Element-in-Tension: Wellness

In the late 1800s, Caracas was broadly considered a cosmopolitan city of European ethos, proclaimed the “Paris of South America.” However, given the defective infrastructure and high mortality rates in Caracas, medical leaders in Venezuela frowned upon gaps between the South American city and those in Europe, declaring that Caracas was not yet a “complete city.” In the early 1900s, those conditions spurred debate regarding hygiene in the city, and modernizing hygiene was added to the “police” responsibilities of the state. The resulting Bella Epoca (beautiful era) in Caracas was focused on hygiene, civility and progress[1].

The oil export boom of the 1920s funded new the development agenda for growing Caracas. The city passed ordinances regulating hygiene, technical development controls, and architectural design. Then, in 1928, Banko Obrero, the first housing administration in South America, was formed to provide working-class housing. Though no true comprehensive urban planning occurred during this period, the coordinated consideration of traffic, sprawl, and housing marked the beginning of Venezuela’s era of modern urbanism. Great oil-funded advances in the city’s public health followed – tracking with the growth of oil wealth through the 1970s. 

However, during the oil bust of the1980s and 90s, the substantial advances that had been achieved in Venezuelan public health eroded. In association with neoliberal policies implemented during those decades, medicine was just one of the many industries that became largely privatized in Venezuela. Accordingly, the economic position of the lower classes weakened, and as prices were liberated in the medical industry, larger portions of household income were required to pay for medical care. Fees for health services and medications became unaffordable for increasing numbers of Venezuelans[2], and there was a general decline in the quality of the health system. By the end of the 90s, health care was essentially inaccessible for much of the population. 

After a popular backlash against the impacts of neoliberal policy led to Hugo Chavez’s election in 1998, health was of critical concern in forming the new Venezuelan constitution (1999) which states that “health is a fundamental social right and an obligation of the State” and that the health system should be “decentralized and participatory… guided by principles of free cost, universal availability, inter- sectoriality, equity, social integration, and solidarity.’’[3] Under these guidelines, Health Ministers attempted to translate Latin American Social Medicine concepts into Venezuelan policies and practices. These efforts, implemented in a top-down manner, received little support from physicians who had largely been aligned with political parties previously in power, and also did not well-represent the true concerns of the poor. Thus, the efforts proved ineffective in providing adequate care for impoverished Venezuelans (Briggs).

Finally, an effective approach to public health for the Venezuelan poor was initiated at the local level in Libertador, a municipality of Caracas facing severe problems with living conditions in its barrios. Through interviews of barrio residents regarding their opinions on housing, health care, education, food security, and employment, it was determined that access to health care was their most common concern. A collaborative proposal, called Plan Barrio Adentro, was developed to recruit Cuban medical personnel who would reside in poor neighborhoods to provide free medical service and to work with residents to design and implement local health programs. By 2003, Plan Barrio Adentro was so successful that Chavez tranformed the program into a national plan called Mission Barrio Adentro (MBA). In the following years, the government has extended health care to millions of Venezuelans previously without access. By 2007, over 23,000 Cuban medical professionals were serving patients at over 6,500 sites in marginalized communities (Briggs).

MBA module in Caracas

The development of the free health clinics staffed by Cuban medical personnel has been a focus of the opposition to Chavez’s policies supporting the poor. Venezuelan doctors that look upon the MBA sites as competition have even called into question the qualifications of the Cuban staff. Yet, over the past years, intense antagonism against Chavez’s, acted out in highly visible protests that have gone so far as to block MBA ambulances, have backfired by increasing Chavez’s popularity. The administration has, accordingly, responded by continuing to prioritize and invest in MBA (Briggs).

This story of public health in Caracas over the past century reveals that, as the city grows and the diversity of environs within the city proliferates, provision of services to ensure the wellness of the whole population is challenged. Through segregated and class-oriented development, dramatic disparities have arisen between services provided for the middle and upper classes and those services provided for the poor.

Currently, Caracas is divided into five separate municipalities each with separate governing administrations. Even emergency response services are segmented in the city (police actually wear different uniforms in each municipality) and such complications impede even basic services supporting wellness. As a shocking example of these circumstances, mortal peril in Caracas has grown to be one of the most grave in the world: recent statistics indicated there are 200 violent deaths annually per 100,000 people in the city NYTimes.

Clearly, general wellness, or even mere survivability, is an element of life in great tension in Caracas. As growing class division has split the city, poor residents’ basic rights to life and wellbeing have come into question. However, while circumstances have become extreme, it still does not seem completely resolved that only the well-to-do should be well in Caracas. Given the recent advances in medical care made via Chavez’ MBA, it seems population wellness will continue to be held in tension in Caracas. With more intentional tuning of that element of life, the city may be instrumental in (re)creating a future urbanism of more egalitarian wellness.

[1] Almandoz, A. (1996). European Urbanism in Caracas (1870s-1930s). PLANNING HISTORY, 18(2), 14-19.
[2] Briggs, C. L., & Mantini-Briggs, C. (January 01, 2009). Confronting Health Disparities: Latin American Social Medicine in Venezuela. American Journal of Public Health, 99, 3, 549.
[3] 14. Constitution of the Bolivarian Republic of Vene- zuela. Gaceta Oficial. 36,860, December 30, 1999, Ar- ticles 83 and 84.