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Supply shortages plague Venezuela's public hospitals

By Mike Ceaser | The Lancet

The Lancet, Volume 366, Number 9495, 22 October 2005 | Magallanes hospital in Venezuela's capital hit the headlines in August when four patients died in a night after oxygen supplies ran out. The deaths put the hospital at the centre of a political row—but the incident has also highlighted problems that affect the entire country. Mike Ceaser reports.

Nursing assistant Marleni Acevedo reached into one of the nearly bare shelves in the nurses' station and retrieved a half-litre cardboard carton of cotton balls. This is all the cotton we have for the 40-bed ward until new supplies arrive, she says.

That afternoon, the nurses on duty in Magallanes public hospital, in Caracas, Venezuela, had no alcohol and no running water. The refrigerator and intercom systems were out of order, as were all but one of the building's seven elevators.

It was a typical day in Magallanes hospital—a faded red, white, and green ten-storey building with garbage piled up in front of it. Over the hills surrounding the hospital lies one of the many sprawling slums that swamp most of the city.

In late August, the 500-bed hospital made headlines when four patients died in one night, after oxygen supplies ran out. The deaths drew attention to the fact that, despite Venezuela's unprecedented income from soaring world oil prices, the country's public-health system is plagued with problems. While Magallanes has become a symbol of the health system's shortcomings, doctors, patients, and government officials agree that many of Venezuela's 300 public hospitals share its problems.

Political foes of Venezuela's controversial populist President Hugo Chavez point to the hospitals' plight as proof that his government is failing to improve the lives of the poor, who depend on the public hospitals. Doctors' organisations say the government is underfunding the hospital system. Government officials counter that corrupt hospital administrators and sabotage by doctors are causing the hospitals to fail.

In the wake of the deaths, the Ministry of Health delivered a report to the National Assembly saying: “the nation's hospitals have a functional crisis stemming from more than 20 years of disinvestment”. In September, the government budgeted US$82 million in emergency funding for the system of 300-plus hospitals and assigned hundreds of citizens to assess the hospitals' condition.

But government critics asked why, despite the notoriety of the hospitals' problems and the nation's huge income from record world oil prices, the government waited until the deaths to act.

Dozens of interviews with doctors, nurses, patients, and hospital administrators revealed faults on all sides. In particular, a fundamental lack of oversight and quality control allows problems to compound.

For example, Magallanes' morgue's refrigerator has capacity for only four bodies, and does not adequately refrigerate, workers said. The device's engine clanks and rattles, filling the room with an odour of rot, and a spilling puddles of reddish liquid on to the floor below. In addition to hospital deaths, the morgue also receives bodies of people killed in neighbourhood violence, as well as those of poor people. As a result, the morgue employees said, on some violent weekends bodies crowd the hallways. Because of delays in retrieving the bodies, some have bloated and burst, sometimes contaminating upper floors of the hospital and requiring patients to be evacuated.

Deaths at Magallanes hospital in Caracas drew attention to problems affecting the whole health system. Mike Ceaser

Due to the unsanitary conditions, lack of air conditioning, and broken equipment neither the autopsy room nor the neighbouring cytology laboratory functions well. The autopsy room's water and suction hoses do not work; their wall controls are missing knobs and fittings.

In the cytology laboratory, a technician sits with crossword puzzle books open in front of her. She can't work, she explains, because the equipment is either inoperable or has been stolen. When workers complain to management, they are met with anger, she says. “We just come to fulfil the schedule”, she says.

Picture by Mike Ceaser

Other sections of the hospital function partially. In the emergency room, where many of the 5000 patients seen each month have gunshot wounds, the last of the five X-ray machines has just failed; supplies of analgesics and antibiotics are irregular; and only four of the eight operating rooms is functioning. “What we don't have, we improvise”, a doctor, who requested anonymity for fear of retribution, explains.

Upstairs in intensive care, Ruben Barrientos, a surgeon, says medical supplies are sufficient, but added that the ward had not had air conditioning for three years. As a result, they used the operating room only for urgent cases.

The faulty elevators cause their own chronic problems. With only one or two of the seven elevators working at any time, employees and patients complained of long delays at times when speed is crucial. Patients, dead bodies, and garbage all crowd into the same elevators.

Juan Fuenmayor, who was hospital director in 1995 and 1996, and now heads the cardiology department, blamed many of the problems on an inefficient and unresponsive bureaucracy in the mayor's office, which orders supplies and approves payments. For example, acting in his capacity as director, he had the morgue's refrigerators repaired. However, the mayor's office did not issue payment and so the repair company returned and sabotaged the equipment.

Fuenmayor blamed the occasional lack of running water on the hospital's antiquated water system, which depends on tanks built on top of a nearby hillside. Children sometimes swim in the tanks, he said, and once a boy drowned. But when the National Guard arrived to monitor the tanks, residents of the surrounding high-rises drove them away with gunshots.

Employee apathy and corruption also play a part in Magallanes' troubles. A year and a half ago, the hospital's telephone switchboard was stolen and never replaced, cutting off phone calls from outside. One employee said that her daughter recently brought her baby in to be treated for a urinary infection only to be told by hospital employees to purchase her own gauze, syringes, and medication. But when the employee later came to work, she discovered that the hospital had plentiful supplies.

Patients and staff say Magallanes' problems are typical of Venezuela's hospital system. In Vargas, a public hospital located in a poor neighbourhood a few kilometres from parliament and the presidential palace, a man accompanying a relative who needed a biopsy near her spinal column says the hospital lacks almost everything, including gauze, alcohol, serum, and analgesics. He had to pay private businesses to have X-rays taken and to rent a laparoscope—which alone cost him half a month's salary. “Everything has to be done outside”, he says.

Two young women who work in Vargas' X-ray department say that two of the three X-ray machines are out of order and that the mammogram and ultrasound machines do not work because there is no air conditioning. In addition, the women say, there are no lead vests for protection. “We irradiate ourselves”, they explain.

Even machines that are operational are not necessarily useful. In Magallanes, a doctor displays a chest X-ray taken the week before that was of such bad quality that not even the ribs were visible.

Consistently low salaries do not improve workers' attitudes. Most hospital employees, including nursing assistants, earn the minimum wage of US$160 per month, whereas doctors earn about $240 per month. And for some, pay runs months behind.

Douglas Leon Natera, president of the Venezuelan Medical Federation, a doctors' society critical of President Chavez, blames inadequate funding for many of the problems. Even though Venezuela budgets 8% of its gross domestic product for health, he says that 75% gets diverted to the government's new neighbourhood health clinics staffed by Cuban doctors.

Obtaining funds for hospitals “hasn't been easy with any government”, he says, “but with this one it has been worse”.

Carlos Ocanto, director of Caracas' 14 municipal hospitals, lays much of the blame on the administration of the previous mayor, a diehard Chavez opponent. He explains that upon taking office last December he found large debts, deteriorating infrastructure, and “a cemetery of damaged equipment”, as well as 89 machines purchased with Spanish development assistance that had never been installed.

However, Ocanto says the new administration is making improvements. “We're making investments”, he says. “But there's a lot left to do.”

Back in Magallanes hospital, Mercedes Parica, 66, slowly makes her way down four flights of stairs on an ulcerated leg, gripping her cane and the banister. She says she had to bring her own gauze, parchment, and vinegar for the antiseptic solution for her treatment. 6 weeks before, she had been hospitalised for surgery, but was sent back home when the surgery rooms became unusable. Asked if there will be real improvements to conditions in future, she answers simply: “Let's hope.”

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