One might think that collapse of the healthcare system in Venezuela is a consequence of the Covid-19 pandemic, but what if we remember what healthcare was like in the country before the coronavirus?

A recount

Since 2016, according to HumVenezuela, most public health centers show great deterioration in their physical plants and medical equipment in addition to not having cleaning supplies, nor basic services such as regular water or electricity supply. The whole picture is nothing but a complication to the health of hospitalized patients and medical assistance services.

The precariousness of these health centers is mainly due to the monthly budget they receive. By June 2018, the budget allocated to the Instituto Autónomo Hospital Universitario de Los Andes (IAHULA by its acronym in spanish)), the main hospital center in the state of Mérida, was equivalent to one minimum wage, which represented less than $1 USD.

At that time, when the coronavirus pandemic was not even looming, IAHULA had only 58% of its beds operational, since most of them were deteriorated to the point of being unusable. At the same time, in Bolivar, the state with the largest territory in the country, there was a hospital care deficit of more than 80%, as its standard of 30 hospital beds per 10,000 inhabitants decreased by 63%. At the same time, in the state of Zulia, it was estimated that 80% of hospital beds were inoperative, in addition to the fact that the areas destined for these purposes either for adults or children were seriously lacking in essential elements such as mattresses, bathrooms, air conditioning and illumination.

In general, to the to the lack of hospital beds, there´s need to be add a shortage of basic supplies such as gloves, injectors, adhesives, nebulizers, endotracheal tubes, central lines, gauze, alcohol, stationery (reports, evolution sheets, medical orders), catheters, among other necessary supplies that hinder the provision of priority services.

Likewise, the lack of medical surgical material has decreased the number of surgeries since people must buy 90% of the supplies to perform elective surgeries (those that can wait). Not to count that by 2018 in Zulia 70% of public hospital´s operating rooms were out of service, and the remaining 30% were operating irregularly due to temporary closures forced by equipment failures and problems related to lack of cleanliness, decontamination of wards and emergency rooms.

Regarding hygiene, as a consequence of poor cleaning due to lack of resources, intra-hospital infections have developed, creating new affections to hospitalized patients. In the first half of 2018 alone, 386 people died from bacterial infections or sepsis in Merida. Although the deaths occurred within IAHULA, the patients came from various public health centers.

Although most of these cases affected people between 25 and 64 years of age, children are also affected. In the state of Lara, between 2016 and 2017, 147 children died from Serratia Marcescens at the Dr. Agustín Zubillaga Pediatric Hospital; and although this may seem like a regional problem, the capital -Caracas- does not escape the situation. Between 2017 and 2018, the death of 112 newborns was reported at Maternidad Santa Ana (a Public Maternity Ward) due to sepsis caused by Klebsiella Pneumoniae bacteria,in addition to the death of 12 children and adolescents undergoing dialysis at the J.M. de los Ríos Children's Hospital due to bacterial infection provenient of the water tanks and filters of the units.

No life expectancy at birth

The decay of public services, along with other factors such as malnutrition, has increased deaths linked to pregnancy and birth care. Between 2015 and 2016, maternal deaths in Venezuela grew by 66%, reaching a mortality rate of 140 pregnant women per 100,000 live births, and continued to increase during 2017 and 2018.

The 2017 National Survey of Living Conditions (ENCOVI) estimated that 25,000 pregnant women had never received prenatal control and 15,000 has received so, only from the eighth month after; generating complications at the time of delivery. In 2018 alone, 87 newborns died at the Raúl Leoni Hospital in Bolívar due to causes associated with the absence of prenatal controls, maternal malnutrition and depletion of medicines and supplies. The health personnel of this center received neonates in improvised areas, given that the neonatology service has been closed since March 2018 due to the shortage of medical gases, the breakdown of mechanical ventilators and the serious deterioration of the infrastructure.

Although in Venezuela a third of children under two years of age suffer from chronic malnutrition, especially in poor areas of the country - according to the Venezuelan Food Security Observatory (2021) -, the capacity to care for children's health and eating habits has been affected by the closure of pediatric services in hospitals. In Bolivar, relatives of children hospitalized in the Uyapar Hospital, denounced in October 2018 that an average of 4 children a day were dying due to lack of supplies. In addition, because there is no other health center available for infants in the state, the staff was placing 3 children per bed and others on chairs and even on the floor.

On the other hand, the lack of primary vaccines in the country greatly increased pneumonia in children. In Merida, between 2013 and 2017, pneumonia cases in children from 1 to 4 years old increased 81%, while in children under 1 year old and over 5 years old the increase was 12%. For 2018, there were 626 cases of acute respiratory infections and 11 cases of influenza in infants.

Likewise, the state of Merida is one of the main states with cases of diarrhea in children due to deficient water supply and quality, as well as inaccessibility to hygiene products. Of the total cases registered in 2018, 25% (194) were children under 1 year of age, 28% (219) between 1 and 4 years of age and 47% (360) 5 years of age or older. Cases of severe diarrhea with dehydration are mainly due to rotavirus, which is water-borne and vaccine-preventable and usually affects children under 2 years of age.

Given this situation, in a press release from the Office of the United Nations High Commissioner for Human Rights (OHCHR), experts said in 2018, - We are deeply concerned that children are dying from preventable causes related to the deteriorating state of health facilities, shortages of both health supplies and medicines, as well as the lack of effective sanitation and hygiene measures.

Uncontrolled chronic diseases

Among other calamities, by 2018, almost 100% of public sector laboratories were unable to perform routine or emergency tests in the face of a 90% shortage of reagents, spare parts for equipment, supplies and basic materials such as test tubes, injectors, cotton, alcohol, gloves and sample collectors. At that time, 38% of laboratories were technically closed and 69% of blood banks that performed serological tests on donations did not have reagents and supplies for screening of communicable diseases such as hepatitis B, hepatitis C, HIV, Chagas disease, syphilis and human lymphotropic virus.

The extreme shortages of laboratories and blood banks are the main cause of the suspension of surgeries and do not allow guaranteeing safe transfusion treatments for people with anemia, cancer, renal and hematological problems and the storage and transportation of blood and blood products.

This situation generated, in the State of Bolivar, that 212 people increased the risk of death due to lack of transfusions, since by 2017 they decreased from 1000 monthly transfusions to only 60. In addition, factors such as malnutrition, malaria and hepatitis, have reduced donations in this state and much of the country. In the State of Zulia, a "black market" of blood bags has been created, which are sold outside health centers without any quality assurance.

In turn, diseases such as cancer are becoming more and more complicated to treat. Simple problems such as the lack of air conditioning in chemotherapy rooms mean that people cannot receive all the prescribed sessions. As well as more serious problems such as frequent and sudden power outages that have damaged various medical equipment, the replacement of which is practically impossible due to the high cost involved.

At the IAHULA in Merida the tomography, bone densitometry and radiotherapy equipment has not been working since 2015; the MRI unit which is the only one in the state has not been operational since October 2009, and the brachytherapy equipment has also been unavailable since 2017.

Another delicate case are people who require dialysis and do not find adequate treatment due to machine failures and incomplete supply of medicines. In Zulia, in 2018, three centers reported deaths of people due to frequent power and water outages. Most of these centers do not have an electric plant and if they do, they cannot withstand long interruptions. Also, due to the severe water cuts, many dialysis patients have had to pay for water tanks or request donations of water from the same government agencies. The poor quality of the water supplied by these trucks also leads to the suspension of sessions due to the risk of contamination and damage to the filters of the dialysis machines.

On the other hand, people with serious chronic conditions stopped receiving high-cost medicines in 2016, when purchases of these inputs were suspended in the country, running out in pharmacies and depriving people of their treatments. As of 2018, 3,000 transplant recipients stopped receiving immunosuppressants and, as a consequence, 96 people suffered organ rejection; 5,000 people with hemophilia were denied clotting factors to prevent bleeding and hemophilic arthropathy; 33,000 people with Parkinson's lost their medications, causing them terrible suffering ranging from loss of balance to total rigidity that can lead to death.

Another health condition affected by the poor conditions of the public health service is HIV/AIDS. In Merida, HIV/AIDS is the second leading cause of sexually transmitted infection, and by November 2018 only 59.5% of people with HIV were receiving Antiretroviral Therapy (ART). The conditions of people with HIV have rapidly worsened, not only due to the lack of ART, but also due to the absence of follow-up testing, lack of medication and malnutrition.

That same year, the state of Zulia registered 45 new cases of HIV every week, of which 90% resulted in AIDS, complicating the health condition of patients due to the precarious accessibility to specialized HIV consultations causing patients to developed pneumonia, Kaposi's sarcoma, toxoplasmosis and tuberculosis. That is one of the reasons why in this state, every week they received 20 requests for medical reports to people living with HIV who are forced to migrate in search of treatment and health care.

Re-emergence of epidemics

In these last years of Complex Humanitarian Emergency, 20.2 million people (71%) have been exposed to diseases that spread or re-emerged as epidemics in a large part of the country due to causes such as the weakening of public health and vaccination programs, the suspension of fumigation plans by the government and the internal displacement of the population, incorporated into illegal mining or other informal activities due to the severe economic conditions deterioration of the country.

Among these diseases, Malaria is present in 20 of the country's 24 states. However, Bolivar is the state with the highest number of cases in the country (concentrating more than 80% of the cases for several years), and is the epicenter of the epidemic. However, despite the high incidence and prevalence in the population, the competent bodies do not issue statistics on the progress of the epidemic or inform how to prevent it.

In 2018, 13 indigenous people in this state died in a period of 8 months: 7 due to Malaria and 4 women due to pregnancy complications. In addition, the flooding of the rivers in June and July increased stomach diseases, skin lesions and the risk of malaria, affecting a large number of indigenous children by consuming contaminated water from the rivers, in the absence of drinking water in their communities.

Malaria have spread throughout the country, specially around mining states, (Bolivar State is the principal repository og gold and iron mines in the country) due to the intensification of mining activities and human displacement in order to extract gold and other minerals to survive in the face of the serious regional and national economic situation.

However, there are states such as Mérida that have autochthonous cases in areas where transmission was supposed to have been interrupted. In fact, cases have been reported in municipalities where it was believed that the vector does not exist, increasing the number of Malaria cases by 1000% in 2018.

Other diseases such as Measles and Diphtheria have occurred in about 17 states in the country. Measles in children and adolescents rose by 970%, growing from 727 cases in 2017 to 7,054 in 2019. However, in Mérida out of 104 cases only 1 was confirmed by the National Institute of Hygiene Rafael Rangel in Caracas, with the processing of the rest of the samples being stopped on the basis that, with this one case, circulation of the virus had not been demonstrated. Such a processing of samples stop ocurred in order to guarantee the availability of reagents for surveillance in other states. The same happened with Pertussis, 53 suspected cases were recorded, without ever confirming any of the cases, even though there were 3 deaths from this cause up to August 2018.

On the other hand, in 2016 an outbreak of Diphtheria began in the country, affecting Merida, where once again the lack of vaccines is pointed out as one of the causes of the reappearance of the infection, since the coverage of the pentavalent scheme that protects against it was 13% in the first quarter of 2018, 9% in its first booster and 9% in the second. By August 2018, only 28% coverage was reached, after a vaccination day with diphtheria toxoid, which shows that the population of Merida is still vulnerable to this epidemic.

How did Venezuela face the pandemic?

The intensification of the emergency within the COVID 19 pandemic caused further havoc in the public health system, which was already in collapse as a consequence of a prolonged deterioration of its physical, institutional, operational and financial capacities.

When the first cases of Covid-19 were reported in Venezuela, 46 public hospitals throughout the country were designated to care for the most severe cases. At that time, a total of 11,000 beds and 1,213 intensive care beds (ICU beds) were reported in public and private facilities. In June 2020, the total number of ICU beds were reported at 206, of which 50% did not have ventilators and 48% were concentrated in the Capital District and Miranda State. As of June 2021, there were 237 ICU beds, with an occupancy rate higher than 50% due to the increase in the number of cases in 2021. Many people with coronavirus stayed at home suffering the risk of worsening its health, due to late attention, lack of oxygen and/or medicines.

With the pandemic, the number of people who request health services in the public health system, but also in the private health system, rose to 18.8 million. In addition, the proportion of people without financial protection increased to 91% and those without financial resources for health expenses to 59%. The loss of public health services represented a severe deprivation for 10.4 million people with serious health problems, both chronic and acute, including cardiovascular, diabetic, renal, pulmonary, cancer and others.

The data indicate that, as of June 2021, the number of people with the most prevalent health problems increased to 20.4 million, not including Covid-19, most of them impoverished, without any financial protection to meet the costs of illness and with difficulties to have access to medicines due to shortages, high costs and indefinite suspension of programs for high-cost treatments.

In addition, public hospitals, occupied in the care of the pandemic, reported health services with 82% of inoperability for diseases other than Covid-19, in particular, due to the increase of 70% in the withdrawal of medical personnel and 88% in nursing personnel. In these centers, the shortage of supplies reached 83%, the number of operative beds continued to decrease, and although the number of beds available to treat serious Covid-19 cases improved as they increased, physicians did not have the necessary clinical equipment.

The situation worsened with the increase in failures of basic services; in the country's public hospitals, 75% did not have a regular water supply and 73% suffered from electricity failures. In addition, new problems were generated, such as fuel shortages in a large part of the country, making it difficult for patients and health personnel to move around due to the lack of transportation and long lines for fuel, which in some states of the country could last for days.

Likewise, part of the massive resignations of health personnel -since the beginning of the pandemic- is due to the poor conditions in which they work. According to the Health Monitor of the Venezuelan Trade Union Network, during 2021 there were 6,114 health workers infected with Covid-19, since - despite the arrival of vaccines, health personnel are exposed to the worst conditions, without supplies or measures to guarantee them protection - so that by the first semester of 2021 nearly 700 health workers had died from Covid-19 contracted in the course of their work.

By June 2021, 11.4 million people did not have basic protective equipment against the coronavirus nor isolation areas at home in case of infection. In addition, at that time, 85% of the population had not yet been vaccinated and diagnostic capacity remained low due to a deficit of more than 60% of polymerase tests (PCR).

Although at that time the lethality of cases was increasing, the practice of not registering deaths suspected of Covid-19 was maintained, unless there were confirmed positive results, many of which arrived with great delay, even after the deaths.

In relation to the above, it can be said that the pandemic occupied most of the activity of the country's health centers, with no capacity or preparation to handle the cases. Although in the designated public centers the number of beds and intensive care equipment increased a little it was not enough to meet the icreasingly curve of cases.

Therefore, before and during the pandemic, the risk of dying in a public hospital in Venezuela is quite high, causing extreme vulnerability to people due to the precarious conditions of care.