources. position had weakened, faced large fees for education, food security, and employment. By December 2003, Plan Barrio Adentro many health services and medications.12,13 By Residents identified health care as their was so popular that Cha´vez transformed it into the late 1990s, class-based health disparities greatest concern and detailed institutional, a national plan based on the same basic fea- were enormous and much of the population transportation, and security barriers to obtain- tures, and the program was renamed Mission effectively lacked access to health care. ing medical treatment, especially during night- Barrio Adentro.19 MBA inaugurated a network The health policies of Cha´vez’s government time hours.18 Community leaders, residents, and of ‘‘missions,’’ broad social programs focusing on shaped the 1999 Bolivarian constitution, which IED workers were equal participants in these such issues as education, culture, homelessness, declared that ‘‘health is a fundamental social discussions, and they collaborated on a proposal housing, and food security.21 As of December right [and an] obligation of the State’’ and that to recruit physicians who would live in poor 2006, MBA included 23789 Cuban doctors, the public health system must be ‘‘decentral- neighborhoods and provide free health care and dental specialists, optometrists, nurses, and other ized and participatory ...guided by the prin- to involve residents directly in any changes personnel22 and more than 6500 sites where ciples of free-cost, universal availability, inter- instituted. patients were seen. By July 2007, 2804 primary sectoriality, equity, social integration, and IED presented the information gathered to care stations23 were being staffed by physicians, solidarity.’’14 Cha´vez initially appointed Gilberto Freddy Bernal, mayor of the Libertador community health workers, and health pro- Rodrı´guez Ochoa as health minister in 1999; Municipality, who issued a call for physicians moters. Sports professionals created dance and Marıá Lourdes Urbaneja, past president of the to live and work in poor neighborhoods. Fifty exercise classes for the elderly, and physicians Latin American Social Medicine Association, Venezuelan physicians responded, but they provided more than 100 types of free medica- took over the post in 2001. declined to live in barrios (30 left immediately tions. According to our interviews and observa- Both Ochoa and Urbaneja attempted to upon learning that they would be required to tions, mental health issues have not been prior- translate LASM principles into policies and live in barrios; the remaining 20 participated itized. practices.15 Nevertheless, these policies and but were assigned to provide secondary care A second phase, initiated in 2004, included practices were largely ineffectual in transforming and thus were not required to live in barrios).19 319 integrated diagnostic centers, 430 inte- the Ministry of Health and providing adequate Recalling Cuban doctors who provided emer- grated rehabilitation centers, and 15 high- health care for the 50% of Venezuelans living in gency care after the tragic mudslides of1999 and technology centers as of 2007.23 Some facilities poverty.16 The Venezuelan Medical Federation remained as health care providers in some were located in higher income areas. A third was aligned with the traditional political parties neighborhoods, Bernal initiated discussions with phase is under way that involves upgrading that lost power in the 1990s, and many members the Cuban Embassy that yielded an agreement to hospitals. The fourth phase focuses on building who worked in the private health sector opposed bring to Libertador a group of Cuban physicians 15 new public hospitals, of which the Dr Cha´vez’s emphasis on reinvesting in public who would provide the clinical services needed Gilberto Rodrı´guez Ochoa Latin American Chil- health. The federation’s hostility toward Cha´vez for the creation of what came to be known as dren’s Cardiology Hospital is the most notable and an opposition-led coup and oil strike were Plan Barrio Adentro. The Cubans were trained in example. important factors leading to the failure to imple- general integrated medicine—a specialty empha- From the start, MBA was a major focus of ment LASM principles. In spite of their pro-poor sizing familial, community, and environmental criticism from those opposing the Cha´vez gov- orientation, policies continued to be generated contexts and a critical approach to the intersec- ernment’s pro-poor policies. The Venezuelan within the Ministry of Health in a top-down tion between biological, epidemiological, social, Medical Federation claimed that the Cubans fashion rather than being worked out collabora- and humanitarian dimensions—as well as other were not physicians and that they ‘‘prescribe[d] tively with underserved sectors. Thus, at the specialties.20 Community workers assisted resi- dangerous, outdated medicines.’’24(p1874) Op- same time that new policies failed to gain much dents in forming neighborhood health commit- position media suggested that ‘‘cases of malprac- support from middle-class physicians, they did tees. tice by the [Cuban] doctors continue to create not resonate deeply with the concerns and per- When the first 58 physicians arrived in April uncertainty among the population,’’25(p14) and spectives of the vast ranks of the poor.17 2003, they were placed in homes and used the ‘‘they seem to be more herbalists than profes- One local jurisdiction in Caracas, Libertador same space as a living area and examining sionals—they mainly prescribe the sort of brews Municipality, faced pressing social problems in room. Two additional groups of physicians seen in this country in the 1930s.’’26(p22) some of its poorest neighborhoods (or barrios); followed. Health committees accompanied Our study built on previous assessments of as a result of this situation, Libertador, which physicians on afternoon house-to-house vis- LASM and critical epidemiology and accounts was aligned with Cha´vez, created the Institute its—meeting families, assessing health needs, of the transformation of LASM theories into for Endogenous Development (IED) in 2003. treating patients, and conducting censuses—as policies and practices. We used a detailed case IED was established to foster social programs well as on emergency house calls. Committees, study to analyze the complexities that arose in confronting living conditions in the municipal- whose members included many individuals efforts in Venezuela to translate LASM theories ity. In this effort, sociologist Rubeń Alayoń without previous leadership experience, into policy and policy into practice. Previous

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research had documented the depth of health In June through August 2006, we worked recorded. Interviews were semistructured and disparities in Venezuela, their roots in race and with 3 US-based graduate students and 3 were an average of 32 minutes in length. class inequalities,27 the effects of policies insti- Venezuelan assistants. During this period, the We developed instruments based on our tuted in the 1980s and 1990s on health care interview instrument was further refined on the 2004 preliminary research in collaboration services and sanitary infrastructures,12 and basis of the previous year’s results. Research with community members, clinicians, and ad- MBA’s place in health and social policies.28 We continued in the 2 communities, MBA facilities, ministrators. The instrument administered to viewed MBA in the context of obstacles facing and government offices, providing greater eth- residents focused on demographic information, previous attempts (during 1999–2003) by nographic depth, filling gaps in the data, and experience in using health services before and Cha´vez’s government to transform the public allowing us to assess how perceptions and par- after 2003, involvement with MBA, perspec- health system and examined ethnographically ticipation had changed from 2005 to 2006. tives on Cuban doctors, use of other govern- how these impediments were overcome through The research team also worked in La Guaira ment services, and media consumption. We involving poor communities and community and Naiguata´ (large and small communities, developed different instruments for Cuban and workers in the planning and implementation of respectively, in coastal Vargas State) and in Venezuelan health professionals; in addition to the Cuban physician program. Moroń and Alpargatoń (a small city and a questions regarding professional training, Interviews with professionals and residents semirural area, respectively, in the central state perceptions of health conditions and MBA, who participated directly in the early stages of of Carabobo). Adding these sites expanded data objectives, and experiences working with low- the project enabled us to pinpoint factors that on MBA implementation and community re- income communities, Cuban interviewees were generated extensive popular support in poor sponses in different areas of the country and in asked about their motives for and experiences communities, in spite of widespread attacks by communities of different sizes. We also spent living and working in Venezuela. the anti-Cha´vez opposition and the media. 1 week in a rainforest area of Delta Amacuro Given the crucial role of some 24000 Cuban State. We surveyed 270 heads of household Ethnographic Observations and health professionals, our ethnographic ap- in Santa Teresa, 23 de Enero, La Guaira, Documentary Research proach enabled us to complement our primary Naiguata´, Moroń, and Alpargatoń in August Members of the research team conducted focus on the participation of low-income resi- 2006. During 2005 through 2007, we made a systematic observations at neighborhood and dents with information on how the involve- total of 4 additional visits of 1 to 2 weeks in clinic sites at which MBA physicians pro- ment of Cuban doctors abroad29,30 translated duration. vided primary health care, focusing on qual- into day-to-day interactions with communities. Our study was independent of government itative descriptions of social interactions in institutions and both governing and opposition waiting rooms and the role of health profes- METHODS parties. One of the study’s strengths was its mix sionals and health committees in structuring of quantitative and qualitative methodology, intakes and clinical interactions. The re- In August 2004, we returned to low-income with an emphasis on ethnographic observation searchers accompanied committee members areas in Venezuela where we had previously and interviewing. on household visits, noting the types of in- conducted ethnographic research for nearly 2 formation they exchanged with household decades. We contacted MBA and Ministry of Interview Details residents. Health officials, as well as members of the Team members interviewed 221 residents, Tape recordings, photographs, and notes opposition, and we visited MBA facilities. Pre- 41 health professionals, and 28 government assisted us in documenting public meetings and liminary interviews and observations in these employees. In each community, we stratified events, especially health committee meetings, sites informed the design of our study. residents according to their age, gender, degree meetings between committees members and In June through August 2005, accompanied and type of involvement in MBA, and political other residents, and meetings between com- by 2 US-based students, we conducted re- affiliation. We did not select only individuals mittees and health professionals or adminis- search in a mixed working-class/middle-class suggested by MBA personnel but used ethno- trators; these interactions focused on planning, community, Santa Teresa, and impoverished graphic observations to identify potential in- gathering of necessary resources, health pro- hillside communities and large housing projects terviewees. We thereby avoided a potential motion and education, and prevention. Political in the 23 de Enero barrio, near the center of source of bias—exclusion of perspectives that rallies were documented. Observations of daily Caracas. Along with the students, we con- contrasted with those of members of health interactions in homes and public spaces per- ducted observations and interviews in MBA committees and MBA personnel—and obtained mitted assessments of broader patterns of so- and Ministry of Health clinics and interviewed a broad range of responses. cial interaction, social relations, political orga- residents in their homes and in public spaces. We conducted additional interviews in nization, and the expression of priorities and We also conducted interviews and ethno- Caracas and in Maracay (Aragua State), Timote social concerns. Principal sites were visited by graphic observations in ministry and local (Me´rida State), and Los Robles (Nueva Esparta multiple ethnographers to cross-check data. government offices that focused on MBA and State). Potential interviewees were approached Documentary materials included media cover- other health programs and documented meet- in person and occasionally via telephone; all age, photographs, official documents, Web ings, rallies, and other events. interviews were conducted in person and tape sites, and video documentaries.

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Survey unlike previous efforts, the program emerged Presidente) indicated that the president often We surveyed 270 heads of household (177 from planning undertaken in underserved reiterated LASM principles and acted as a women and 91men—in 2 cases the respondent’s communities. Interviews with the planners, of- health promoter. ‘‘You’ve got to breastfeed gender was not recorded) in the areas studied ficials, community workers, and residents in- her,’’ he exhorted a mother, ‘‘we’re doing a (with the exception of Delta Amacuro State) by volved suggested that the planning process, breastfeeding campaign—this is World Breast- sampling every 10th house in blocks selected at rather than being ‘‘top-down’’ or ‘‘bottom-up,’’ feeding Week.’’ As shown in Figure 1, 27% of random. Surveys focused on health care use; was ‘‘horizontal,’’ resulting from creative dis- those surveyed reported that they watched or assessments of MBA and Cuban physicians; cussions between academics, officials, and res- listened to the Cha´vez broadcasts weekly, and participation in health committees; differences idents. When the first 58 Cuban physicians 40% indicated that they did so ‘‘occasionally.’’ and similarities between private, MBA, and arrived, many residents reported that they Health planners involved in Plan Barrio Ministry of Health services; definitions of health; were astonished that these doctors would live Adentro and the early stages of MBA stressed media consumption; and political views. Given in poor neighborhoods and share the daily lives that pro-poor, rights-oriented principles also the emphasis on these issues rather than health of residents. Interviews indicated that positive, emerged in other missions—large-scale public conditions or outcomes, it proved necessary to egalitarian doctor–patient relationships and projects that addressed the needs of low-in- develop our own survey instrument, drawing on 24-hour availability of free medical care en- come Venezuelans and focused on food secu- ethnographic observations and interviews. gendered widespread acceptance and other rity, literacy, education, housing, and employ- neighborhoods’ petitions for Cuban doctors. ment—providing the ‘‘integrative’’ frame for Data Analysis Community workers noted that they came health care advocated by LASM. Figure 2 After native speakers of Venezuelan Spanish from poor backgrounds; most had obtained shows that 35% of the individuals we surveyed transcribed recordings, team members ana- university degrees that, although not required, believed that the MBA and other missions had lyzed transcripts of interviews and meetings, enabled them to provide cultural translations produced ‘‘very positive changes,’’ and 42% photographs, field notes, and documentary across class lines so that residents of low- believed that they had produced ‘‘positive’’ materials separately. We converted recurrent income communities and government officials changes; only 3% believed that they had led to keywords and themes into codes and used could develop common frames of reference ‘‘negative’’ or ‘‘very negative’’ changes. NUD*IST version N7 software (QSR Interna- and goals. Interviewees agreed that planning Opposition physician Mariana Ortı´z said of tional, Cambridge, MA) and visual inspection to and implementation were ongoing and that her Venezuelan colleagues, ‘‘MBA is viewed identify the sentence fragment types in which residents were directly involved. A woman quite negatively; it’s seen as competition for these key terms and themes appeared, such as who hosted one of the first physicians illus- [Ministry of Health] hospitals and [private] definitions of health, accounts of the origin of trated this collaborative problem solving: clinics.’’ Interviews with laypersons and health MBA, and perceptions of its efficacy and effects. professionals aligned with both the opposition From the transcripts of interviews, The doctor said to me, ‘‘I need a cot.’’ I said to and the government suggested that such criti- him, ‘‘And where am I going to get a cot? I can passages dealing with key terms and themes find you a tabletop, and we’ll use some beer cisms resulted in MBA being a major test of were stratified through an inductive procedure crates, and that will make a cot.’’ And we put on a Cha´vez’s government. Interviews and media designed to reveal participants’ full range mattress and sheets, and he saw his patients there analyses indicated that the intense antagonism just fine. of perspectives on key issues and their relative of the Cha´vez opposition had the unintended frequency. The data obtained were not medi- Our data indicated that, from presidential consequences of raising MBA’s visibility and, ated by conceptual operations or definitions and statements and national policies to clinic visits once it gained extensive popular participation, were not measured via structural instruments. and health committee interventions, patients enhancing Cha´vez’s popularity. Health profes- We translated and backtranslated selected received the same messages about health as ‘‘a sionals who worked with MBA reported that texts. The Survey Research Center of the fundamental social right,’’ about preventive opposition supporters sometimes blocked am- University of California, Berkeley, double coded medicine, and about community participation, bulances and banged pots and pans, scaring and cross checked survey data and calculated thereby minimizing discrepant understand- patients. Our interviews in working-class com- 31 frequency distributions; data were treated as ings. Crucially, residents reported that physi- munities suggested that MBA crucially influ- descriptive statistics rather than being used for cian–patient interactions reflected an egalitarian enced Chavez’s 59% to 41% victory in the tests of significance. The mix of qualitative and attitude that fostered participation. According to 2004 presidential recall referendum. The offi- quantitative data gathered aided our under- one patient: cials we interviewed indicated that these elec- standing of MBA and perceptions of the program toral results led the government to make MBA a They treat you marvelously well—‘‘Come over as opposed to predicting health outcomes. here, have a seat, what’s wrong?’’ ‘‘Look, I have top priority and invest considerable resources. this.’’ ‘‘Ah ha, you need an x-ray, right away.’’ ... Most residents of poor neighborhoods RESULTS Look, if they treat you the way that you should reported that they viewed MBA as ‘‘their’’ be treated, it makes you want to go to the clinic. program; Ministry of Health efforts to exert Professionals involved in the discussions that Our analysis of broadcasts of Cha´vez’s limited control were sometimes resisted as resulted in Plan Barrio Adentro reported that, weekly radio–television program (Alo´, meddling on the part of out-of-touch

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listed health as their greatest concern. (The overall focus of the survey on health probably inﬂuenced this result.) Figure 3b shows that 55% of the respondents deﬁned health as a constitutional right, as opposed to the absence of sickness (16%) or access to health care (8%). Figure 3c shows that 62% rated MBA services as ‘‘excellent’’ or ‘‘good,’’ whereas 10% assessed them as ‘‘average’’ or ‘‘poor.’’ In addition, 51.3% reported that an MBA facility was located within a walking distance of 5 minutes. Finally, as shown in Figure 3d, 37% of the respondents reported that family members had used MBA services during the past year, as compared with FIGURE 1—Frequency of respondents’ watching or listening to President Cha´vez’s 22% using private institutions and 14% using radio–television program, Alo´, Presidente. Ministry of Health facilities. Eleven percent of the respondents served on health committees.

DISCUSSION bureaucrats. Interviewees occasionally com- private clinics prescribed expensive tests or plained that health committees distributed re- procedures. Some supported MBA whereas Some elements of MBA reﬂect the speciﬁc sources unfairly and limited the participation of others remained distrustful. Interviews with circumstances of recent Venezuelan history, opposition supporters, although other residents opposition politicians and media analyses in- particularly the policies of and opposition to the disputed these claims. Ethnographic research dicated that, beginning in 2005, anti-Cha´vez Cha´vez government; Venezuela’s abundant oil and interviews conducted in Delta Amacuro criticism focused more on the perceived failure revenues, which provided the substantial re- State suggested that, in some areas, roadblocks of MBA to deliver services than on elimination sources needed to build the program; and the placed by regional governments, the weakness of the program. In the 2006 presidential cam- extensive cooperation between Cuba and Ven- of social movements, or, as in Delta Amacuro’s paign, opposition politicians promised to im- ezuela, with Venezuelan oil being sent to Cuba rainforest, low population density limited MBA’s prove rather than dismantle MBA. and Cuban doctors being sent to Venezuela. popular reception and institutional growth. Descriptive survey data are reported in Fig- However, as discussed next, several key issues Many middle-class Venezuelans, even ure 3. Half of the individuals surveyed were affecting the project’s future remain unclear. Cha´vez supporters, characterized MBA high school graduates; 17% had gone on to Some politicians have suggested subordi- as a program ‘‘for the poor.’’ Some residents higher education. Respondents ranged in age nating health committees to community coun- repeated opposition criticisms of Cuban pro- from 17 to 86 years and were widely distrib- cils, which have broad administrative duties fessionals and heeded calls to boycott the uted within that range. Forty-eight percent and manage resources distributed by the gov- MBA. Opposition supporters reported that they backed Cha´vez, 10% supported opposition ernment to communities; if this occurs, their sometimes used MBA facilities in emergencies, parties, and 36% listed no political alignment. autonomy and effectiveness will probably di- e.g., to avoid a long trip, or when doctors in As shown in Figure 3a, 151of 270 respondents minish. As Cuban physicians become less available, will Venezuelan physicians trained through the MBA in general integrative medicine overcome middle-class perceptions of barrios as spaces of criminality and chaos, put aside their material aspirations, and choose to live there? If not, will the MBA maintain popular support and involvement? Training low- income Venezuelans as physicians may prove crucial in the long run if graduates are willing to stay in their communities. MBA was intended to transform the public health system as a whole,17 but Venezuela has not accomplished FIGURE 2—Respondents’ assessments of changes produced by Mission Barrio Adentro. this goal as of yet. Nevertheless, our study affords a number of valuable insights.

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FIGURE 3—Descriptive survey data showing (a) the number of respondents listing primary concerns in 1 or 2 of 7 areas (sample size is n>270), (b) respondents’ deﬁnitions of health, (c) respondents’ assessments of the quality of Mission Barrio Adentro services, and (d) respondents’ use of Mission Barrio Adentro, Ministry of Health, and private facilities.

First, the discussions that gave rise to Plan and national levels indicate that direct local increased its visibility, but additional examples Barrio Adentro suggest that devising plans for involvement and creative, flexible problem- are needed to assess the effects of media cov- ameliorating acute health disparities can ben- solving approaches should continue through- erage on funding and community support for efit from in-depth discussions joining research out the life of the program, no matter how large efforts intended to address acute health ineq- and theory with underserved communities’ in- its scale. uities. depth knowledge of their problems and possi- Third, medicine and public health generally Fourth, although nonprofessional health ble solutions. Top-down and bottom-up per- seek to eschew overtly political orientations; promoters participated in day-to-day MBA spectives are inadequate; effective interven- nevertheless, the importance of political sup- clinical and preventive activities, community tions emerge through synthesizing academic, port for MBA gained after the 2004 presiden- workers—who came from underserved com- policy, and grassroots perspectives in a ‘‘hori- tial recall referendum in Venezuela suggests munities but obtained university training—- zontal’’ approach. The most significant compo- that when interventions become major sources played a crucial role in the creation of Barrio nents of the planning phase can best be un- of political support, leaders are more likely to Adentro. Thus, we recommend that efforts to dertaken in affected areas. Second, our findings make health a political and budgetary priority. train health workers for programs targeting regarding the crucial role of health committees The extensive media coverage, both positive acute health disparities include individuals in continuing to shape MBA at both the local and negative, focused on MBA greatly whose class backgrounds and educational

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achievement enable them to negotiate under- University of California, Berkeley. Participants provided gob.ve/lista.asp?sec=190702&txt=barrio%20adentro. served communities and spaces dominated by verbal informed consent. Accessed July 3, 2007. professionals. Such individuals can foster cre- 20. Barrio Adentro: Derecho a la Salud e Insercioń Social en Venezuela. Caracas, Venezuela: Pan American Health ativity and innovation, deeper knowledge ba- References Organization; 2006. ses, more effective communication, and strong 1. Waitzkin H, Iriart C, Estrada A, et al. Social med- 21. D’Elia Y, ed. Las Misiones Sociales en Venezuela: interinstitutional linkages, particularly in the icine then and now: lessons from Latin America. Am J Una Aproximacioń a Su ComprensiońyAna´lisis. Quito, Public Health initial planning and implementation phases. . 2001;91:1592–1601. Ecuador: Instituto Latinoamericano de Investigaciones Sociales; 2006. Finally, the observed role of positive, egali- 2. 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Clara Alternativa. Mexico City, Mexico: Friedrich Ebert Stiftung, 30. Carrillo de Albornoz S. On a mission: how Cuba Mantini-Briggs is with the Department of Geography and Ediciones Era; 1997. uses its doctors abroad. BMJ. 2006;333:464. the Department of Anthropology, University of California, 10. Fernańdez M, Curto S. Uruguay: Participacioń social 31. Getrich C, Heying S, Willging C, Waitzkin H. An Berkeley. en salud y el papel de la epidemiologıá. In: Breilh J, ed. ethnography of clinic ‘‘noise’’ in a community-based, Requests for reprints should be sent to Charles L. Briggs, Informe Alternativo sobre la Salud en Ame´rica Latina. promotora-centered mental health intervention. Soc Sci PhD, Department of Anthropology, University of California, Quito, Ecuador: Centro de Estudios y Asesorıá en Salud; Med. 2007;65:319–330. Berkeley, CA 94720-3710 (e-mail [email protected]). 2005:214–219. This article was accepted July 9, 2008. 11. Fein M, Ferrandini D. Equidad real en la oferta pu´blica en la salud: el norte de un gobierno municipal Contributors democra´tico. In: Breilh J, ed. Informe Alternativo sobre la C. L. Briggs and C. Mantini-Briggs shared equally in Salud en Ame´rica Latina. Quito, Ecuador: Centro de originating the study, supervising all aspects of its Estudios y Asesorıá en Salud; 2005:223. implementation, conducting the data analysis, writing the article, and reviewing drafts. 12. Jaeń MH. El Sistema de Salud en Venezuela: Desafıós. Caracas, Venezuela: IESA; 2001. Acknowledgments 13. Urbaneja ML. Privatizacioń en el Sector Salud en Venezuela. Caracas, Venezuela: CENDES; 1991. This research was supported by the Salus Mundi Foun- dation of Tucson, AZ. 14. Constitution of the Bolivarian Republic of Vene- We deeply appreciate the participation of community zuela. Gaceta Oficial. 36,860, December 30, 1999, Ar- members, health committees, and Venezuelan and ticles 83 and 84. Cuban health professionals in this study. Alexandra 15. Plan Estrate´gico Social. Caracas, Venezuela: Minis- Anastasopulos, Reneé Asturias Penãlosa, Amy Cooper, terio de Salud y Desarrollo Social; 2002. Amy Gardner, Silvia Go´mez, Andreina Guía, Xochitl 16. Instituto Nacional de Estadı´stica. Summary of social Marsilli Vargas, Claire Mertz, Thomas Ordoń˜ez, A´ ngela indicators 1997–2008 [translation]. Available at: Pinto, Carmen Rojas, Megan Strom, Carina Vance, http://www.ine.gob.ve. Accessed June 9, 2008. and Erick Valero participated as research assistants. Jaime Breilh, Lemyra DeBruyn, Carson Henderson, 17. Alvarado CH, Martıńez ME, Vivas-Martıńez S, Asa Cristina Laurell, Mark Nichter, and Howard Gutie´rrez NJ, Metzger W. Cambio social y polı´tica de Waitzkin provided valuable comments on previous salud en Venezuela. Medicina Social. 2008;3:113–129. versions. 18. Alayoń Monserat R. Barrio Adentro: combatir la exclusioń profundizando la democracia. Rev Venez Econ Human Participant Protection Ciencias Soc. 2005;11:241. This study was approved by the institutional review 19. Defensoria del Pueblo. Sıńtesis del Plan Barrio boards of the University of California, San Diego, and the Adentro, 2003. Available at: http://www.defensoria.

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