A few weeks ago, I wrote up the following Q&A for an NGO concerned about the HIV treatment crisis in Venezuela. Below is an edited version of what I submitted to them. There is much more to be said, especially on the Global Fund’s refusal to act in Venezuela, as well as the regional implications of inaction. I will follow-up on these issues in a future post.
In the past five years and especially the past year, Venezuela’s human immunodeficiency virus (HIV) treatment program has fallen into crisis. Stock-outs of antiretroviral (ARV) therapy are the norm, undermining viral suppression and thereby exposing the patient to acquired immune deficiency syndrome (AIDS). Shortages of medicines and medical supplies contributed to a 75% increase in AIDS-related deaths from 2011 to 2015. This crisis is the result of a political conflict that has brought with it an economic collapse. Government corruption schemes based on foreign exchange distortions leave it without enough foreign currency to import basic goods leading to widespread shortages of food and medicines. Marxist economic theories and political and economic stake-holders prevent needed changes in economic policies. And political change is being prevented by restrictions on civil and political rights. A complicating factor is that the government of Nicolas Maduro, for political and ideological reasons, has refused to accept international food and medical aid. Change in the near future seems unlikely as the government has won three elections over the past six months and the political opposition is in a state of disarray.
- What is the current state of HIV treatment and access to medication in Venezuela? How has this access changed in recent years?
There is currently no cure for Human Immunodeficiency Virus (HIV), however medical treatment has enormously improved and even gained the upper hand on the epidemic. Treatment focuses on anti-retroviral drugs (ARVs) which work by suppressing HIV to the point that it cannot produce AIDS. Successful ARV therapy can even bring an HIV positive (HIV+) person to the point that he or she is no longer contagious. Successful ARV therapy can allow HIV+ individuals to lead long and productive lives.
However, successful treatment requires consistent medication and monitoring. Going a month or two or six without ARV drugs allows HIV to flourish, exposes the person to developing AIDS, and makes them contagious. Worse yet, they tend to develop drug-resistant strands of the virus that can no longer be contained by the drugs.
On October 11, 2017 two international HIV advocacy groups released an important report called: “Resurging epidemics, a broken health system, and global indifference to Venezuela’s crisis” (ACCSI and ICASO 2017). It documents surges in malaria, tuberculosis, and the collapse of Venezuela’s HIV Program. The central problem of the latter is stock-outs of antiretroviral therapy (ARVT) drugs. The 2017 Global AIDS Update found the same (UNAIDS 2017). In August of this year, Caritas Venezuela reported that 114,000 people were without HIV drugs either because of stock-outs or because they were never incorporated into the system (Caritas 2017 para. 9).
Currently ARVs come and go, arriving for a month or two, then disappearing for several more. The following is a table compiled by a Venezuelan non-governmental organization (NGO) that monitors stock outs. Table 1 lists the ARVs that were unavailable at the beginning of September of this year and how long they had been out of stock.
Table 1. List of ARV stock-outs as of September 8, 2017, reported by RVG+, (ACCSI and ICASO 2017).
|ARV stock-outs as of 8th September 2017 and # of people affected|
|ARV||# of persons affected||Out of stock|
|Darunavir (Prezista)||850||Four months|
|Etravirina (Intelence)||483||Six months|
Rilpivirina + emtricitabina + tenofovir
Arrived Friday, 5 September, 2017
|13, 116 personas||Two months|
Resuming therapy is not just a matter of restarting the same treatment, as gaps in treatment allow resistant forms of HIV to develop. Health care professionals require viral-load tests in order to know which ARVT drugs and how much of them to use. But HIV activists report that these tests have not been available for 18 months (ACCSI and ICASO 2017, 10). This makes it impossible to determine whether changes in treatment are needed after a patient has been off of treatment for a month or more.
Due to the decline in treatment–from stock-outs of ARVs to a lack of tests, to medication for opportunistic infections–AIDS related deaths surged by almost 75% from 1900 in 2011 to 3300 in 2015. “Deaths prevented by ARVs” are estimated to have fallen by a quarter in the same time period (ACCSI and ICASO, 9).
Ten years ago Venezuela had a model HIV program that aimed to provide free ARVs to all HIV+ individuals. Investment peaked in 2007 but declined after that. Stock-outs began in the recession of 2009 and by 2012, Venezuela occupied first place among Latin American countries for having the most ARV stock-out episodes (AVESA, ACCSI and Aliadas en Cadena 2015). The situation progressively deteriorated and in the past two years has become a crisis.
In its 2017 update, UNAIDS (2017) showed that the number of people who had been receiving ARVs in the region had doubled in the past six years, but noted that Venezuela, along with Bolivia, Paraguay and Guatemala, was struggling to keep up.
- Can you provide some context to the declining access of medication and health care? What are the driving factors behind it?
Venezuela’s health care crisis is one facet of the country’s economic meltdown, caused by a lack of foreign currency for importing medicines and medical equipment. This an entirely unnecessary crisis, resulting from a political project that has failed in the basic tasks of governance, but holds on to power through clientelism, corruption, and force.
Venezuela’s current, state-directed economic model was developed by President Hugo Chávez during the oil bonanza years from 2004-08. With record oil income flowing in, Chávez maintained an overvalued currency that resulted in cheap imports that increased the population’s consumption levels. This also had the consequence of making Venezuelan industry uncompetitive both domestically and abroad, which in turn meant that Venezuela became ever more dependent on imports.
This model already showed weaknesses when the global recession hit in 2009, as Venezuela was affected more than other countries in the region. However, the model was kept afloat in the coming years by $50 billion in loans from China. These were used by the government for unsustainable levels of spending that created 5% growth through 2012 and allowed Hugo Chávez to be reelected by a ten-point margin.
When Hugo Chávez passed away from cancer in 2013 and Nicolás Maduro became president, he inherited an economy with an inflated currency, growing debt, and growing shortages of basic goods (Smilde 2013). However, partly because of his political weakness and partly for ideological reasons he has refused to make obviously needed reforms to the economy. As a result, economic distortions have gotten to absurd levels. During the Chávez government the parallel rate for dollars was often 200 or 300% higher. So for example if at the official rate $1 got you Bs.3, on the parallel market $1 would get you Bs. 9.
But during the Maduro government these distortions gone to absurd levels. Currently at the official rate $1 is worth Bs. 10. But on the parallel market, $1 will fetch Bs. 100,000. These distortions create opportunities for windfall profits for those with access to official rate dollars and has created all sorts of corruption schemes. Businessmen with ties to the government, or government officials using fictitious companies, get access to dollars to import goods, but only use some of those dollars to actually import the goods, and use the rest for capital flight or to put back on the parallel market, easily making 1000% profits (Smilde 2015).
The large, often dramatic difference between the official and parallel exchange rates creates irresistible incentives for dollars to be siphoned off into corruption and capital flight. And the dollar crunch creates scarcities directly—by making it harder to import finished goods—and indirectly—by making it harder to import inputs and machinery needed for manufacture. Thus the Venezuelan economy has a lot of liquidity, but not enough things to buy. Goods whose prices are effectively controlled are scarce; the prices of everything else are soaring.
The net result is that there were significant scarcities already in 2013 when oil was over $100 per barrel. In 2015 the oil price plunged to below $50 a barrel. As a result, not only was a small segment of Venezuela’s foreign currency earnings going to imports, with the rest going to corruption. That segment itself, in absolute terms, was reduced by half.
Between 2013 and 2017 the Venezuelan economy has contracted by one third (Hausmann and Santos 2017). The International Monetary Fund recently predicted that economic contraction will be 12% in 2017 and 6% in 2018 while inflation this year will be 652.7% this year and a whopping 2,349% in 2018 (Reuters 2017). Not only has the price of oil dropped from an average of $101 in 2013 to $35 in 2016. Oil production itself has dropped. In 2017 oil production was 16% less than in 2013 (Hausmann and Santos 2017). This combination of declining prices and production means that foreign currency income has declined by two thirds since 2013. Oil provides 96 of every 100 dollars that come into the country. Leading economists project that this year imports to Venezuela will be around $15.5 billion, which amounts to a 72% decrease from 2013, the year Nicolás Maduro was elected (Salmerón 2017). Put differently, the Venezuelan economy, completely dependent on imports, has roughly 1/3rd of the goods in circulation as it did just four years ago. These problems are only becoming more acute as Venezuela edges into default.
The impact on public health care in Venezuela has been devastating. One a hospital survey carried out by the Central University of Venezuela says that 76% of hospitals suffer from acute scarcities of medicines, 81% have a lack of surgical materials, and 64% have shortages of infant formulas. Syringes and medical tubing are reused (ACCSI and ICASO 2017, 6). Another report suggested (2017, 5) that only 10% of testing laboratories are functioning.
As a result, many of the public health achievements of the last half of the Twentieth Century have been reversed in recent years. For example, Maternal Mortality Rate (MMR) is one of the most important indicators of the state of a health care system (Méndez and Figueroa 2016) because it effectively measures the state of preventive care, the state of routine hospital care, as well as emergency and intensive care (King 2012). Over the past ten years the MMR has increased by 12-15% each year, but most alarmingly, it increased by 65% from 2015 to 2016 (Méndez 2017 para. 8-12).
The same is true of other key indicators such as infant mortality. It has been growing by 5-8% a year, including a 30% from 2015 to 2016 (Méndez 2017 para. 13-14). And malaria, a disease that had been defeated back in the era of DDT, shows a similar deterioration from 45,824 cases in 2011 it grew to 240,000 cases in 2016 (Méndez 2017 para. 15-17). In 2016, 13 of Venezuela’s 23 states were judged to have epidemic levels of malaria, compared to 3 in 2012. It should be pointed out that the tendency worldwide with such indicators is downward, towards a reduction of maternal and infant mortality, as well as malaria. Venezuela’s indicators reveal a collapsing public health system.
- Briefly describe the broader political crisis in Venezuela. How have government actions impacted access to HIV treatment?
One of the most striking aspects of the current context is how similar the prescriptions of opposition and pro-government economists have become. Indeed, in July 2016 a group of economists recruited by the Union of Southern Nations (UNASUR), with the blessing of the Maduro government presented a proposal for reform of the economy. Unfortunately, it was then completely ignored. So what prevents the Maduro government from making obvious and necessary reforms? First, the anti-neoliberalism at the center of Chavismo, and second, the development of stakeholders.
Hugo Chávez catapulted himself to the public stage in February 1992 through a coup against Carlos Andres Pérez whose government had implemented a radical structural adjustment package three years earlier. That package led to el Caracazo, three days of rioting and violence in February 27, 1989 that Chávez and other coup leaders said led them to decide to throw their coup. Within Chavismo, February 27 is still portrayed as the day “the people of Bolivar woke up.” While the discourse of socialism was not adopted until just before his second term, from the beginning, opposition to neoliberalism was the cornerstone of Chávez’s ideology. Chávez’s message was that neoliberalism had made the rich richer and the poor poorer and that in the new Bolivarian revolution, Venezuela would have enough resources for everyone. This message found people willing to listen, for during the twenty years from 1978 to 1998, representing the beginning of the decline of Venezuela’s import-substitution-industrialization period through the end of the neoliberal period, Venezuela had the worst economic performance in the region.
In February 2013, when Hugo Chávez was on his deathbed and Nicolás Maduro was acting president, he carried-out a 46.5% devaluation. Taking on the “third-rail” of Venezuelan politics taught Maduro a lesson he apparently has not forgotten. His job approval ratings immediately took a hit because of the inflation spike, only recovering with the death of Hugo Chávez pushed this off the stage. This devaluation was likely a factor in Maduro’s small margin of victory just a month later. He seems to have learned a lesson and time and again has avoided devaluing when everything points in this direction.
Maduro was elected in April 2013 by a razor-thin margin and has been under extraordinary pressure from the moment he took office. Opposition candidate Henrique Capriles refused to concede that election, causing a political crisis that lasted a month. In 2014, a protest movement brought Venezuela to a standstill for four months, demanding Maduro’s resignation. 42 people died in the conflict. In 2015 the opposition swept to a landslide victory in legislative elections and took power vowing to force Maduro out of the presidency. In 2016 they pushed for a recall referendum, which was blocked by the government in October 2016. This year saw a four month cycle of street protest that led to 130 deaths, most of which were at the hands of the government’s repressive apparatus. Since 2014 the government has invested millions of dollars in anti-riot equipment including not just tear gas and rubber bullets but armored vehicles and water-hose tankers. At the end of July, the Maduro government held an unconstitutional election for a Constituent Assembly to rewrite the country’s constitution. Thirty-eight countries around the world do not recognize this Constitutent Assembly as legitimate (De Alba 2017).
The government keeps all of this together through networks of patronage. Many, perhaps most government officials are involved in illicit business exchanges through access to official rate dollars. From the beginning Maduro has seen Venezuela’s armed forces as a security blanket and has dramatically increased their profile in the government. In citizen security he has removed civilians and placed active or retired military officers in every leadership position from the head of the National Police to the Minister of Interior and Justice. He has also given the military a television station, a bank and control over large parts of the importation of basic goods. This has led to lucrative corruption rackets in food importation (Dreier and Goodman 2016).
One can add to this, the United States regime of targeted sanctions and other blacklists naming government officials. Starting in 2015 the US government designated Maduro government officials who are accused of human rights abuses or corruption for targeted sanctions, revoking their visas and freezing any assets they might have in the United States. As I have argued, along with many others, these measures effectively increase the “exit costs” of these officials providing Nicolás Maduro with a cadre of ultra-loyalists that see their fate as synonymous with the government’s (Smilde 2017a). Among these sanctioned officials are the rectors of the National Electoral Council who have done whatever they can to give the Maduro government a façade of electoral legitimacy.
The government self-perpetuation is facilitated by an opposition with long-term dysfunctional tendencies. Throughout the Chávez and Maduro years it has been consistently out of touch with the population and divided amongst itself. While they have had some notable victories—such as the 2015 legislative elections—they have repeatedly failed to develop a concerted strategy in more difficult moments. This showed in October’s regional elections. Overconfident that they would sweep the elections against an unpopular government, they failed to turnout their vote and failed to have any strategy for confronting the loss.
In sum, the Maduro government has held together by stake-holders who have fabulous benefits in the current context, and everything to lose if there is a transition back to democracy. The political opposition is currently in a state of disarray and will likely be divided for some time to come. It is hard to be optimistic that there will be a transition back to a well-functioning democracy any time soon.
- Who are the decision makers who control distribution of and access to HIV treatment? How have they responded to the crisis?
Venezuela has an AIDS program that was once admired throughout the developing world—providing free, public access to HIV ARVs—but which is now in ruins (Nolen, The Globe and Mail, June 23, 2017). The National AIDS Program (PNSIDA) is housed within the Ministry of Health. It is responsible for planning, establishing norms, executing politics, programs, projects and coordinating the financing of the government’s response to HIV and AIDS. The government has a strategic plan to confront HIV with the support of ONUSIDA as well as Venezuelan NGOs.
As with most of the programs created during the oil bonanza of the Chávez government, it was centralized, with scarce contribution of community organizations. In the report card provided in the 2017 UNAIDS Global Update Venezuela’s program received high marks for having a national plan and for having a national plan and a “treat all” policy, but low grades in the availability of community-based testing, lay-provider testing, and self-testing, as well as for the lack of community-based providers of ARVs (UNAIDS 2017).
The Minstry of Health is the only institution that can buy ARVs in large quantities. However its processes are cumbersome and suffer from a lack of mechanisms for follow-up, control and estimation of demand. This generates budgetary and distribution problems (AVESA ACCSI and Aliadas en Cadena 2015). Worse yet, it suffers from continual governmental instability. One consistent impediment to the effectiveness of Venezuela’s socialist governments is the continual change of ministers and other political appointees. This, of course, is a classic technique of authoritarian leaders seeking to prevent their underlings from developing too much power. However, it seriously undermines effectiveness and continuity of policy.
For example, in describing the stock-out of one common treatment (Efravirenz + Emtricitabina + Tenofovir) that occurred this year from June to September, HIV activist Feliciano Reyna told the following story (quoted in Sleinan 2017 para. 7):
“Starting with the administration of Minister Luisana Melo, there were delays in orders. Then there was Cabinet switch to [Minister] Antonieta Caporale and, after that, another change to the current Minister, Luis López. This implied a delay in purchases and delays in the medicines, which would arrive two or three months late, when there was no more inventory in the country.”
The Ministry of Health is part of the executive branch of the government and it is to be expected that it will be articulated with the political plans and goals of the presidency. As will be described below, one main strategy of the Maduro government has been to completely deny there is any kind of crisis in food or medicines. As part of this strategy, the Ministry of Health stopped emitting weekly epidemiological bulletins in October 2014. These bulletins are considered by public health officials to be their basic tool for monitoring important diseases and alert professionals and the population of any emerging epidemic.
However, these ministries often have midlevel career professionals who believe in what they are doing. Early in 2017 the Ministry suddenly published the epidemiological bulletins from 2015 and 2016 on its web page, showing alarming increases in a number of diseases (as described above). Minister Antonieta Caporale was promptly fired, demonstrating the consequences of breaking with the official line (ACCSI and ICASO 2017, 6).
- What is the role of international aid agencies?
Experts suggest that Venezuela would need approximately $12 million to provide a 6 months supply of ARVs to its HIV+ patients and another $23 million for HIV rapid tests (to control viral count) as well as substitute breast milk (so that HIV+ mothers do not pass the virus on to their babies) (ACCSI and ICASO 2017).
Multilateral agencies such as the United Nations have the resources to provide aid to Venezuela, but can only do so if the government declares a humanitarian emergency and requests it. The Maduro government refuses to do so. In early 2016 the Maduro government denied an opposition request to enroll Venezuela in a World Health Organization program that could provide subsidized medical supplies. And in May 2016 it vetoed a law from the opposition National Assembly that would have facilitated international food and medical aid (Daniels 2017, para. 21). Activists have argued that the government’s denial of foreign food and medical aid amounts to a human rights violation even more serious than the violence carried out against protestors (Smilde 2017b).
This would be just normal political wrangling if the government simply wanted to be the one who gets credit for soliciting the foreign aid. But the problem goes much deeper than this. The government denies that there is any problem. Chavismo defines itself in contrast to capitalism which is portrayed as greedy and inhumane, while socialism is generous and humane. Within this discourse it is next to impossible for the Maduro government to assume they have a humanitarian crisis and accept aid from abroad. Indeed, while an increasing number of Venezuelans are going hungry and without medicines, the Maduro government has sent aid to Peru after its floods in March 2017, as well as to Antigua and Barbuda after Hurricane Irma in September, 2017 (teleSUR-ACH 2017 para. 3).
And it is not just a political issue for the government. One of the strategies of the Venezuelan opposition during the entire Chávez period has been to portray Venezuela’s political crisis as a human rights crisis and thereby making it incumbent upon the international community to intervene. They frequently talk about the need to open a “humanitarian corridor” as if there was a need for safe passage from one place to another as in a war zone. This is a fiction as people and goods flow in and out of Venezuela every day. Indeed some in the opposition would likely oppose the idea of providing food or medicine aid to the government because it could be funneled through its clientalist networks, fortifying the government’s model.
There are some aid agencies that are active in Venezuela on a routine basis and therefore do not need a special declaration of emergency. However, their efforts are not on a scale that they could really address the need. UNAIDS supports community-engagement and advocacy around HIV. UNICEF has provided ARVs for infected children. And the Pan-American Health Organization (PAHO) has helped the government negotiate lower prices. But the government has fallen in arrears with it as well, leading to stock-outs in key ARVs. More recently PAHO has provided some ARVs using its resources. But it cannot do so on the scale necessary to address the crisis (ACCSI and ICASO 2017).
The most important possibility is the The Global Fund to Fight AIDS, TB and Malaria. The Global Fund is not a multilateral agency and can come in and give aid with a declaration of emergency or invitation. It has the resources needed to fully address Venezuela’s ARV needs. In 2016 activists wrote a letter the Global Fund, describing the crisis and asking them to send assistance to Venezuela. The Global Fund responded in January of this year that Venezuela did not qualify for assistance. Venezuela is classified by the World Bank as an “upper middle income” country which means it can receive aid only if it has a 1% rate of prevalence in the general population or a 5% rate in a “key population” as defined by the Global Fund (men who have sex with men, sex workers, people who use drugs, or transgender persons). Venezuela does not have a 1% infection rate in the general population and simply does not have data on key populations (ACCSI and ICASO 2017).
Getting the Global Fund to provide ARVs to Venezuela does not seem promising in the near future, nor does getting other sources to act as the government is unlikely to declare a humanitarian crisis. The government still portrays itself as successful in reducing poverty and expanding education and health and in the position of helping other countries. Indeed, the Maduro government sent humanitarian aid to Mexico after its earthquake in September 2017 (teleSUR-gp-HR 2017).
The authors of the ACCSI / ICASO report summed up the situation as follows.
The devastation faced by Venezuelans is being perpetuated in part by the arbitrary rules and regulations that shape global health aid eligibility. It is proof that the global health architecture is not prepared to deal appropriately with country emergencies and has exposed a gaping crack in the framework of a what should be a robust and effective global health response. Moreover, despite extensive documentation, Venezuela’s government denies there is an emergency – providing the political and policy blinders for many other governments and some UN agencies to look the other way (ACCSI and ICASO 2017).
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