Venezuela: out of the headlines but still in crisis

Bull World Health Organ 2022;100:466–466A | doi: http://dx.doi.org/10.2471/BLT.22.288269 Editorials 466 The Venezuelan political and economic crisis threatens the citizens’ health, though assessing its full impact is diffi- cult due to lack of information. Available evidence shows a health system near col- lapse and the reversal of several decades of health gains.1 High levels of inflation and generalized poverty underscore the difficulties of maintaining health and adequate nutrition amidst the coronavi- rus disease 2019 (COVID-19) pandemic and rising global food insecurity. In contrast to decreasing regional trends for Latin America and the Carib- bean, under-five mortality in Venezuela has increased by an estimated 40% dur- ing the past decade. Current under-five mortality estimates are as high as 29 deaths per 1000 live births, with infants accounting for the majority of these deaths.2 At the general population level, noncommunicable diseases account for two thirds of deaths, followed by inju- ries, and communicable, maternal and perinatal conditions.3 Recent indica- tions suggest a 3.5 year decrease in life expectancy compared to the previous generation.4 Government expenditure dropped by approximately one percentage point of GDP (gross domestic product) in the periods 2000–2010 and 2013–2019 and they remain more than one and a half percentage points below the Latin American and Caribbean region’s aver- age.5 Water and electricity shortages, infrastructure decline and emigration of health personnel have led to a pro- gressive loss of health system capacity. In March 2020, just before reporting the first local COVID-19 case, more than half of public hospital beds were inoperable and most laboratories were not fully operational. The pandemic exacerbated the situation, resulting in drastic reductions in non-COVID-19 bed capacity and surgical procedures.6 Access to health care and medicines remains limited due to health system ca- pacity and supply chains, as well as high out-of-pocket expenses. In mid-2021, an estimated 18.8 million Venezuelans lacked access to health services, includ- ing 10.4 million with chronic diseases.7 Decreases in vaccination coverage have led to increased cases of measles, diphtheria and other vaccine-prevent- able diseases; measles re-emerged in a 2017–2019 outbreak of about 7000 con- firmed cases. Despite recent vaccination campaigns, vaccination coverage is low and only half of infants are fully vacci- nated for diphtheria–tetanus–pertussis and less than one third for measles.5 Malaria cases increased by nearly 900% between 2007 and 2017, and since 2017, Venezuela accounted for more than half of all malaria cases in South America.8 Underreporting is a concern for nearly all infectious diseases, including CO- VID-19. Access to adequate sexual and reproductive health services is limited. COVID-19 disruptions led to reductions of approximately 75% in skilled birth attendance, antenatal care and contra- ceptive use, which compares to regional declines averaging closer to approxi- mately a third or less.9 Venezuela has the highest adolescent fertility rate in South America and fertility is projected to in- crease, despite rising numbers of women seeking abortions as a result of the scarce and costly nature of reproductive health services and contraceptives.10 Mental health is another major concern, as levels of anxiety and depres- sion have increased and the crisis has curtailed mental health service capac- ity.10 However, the health system has limited to no capacity to care for patients with severe mental health disorders. Medication shortages have caused the deterioration of patients with previously well-controlled conditions, prompting The World Federation for Mental Health to declare a mental health crisis in the country. Data on nutrition in Venezuela are scarce and national wasting estimates unavailable. A nongovernmental or- ganization with nutrition programmes in multiple states found that 12% (5575/46 462) of children screened between 2017 and 2019 were wasted, with wasting rates almost double that figure in some states.11 Nutrition pro- gramme coverage is inadequate, with less than half of the target number of beneficiaries reached in many states in 2021, and rising numbers of consulta- tions for undernutrition.10 Widespread efforts to ensure food security are critical given recent evidence of rising nutri- tion concerns and expectations that the global food crisis will make an adequate diet unaffordable for Venezuelans. Some 14.3 million people in Ven- ezuela need humanitarian assistance, the third most of any country in the world.12 Funding shortfalls for the United Nations appeal have translated to high levels of unmet needs. Further health sector investment is critical for addressing health needs and for mitigat- ing the effects of the health system crisis. Given health worker shortages, investing in additional lower-level health workers who require less extensive training could expand access to basic health services, thereby allowing more qualified health providers, who are in short supply, to attend more complicated cases. To optimize effectiveness, health workers must have adequate supplies and medi- cations to provide essential primary and preventive care. In primary care, health policy-makers should consider ensuring high coverage levels and ser- vice provision capacity in several areas, including maternal and child health and nutrition, sexual and reproductive health, noncommunicable diseases and mental health. ■ Venezuela: out of the headlines but still in crisis Shannon Doocy,a Kathleen R Page,b Charissa Liu,a Hayley Hoaglunda & Daniela C Rodrígueza References Available at: http://www.who.int/publications/ journals/bulletin a Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Suite E8132, Baltimore, MD 21205, United States of America (USA). b Johns Hopkins University School of Medicine, Baltimore, USA. Correspondence to Shannon Doocy (email: doocy1@ jhu .edu). E itorials Editorials 466ABull World Health Organ 2022;100:466–466A | doi: http://dx.doi.org/10.2471/BLT.22.288269 References 1. Page KR, Doocy S, Reyna Ganteaume F, Castro JS, Spiegel P, Beyrer C. Venezuela’s public health crisis: a regional emergency. Lancet. 2019 Mar 23;393(10177):1254–60. doi: http:// dx .doi .org/ 10 .1016/ S0140 -6736(19)30344 -7 PMID: 30871722 2. [Under-five mortality rate – total]. New York: UN Inter-agency Group for Child Mortality Estimation; 2020. Spanish. Available from: https:// childmortality.org/data/Venezuela%20(Bolivarian%20Republic%20of ) [cited 2022 Jan 12]. 3. Global health estimates 2019: deaths by cause, age, sex, by country and by region, 2000–2019. Geneva: World Health Organization; 2020. Available from: https://www.who.int/data/global-health-estimates [cited 2022 Jan 12]. 4. Women on the edge 2019: women’s rights in the face of the worsening complex humanitarian emergency in Venezuela. Caracas: Asociación Civil Mujeres en Línea, Asociación Venezolana para una Educación Sexual Alternative (AVESA), Centro de Justicia y Paz (CEPAZ), Centro Hispanoamericano de la Mujer FREYA; 2019. Available from: https://cepaz. org/wp-content/uploads/2019/09/WOMAN_LIMITE_web_compressed.pdf [cited 2022 Jan 12]. 5. Domestic general government health expenditure (% of GDP) Venezuela, RB, Latin America and Caribbean. Washington, DC: The World Bank; 2022. Available from: https://data.worldbank.org/indicator/SH.XPD.GHED. GD.ZS?locations=VE-ZJ [cited 2022 Jan 12]. 6. Encuesta nacional de la ONG Medicos Unidos de Venezuela sobre capacidades del sistema de salud para afrontar la posible epidemia de Covid-19 en nuestro país. Caracas: Medicos Unidos de Venezuela; 2020. Spanish. Available from: https://sfo2.digitaloceanspaces.com/estaticos/var/ www/html/wp-content/uploads/2020/03/ENCUESTA-MUV-COVID-19.pdf [cited 2022 Jan 12]. 7. Boletín Epidemiológico No. 6, Año 3 - Primer trimestre: enero–marzo 2021. Caracas: Caritas Venezuela; 2021. Spanish. Available from: http://caritasvenezuela.org/wp-content/uploads/2021/06/BOLETIN- EPIDEMIOLOGICO-1ER-TRIMESTRE-2021-r-PARA-WEB-comprimido.pdf [cited 2022 Jan 24]. 8. Report on the situation of malaria in the Americas. Washington, DC: Pan American Health Organization Regional Malaria Programme; 2017. Available from: https://www3.paho.org/hq/index.php?option=com_docman&vi ew=download&slug=malaria-technical-advisory-group-session-2-june- 2019&Itemid=270&lang=en [cited 2022 Jan 12]. 9. Scenarios in women’s, newborns’, children’s, and adolescents’ health in the Americas in the context of COVID-19. Washington, DC: Pan American Health Organization Regional Malaria Programme; 2021. Available from: https:// www.researchgate.net/publication/353559439_Scenarios_in_Women's_ Newborn's_Children's_and_Adolescents'_Health_in_the_Americas_in_ the_Context_of_COVID-19 [cited 2022 Jan 24]. 10. Doocy S, Page KR, Liu C, Chou V, Hoaglund H, Rodriguez C. Venezuela health profile. Houston: Simón Bolívar Foundation; 2021. Available from: https://www.simonbolivarfoundation.org/presentations/VZHealth%20 Profile15Mar22.pdf [cited 2022 Jun 20]. 11. Raffalli S, Villalobos C. Recent patterns of stunting and wasting in Venezuelan children: programming implications for a protracted crisis. Front Sustain Food Syst. 2021 May;5:638042. doi: http://dx.doi.org/10.3389/ fsufs.2021.638042 12. Global humanitarian assistance report 2021. Bristol: Development Initiatives; 2021. Available from: https://devinit.org/resources/global- humanitarian-assistance-report-2021/ [cited 2022 Jan 24].