Even though a large portion of the problem lingers as a result of decades of inequalities from before Chavez government, and the health of the country has improved with increasing access to clinics thanks to social programs like Misión Barrio Adentro, women like Sara are dying in Venezuela because politicians are still afraid of condoms. More must be done to address sexual and reproductive health.
Sara tells me a recent history, proudly detailing the transformation of healthcare from a commodity available only for the rich, to a shared commonality for all. Before Venezuelan President Hugo Chavez implemented broad reforms redistributing oil revenues towards the social sector, many poor and rural families could not afford to go to doctors. Like in the United States, the mixed private-public healthcare system failed to deliver health prevention services to the country’s most needy families. Sara and her family used to wait until her children were gravely ill before borrowing money from family and friends to go to the clinic in town. Now, a new clinic is located within walking distance from her house, and she pays nothing for a doctor’s services, drugs, or medical supplies.
This clinic is one of thousands which have opened over the past 5 years. As a medical student and a 2006/07 Fulbright Scholar, I studied the expansive transformation of Venezuela’s healthcare system, from its theoretical underpinnings to my direct participation. Chavez launched a national program called Misión Barrio Adentro [Mission Inside Neighborhood] in 2003 that expanded access to primary care and preventive health services. In fact, access grew 6 fold in 6 months. Even though free public health centers existed before, both difficulties in reaching clinics and the high costs for medicines and supplies made true access to healthcare a pipe dream for many.
Though Sara gave birth at a hospital nearby in the State’s capital city of Merida, the lack of primary care clinics in the past had prevented her from having a pap smear, or any other regular health services. But now Misión Barrio Adentro has provided Sara and her family with oral rehydration salts when her baby was sick with diarrhea, antibiotics for an ear infection for her older child, and daily medication to treat chronic high blood pressure.
One morning in April, Sara comes in ready for her pelvic exam. She’s heard of our clinic’s neighborhood campaign for 100 percent preventive healthcare exams from a flyer we posted the week before near the grocery store. Sara will receive a thorough check up as a part of this new community program. The goal of this campaign, my physician mentor explains, is to actively create community health, "because many people have been without healthcare for so long, they don’t know if they have a chronic disease like hypertension or diabetes. So on our health census, when you ask them ‘Are you sick?’ they answer ‘No’." Feeling sick has become normal for some families who have been with out primary healthcare for decades.
The goal of seeing Sara in our clinic is both to provider her with free healthcare services and to help the community better understand its health needs. "The community can make better decisions when we know what we are sick with," reported the local chair of the community health committee. Through medical schools integrated with Misión Barrio Adentro, all medical students complete an "Analysis of the Community’s Health Situation" which helps "determine the principal problems of the community, [and] gives them an order of priority in order to create a plan of action, so that we can execute a solution on a short, medium, and long term." Accurately knowing the prevalence of disease makes community-directed interventions more effective.
The exam begins by finding out information about Sara’s past medical history. When I ask how many children she has, Sara responds, "Seven, but only 5 are alive." Life for women is hard in rural Venezuela; infant mortality rates are falling, but still relatively high. According to the World Health Organization’s Situación de Salud de las Américas Basic Indicators 2002, in 2000, the period after Chavez won his first election, Venezuela had a maternal mortality rate of 60.1 and an infant mortality of 17.7 per 1000 live births. UNICEF reports the lifetime risk of dying in childbirth is one in 300. Venezuela performs better than the continent’s average for the same year, and better than neighboring Brazil and Colombia. Still, Cuba shines as an example with 5.8 infant mortalities per 1000 live births even though its gross national income per capita is a quarter of that of Venezuela.
One year after the opening of Misión Barrio Adentro, maternal and infant mortality indicators improved, falling to 54.0 and 17.5 respectively. Even though fewer moms and kids are dying, Venezuela has much room for advancement before reaching Cuba’s levels of low rates of maternal and infant death. Like the United States, in the rural Andes Mountains, the burden of disease morbidity and mortality falls heaviest to poor women and children like those in Sara’s family.
After her exam, the doctor informs Sara that her results will be available in about a month. Clinics in this region are participating in a joint study between the ministry of health and the autonomous Universidad de Los Andes to test for rates of HPV (Human Papilloma Virus), the leading cause of genital warts. HPV matters because it represents a leading risk of cervical cancer, a killer of women across the developing world. Using high tech DNA testing, we can identify specific types of the viruses, determining the difference between strands correlated high or low risk of becoming cervical cancer. This level of care-identifying between the specific types of HPV-is not available as a standard of care in the majority of clinics in the United States.
HPV and Gendered Healthcare
It is prohibitively costly to test for specific HPV strains, and in my clinical experience in the United States, we simply don’t test. The CDC states that there are nearly 100 strands of HPV, 30 of which are transmitted sexually, 10 of which are associated with cervical cancer. Serotype 16 and 18 are the biggest culprits, and the newly released vaccines protect against these strands.
When Sara comes in, a month later, we inform her that she has tested positive for a high risk HPV. The first time I saw a case like hers, I was surprised. A monogamous woman with a sexual history of one partner, her husband, is not a likely candidate for a sexually transmitted infection. However, her situation is not unique. Eyeballing from my clinical experiences, I estimate high risk HPV was found in approximately 10 percent of the women we served. Some men are known to have multiple sexual partners, and part of the machismo code means that women are unable to ask men to use condoms without facing emotional, physical or economic retaliation.
Although important from an individual patient perspective, these high rates of HPV correlate to extremely high rates of mortality due to cervical and uterine cancers. This is the number one cause of death due to cancer, above lung and breast cancers, for adult women in Venezuela. Luis Spagnuolo, of the Universidad Central de Venezuela wrote in an article about sexual health, "Its not an accident that in 90 percent of the cases we find HPV in the lesions of cervical cancer. HPV is the cause, not a mere correlation." Studies confirm that worldwide HPV DNA is detected in 93 percent of cervical tumors, with no significant variation among countries. HPV 16 was present in 50 percent with HPV 18 in 14 percent of the lesions.
According to the PanAmerican Health Organization, South America faces over three times the mortality rate from cervical cancer than North America. In a continent with high rates, Venezuela is among the highest in the continent-over 30 deaths per 100,000 women per year. These statistics are particularly important because cervical cancer can be prevented by the early identification and treatment of precancerous lesions.
Why are rates of cervical cancer and HPV so high in Venezuela? Before programs like Misión Barrio Adentro, most women did not receive pap smears because they couldn’t travel long distances and clinics weren’t open during convenient times, had long waits, and services and laboratory fees were prohibitively expensive. Because of a lack of access to health prevention services like pap smears, treatable HPV lesions led to deadly cancers. In the face of poverty, gender plays an increasingly salient role.
Recently, access to pap smears has rapidly expanded for screening services underneath the Ministerio de Poder Popular para la Salud [The People’s Power for Health Ministry] program. But the accumulated social debt over the years has lead to enormous gaps in preventive health services for poorer women in Venezuela. In 1996, a bulletin by the Pan-American Health Organization described how women with primary education have twice the cervical cancer incidence than with higher education; illiterate women had six times the rate of university-educated women. Generations of poor women have not received appropriate healthcare, and it will take at least a generation before seeing the full results of new social programs like Misión Barrio Adentro that are designed to meet the needs of the underserved population.
If it were simply a matter of expansion of access to services, Misión Barrio Adentro would resolve this problem. But lack of access alone is not enough to describe the deadly impact of HPV and cervical cancer in Venezuela. The issue is more complex. For one thing, in sexual health domains, quality of care is significant. A perception of poor delivery of medical services makes women much less likely to seek out invasive preventive pelvic exams. On top of that, results of pap smears can take up to 3 months in Venezuela, although waiting for a month was more the norm in my clinic. Venezuelan women also mentioned in a survey that the pelvic examinations were in places that are not appropriate according to them, such as schools or houses. While care was used to ensure privacy, shutting doors to rooms and hanging dark curtains over windows, Misión Barrio Adentro frequently relies on community sites and home-based clinics.
Additionally, as many researchers have pointed out, if treatment is unavailable, many women feel disempowered by knowing the results of a screening test. In the area I was working in the public domain, there was one functioning colposcopy instrument, the tool that is needed for treatment of lesions. Women could pay private clinicians, or choose to wait up to 3 months for free care. Some women feel it is better not to get screened at all than to wait so long for potential treatment.
Besides patient care, national health policy influences rates of mortality in women’s health. Unfortunately, rates of HPV have been traditionally under-reported in Venezuela, as have many sexual transmitted diseases and infections. According to the Ministry of Health, in 1999 the rate of reported cases of HPV in Venezuela was at 2 percent, while the global prevalence of HPV is estimated to be nearly 80 percent. I fear that this lack of appropriate collection and analysis of public health data negatively impacts women’s health more than men’s health and the health of poor communities worse than richer communities. In general, sexual health is seen as a taboo topic, and this is only reinforced when public health measures are not appropriately discussed and implemented. If governments do not take the time to thoroughly measure diseases, how can women fully trust governmental policies and responses?
Undoing the Taboo of Sexual Health
The lack of appropriate open and honest discussion about sexually transmitted diseases goes beyond data and policy. Although vast changes to the health sector have positive impacts on poor families in Venezuela, sexual health issues remain discordantly unaddressed. This issue is not isolated to Venezuela; sexual health issues facing women often are under funded and under recognized internationally. As a result, there is a policy-practice mismatch in Venezuela regarding sexual health. The constitution guarantees access to healthcare, under articles 83 and 84. New laws describe universal access to birth control services and sexual education. In the national health law that’s being discussed in legislature, Article 14 Policies for Responsible Sexual and Reproductive Health That is Without Risk states:
"The Institutions of the National System of Public health will develop policies and actions that favor the responsible & healthy exercise of sexuality and human reproduction, without risks, as a right of the all people to make responsible, free, and informed decisions about the number and spacing of their children. The policies and actions for sexual and reproductive health will guarantee the access to health and education and family planning services that are safe and effective, based on scientific and technical criteria, and based in research in family planning, fertility and biology of reproduction."
However, reality consistently proves that sexual health services are not equally distributed. Poorer women disproportionately face higher rates of cervical cancer, not to mention a greater burden from unplanned pregnancies, deaths from back-alley abortions, and spread of other STDs. Though a large portion of the problem lingers as a result of decades of inequalities from before Chavez government, more must be done to address sexual and reproductive health.
I did not have access to condoms for my patients at any of the clinics, either in the traditional public healthcare system or in Misión Barrio Adentro clinics. Patients desperately needed condoms, but were told to purchase condoms at the local pharmacy, where a small package cost more than many families spent on food for a day. Poverty makes purchasing condoms on the private market nearly impossible. At every opportunity, I spoke with other physicians, nurses, community leaders, and hospital directors. The lack of condoms was not isolated to one or two clinics. Across the state, from urban barrios to rural clinics, public clinics did not have condoms available for distribution. The list of identifiable culprits for lack of condoms includes religion, doctor’s biases, and flaws in the distribution programs at a national level.
Condoms represent one of the most important interventions in reducing the spread of STDs. Although using condoms doesn’t fully protect against HPV because the virus is often spread during foreplay, their use is associated with regression of lesions for both men and women, according to articles in the International Journal of Cancer.
The rapid expansion of free primary health services through Misión Barrio Adentro needs to be paralleled with an expansion of programs designed to improve the sexual health of underserved communities. Even if condoms were freely available, in my community clinic many women were not free to demand that their partners use them. "Asymmetries of power related to gender, wealth and social status influence the control people have over their sexual relationships and lives and their ability to make and enforce decisions," writes Dr. Rene Loewenson, a coordinator for the United Nations Research Institute for Social Development in a 2007 article in the journal AIDS Care. Domestic violence and economic coercion shape the reality of many women; simply providing condoms would not eliminate the need to address these issues.
Though sexual education is now mandatory part of primary and secondary education, I have found that not all programming accurately discusses prevention. For example, in a school play of sixth graders that I attended, HIV infection was explained as the result of "girls not listening to their parents and having boyfriends." Most people know that AIDS is spread through unsafe sex, but unquestioned stereotypes run rampant: only homosexual men get AIDS, only promiscuous women get STDS, only drug users should be tested for HIV. Basic education needs to be coupled with other strategies to promote use of condoms. Even though many men understand that condoms work to prevent STDs, 75 percent have not used condoms consistently. Among sex workers, 38.5 percent never use condoms. Also, over 40 percent of sexually active youth, in urban areas in Venezuela do not use condoms. This figure is higher in rural areas where access to condoms is more difficult.
Besides lack of free condoms, the fundamental challenges to improving sexual healthcare across Venezuela remains, at heart, an ingrained machismo. Women die because, in spite of rhetoric promoting health as a human right, sexual health is still marginalized.
Rebecca Trotzky Sirr is a medical student in the United States loving her 80hr/week rotations in hospitals in the Twin Cities. She had the privilege of studying postgraduate public health at la Universidad de Los Andes in Merida, Venezuela while working with Cuban and Venezuelan doctors through the Misión Barrio Adentro in the Municipality Santos Marquina. She believes that US physicians can learn from Venezuela’s expansion of universal healthcare based in human rights. Rebecca received a Fulbright Award to research Venezuela’s success and challenges in redesigning its social system. She is a single mom to an amazing 3rd grader, Zev, who learned to enjoy arepas at La Escuela Bolivariana de la Mucuy Alta.
Contact Rebecca at revolution.is.medicine @ gmail.com
1. Dra Yaquilina Martinez Vera
4. Prevalence of human papilloma virus in cervical cancer: a worldwide perspective. International biological study on cervical cancer (IBSCC) Study Group. Bosch FX; Manos MM; Munoz N; Sherman M; Jansen AM; Peto J; Schiffman MH; Moreno V; Kurman R; Shah KV J Natl Cancer Inst 1995 Jun 7;87(11):796-802.
5. Dzuba IG, Calderón R, Bliesner S, Luciani S, Amado F, Jacob M. A participatory assessment to identify strategies for improved cervical cancer prevention and treatment. Rev Panam Salud Publica. 2005;18(1):53-63
6. Corral, P. Cueva, J. Yepez and E. Montes, Limited education as a risk factor in cervical cancer. Bull. Pan Am. Health Organ. (PAHO) 30 4 (1996 (December)), pp. 322-329.
7. Perceived barriers and benefits to cervical cancer screening in Latin America I. Agurto, A. Bishop G. Sánchez, Z. Betancourt and S. Roblesa Preventive Medicine Volume 39, Issue 1, July 2004, Pages 91-98
8. Condom use promotes regression of human papillomavirus-associated penile lesions in male sexual partners of women with cervical intraepithelial neoplasia. Bleeker MC; Hogewoning CJ; Voorhorst FJ; van den Brule AJ; Snijders PJ; Starink TM; Berkhof J; Meijer CJ Int J Cancer. 2003 Dec 10;107(5):804-10. Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papillomavirus: a randomized clinical trial. Hogewoning CJ; Bleeker MC; van den Brule AJ; Voorhorst FJ; Snijders PJ; Berkhof J; Westenend PJ; Meijer CJ Int J Cancer. 2003 Dec 10;107(5):811-6.
9. Learning from diverse contexts: Equity and inclusion in the responses to AIDS. AIDS Care [0954-0121] Loewenson yr:2007 vol:19 iss:Suppl1 pg:S83 -S90
10. Psychocultural barriers of Venezuelan men to practice safe sex.Barrios L. Int Conf AIDS. 2002 Jul 7-12; 14:.Universidad Central de Venezuela, Comsalud, a.c., Caracas, Venezuela
11. CAMEJO, María I, MATA, Gloria y DIAZ, Marcos. Prevalencia de hepatitis B, hepatitis C y sífilis en trabajadoras sexuales de Venezuela. Rev. Saúde Pública, jun. 2003, vol.37, no.3, p.339-344. ISSN 0034-8910.