VENEZUELA’S MEDICAL REVOLUTION: CAN THE CUBAN MEDICAL MODEL BE APPLIED IN OTHER COUNTRIES? by Christopher Walker Submitted in partial fulfilment of the requirements for the degree of Master of Arts at Dalhousie University Halifax, Nova Scotia December 2013 © Copyright by Christopher Walker, 2013 DEDICATION I would like to dedicate this research project to an old friend and mentor Therese Kaufmann. Though in her later years and facing many health challenges, her support as a friend, neighbour, tennis partner and caretaker has to be acknowledged as a pivotal person in my life growing up. Her generosity, friendship, compassion, patience and belief in me was truly extraordinary. I would also like to dedicate this to my dear friend and colleague Mahkia Eybagi, for showing many of us what it means to face real life challenges with strength, compassion, dignity and kindness. ii TABLE OF CONTENTS LIST OF TABLES ............................................................................................................ v LIST OF FIGURES ........................................................................................................ vi ABSTRACT ..................................................................................................................... vii LIST OF ABBREVIATIONS USED .......................................................................... viii ACKNOWLEDGEMENTS .............................................................................................. ix CHAPTER 1 INTRODUCTION .................................................................................. 1 1.1 “ARE YOU CHAVISTA OR OPPOSITION?” ................................................................. 3 1.2 OUTLINE .................................................................................................................................. 5 CHAPTER 2 THEORETICAL FRAMEWORK AND LITERATURE REVIEW ... 8 2.1 THEORETICAL FRAMEWORK ............................................................................................ 8 2.1.1 Structural Violence ............................................................................................................. 8 2.1.2 Vincent Tucker’s Critical Holism ............................................................................. 11 2.1.3 Latin American Social Medicine .............................................................................. 13 2.1.4 Diane Stone’s Transnationalization of Policy Learning ........................ 15 2.1.5 Summary ................................................................................................................................. 16 2.2 LITERATURE REVIEW ...................................................................................................... 16 2.2.1 Economic Growth and Health Indicators—is health without wealth possible? ..................................................................................................................................... 17 2.2.2 Why are Impoverished, Rural and Marginalized Populations Often Overlooked When Providing Health Care? .......................................................... 24 2.2.3 Which Aspects of Private and Public Health Care Systems Should be Adopted by Developing Nations in Order to Address Medical Accessibility? ......................................................................................................................... 28 2.2.4 Primary Health Care Foci: an analysis of preventive and curative primary health care approaches .......................................................................... 31 2.2.5 Is Reforming Medical Education in Developing Nations a Prerequisite for Improving Health Indicators? ............................................................... 35 2.3 SUMMARY ............................................................................................................................. 41 iii CHAPTER 3 THE TRANSITION TO REVOLUTIONARY MEDICINE IN VENEZUELA .................................................................................................................44 3.1 VENEZUELA PRE-CHÁVEZ .............................................................................................. 44 3.2 CHÁVEZ’S VISION FOR HEALTH CARE ..................................................................... 49 3.3 CHÁVEZ AND THE CREATION OF MISIÓN BARRIO ADENTRO ........................ 50 3.4 THE CUBAN HEALTH CARE SYSTEM AND ITS ADAPTATION IN VENEZUELA ........................................................................................................................................ 53 3.5 MISIÓN SUCRE—THE MEDICAL EDUCATION MODEL ....................................... 64 3.6 SUMMARY ............................................................................................................................ 68 CHAPTER 4 RESEARCH FINDINGS: ASSESSING THE IMPACT OF REVOLUTIONARY MEDICINE IN LARA ................................................................ 70 4.1 POLARIZATION ................................................................................................................. 72 4.2 FRAGMENTATION ............................................................................................................. 73 4.3 ACCEPTANCE OF THE CUBAN MEDICAL PERSONNEL ........................................ 76 4.4 CHALLENGES OF CHANGE ............................................................................................. 82 4.5 STRUCTURE OF THE HEALTH SYSTEM ..................................................................... 85 4.6 MISIÓN SUCRE AND SOFT POLICY TRANSFER ................................................... 90 4.7 THE IMPACT OF MBA .................................................................................................... 99 4.8 THE VACCINATION PROGRAMME ............................................................................ 101 4.9 STRUCTURAL VIOLENCE AND THE USE OF SOCIAL WORKERS ................... 103 4.10 SANITATION................................................................................................................... 104 4.11 PRACTICE IS THE CRITERION OF TRUTH ........................................................... 105 4.12 SUMMARY ........................................................................................................................ 107 CHAPTER 5 CONCLUSION .................................................................................. 110 BIBLIOGRAPHY .......................................................................................................... 120 iv LIST OF TABLES Table 1 Evolution of the Cuban Medical System from pre-Revolution to 2006....54 Table 2 Venezuela—Key Indicators.......................................................................68 Table 3 List of Interviews.......................................................................................71 v LIST OF FIGURES Figure 1 Diagram of the Semi-Parallel Health System in the Torres Region..........74 Figure 2 Diagram of Carora’s Vertically Integrated Medical System.....................87 Figure 3 Diagram of Cuba’s Vertically Integrated Medical System........................88 Figure 4 Comprehensive Community Medicine Courses in Misión Sucre..............94 vi ABSTRACT This thesis analyzes the Cuban medical adaptation in Venezuela called Misión Barrio Adentro (MBA) and seeks to answer the question of whether MBA shows promise as a health system that improves medical accessibility for impoverished and marginalized populations. In many cases MBA succeeds by: utilizing a free universal health care system; locating health centres in previously underserved areas; providing medical education scholarships to populations from non-traditional backgrounds; creating a catchment system based on medical accessibility; scaling up the medical workforce to 60,000 community doctors by 2019; and broadening the very praxis of what health means in a Latin American social medicine approach. However, some challenges remain including issues of corruption, fragmentation, and polarization. Issues regarding internal and external migration of Misión Sucre-trained physicians remain to be comprehensively evaluated. However, the capacitation of non-traditional medical personnel, imbued with conciencia, is significant and could well become an important example for other countries. vii LIST OF ABBREVIATIONS USED AIDS Acquired Immunodeficiency Syndrome CDI Centro de Diagnóstico Integral / Integrated Diagnostic Centre CMDAT Centros Médicos Diagnósticos de Alta Tecnología / High Technology Diagnostic Centre COPC Community-Oriented Primary Care CP Consultorios Médicos Populares / House Clinics ELAM Escuela Latinoamericana de Medicina / Latin American School of Medicine GNI Gross National Income GNP Gross National Product HDR Human Development Report HFA Health for All HIV Human Immunodeficiency Virus IMF International Monetary Fund LASM Latin American social medicine LDCs Least Developed Countries MBA Misión Barrio Adentro MDC More Developed Country MIC Medicina Integral Comunitaria NGO Non-Governmental Organization OPEC Organization of the Petroleum Exporting Countries PAHO Pan American Health Organization PDVSA Petróleos de Venezuela, S.A. PHC Primary Health Care R&D Research and Development SAP Structural Adjustment Programme STI Sexually Transmitted Infection TB Tuberculosis TED Technology, Entertainment, Design TPI Transnational Pharmaceutical Industry UN United Nations UNDP United Nations Development Program USA United States of America