For doctors in Venezuela, the simplest disease can become a tragedy

In a country where an official epidemiological bulletin is published only irregularly, Julio Castro gathers health statistics through a digital tool that allows him to monitor hospitals across the country.

Doctors in the network fill out questionnaires about the availability of medicines and surgical supplies in public health centers, whether emergency services are working properly and other key issues. The network issued nationwide reports for 2014, 2015 and 2016. Castro uses another digital tool to monitor the availability of drugs defined as essential by the World Health Organization.

Castro also works as an infectious disease and internal medicine physician at the private Policlínica Metropolitana in Caracas and teaches at the Tropical Medicine Institute of the Central University of Venezuela, the country's top university and his alma mater. He studied biostatistics at the Harvard School of Public Health, where he also did an internship on infections among organ transplant patients.

1. How's medicine today, compared to 10 years ago?

It's very different. The shortages of medicines and other supplies are now part of our daily practice. For example, the test tells me the ideal antibiotic for a urinary tract infection is A, B or C. You chose one, according to the patient's age and health. In Venezuela now, it's likely that there's no A, and probably no B or C. None of them. So we have to figure out something between what is technically ideal and what is logistically available.

2. What are your patients’ most frequent complaints?

One is that they can't find the medications, and the other is the tests. For example, if they have to have a bone scan because of a bone infection, they may wait for two months, and sometimes never get one, because there are no chemical reagents. I also have a lot of patients with HIV who need special tests, for example to determine their viral load. Those patients have not been able to find reagents for months. We are doing treatments a bit blindfolded. We don't have the usual way to monitor this, like other countries do.

3. How many drug options are you including in each prescription

Four or five.

4. Any especially difficult cases that have kept you up at night?

In tropical medicine we see a lot of patients with leishmaniasis, a parasitic disease that is widespread in Venezuela because it's a tropical country. Today, we have no drugs for it. It is an ulcer that appears on the skin, maybe on the nose, an ear, on the face. This is obviously frustrating because you make the diagnosis and then you have to tell them to go to Colombia or the United States for treatment. Leishmaniasis is more common in poor or rural areas, so the people who live there generally don't have the resources to do that. They simply have to live with the ulcer. We can’t do anything for those patients.

5. Is your salary enough?

I am embarrassed to tell you my salary. It's not even one US dollar a day, even though I have 25 years of experience. I live from my private clients. A doctor who works only in a (public) hospital, for example, gets a salary that is not enough.

6. Has your work been affected by the high levels of crime?

We try to go home early. If a patient has an emergency overnight, you deal with it on the phone with the doctor on duty at the clinic.

7. Have you thought of emigrating?

No, because of family, ethical and economic reasons. I am 52, and at my age it is not so easy to emigrate. I have my children here, and I decided against it. I expect that a young doctor, who cannot even buy food with the 30,000 bolivares ($30) he earns, would consider leaving for another country.

Ana Vielma commutes 13 miles each day to her job at a hospital in Antímano, a dangerous part of Caracas. She doesn’t mind the long and risky travel, or the way the hospital, Dr. José Ignacio Baldó Hospital, known as El Algodonal, has deteriorated. There, “you learn from the patients,” she says. She tries to help them with her own money.

Every Monday for the past two years, she has written a report detailing everything that is missing or broken in her sector. She sends it to the head of the Clinical Pulmonology Service, which then forwards it to the hospital administrators. She has never received a reply.

The hospital's Simón Bolívar Tuberculosis unit pioneered the treatment of tuberculosis and thoracic reconstruction in the 1940s. Vielma has worked there since 2004, when she started post-graduate studies. Today, two of its three wings are closed, their doors blocked by black garbage cans. The morgue is also closed, and no ambulances are based at the hospital.

1. How's medicine today, compared to 10 years ago?

Our hospital was the one that had no shortages. We had antibiotics, drugs that people had to pay for in other hospitals, medical supplies, surgical masks, containers for samples … Yes, sometimes we had no water, we had no x-rays. We had problems. But we had more than others. El Algodonal even sent drugs to other hospitals that did not have them. Then things began to change, and two years ago they turned bad.

I think that aside from the supplies, the problem at El Algodonal has been the infrastructure. They started to remodel it in 2007 and left the work half-done. There are closed, abandoned areas, empty beds. The doctors who retired, like the pathologist, were not replaced. They closed internal medicine, nephrology and cardiology. Only pulmonology, thoracic surgery and general surgery are still open. We have no more specialists. Everything has been slowly shutting down.

2. What are your patients’ most frequent complaints?

The shortage of medications and inhalators. Most of the inhalators are not made in Venezuela, and if the government doesn't pay, they are not imported. You can't find them, and if you find them they are very expensive. And if you buy one, there are none for later. Without an inhalator, the illness gets worse, breathing becomes more difficult and by the time they get to a hospital maybe you can save them, maybe not. We also don't have the means for doing biopsies, so patients have to go to private services.

3. How many drug options are you including in each prescription?

As many as I can. But there are medicines, like an intravenous treatment for fungus, that is only sold through hospitals. A person can't buy it in a pharmacy, and the hospital doesn't have it. The drugs for pulmonary diseases are very specific, and people don't understand that. They tell me, “Doctor, you have to fix our problem,” and sometimes they blame me.

4. Any especially difficult cases that have kept you up at night?

The patients we diagnose with advanced lung cancer die waiting for an appointment unless they know someone or you give them a contact so they can be treated quicker. When we make the diagnosis, we refer them to the specialized hospitals because we don't have an oncologist. They can die waiting two, three months for an evaluation by an oncologist. That's happened.

5. Is your salary enough?

It's not enough for anything. I also have private patients, and those have dropped more than 50 percent.

6. Has your work been affected by the high levels of crime?

Yes. We try not to leave late. A hospital doctor was kidnapped in February. We also don't have lightbulbs, waste baskets and oxygen connections, because people stole them.

7. Have you thought of emigrating?

Yes. I've thought about it, but to practice anywhere else depends on the laws of each country, and it's complicated everywhere.

Indira Calzadilla worked 24-hour shifts at the Miguel Pérez Carreño Hospital in Caracas, seeing one patient after another. In the working class neighborhood of Caracas, she saw incurable diseases, patients with no relatives, patients who had come from far away -- all those that landed in the Type IV hospital, which handles the most urgent cases.

She did her post-graduate studies in internal medicine and gastroenterology at Pérez Carreño and worked there until 2009, when she went into private practice. Calzadilla's work in the private sector has not been easy. Faced with shortages of drugs and medical supplies, she tries hard to help patients who need treatment, from copying medical reports to asking colleagues and hospitals for a hand.

When she goes to a pharmacy to buy anything, she asks what drugs they have in stock for gastroenterology, so she can consider that when writing prescriptions. The last pharmacy she visited had nothing at all for gastric diseases.

1. How's medicine today, compared to 10 years ago?

I think the main change is the shortages. I never before had to write several medications in one prescription, never. I have patients who have left crying because they can't get treatment. They can't get treatment because we don't even have clamps. Everything has turned into a tragedy. What was simple has turned into a tragedy.

Insurance policies also don't cover much. They don't generally even cover simple procedures. Before, everyone's insurance covered gallbladder stones. Not now. We don't have the reagents for the tests. I live with that problem every day with the patients who have viral hepatitis.

2. What are your patients’ most frequent complaints?

They can't find the drugs. They even stop coming to the office because they say, “Why go when I can't get the medicine?” There are diseases that are easy to treat but can get complicated when the treatment is not timely, like diarrhea. I give them hydration and antibiotics, something to replace the intestinal flora. I give them a prescription for all of that, and they can't find it. The diarrhea continues and they come back dehydrated, with renal failure, and they tell me, “Doctor, I looked all over Caracas but could not find it.”

3. How many drug options are you including in each prescription?

Now I am giving up to five alternatives in one prescription. They are very long and can be confusing. I have to explain it well to the patient, that it's not all of the drugs, just one of them.

You find out what's happening directly from the patients. Sometimes they come back and tell me, “I can't find this.” Some don't blame me, but others say, “What's wrong with this doctor? How can he prescribe this?”

4. Any especially difficult cases that have kept you up at night?

The chronic patients. That's not my specialty, but we all have chronic patients, like people with hypertension. If you have hypertensive patients who are not getting treatment, that's a time bomb. There's also depression. The patients are not just sad because of their diagnosis, but now they are sad because the leave the office thinking they are not going to find the drugs you prescribed. And hunger. That's also new. Patients are thinner. Before, they ate out a lot. Now they've changed. And I'm talking about losing up to 20 kilos (44 pounds) and they tell me, “You know. The Maduro diet.”

5. Is your salary enough?

My salary basically buys the food. Entertainment is very limited, because of both the high cost and the crime. The quality of life is diminishing. You start to sacrifice recreation.

6. Has your work been affected by the high levels of crime?

The night shifts are dangerous. I got to work one morning and ran into a colleague who just had his car stolen. He went in, performed surgery on a patient and then went to file the complaint.

7. Have you thought of emigrating?

Yes, just started recently. I have baby who is more important than anything else, and there's no milk, no food. It's a catastrophe, finding things for him. It's not fun, really.

Magly Pereira’s patients are newborns and children up to the age of 12. She sees them at the Domingo Luciani Hospital, where she's worked as a dietician for six years. She worked for the Red Cross and then went into private practice but returned to the public sector because she wanted to do more.

Pereira always asks parents what they've eaten in recent days. They tell her they're not eating much meat, pasta or rice because those items are too expensive. They eat a lot of plantains, zucchini and pumpkin, because they are cheaper. But they are not very nutritional. Many of the parents are undernourished.

As a Type IV, the Domingo Luciani Hospital in a working-class section of Caracas receives complex cases that allow her to use her clinical expertise. She graduated from the Central University of Venezuela as a nutritionist, and has a post-graduate degree in endocrinology and metabolism.

She used to buy formula for her patients in pharmacies, but now can't find the product anywhere. When she receives samples of vitamins at her private practice, she takes them to the hospital for the most serious patients. She buys milk for the smallest patients, but there's less milk for sale every day. “The world is shrinking because there are no supplies,” she said.

1. How's medicine today, compared to 10 years ago??

I started practicing in 1994, and the change has been brutal. We always saw bad nutrition. Now we see more more under nourishment. Before, we saw babies who came with some type of nutritional deficit that was the result of a disease. But today we're seeing malnutrition as the cause of the office visit and even the cause of the hospital admission. And the fundamental reason for that is the food shortages that are hitting us.

In my private office I see the same thing in adults. Patients who lose 14 kilos (30 lbs) in a short time without a diet, which is significant. There's always been people without much money, but the food was usually covered. Today, it's not that way.

2. What are your patients’ most frequent complaints?

Patients tell you, “The problem is that there's none of this, none of that and none of that.” And that's only the food. There's also none of the baby formulas or vitamins that I can prescribe.

3. How many drug options are you including in each prescription?

I have to write down several. If I prescribe B Complex, I give them several options. Same for formula. And sometimes I tell them to buy whatever they can get. There are cases so extreme that if the mothers can find only regular milk for babies less than two years old, I tell them to buy it. They have to get something. It's very difficult.

4. Any especially difficult cases that have kept you up at night?

It worries me that children are the most affected, because they only grow once. We are seeing a significant drop in height, delays or halts in growth. That says a lot about the troubles this generation could face down the road.

It bothers me that I don't have a way to help. I don't have the most basic way, which is food. With babies that have special deficits or problems, there's nothing you can do.

5. Is your salary enough?

No. Definitely No.

6. Has your work been affected by the high levels of crime?

Yes, a lot, for all of us. In fact, a doctor was murdered in the hospital, and several attacks by robbers inside there have been reported. They have taken steps to improve security, but, for example, when we're on duty we don't stay past 7 pm. It's very dangerous.

7. Have you thought of emigrating?

Yes, and now for sure. Every day, there are things that we cannot control. It's not easy. I don't know how long I can stand it, because I have family. Everything that I see in the hospital, I also see it in my home. This is a tragedy. The logical thing is to leave legally, so you can work as a doctor somewhere else. It's more complicated when it's a career in health, but it can be done.

When Manuel Guevara inserts a tube in a thorax during surgery, he doesn’t have a device that connects the tube to the machine that maintains the patient's pleural cavity. He makes it himself. If he does not have a compress, he uses any gauze he can find. If he's missing any surgical materials, he sends one of the patient's relatives to the nearest pharmacy to buy it. Only 27 years old, he's learned how to make do, although he doesn't always manage.

At the José María Vargas Hospital, where he's doing post-graduate studies in general surgery, there's been a shortage of suturing materials since last year. There's also a shortage of surgery scrubs. If the patients don't bring them, he has to send them to another hospital. That’s risky at night, when everyone is afraid of going out. It's a dangerous area.

Gunshot victims or patients with appendicitis who arrive at night also have to be sent to other hospitals because there's no anesthesiologist on duty, even though Vargas is a Type IV hospital that is supposed to receive all kinds of emergencies 24 hours a day. Since he arrived from the city of Valencia for his post-graduate studies, Guevara has witnessed the hospital's deterioration.

1. How's medicine today, compared to 10 years ago?

The changes have been for the worst. Starting a year and a half ago, everything has been deteriorating, even the personnel. Everything has been eroding away. I think it's because of the doctors who left. The postgraduate slots are not filled, and they have to do a lot of work to bring in doctors who will fill available slots. The postgraduate slots in internal medicine and pediatrics are never filled, and anatomy was closed.

A lot of doctors have left. In my group of 20 close friends who graduated from the University of Carabobo, only four of us are still in Venezuela. Twelve are in Spain and four in the United States.

2. What are your patients’ most frequent complaints?

They always, always, complain that they have to buy the supplies for their surgery. Sometimes they have to buy 70, 80 and even 90 percent of what's used for an operation. Before, I asked them for a few little things. Now you have to ask them for the laparotomy kit, the compresses, the surgery scrubs, chemicals. Thank God that Venezuelans are good people, and the doctors work with whatever we have. No one knows what it's like to get sick in Venezuela, unless you live it. The patient doesn't have the capacity to fix these problems, and we don't have the capacity to fix these problems, because there are no supplies.

3. How many drug options are you including in each prescription?

At least four or five. We simply don't have them, and people have to hoof it all over Caracas looking for an antibiotic or a pain killer. There are drugs that are really critical, medicines that you know they are not going to find, so you don't send them out. But if it's the only option, they ask for it all over Venezuela because sometimes by asking you can find something, maybe in the states of Bolívar or Zulia.

4. Any especially difficult cases that have kept you up at night?

I had a patient with cirrhosis who had a problem at home. He had a knife wound in the stomach and we had to cut out part of his colon and then reconnect it. I can't tell you what I had to go through to find the drugs for the man. He was an alcoholic, abandoned, I assume because of his drinking problem. I had to find absolutely everything he needed, starting with antibiotics, to fight with whoever I had to fight for just 500 cc of solution, almost beg, because these kinds of patients need to be well hydrated. I paid for all his medicines. I've done that more than once.

5. Is your salary enough?

No. Our base salary is 18,000 bolívares ($18) and with extra hours we could reach 40,000 ($40). They just raised it to 27,000, but we still don't know about the extra hours. Maybe if I add everything together it comes to 50,000 bolivares. Just renting a room in Caracas costs 20,000 to 30,000 bolívares, leaving me with 20,000 for the month.

6. Has your work been affected by the high levels of crime?

Yes. A patient attacked one of my colleagues about five months ago. Punched him and punched him, and knocked him out. The hospital has no police, just unarmed security guards and the militia – those groups created by the government, generally older people. You don't know if they can defend you or you need to defend them. There are patients who are criminals, with gunshot wounds. Those are real problems, but they're not the majority. They threaten you almost daily. It's usually the criminals' relatives who come in very aggressively. They tell you, “I am going to kill you if you don't save them.” On the overnight shift, we are at God's mercy.

7. Have you thought of emigrating?

Yes, I've thought about it and looked for options. I thought about it when I graduated from medical school, but I had a lot of hope of doing something in Venezuela and my father insisted I do the post-graduate here. If this doesn't get any better, there's the option to emigrate, but nothing is simple. I think medicine is one of the hardest careers to practice in a foreign country.

Shifts in her hospital started at 3 a.m., although her contract said they should start at 7 a.m. Senior residents went to sleep on duty and left her and her inexperienced colleagues in charge. Their supervisor verbally abused them.

She worked more than nine months at the hospital, in the state of Falcón, without receiving her base salary or pay for extra hours while she did a post-graduate in general surgery. She paid her costs out of her savings, and even bought medicines for the patients who needed them.

She complained to the head of the post-graduate system in Caracas, who confirmed that he had received many similar complaints. She now works in the private sector and prefers to remain anonymous because of fears of reprisals. Natalia Mujica is not her real name.

1. How's medicine today, compared to 10 years ago?

Ten years ago there were good professors and we followed protocols because we had well trained personnel and supplies. Today, medicine is war. You work only with your hands, or you can simply ask God to cure the patients who die every day because of the shortages of supplies and qualified personnel.

2. What are your patients’ most frequent complaints?

That there are no drugs, no food, or that it takes a long time to get appointments in public hospitals so they have to try to pay for a private doctor. The hospital was not different. Patients came in giving orders. They did not respect the doctor or what she prescribed. They got angry if they could not find something. It's not just the economic crisis. We're losing our education and values, both patients and colleagues. There were shortages, but the director told us that we couldn't tell the patients. How could we say that everything was good, when everything was bad?

3. How many drug options are you including in each prescription?

Five or six, whatever is available.

4. Any especially difficult cases that have kept you up at night?

A woman named Aura. She had metastasis, which made her intestines stick together. I spent an hour and a half every day bathing her, changing her and making sure her treatment was good. She also had renal insufficiency, and as the days passed she couldn't walk any more, but she was conscious, and very grateful.

Then one day, she was denied treatment in the hemodynamics section because she might contaminate the area. Some people even made sick jokes about it. The patient has a right to treatment and to a dignified death. Her human rights were violated. She wound up being almost my daughter, rather than a mother. I bought whatever she needed with my money, and brought her things from my home. She died. Those are the things that mark you, that should not happen.

5. Is your salary enough?

No.

6. Has your work been affected by the high levels of crime?

Anyone working in trauma or general surgery is at risk. Some wounded delinquent can came in, and then others come in during the surgery to finish him off. And you're in the middle of it all. One time we were doing a shift in a rural hospital in Tucupita when we had to treat a criminal. He arrived all shot up, in bad shape. And then his relatives came in and broke the doors to the surgery room, because he had to be treated immediately, he had to be saved.

7. Have you thought of emigrating?

Yes. I woke up one day and decided that if I had to study some more, it had to be somewhere else and in the right way. I left the hospital and the postgraduate slot. I worked there nine months without pay. They paid me six months after I left, but not the extra hours.

Later this year I will move to another country where I can have more opportunities, where I can have a job contract, where my salary can allow me good life. Sadly, that's something that doesn't exist in my country.