Late President Hugo Chavez argued that Venezuela’s community doctors must be “doctors of socialism”; committed to free public healthcare and community service. These interviews with recently graduated community doctors from Venezuela, Colombia and Bolivia give a firsthand insight into the new kind of doctor Venezuela is creating for itself and the wider world.
One of the most ignored aspects of Venezuelan politics and society in international media in recent times has been the Bolivarian government’s effort to train 60,000 doctors in a new Cuban-inspired and assisted medical education program. However the National Training Program in Comprehensive Community Medicine has been described in Social Medicine as “the most ambitious example of scaling up of physician training in a single country”,[i] and is producing thousands of new professionals for the country’s revitalised national public healthcare service. An overview of the program is provided in the first part of this study, which examines the structure, goals, and debate around comprehensive community medicine.
The success of the effort to create a national health service with clinics in every community and pro-active doctors committed to preventative care and public service depends in large part on the kind of doctor that the MIC program is producing. Relevant to this is the fact that the great majority of entrants come from middle and lower income backgrounds. Further, the majority of the program’s graduates are female. As such, the MIC program has opened the door to thousands of new medical students who previously had their aspirations shunned by the country’s elite medical schools for reasons of economic or class discrimination.
During their six years of study and two years of obligatory residency trainee and graduate community doctors have had to tackle a new way of learning medicine, promote preventative healthcare in their communities, and balance the range of life’s demands that any medical student has to face. They have also had to confront criticisms and attacks from the private press and traditional medical establishment, and upon entering public hospitals, active hostility from some of their conventional medical colleagues.
Late President Hugo Chavez, whose agreement with Fidel Castro in 2005 founded comprehensive community medicine in Venezuela, argued that community doctors must be committed to public healthcare and become “doctors of socialism”. In the following five interviews conducted in the state of Mérida in the Venezuelan Andes this article talks to a group of recently-graduated community doctors from all walks of life, as well as some foreign students of the MIC program. Their testimonies offer a firsthand account of the reality of the comprehensive community medicine program, and give an idea of the experiences, values, and future aspirations of the medical professionals now at the forefront of Venezuela’s growing public healthcare system.
These are stories which give an insight into how this system is being constructed to serve the needs of the whole Venezuela population, and how such a system could be built in other countries in the future too.
Spokesperson for Class of 2012 MIC Graduates in Mérida State
“I entered the neighbourhoods where there was the greatest need, and said to myself, “This is for me”. (Manuel Maldonado)
Manuel Alejandro Maldonado is the spokesperson for community doctors of the 2012 graduation year in Mérida state. We spoke at the end of his work day in the El Llano ambulatory [mid-level clinic] in Mérida city, where he works alongside doctors from the traditional medical system. He told me about his experience entering the comprehensive community medicine program, dispelled some rumours about the quality of the training, and commented on work relations with doctors from the traditional, generally pro-opposition, medical system.
Why did you decide to enter the MIC program and become a community doctor?
Well to begin with, I had recently graduated from high school, a time when all Venezuelans begin to hope they will get a place to study in the traditional universities. So I finished high school and I was thinking about applying for a place in the traditional university system, in this case the University of the Andes (ULA) [the Universidad de Los Andes (ULA), located in Mérida city, is considered one of the best public universities in the country, including for the study of medicine].
Around this time I found out about the comprehensive community medicine program. I entered a process known as the pre-medical course, which I began with the intention of analysing for myself what comprehensive community medicine was like, and if it would fulfil my expectations to continue. I was a little hesitant when I entered, although I’ve always been clear and I’ve always been with the [Bolivarian] revolution. I had my doubts because of all the stories that they [the opposition] told about the Cuban doctors. Thus I didn’t know and wanted to experience it for myself, so I entered.
The pre-medical course lasted eight months [this course is in order to evaluate possible entrants to MIC and ensure aspiring entrants are competent in subjects such as maths and sciences before beginning the program]. In those eight months we studied the basic subjects such as biology, maths, chemistry, all those. In my municipality our group for the second wave was 120 people, of which one hundred passed and twenty failed. Those twenty were above all people who were of an older age and no longer remembered the basic subjects. But it’s important to highlight that they were given the chance to begin to study, and on the way they realised that they didn’t have the ability in that moment; for whatever the reason may have been.
Then we entered the first year of the program and something impacted me and made me never apply on any occasion for a place in the traditional universities. This was: community medicine has the Mission Barrio Adentro [a network of free health clinics staffed by doctors from Cuba], right, and Barrio Adentro is spread throughout Mérida state and the country as a whole. Thus as soon as we began the first year we were included in the rural health clinics where we saw in the flesh the essence of comprehensive community medicine. We didn’t give out prescriptions of course, nor undertake any medical procedures; but we did observe the conduct of the Cuban doctor in charge of the clinic, where we met excellent Cuban doctors with excellent scientific and technical abilities, and with human warmth, which is what also characterises comprehensive community medicine.
So I became more enthused. The treatment towards patients and the feeling of being in a neighbourhood (barrio) where the greatest needs are enthused me more, so I said: “This is for me”. And I liked the way the program was done, how in the mornings we were immersed in the clinics in the neighbourhoods throughout my municipality, and in the afternoons we had formal teaching. I liked that mix: the community part and the teaching part at the same time.
And yes, it was quite a big change [in teaching methods] to begin with because we studied integrated subjects such as morpho-physiology and morpho-physio-pathology, which addressed embryology, anatomy, physiology and systems pathology within the same subject. However I think that it’s the most didactic way to undertake medical education as such. We began with the video conferences [a MIC teaching method] with our monitors, who were there to clarify doubts about the information presented in the video conferences. From the beginning these monitors were medical specialists from Cuba, highly trained, and truthfully I thank them, as it’s because of them that I am what I am today. But what they gave us most was this human warmth that our fellows, our brothers, have. They gave us all their energy, all their charisma, and many of us assumed it, we assimilated it as part of our personality and professional ethic, although there are a few around who didn’t assimilate it fully.
But that was what motivated me, being in contact in the flesh [with communities] from the start of the degree to the end. Today we are the hope for the birth of a new Venezuelan healthcare system, taking into account the four fundamental pillars [of MIC], which are: prevention, promotion, curing and rehabilitation of the patient. That was our undergraduate experience, in the degree. It was a lovely experience where we shared with all of our fellow students and teachers, and where we built an affinity with the community. That is what is wanted; that the doctor goes to the community and not that the community comes to the doctor, because throughout history a status has been created, a stairway whereby the people see the doctor as a god, and no: we are just the same as them. The only thing we have is a little technical and scientific knowledge to be able to help them.
It’s interesting to listen to how the academic education of the MIC program is, because only yesterday someone in the street, who I don’t believe possessed direct experience of MIC, told me that a trainee community doctor can’t fail, that is, it isn’t possible to fail the program, and that furthermore the program’s teachers aren’t properly trained.
Well, the situation is the following. As in all [medical degrees], we go through our medical education with our teachers, who clarify our doubts. Some are excellent, some good, others regular, and some not so, as in all universities. However I’ve always said something: we, as students, must be interested, that is we must demonstrate interest and not just accept what we learn in class, but rather arrive home with active curiosity and revise books about the subject to deepen our understanding. That is what forms a true doctor and a true professional with great knowledge. However if we just accept what we’re given in the video conferences, if we don’t investigate any doubts we have, and when we’re in the community and in contact with patients we don’t ask, we don’t speak, we don’t touch the essence of the pathology in that moment, then we’re never going to be good professionals.
In terms of evaluation, that’s false to a certain extent, because we are evaluated on the basis of twelve points out of twenty, that is, s/he who has ten points, eleven points, fails an exam. This is something that is generally not practiced elsewhere; in our country evaluations are on the basis that zero to nine points is a fail, and ten points or above is a pass. Not for us: twelve points to make it more demanding.
Do you think that the majority of community doctors, in your experience, share the program’s values towards community service and public healthcare, rather than seeing healthcare as a business?
With respect to that, I would say yes, that the great majority is totally committed to our style of training and our commitment with the revolution, which is to serve the communities in the [social] debt our country has had for more than 50 years [toward the disadvantaged]. So the majority are committed. But as with everything, we don’t all have the same consciousness, and others have been weak of mind and have allowed themselves to be taken, or seduced, by the old interests, forgetting the true Hippocratic Oath, which we want to revive.
What’s the experience been like of working in a public hospital as a graduated doctor? How have professional relations been with doctors from the traditional sector?
Actually, we begin [training placements] in public hospitals from our fifth year of the degree, in the big hospitals in all municipalities.
When we first entered it was a clash. The traditional doctors looked on us with the stigma that they had toward us, that we were useless. It was ignorance; ignorance plus the political tint that was always put on the issue. The two joined, and this greatly harmed us. So we entered, and yes, we were victim to humiliation, psychological mistreatment, and on some occasions, physical mistreatment. But this helped forge our character and many of us began to make the cut and make ourselves respected, and demonstrate to them – of course it wasn’t our objective to demonstrate to anyone that we were good – but with our work make them see that we could [perform well] too. And so thanks to that [good work] little by little we have won that respect. But there’s the other part, the political part; the country is vey polarised. Thus the political aspect has been taken very seriously and this has greatly affected [relations with the traditional medical sector].
Do you community doctors feel sufficiently supported by the government, given that you have experienced these difficulties with the other medical sector?
We have felt supported ever since the program began, even more so here in Mérida which is a revolutionary state [i.e. the governor belongs to the government´s United Socialist Party (PSUV)]. However, with the latest change of health minister [the appointment of Isabel Iturría in April 2013], she has come with a different mentality. I consider her a very well-educated, prepared woman, but she is very technocratic, that is, very perfectionist. However she has to understand that the political aspect is also relevant, and that we are in a training process. Nevertheless little by little she has been assimilating this and recently has changed her outlook a lot.
But on the governmental side of things we have had a lot of support as we are the standard bearers of the government and the new healthcare system being born. Therefore they have respected us and have always held out their hand to us. And here in Mérida state, the [regional] Health Authority with the director Doctor Denis Gomez has been perfect, we’ve had very good contact, very good assimilation, and hand in hand with the government we’ve been confronting this war that they [the opposition] have waged against us.
I also see that you are working here with doctors from the other sector and you seem to get on well, that is, not everything is conflict.
Because each of us have won this [respect] for ourselves, through our own effort. When a community doctor enters an institution, our objective is this; make ourselves known, and remove this bad image that was created by ignorance, I repeat once more, and by the political tint. Thus we’ve managed to arrive at having a very good affinity with doctors from the traditional sector, and of course, this is the change that happens when the unknown becomes known. When you see and interact with another colleague [this change occurs], and so they have seen that we are capable. Furthermore we are now mixed with them throughout all [public] medical centres, united and working together, and as such we have had good relations. And that’s how we’re going, winning spaces bit by bit, which is the objective.
What is your evaluation of the health policies of the Bolivarian government in this period, and what more needs to be done?
In evaluating this great change that has occurred in our country, I would say it [health policy] has been excellent. A lot still needs to be done, but we are a system that is not unique, that is not autonomous to us, it’s one that already exists in Cuba, in Canada, and if we look at the record of who has the best health indicators on a global level, in prevention and promotion, it’s our fellows in Cuba.
We have a free, public healthcare system, as an obligatory right for every citizen in the country. Because of that I evaluate it as excellent. Of course there’s a lot we still need to do, we’re a growing country and so we’re undertaking that task.
Do you have any further comment that you’d like to make?
Just to thank you because it’s good that people know about these things, because all these [negative] comments that have been made are due to ignorance. What needs to be done is make who we are even more known to the communities; what we are going to create, and that it is the community that benefits.
Comprehensive Community Doctor, Class of 2012
“I was an example to my daughters”
Yanetzi Paredes is one of many graduates of comprehensive community medicine who have had to balance study with being a parent: in Yanetzi’s case as a single mother with two daughters. She now works in the HULA, the largest hospital in the Venezuelan Andes. In her interview Yanetzi talked about the experience of studying comprehensive community while bringing up her daughters, and also described a little about her working life and hopes for the future.
Why did you decide to study comprehensive community medicine and become a community doctor?
My main motivation was because in my first degree, when I finished high school, I studied medicine in the University of Zulia, Maracaibo. Due to personal and family problems I had to end my studies and move to Mérida. When I tried to enter the medical school of the University of the Andes (ULA), Mérida, I didn’t get a place. This was 1994. After that I studied modern languages en the ULA, but I then had to leave the country, and I didn’t finish that degree in Mérida but rather in Maracaibo, once I was in Zulia state again.
Six years later I returned to Mérida again, with my two girls and separated from their father. Nicol was five years old and Michelle was four, it was 2005. That year I spoke with some Cuban doctors who told me about the National Training Program in Comprehensive Community Medicine. A family member commented to them that I used to study medicine, and they motivated me and told me to study again. I was already at a mature age, I was thirty-three, I’m forty now. But I was given the opportunity and I signed up, although at that time I couldn’t see myself studying again. However as I was unemployed and this door had opened for me, I couldn’t believe it either.
I said, “Wow, medicine!” and everyone speculated that it was a three-year program, a technical diploma. But then I realised that it wasn’t three years, it was a six year degree plus a pre-medical course that lasted almost a year, so the course of study lasted almost seven years. It was a completely holistic degree from the moment we started; all the subjects were studied in an integrated way, and we really studied. The program has a future, it continues having a future for those students who can’t enter the traditional universities, and they can trust in and enter the National Training Program in Comprehensive Community Medicine.
How did you manage the experience of studying medicine while bringing up your daughters?
(Laughs) Ahhh, [it was] a totally marvellous experience, because my daughters and I went through a lot together. They saw me studying, and from there I say that my daughters are very studious, because they saw me at a mature age studying all the time. So much so that there were moments that I had free, or I sat to watch TV, and my seven year old daughter would arrive and say, “Mum, you can’t want television, you have to go and study human morpho-physiopathology”. And in reality, I think I was an example to them. Nicol is now fifteen and Michelle thirteen, they are very studious girls and apart from high school they are musicians in the symphonic youth orchestra in Mérida. So we grew up together and were always tight for time: when I left my classes I had to leave running to collect them from school.
Now you work in the largest hospital in Mérida state, and I believe, in the Venezuelan Andes. What’s the work been like there, in terms of contact with patients and doctors from the traditional sector?
The University Hospital of the Andes (HULA) is a place where it is necessary to enter with an open mind, a lot of experience, and a great sense of responsibility. Patients are received from all over, and patients of every type, with every kind of pathology. The patients are very receptive. They are amazed when a community doctor attends to them in adult emergency, and they leave very thankful for the treatment they have received. They are pleased and they come over to say goodbye, they create a bond of friendship. I’ve already made some bonds of friendship with patients, because they really do leave completely satisfied with the medical attention that has been offered to them.
In terms of the relationship with the doctors there [from the conventional system], well, some have been receptive, and others have not been receptive at all. They look down on us and they talk about what a community doctor is and isn’t. I think that in this case it is necessary to think a lot about what is the medical ethic, because as human beings we shouldn’t be talking about people who aren’t present, and much less with slander. We are part of this continuous mocking and slander, but it’s a minority sector, to call it as such. I say that sometimes they are the ones that aren’t mature. Nevertheless, [for others] there is the human side and the medical ethic, and many are professionals, and so they concern themselves with the wellbeing of the patient.
Why do you think that in this group which exists within the traditional medical sector there exists rejection and contempt toward the community doctors?
Well, we have to take into account that in Venezuela the only people that could study medicine were an elite group, the children of rich parents. Therefore when the National Training Program in Comprehensive Community Medicine arrived, humble [less well off] people entered [into the world of medicine and the hospital system], and I think there is a social clash between those who have a little more and those who don’t; because they had the opportunity to enter the traditional medical school and others couldn’t or can’t. So I think more than anything it’s a social clash.
It also has to do with how medicine works in Venezuela, and how it used to work when it was completely commercialised. That is, every medical exam, laboratory exam, X-rays, everything, absolutely everything, had to be paid for. And with the arrival of the new revolutionary socialist government, the presidency of the supreme comandante Hugo Chavez, this changed. It can be said that medicine in Venezuela changed completely, it spun 360 degrees. Until socialism arrived in Venezuela everything headed in the direction of privatisation. And good, from then until now it’s been maintained and we hope that with the new comprehensive community doctors this new medicine and this prototype of healthcare in Venezuela can be maintained [into the future].
What are your future professional plans? Do you think you will stay within the public sector, or would you like to work in a private clinic?
My immediate plan at the moment is to culminate, with responsibility, love, and endeavour, with all that I have, my article eight [the legally required two year residency in the public sector after graduating]. After that, if I am given the opportunity to apply for a postgraduate degree, I ask God and the new National Healthcare System that the door is opened for me to complete a postgraduate in otolaryngology (ORL – study of hearing, face, neck, and upper respiratory system). Why? Because I’ve realised, at least here in Mérida, that it’s very difficult to find a public otolaryngologist.
And well, the question of whether I’d stay in the public sector surprises me a little, because of course I would. The idea isn’t to go into the private sector, but rather I want to be an otolaryngologist in the public system for the most humble people and arrive to the neediest sectors. This is because I’ve seen how patients turn up and need a specialist of this type, and they can’t find one.
Do you have any other comments for the readers of this article?
Yes, I’d like to contribute something: to say to the people of Venezuela that they have doctors they can count on. We are human beings the same as everyone, with our defects and virtues, so let them [the people] be the judges. What is a community doctor in truth? We are those who arrive in the communities, who reach the most humble sectors, and during this time they will realise what our work is like. Selflessly we’re going to be there in the public sector, at the hour and the moment that we are called and needed.
Also for people abroad, I’d like to say that all these comments and everything transmitted on television is not as they say. I have a sister who lives in Miami and she is always calling me and asking me, “Is it true what’s happening in Venezuela, is it true this and that, how are you doing?” And it’s me who has to talk to her and make her see how things are in reality, not like the television says. So she gets a little alarmed and sometimes is a bit worried and I tell her, “Calm down, things are fine, things are going fine here”. It’s not like the television and yellow press, or in reality anti-socialist press, say, who want to stain this image; this image and the legacy that our president Hugo Rafael Chavez Frías left us.
#3 Gustavo Uzcategui
Comprehensive Community Doctor, Class of 2012, Mérida state
“We’re doctors without borders”
Gustavo Uzcategui is from a small town called La Azulita, nestled between the Venezuela Andes and Lake Maracaibo. We spoke before he began his shift in accident and emergency in the Sor Juana Ines de la Cruz hospital in Mérida. During his interview he addressed some of the falsehoods that have circulated about the MIC program. He also said that after his experience working in obstetrics in the hospital, he would like to specialise as an obstetrician/gynaecologist and contribute to the training of the comprehensive community doctors of the future.
Why did you decide to enter the MIC program and become a community doctor?
To begin with my aspiration was to enter a traditional university like any other Venezuelan, but I didn’t know about the National Training Program in Comprehensive Community Medicine. Bit by bit I investigated and found out about the program, [including] that I could study in my own municipality. Therefore I wouldn’t have to abandon my family or move to Mérida city, I could study in my home town, and they had the teachers and the study materials there. That motivated me and I said “well, you get educated where you can”.
Before that I was assigned by the National University Planning Office to study veterinary medicine in a traditional university. However when I signed up for the degree in comprehensive community medicine I registered with the intention of finishing the program, and I did.
What do you think makes a community doctor different from doctors graduated from the traditional universities?
The humanist element is what differentiates us most. We are in direct contact with the community from the first year of our degree, which doesn’t happen in the traditional universities. It is during the fifth or final year of their degree when they do their three month rural residency that they have contact with a community in reality, very contrary to our experience. We do the house to house visits, the neighbourhood surveys, and we are directly connected to the life of the patient and their family because we see the patient as a holistic being. Thus we don’t only focus on the person’s state of health but also their lifestyle, in such a way as to improve their standard of living and that of their family too.
In the context of certain negative comments about the community doctors in the private press, what has been the reception of patients towards you and your colleagues upon entering into the conventional public hospital system?
Regardless of the hospital that you graduate from, whether it is the Bolivarian University of Venezuela, the University of the Andes, or any other university, the patient comes to the hospital because they need medical care. In the majority of cases they aren’t looking out for which university you’re from. The important thing is that you attend to them, that you are compassionate, that you listen to them, that you examine them, and that you give importance to the case due to which the patient has come. If you give the patient good care and you know how to diagnose them and manage their case, the patient is going to leave very thankful regardless of the doctor that treats them.
In another interview, one of your colleagues affirmed that upon entering the public hospitals you community doctors have received hostility from some doctors in the traditional system. However as they have become acquainted with you and your work, this hostility has reduced. What has been your experience in this respect?
At least since the beginning of the fifth year placement when we entered the University Hospital of the Andes (HULA), the other residents from the traditional university and the medical team including specialists in the university hospital had an attitude of comparison and discrimination with respect to those of us who came from the Bolivarian University of Venezuela. However sometimes they act like this due to being misinformed, because many of them would say that we were being trained in three years, and that we were receiving a bursary that was equivalent to a very big wage, which is a lie.
When one talked to them it was possible to inform them that our degree is a normal six year degree, which has in fact more residency hours than the traditional universities. And yes we receive a bursary to help us study, because unlike them we don’t have our own faculty and generally we have to commute to another municipality to be able to attend the seminars and video-conferences. The majority of us come from lower classes where we’ve never been able to afford expensive studies as such. The majority of my colleagues have children; they are mothers and fathers with families. So because of that we received an economic contribution, and also because of that they discriminated against us, because they thought we were getting paid [to study].
Also, in many cases they thought that our curriculum of study wasn’t up to standard with the traditional universities. This is false because our curriculum, before being delivered by the National Training Program, has been studied by the National University Council, which is the body that approves [national] curricula of study.
Do you feel supported by the government in general and the Ministry of Health in particular?
In every way, because as soon as you sign up you feel the commitment that not just the Cuban Medical Mission has, but also the different government bodies that support the program. We’ve always felt supported, to the extent that as soon as we graduate we are contracted by the Ministry of Health to work in public sector health centres, because that is the commitment that we were given.
We are also doctors without borders. We don’t know if tomorrow some country is going to need humanitarian aid, and if Venezuela decided to offer that service, it would send doctors graduated from our National Training Program.
During the presidential election campaign in April this year the opposition candidate Henrique Capriles promised that if he won the elections he would maintain government social programs, and he appeared to put distance between himself and neoliberal policies such as the privatisation of healthcare services. What is your opinion of those comments, and what do you think would be the policies of a government of the opposition toward the public health sector and the community doctors?
That’s quite a broad question, isn’t it (laughs)! Personally, I don’t believe in anything that the opposition ex-candidate has said because it appears that as a state governor he has never helped the social programs in his own state [Miranda]. If he hasn’t done it with his own state and he’s allowed the abandonment and deterioration of social programs there, he’s not going to maintain them in the rest of the country.
I think that with a government of the opposition it would be very difficult for us to exercise community medicine, because we see medicine as a humanist vocation, and they [private sector doctors and the conservative opposition] see medicine as a managerial vocation and as a means to make money. They see the patient as a commodity, that is, we squeeze them, we squeeze them, we take everything that we can, and we leave them without money.
We don’t see it like that, and we can observe that the Bolivarian revolutionary government has always set out to bring healthcare to every corner o the republic, and to there we have arrived. And if any corner still remains to be covered, we’ll get there too. However only the revolution guarantees this, a government of the opposition is never going to guarantee that we are directly linked to patient care and the community.
Do you have any other comments for the readers of this article?
Yes: that this program is a reality, a righteous reality of the supreme comandante, [who has] now passed away, our comandante Hugo Chavez, who had this idea of training a certain number of doctors to meet the healthcare needs of the Venezuelan people; above all the most excluded classes, the most disregarded classes, those who had always been rejected or didn’t have the economic means to go to a health centre.
In Venezuela a transformation of the National Healthcare System is being achieved, not just with the training of new doctors, but also with the creation of new healthcare institutions; ambulatories, community clinics, level IV [high technology] hospitals, which allow the patience access to free, quality and specialised healthcare. We have the capacity and the technical-scientific tools to attend to any patient at any level of healthcare, be it prevention, promotion, curing, or rehabilitation.
Comprehensive community medicine is a program that is growing every day, [and] that is being perfected every day. Our greatest motive is that the patient leaves cured, that they leave satisfied with the care that a community doctor or a doctor from any university can offer them, and that this patient comes to the public healthcare service guaranteed by the state, with first class service.
This doesn’t stay here. A new phase of specialisation is coming, where each one of us that has graduated from the National Training Program will have the possibility of aspiring to further studies. These will be in the branch of medicine that each doctor feels most identified with, and also depending on the country’s healthcare needs. If the country needs a thousand orthopaedic surgeons, the state will guarantee the training of the personnel required to cover said necessity.
We comprehensive community doctors, despite the difficulties that we have been presented with, continue fighting the battle day by day, and are ready to cover the needs of the new National Public Healthcare System that began with comandante Chavez and continues with President Nicolas Maduro.
Do you know what specialisation you would like to undertake?
Yes. At the moment, during the rotations through different hospital services, I’ve identified a lot with gynaecology/obstetrics, the care of pregnant women, and valuing the life of the foetus, the new being coming into the world. In the future I’d like to do the postgraduate and be an obstetrician/gynaecologist.
After having this specialisation I believe I’d stay in the public sector; not just for the work aspect, but also for the educational side, because as a specialist you can contribute a lot to the undergraduate students that are going to be in the training process. I’d like to be a teacher in the National Training Program of Comprehensive Community Medicine, and I have in mind that soon a class IV hospital is going to be inaugurated in El Vigia [a large town near Mérida city], a hospital where all medical services will be offered. It will be a top-level hospital, from where we will also be able to contribute a lot to the community. That is, work with patient care, and also in the training of new doctors. As we already know the system, who better than us to collaborate, support, and contribute something, now that we’ve received something from the government?
#4: Ana and Paola
Community Doctors, Class of 2012, Mérida state
“We came to Venezuela in an adventure to achieve our goals”
Ana and Paola Leal, from near Bucaramanga, Colombia, came to Venezuela to study comprehensive community medicine. In their interview they explained that the public health system in Colombia is semi-privatised, and the level of free service that a citizen can receive depends on their income, with those on lower incomes able to access more free services. Nevertheless, non citizens or those without an identity card cannot receive any free medical care, while in some public hospitals it is necessary to queue for several hours to be attended.
The two sisters also spoke of their impressions of the MIC program and their experiences working in Venezuela’s National Healthcare System.
Why did you decide to come to Venezuela and study comprehensive community medicine?
Ana: I came because comprehensive community medicine allowed the possibility for foreigners to come and study the program. I finished high school, I had few choices for my studies and one was to come to Venezuela and study medicine, so I took advantage of it.
The program isn’t just in this country but also in Cuba, and the [Venezuelan] government signed agreements so that Cuban doctors came to Venezuela, who then became our tutors. Therefore it’s a very nice mechanism, and very complementary, because they give you a curriculum of studies that integrates all subjects. As time passes the results are being seen, as with the first and second graduations of comprehensive community doctors, which is satisfactory for the country and its human resources, [supplying] the doctors that were lacking.
What is the system to enter medical school in Colombia like? Is it very elite, or more open?
Ana: I don’t have much knowledge of how that system functions now because I’ve been in Venezuela for almost nine years, so I couldn’t tell you what it’s like normally. Also I never applied in Colombia, nothing like that, but rather I had the opportunity to study in Venezuela and I came with my eyes closed.
However in Colombia they also do introductory courses and people have chances to enter, although not as many as here [in Venezuela]. The universities are semi-private, and you have to pay according to your economic status in society.
So do you have to pay to study medicine in Colombia?
Ana: Of course you have to pay. It depends on your social class; if you are from a lower class you will pay a minimum amount, but if you’re from an upper class you have to pay a larger amount. Likewise in any university you need to take part in a competition to enter, you do your exams, and if you pass your exams you enter the university. But a lot of people compete for very limited places and that makes it very difficult to enter a public university. There are also private universities that offer medicine, but they are expensive and almost no one can enter.
How would you evaluate the comprehensive community medicine program? Do you feel that it has given you a good medical education?
Ana: For me, [the key to] medical education is to study. If you want to be a good doctor, put in the effort to study and study. If you want to be a bad doctor, don’t study. If you don’t prepare properly for exams you will see the result will be when a patient comes to you. If you didn’t study properly, you won’t be able to give the patient a correct diagnosis. This is a deficiency that can be seen within a traditional university or comprehensive community medicine.
Paola: Yes, comprehensive community medicine offers good medical training, because in the first four years you have Cuban doctors as teachers. Then from the fifth year you have [contact with] Cuban and Venezuelan doctors. Therefore there is a very nice experience and very good training because you interact both with Cuban doctors and Venezuelans who are specialists in different areas, [for example] gynaecology / obstetrics, adult emergency and internal medicine.
Thus I think it’s a good education. However it’s a very new program, so people still aren’t aware. That is, [comprehensive community medicine] isn’t like a traditional university with a faculty and nice infrastructure, but rather it’s organised [geographically] in nuclei. However you can see that patients are now taking on the fact that we are doctors, unlike before, when people, or the opposition [had a negative attitude toward community doctors], because it also has a lot do with politics.
In terms of the political element, the opposition try to make it look like we don’t have medical knowledge, and this generates a lot of controversy. However it’s a good training program because in other parts of the world you’re not going to have classes with Cuban doctors and relate that [knowledge] in classes with Venezuelan doctors too.
In addition to being professionals the Cuban doctors are very humble, coming from another country and leaving everything behind to better themselves too. They are very human and are trained to teach classes, and they have a curriculum to follow. They do video conferences, workshops, seminars, exams, and they evaluate us weekly.
Now that you have graduated, what’s it been like working in the public sector?
Ana: The experience has been marvellous because it’s not the first time that we’ve attended patients, but rather it’s something routine, it’s something normal for us. We’re with patients from our first year so by now you don’t feel nervous or afraid, which disappears with time. However we are complementing this experience with our knowledge. Also no matter what, there are things that will appear that are new and you have to confront them, so the work is very nice.
Paola: After graduating I was sent to work in a rural ambulatory in a remote part of Mérida state for six months. It was a mountainous Andean zone where the population is very humble and plant potatoes and cabbages, things like that. It was a really nice experience, because before my arrival there wasn’t even a doctor in the ambulatory, just a technical nurse. Therefore when you arrive it’s a great help, and they see and respect you, so the patient – doctor relationship is very good. It was a nice experience and you get to know the patients so there’s a feeling there.
Right now I’m working in hospital accident and emergency, and it’s also still part of my training because us [graduated] community doctors are undertaking our two-year article eight, which is a six month rural placement and six months each in three hospital areas; internal medicine, gynaecology / obstetrics, and paediatrics. So I’ve done my rural placement, and now I’m in the hospital hand in hand with specialists and residents, where we’re a very strong team.
As people from another country, in this case neighbouring Colombia, have you been treated any differently in the workplace?
Ana: The truth is that as you’re Colombian you have an advantage, because people say that Colombians are very aware, and that we’re hard workers…and they can see that we pull our weight. Therefore if we have a doubt around a teacher or doctor, we can ask them without a problem.
What are your future professional plans? Do you think you’ll stay in Venezuela for a long time, or will you go back to Colombia?
Ana: I think that you need to have short and long term goals. Short term the plan is to stay in Venezuela; however this could become long term because things can always change.
Paola: For me the plan is to finish my two years of article eight, do a residency and then a speciality, and then work here and in Colombia.
Are there any other comments that you’d like to offer?
Paola: That you shouldn’t believe everything that they say on television, that in Venezuela people are going hungry, that’s not true.
In terms of health, there’s a very good infrastructure, and it’s a free service. Here no one has to pay anything, and the person that wants to pay can do so in a private clinic. However a foreign person can come here, for example a Colombian, or a Scot, or a Chinese or Japanese person, and in hospital they will be attended to without requiring an identity card, there isn’t discrimination against your nationality. The health service here is free for the whole world. In Colombia if you don’t have an identity card you won’t be seen, or you have to pay.
Thus people don’t thank what they have or don’t value what the country has, and I say to the Colombians that see this interview that there are very good study opportunities here. So it’s not necessary to talk [about Venezuela] for the sake of it, but rather one should have knowledge and a base upon which to pass comment, and not just believe what others say about this country.
Ana: Just to say that we sisters came on this adventure to better ourselves, to achieve our goals, and one of those was to be a comprehensive community doctor. So things worked out very well for us.
#5: Viviana and Erick
MIC students, the Latin American School of Medicine (ELAM), Class of 2013
“We will go back to our countries to help our people”
In my final interview I spoke with two comprehensive community medicine students from Bolivia, who are finishing their placements in the Barrio Adentro clinic in Barrio Pueblo Nuevo, Mérida city. Viviana Arequipa, from La Paz, and Erick Cuba, from Cochabamba, came to Venezuela to study MIC through the “Salvador Allende” Latin American School of Medicine (ELAM) in Caracas, and are part of the first graduating year of the institution. They will graduate in December.
To begin the interview Viviana Arequipa explained a little bit about why she and Erick had come to Venezuela to study MIC with the ELAM, and how the international medical school was founded. She said that the ELAM was an initiative of the Bolivarian government to train doctors from other countries with the aim of helping to meet public healthcare needs in Latin America and the wider world. The ELAM was founded in 2007 with the intake of around 700 students from 14 countries in its first year. The largest group of that year was from Bolivia, with 450 students, who were selected following criteria such as support for public healthcare or left-wing values, or for not having the economic means to study medicine in their home country. According to Viviana and Erick many of the students who began in that first year have not made it to the end of the program, and later on in the interview they made some criticisms of MIC’s training. However they also offered their opinion that the educational quality of the ELAM had improved a lot since its founding.
Supported by Cuba and modelled on the ELAM in Havana, between its various year groups the ELAM in Caracas is currently training over 2000 students from 42 countries particularly from Latin America and the Caribbean, Africa, the Middle East (including Palestine), and Asia. All study on Venezuelan government scholarships and enter with the condition that once they have graduated they must return to their home country to strengthen public healthcare there and serve the needs of their peoples.
So, what are your plans after graduating?
Erick: The idea is what [program authorities] proposed to us when we were selected, that once we finish our studies here in Venezuela, we go to our countries to help people there too. It wouldn’t be good or fair that a socialist country allows us to study for free, with a bursary, not so much but enough for us, and afterwards we go back to our countries and become mercantilist. They have always focused us on the importance of this.
Due to this there is a political act in comprehensive community medicine, because we are very different from capitalist doctors. That’s why they told us that once we finish our studies, “go to your countries and help your people too”, because over there in Bolivia a lot of doctors are needed. There are a lot of people that need [medical attention] and don’t have the economic means [to go to a private clinic]. When a doctor enters a capitalist hospital, rather than focusing on the patient’s pain they focus on their wallet. If the patient doesn’t have any money, they say “We can’t help you”, because the patient doesn’t have the means to pay or buy medicines. [In the ELAM] they told us that this isn’t good, and cannot be. This sat very well with us because we also come from lower classes, from the part of society where we’ve felt this necessity. We have experienced it, some but not all, and we’ve [all] seen it.
When the first wave of comprehensive community doctors graduated in 2011, some journalists in the private press and representatives of the traditional medical sector issued criticisms of the program in terms of its quality and the quality of its graduates. What’s your opinion on the matter?
Viviana: Well all students are different, and there are students with deficiencies, that is true. The Cuban doctors can’t give us the teaching that perhaps they’d like to, because they need to be in the clinics, working night shifts, and teaching, and we understand that they can feel tired. Also around 60% of the degree is autonomous learning, so it depends on how much each student studies. But there are some students of course that have children…so it depends on each student, and the ability of each student.
Erick: I think criticism is good, because no university appears perfectly formed. In the Bolivarian University of Venezuela (UBV), with the first graduating class in medicine, I think that it should go a bit further. However I think that it [the UBV] is better than other universities when they are first inaugurated. And these [aforementioned] deficiencies are more personal than anything else. Taking these criticisms into account, I think that Venezuelan doctors should help their people too, because when the comandante [Hugo Chavez] came [to the ELAM] he told us, “I held out my hand to Venezuelan doctors but they opposed me and didn’t want to give you classes, so I brought Cuban doctors”. And, well, as my colleague said there are doctors that graduated who were well prepared, but there are others who had deficiencies because they hadn’t done their part.
Personally, the program’s education has given us a lot, but I think that you must always study medicine and keep up to date. Therefore, yes it’s given us a lot, but that doesn’t mean that now I’ve graduated I’ll throw my books away, no. You must always study
Coming from another country, what’s the experience of living and working here been like?
Viviana: Since the first year of the program I’ve felt good because I’ve been in communities where the people are humble, and I’ve always felt their human warmth. Of course in the hospitals we’ve had to be with doctors that don’t agree with this process [i.e. the government]. However as we are always respectful, we’re never dared to talk with them about politics, because at the end of the day, medicine isn’t politics.
Erick: The experience was very welcoming here in Venezuela. First I was in Bolivar state, almost on the Brazilian border [undertaking placements]. It was cool, you could feel that the revolution reaches from one corner of the country to the other. You could feel the revolution there [in Bolivar] because there were Cuban doctors and Venezuelan doctors; those who are with this process and helping the people. And in that sector, Kilometer 48, there are indigenous people of different ethnicities, of other languages and cultures. In that zone [one of the indigenous groupings] are Kariñas, who speak English and French [in addition to their native language]. The distribution of medicines was also undertaken there, and there was a translator present.
Then I went to Monagas state [also in the east of Venezuela], where there are also good and bad people. Some very shameless pro-opposition people go to the CDIs, and once they have the free medicine, speak badly of the government again. I don’t understand some of them but they’re tolerated, the revolution doesn’t cause anyone harm.
And finally I came here to Mérida to finish, because there [in Monagas] there were many pro-opposition people in the hospitals that sometimes bothered us, this affected me because being a doctor means helping another person and not treating someone according to how much money they have. Sometimes they treated someone who had [money] well, but for the ones that didn’t they quickly gave them some medicines and did no more. I didn’t like that and so I came here, also because here they let you enter [observe / assist] surgery and they allow you do perform some [medical] procedures.[ii] So, I’m here finishing the degree and having a great experience because I went from one corner of the country to another.
All interviews conducted, translated, edited and abridged by the author.
[i] Borroto Cruz & Salas Perea (2008), The National Training Program for Comprehensive Community Physicians, Venezuela, Social Medicine, Vol. 3 No. 4
[ii] Note: Erick Cuba appears to refer to two phenomena that according the investigations undertaken for this article, exist in at least some public hospitals and among some, but by no means all, conventional doctors. The first is when a doctor in a public hospital treats a patient better due to their physical aspect or social class. The second is where conventional doctors try to impede MIC students and graduates in hospitals from learning by preventing them from undertaking certain procedures such as assisting in surgeries or performing births. The reasons for this have been outlined in other interviews in this investigation, as well as in the introductory article on the topic.