It was the closest the Venezuelan government has come to admitting a crisis. Since the summer, social media had been abuzz with news of patients in the southern department of Bolivar presenting with diphtheria, a disease eradicated in the country 24 years ago.
After months of ignoring the outbreak, Socialist Party Vice President Diosdado Cabello took to the airwaves. The U.S. Central Intelligence Agency, he told viewers, was orchestrating “biological war” in Latin America. “They are coming with diphtheria to terrorize the Venezuelan people.”
There is no conspiracy, of course; there is simply a crisis. Amid the worst economic downturn in its modern history, Venezuela’s health system, food supply, and basic services have collapsed. Grocery store shelves are empty; pharmacies have nothing in stock; hospitals lack resources or personnel to treat patients; and gang violence is spiraling. Diseases eradicated decades ago are resurgent epidemics. One international organization with operations in Venezuela told Devex that about half of all patients who enter public hospitals will die there.
Venezuela’s government shows no interest in fully admitting the extent of the problem. And that combination of economic collapse and official denial has created a humanitarian crisis far worse than it appears, as Venezuela’s institutions have been eroded. Even if humanitarian supplies flooded into the country overnight, little would change for months or longer.
Diphtheria is telling of the structural decay. The infection is easily preventable through vaccination — a pillar of preventative public health. Diphtheria’s reappearance indicates that swathes of children aren’t receiving basic care.
“The damage to the [health] system is generalized and profound,” former Venezuelan health minister Dr. José Félix Oletta L. told Devex in Spanish by email. “It will take years to recover.”
Oletta estimates that Venezuela needs immediate humanitarian aid of $500 million. Lacking that, the country is “incapable of providing the necessary products and services to attend the needs of the population.”
Denying a crisis
President Nicolás Maduro’s silence about the humanitarian situation is rooted in politics, analysts say. Facing an unprecedented challenge to 17 years of Socialist Party rule, former President Hugo Chavez’s hand-picked, elected successor rejects any suggestion that his government has faltered.
Maduro has blamed shortages on greedy businessmen and urged citizens to grow herbal gardens to treat disease. Officials have warned doctors from speaking about the diphtheria outbreak, treating whistleblowers as traitors to the ruling Socialist Party’s revolutionary project.
“They do not recognize that [there] exists a humanitarian crisis,” Dimitris Pantoulas, a Caracas-based political consultant and visiting fellow at the IESA business school, told Devex. “They consider that the economic problems are due to an economic war waged by the private sector and the opposition.”
Shortages of everything
The first manifestation of Venezuela’s crisis appeared through absence. Over the course of the last three years, products started to disappear from the shelves. First, consumer goods such as toilet paper and diapers were difficult to find. Soon, buyers waited hours in line for basic food items and medicines.
The shortages stem from a triad of ill-fated policies and equally bad luck. During two decades of Socialist Party rule, the government nationalized a host of factories and industries and intimidated or out-priced the few independent manufacturers that remained. Even as local production fell, Venezuela implemented stiff price controls on most basic goods and services, pushing the cost of everything from petrol to rice to medicine well below market value. Simultaneously, the government regulated the official exchange rate between dollars and the local Bolivar currency.
Former president Chavez could sustain those policies when the price of oil hovered above $100. But as it collapsed in 2014, Venezuela’s budget deficit soared. Constrained by artificially low exchange rates, manufacturers couldn’t afford to buy the dollars they needed to import the components to manufacture consumer goods — for example the active ingredients in generic medicines. Nor could the government afford to import fully formed items and food. Venezuela today has enough dollar currency reserves to service its debt — but that’s all it has enough for.
Every industry has coped as best it can, but in almost every case that has meant taking on crippling debt. The pharmaceutical industry, for example, is today estimated to hold at least $4 billion of debt with foreign importers, which have now largely cut off credit lines. Medical imports in 2015 covered only 10 percent of estimated market demand, according to Oletta.
The black market has filled some of the gap, but costs are prohibitive for the majority of Venezuelans who are still paid in Bolivars valued at the official exchange rate. Basic commodities can easily consume a week’s wage.
“One can of Coca-Cola costs one full day of work,” an unregistered Venezuelan refugee in Bogota, Colombia, recently told Devex.
As a result of the shortages and high costs, Venezuelans simply aren’t eating enough. Compared to 20 years ago, the average consumer eats just one-third the amount of corn and half the rice, according to data from the local civil society group Red por la Defensa al Trabajo, la Propiedad y la Constitucion (Network for the Defense of Work, Property, and the Constitution).
The international Catholic charity Caritas, one of the few allowed to work in the country, recently distributed a cookbook with recipes aimed at stretching commodities and using few ingredients.
“It takes more than 10 times the minimum wage to purchase the basic bread basket,” Caritas Venezuela Director Janeth Márquez said in a recent statement. “Children are fainting from hunger at school. Absenteeism is on the rise. Teachers say that their children are distracted. Out of 40 students 20 don’t attend because they have no food.”
The health system: A terminal patient
Venezuela’s once-robust health system has been among the first to feel the impact of the crisis. The country’s 300 public hospitals once offered near-free care to all residents and had a reputation for quality that attracted patients from across the region. A parallel system run by Cuban medics operated 35 community centers — a way for the small island nation to repay Venezuela for more than a decade of heavily discounted oil shipments. Finally, a private system of clinics augmented care.
Today, all three systems are in disarray, lacking even the most basic operational funding, medications, supplies and personnel. “People who are in the implementation side [of the health system], they have no money, no logistics, and no commodities,” said Dr. Leopoldo Villegas, a former adviser of the Venezuelan Ministry of Health and international malaria expert who co-founded Venezuelan-based consultancy Asociación Civil Impacto Social.
Public hospitals are the worst hit and operate on a principle of extreme triage. Doctors must now make daily medical decisions about which patients to save, with not enough supplies or equipment to care for all. Gloves, clean needles and sanitizing soap are all lacking. Patients are often left to procure their own drugs — if they can find them. Child mortality has risen to 18.6 per 1,000 live births, higher even than rates in Syria, the Wall Street Journal recently reported.
Malaria provides an example of how medical professionals have tried to cope. This year, Venezuela will have nearly 12 times more cases than it did in the year 2000. Yet according to an open letter sent by four former Venezuelan health ministers to the World Health Organization and Pan-American Health Organization, the country had completely exhausted its stocks of effective malaria treatment as of Sept. 1.
“Since there are no antimalarial drugs in the country, doctors are either using 50 percent dosage of the only drug left or they are giving patients inefficient treatments such as co-trimozaxole, which malaria first showed resistance to one of its components in 1957,” said Villegas.
Patients along Venezuela’s borders are also flooding into border towns in Colombia and Brazil, at times overwhelming services. As Devex reported this summer, tens of thousands of Venezuelans took advantage of humanitarian corridors into Colombia in June and July to buy basic medicines and food supplies.
Malaria patients in Venezuela’s Bolivar state, which has one of the highest caseloads, are likewise seeking treatment across the border in Brazil. There, the local government of Roraima state said in August that 78 percent of its malaria cases came from Venezuela.
Venezuela’s health system was once among the region’s most robust. In 2001, the country had about as many doctors per capita as the United Kingdom, and a dozen medical schools for its population of 30 million. But massive human flight from Venezuela has decimated the health sector. Hundreds of thousands of Venezuelans have left their country since economic crisis began several years ago, though there is no official data. Among them, have been an estimated 12,000 doctors, by Oletta’s count.
Nurses, technicians and other skilled professionals have also left, or abandoned public positions that don’t pay enough to live on. Medical schools are meanwhile facing the same cash crunch of all public institutions.
The reason many doctors leave Venezuela is less about shortages than about their own personal security. Drugs and medical services are now a lucrative commodity and ripe for criminal expropriation. Earlier this year armed groups began imposing themselves on hospitals and other institutions, demanding services for their own injured and sick and at times charging fees for medicines and services. Last month, for example, some 20 armed men and women took control of the University Hospital of Venezuela and established an office from which to run their fiefdom on the first floor.
The black market is also largely under armed control. Reporting from the Colombian border in August, Devex heard how armed groups with links to both countries have moved from narcotics trafficking into basic supplies and medicines. “Contraband of food and medicine — you wouldn’t think that they are very so strong, but in reality there are structures around them that are very strong,” Victor Bautista director for development and border integration at the foreign ministry, said in an interview then.
Even if a treatment is available, costs are prohibitive. “A lot of medicines are brought in from Colombia and resold to Venezuelan buyers at an extremely high cost and an extraordinary margin of profit,” Oletta told Devex. Malaria treatment, for example, is officially free. “Corruption and shortages mean that the treatment could cost between $80 and $100 dollars.” He estimates that the black market now represents more than a tenth of the entire stock of medicines in the country.
Meanwhile violence itself is becoming a public health problem. Just as there are few ways to treat chronic and infectious disease, trauma wounds are going uncared for. The Venezuelan Observatory on Violence recently reported that the country has seen 16,000 murders between January and September 2016. That would put the country at a tie with El Salvador for the world’s highest murder rate.
What worries public health officials most about Venezuela’s health crisis is the lack of transparency. The government stopped publishing weekly epidemiological bulletins in November 2014 and since then, the medical community has been left to guess just how bad the situation is.
Villegas and four former health ministers — Oletta, Dr. Angel Rafael Orihuela, Dr. Carlos Walter W. and Dr. Pablo Pulido M. — have worked to reconstruct the data for the estimated malaria caseload.
Based on private discussions with officials as well as their own contacts on the ground — former colleagues, whistleblowers, and citizens who go to hospitals and morgues to count casualties — they believe there are more than 350,000 cases of malaria in Venezuela today. The country is now responsible for nearly half of all malaria on the South American continent.
“We believe that this malaria epidemic will reverse last decade’s regional achievements in malaria control, prevention, and elimination and therefore, it will affect global targets moving toward malaria elimination,” the former ministers warn in an open letter sent to the leaders of the World Health Organization, Pan-American Health Organization, and the The Global Fund to Fight AIDS, Tuberculosis and Malaria.
“As an organization, we are deeply concerned about the reported rise in malaria cases in Venezuela, and have been following the situation closely,” Global Fund spokesperson Melanie Brooks told Devex. The fund is “considering a multicountry malaria grant that may provide long-term support to address the regional consequences of Venezuela’s increasing malaria rates.”
The Bill & Melinda Gates Foundation, which is working to eradicate malaria and currently has no programs in Venezuela, is also watching. “The current situation demonstrates that resurgence is a risk when health systems/financing fails,” Bruno Moonen, the foundation’s deputy director for Malaria, told Devex by email.
If so little is known about malaria — a disease for which public health officials on the ground are trained — far less can be ascertained about new threats such as the Zika virus. Oletta recently published estimated 2015 incidence rates for chikungunya virus (16,293), Zika virus (412,962), and dengue (52,152) — all significant rises.
“The capacity of the government to undertake the necessary epidemiological vigilance and respond through prevention and control to new public health threats like outbreaks has collapsed,” Oletta concluded in a private February report sent to advocates and public health officials.
No help wanted
As it denies the crisis, Venezuela has turned down international aid from even its closest allies. Offers of help from neighboring countries have so far gone unacknowledged. Most recently, Venezuelan representatives in the parliament of regional bloc Mercosur voted against allowing the organization to send medications to Venezuela.
NGOs and civil society groups that do have limited access to the country operate in constant fear of being shut down or having supplies seized. Caritas and Medicins Sans Frontiers were among several international NGOs with current or former operations in Venezuela declined to comment for this story.
Some U.N. agencies and regional international organizations are able to operate in Venezuela, including UNAIDS, UNICEF, and the Pan-American Health Organization. Still, their operations are highly constrained by the necessity of working with the government through its health ministry, the Ministerio del Poder Popular para la Salud. Crucially, those organizations must use MPPS statistics to procure medicines, which could mean a significant underestimation.
PAHO, which would normally help facilitate drug procurement for outbreaks such as malaria, is particularly constrained. The Venezuelan government owes the organization an estimated $40 million, according to the open letter from health ministers. That debt has delayed the procurement of new antimalarials for 2016, the letter says. PAHO did not respond to multiple interview requests from Devex.
Villegas, together with other former Venezuelan health officials, believe that — if given the opportunity — a wide range of international actors would step in. “It’s not a question of who’s willing,” he told Devex.
The Global Fund, for example, is thinking about innovative ways it could help since Venezuela’s middle income status makes it ineligible for most standard grants.
“We do recognize that there is support that the Global Fund could potentially provide to partners working on the response in Venezuela,” said Brooks. “We have been in regular contact with key partners including PAHO, WHO and UNAIDS to gather more information and assess whether the Global Fund can assist as a part of a broader and coordinated response, for example through facilitating access to competitive pricing for emergency procurement of commodities such as mosquito nets, which (while requiring a board exception) could support a short-term response to the HIV, TB or malaria needs in Venezuela.”
Getting worse, not better
Venezuela’s humanitarian crisis is likely to get worse before it gets better. Poor nutrition and lack of access to basic medicines are already impacting childhood development. Patients with chronic conditions such as cancer, diabetes and mental health disorders have largely gone untreated for months.
If resources appeared overnight, it’s not clear how quickly the situation would improve. The public health system has been so damaged that it wouldn’t be able to distribute supplies.
“Say I got 100,000 bed nets [for malaria] and dropped them in Caracas with support from any United Nations agencies, for example PAHO,” Villegas offers as example. “There wouldn’t be a truck to deliver them to the endemics areas. There wouldn’t be any money to deliver them. You never know if whatever you send will arrive to the population.”
Indeed, even that scenario is a long ways off. There are no supplies on their way to Venezuela, because officially, there is no crisis. Neither the government nor any international aid can pull the health system — and the population — back from the brink before officials admit the very existence of the precipice.
“This is really a humanitarian crisis,” Villegas continued. “If you don’t put a name on things, there is no way to fight them. But there is no way the government will allow anyone to talk about a humanitarian crisis.”
Catherine Cheney contributed reporting to this story.
Elizabeth Dickinson is associate editor at Devex. Based in the Middle East, she has previously served as Gulf correspondent for The National, assistant managing editor at Foreign Policy, and Nigeria correspondent at The Economist. Her writing also appeared in The New Yorker, Wall Street Journal, New York Times, Politico Magazine, and Newsweek, among others.
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