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The Politics of Social Determinants of Health:The Case of Venezuela

EGALITARIANPOLICIES AND SOCIAL DETERMINANTS

OF HEALTH IN BOLIVARIAN VENEZUELA

Carles Muntaner, Joan Benach, Mara Pez Victor,Edwin Ng, and Haejoo Chung

In 1999, newly-elected Venezuelan President Hugo Chvez initiated a far-reaching social movement as part of a political project known as theBolivarian Revolution. Inspired by the democratic ideologies of SimnBolvar, this movement was committed to reducing intractable inequalitiesthat defined Venezuelas Fourth Republic (19581998). Given the ambitiousscope of these reforms, Venezuela serves as an instructive example to under-stand the political context of social inequalities and population health. Inthis article, we provide a brief overview of the impact of egalitarian policiesin Venezuela, stressing: (a) the socialist reforms and social class changesinitiated by the Bolivarian Movement; (b) the impact of these reforms andchanges on poverty and social determinants of health; (c) the sustainabilityof economic growth to continue pro-poor policies; and (d) the implications of

egalitarian policies for other Latin American countries. The significanceand implications of Chvezs achievements are now further underscoredgiven his recent passing, leading one to ask whether political support forBolivarianism will continue without its revolutionary leader.

In recent years, a growing body of research has begun to investigate the politicalcontext of population health and health inequalities (14). These contributionstend to focus on wealthy nations in North America, Europe, and Australia,use comparative methods to contrast welfare regimes or welfare expenditures,and evaluate the health effects of countries transitioning into democratic statesand capitalist economies. As a preliminary general statement, findings indicatethat social democratic countries are often most advantaged in absolute health

International Journal of Health Services, Volume 43, Number 3, Pages 537549, 2013

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outcomes, but not necessarily in terms of health inequalities (2); increases inwelfare expenditures correspond with improvements in health outcomes (3);advanced and liberal democracies tend to be healthier than non-democratic states(2); and transitions into capitalist and neoliberal economies are associated withincreases in health inequalities (1).

Despite these contributions, an under-researched theme in extant literature isthe effect of political traditions and dynamics, understood as left-right ideologies,mass movements, and revolutionary forms of power, on social inequalities andpopulation health. Although politics is essentially about power, most politically-oriented research focuses on institutionalized systems (e.g., welfare and demo-cratic states) as opposed to ideological and power relations (e.g., strong leftistpolitical parties and trade unions facilitate the development of strong welfare

states). For example, a recent literature review among 73 empirical studies onpolitics and health found that less than 15 percent of reviewed studies hadconceptualized political traditions and dynamics as macro-social determinantsof health (2). Given the dearth of attention that has been paid to power politics,more work is needed to understand the social and health consequences of differentpolitical systems and ideologies (e.g., participatory democracy and socialismversus liberal democracy and neoliberalism), forms of productive ownership(e.g., state versus private ownership of means of production), and arrangementsof social class power (e.g., working-, lower-, and middle-class versus upper-middle-class/capitalist class coalitions).

In this article, we use a case study approach to describe the possible effec-tiveness of egalitarian policies in reducing inequalities and improving health inVenezuela circa 1999. Although case studies are an underused research designin comparative social epidemiology, this unit-specific approach allows us tomove beyond asking whether politics and health are related, to consider howpolitical movements and configurations unfold to reorganize social structures andinstitutions that, in turn, affect social inequalities in health. To this end, we providea brief overview of the impact of egalitarian policies in Venezuela, stressing:(a) the socialist reforms and social class changes initiated by the BolivarianMovement; (b) parallel changes in poverty levels and social determinants ofhealth; (c) the sustainability of economic growth to continue pro-poor policies;and (d) the implications of the Bolivarian Movement for other Latin Americancountries. We do not analyze here the shortcomings of the Bolivarian process,given that they have been widely covered in the media and academic literature(including, for example, violent crime in Caracas, the judicial system, corruption,

consumerism, and urban planning). It is also important to note that some of thesocial progress attributed to the Bolivarian Revolution has also been experiencedby other Latin American countries in recent years (e.g., Argentina, Brazil). Withthis said, the historical importance of understanding Venezuelas social and publichealth achievements as accurately as possible has gained added significance sinceHugo Chvez, the movements central figure, passed away on March 5, 2013.

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THE BOLIVARIAN REVOLUTION AND21ST-CENTURY SOCIALISM

Last year, Hugo Chvez and his Bolivarian government were re-elected for ahistoric fourth term, despite receiving waves of media criticism from both sides ofthe Atlantic. Sick with cancer and assailed by the media, Chvez still won by animpressive 11 points. The elections significance, however, has yet to be properlyrecognized or understood by the media or the public. Less acknowledged arethe underlying reasons for Chvezs repeated landslide victories and continuedpopularity over the past decade.

First elected as president in 1999, Chvez set forth a political agenda groundedin the idea of 21st-century socialism, emphasizing state ownership of private

factories and the establishment of co-operatives. Through a number of socialistreforms, known as Bolivarian Missiones, Chvez and his government soughtto redress the inequalities that characterized Venezuelas Fourth Republic(19581998). Comprehensive in scope and ambitious in design, progressivereforms ranged from education (e.g., ensuring functional and numerical literacyamong adults, supporting high school dropouts, and increasing access to post-secondary training) and food and nutrition (e.g., improving access to high-quality,nutritious, safe, and organic food) to economic development (e.g., reorientingeconomic productivity to first meet the social and welfare needs of the margin-alized) and health care (e.g., providing free community health care, hospitalservices, and preventive resources). At its core, Bolivarian Missioneswere large-scale investments designed to increase the availability and quality of social deter-minants of health to the poorest and most marginalizedindividuals in Venezuela.

The decision for Chvez to use his political power to increase the states rolein the economy and to invest government revenues to reduce inequality signifieda radical shift from the modus operandi of previous administrations, whichfavored the private market as the primary arbiter of public goods. In doing so,Chvez changed in fundamental ways how social inequalities, on one hand, weregenerated and reproduced through market mechanisms (e.g., the poor are leftto their own devices to secure an acceptable standard of living) and how thesesocial injustices, on the other hand, could be approached and rectified throughstate interventions (e.g., the poor are fed, housed, and educated to improve theirliving conditions and well-being). As Chvez re-prioritized the human needsofthe marginalized before the wants of the privileged, his popularity soared inVenezuela and soured in Washington.

RESTRUCTURING PRODUCTIVE ENTERPRISES FOR THEPUBLIC GOOD RATHER THAN PRIVATE GAIN

Chvezs popularity can be explained, in large part, by his Bolivarian govern-ments commitment to and effectiveness in reducing absolute and relativeforms of deprivation. Even though governmental pledges to reduce poverty are

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commonplace (e.g., U.S. President Lyndon B. Johnsons War on Povertylegislation in 1964 or U.K. Prime Minister Tony Blairs 1999 commitment tohalve and eliminate child poverty by 2010 and 2020), most initiatives fall wellshort of elevating a significant number of individuals, families, and communitiesout of poverty. The ineffectiveness of conventional anti-poverty measures (e.g.,increasing access to education or health care) is partly explained by the factthat these measures, while well-intentioned, are often disconnected from politicaland economic institutions that unevenly distribute power to some at the expenseof others. It follows that for inequalities and poverty to be significantly reduced,changes are needed in terms ofwhoexercises control over productive enterprises,to whatdegree are workers treated as market commodities, and how valuableresources are distributed between social classes.

Within this context, Chvez was able to significantly reduce poverty bychanging who owned, controlled, and benefited from Venezuelas most pro-ductive enterprises. In 2003, for example, the state assumed ownership of

Petrleos de Venezuela, S.A., one of the worlds largest and most profitable oiland national gas companies. By owning this productive property, the Venezuelangovernment was able to use abundant oil revenues for the benefit of its people,such as building essential infrastructures and investing in social, education,and health services. Rather than allowing profits to benefit a small class ofelite renters, as previous governments had done, profits were earmarked for thepurpose of reducing unfair and avoidable inequalities. The value of oil has alsoincreased during the tenure of the Bolivarian government, rising from less thanUS$10 a barrel in 1999 to more than US$100 this year. Over the past decade,the Bolivarian government has increased social spending by an impressive60.6 percent, a total of US$772 billion (5, 6).

REDUCING POVERTY AND IMPROVING HEALTH THROUGHSOCIAL DETERMINANTS OF HEALTH

Poverty and health, respectively, are not solely defined by a lack of income or theabsence of illness. Both are correlated and multi-factorial, in that poverty andhealth are determined by a series of social processes. In this respect, the BolivarianRevolution in Venezuela set in motion a sequence of social processes, which havereduced poverty and improved health by increasing the availability and qualityof social determinants of health. Next, we provide a descriptive review using thebest available data on the equalizing effects of egalitarian policies (e.g., incomeinequality and poverty, income transfers, education, and food security) and their

beneficial impact on various health outcomes.

Income Inequality and Poverty

The effectiveness of Venezuelas anti-poverty reforms is evidenced by the factthat it has the most narrow income distribution, as measured by the Gini coefficient,



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among all Latin American nations. In 2011, Venezuelas Gini coefficient fellto 0.39 (7). Similarly, rates of poverty and extreme poverty have seen largedeclines during the Bolivarian Revolution (8, 9). Since 1999, poverty has fallenfrom 42.8 percent of households to 26.7 percent, representing a 37.6 percentdecline. Since 2004, when the Chvez government took control of the oil industry,the poverty rate fell even faster, by 49.7 percent (10). Extreme poverty followsthe same trend. From 1999 to 2011, extreme poverty declined from 16.6 percentto 7.0 percent, representing a 57.8 percent decline. Since 2004, the declinehas been 70 percent (7). To date, approximately 20 million Venezuelans havebenefited from various anti-poverty programs (11).

Income Transfers for Seniors, Women, and Disabled People

Prior to 1999, the number of Venezuelan seniors on state pension rolls was387,000. Under Chvezs egalitarian tenure, the state pension system grew bymore than 600 percent. By 2012, 2.5 million seniors received an old-age pension,adjusted to the countrys minimum wage, through the countrys social securityinstitute (12). In addition, unemployed women and disabled individualsbegan receiving income transfers equivalent to 80 percent of the minimum wageto ensure acceptable standards of living among those most socially excludedin Venezuela (14).

Education

The Bolivarian government identified education as a major determinant of bothpoverty and health. As a result, education spending now accounts for 10 percentof Venezuelas gross domestic product (GDP) (13). Consistent with the UnitedNations Educational, Scientific and Cultural Organizations call to further reduceilliteracy, educational reforms known as the Misin Robinson I have taught1.5 million Venezuelans basic literacy skills (14) and have elevated Venezuela tothird place in the region in terms of reading frequency (15). Since tuition-freeeducation was made available from daycare to university, school enrollment hasexploded: 72 percent of children attend public daycares and 85 percent of school-aged children are enrolled in school. The number of new or refurbished schoolshas reached the thousands, including 23 new post-secondary institutions. Vene-zuela now ranks second and fifth in Latin America and the world, respectively,in terms of the proportion of students enrolled in post-secondary institutions (16).

Food Security

While 21 percent of the Venezuelan population was malnourished before theBolivarian government took office in 1998, malnutrition dropped to 6 percentin 2007 (17) and to less than 3 percent in 2012 (14). Similarly, child malnutrition



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has decreased by 58.5 percent, from 7.7 percent in 1990 to 3.2 percent in 2010(18). Venezuelas commitment to establish a network of subsidized food systemshas increased the overall accessibility and affordability of healthy foods in grocerystores and supermarkets. Subsidizing food production has significantly reducedthe amount of food imports, dropping from a high of 90 percent in 1980 to acurrent low of 30 percent. Since the launch ofMisin Agro-Venezuelain 2011,the countrys production of staple crops and the amount of land under pro -duction have both increased (19), 3 million hectares of farming land have beenredistributed (14), and more than 150,000 farmers have joined the program (20).As a result, 5 million Venezuelans now receive free food, including 4 millionchildren in schools, and 6,000 food kitchens feed 900,000 people (21). More-over, several important agrarian reforms have empowered agricultural producers

to increase the overall domestic supply of food. The effectiveness of these foodsecurity measures was acknowledged by the World Health Organization inits recognition that Venezuela has been the most successful country in LatinAmerica and the Caribbean in eradicating hunger (22).

Public Health and Health Care

As Venezuela has devoted a larger share of its economic resources to meetingthe social and welfare needs of its population, an important question is whetherthese investments have resulted in improved health outcomes. A review ofextant literature provides preliminary support for the link between egalitarianpolicies and various public health outcomes. Improved outcomes include butare not limited to the following:

Infant mortality rates dropped from 25 per 1,000 live births in 1990 to 13per 1,000 live births in 2010 (23).

National supplies of clean drinking water are now available to 96 percentof the population, which represents a 41 percent increase from 1999 to2012 (24).

The density of physicians increased 400 percent, from 20 doctors per 100,000population in 1999 to 80 per 100,000 population in 2010 (14).

While previous Venezuelan governments took four decades to build 5,081health clinics, the Bolivarian government has built 13,721 health clinics in13 years, an increase of 169.6 percent (22).

Over the course of nine years, Misin Barrio Adentro, a primary health care

program, has saved more than 1.5 million lives (25) and carried out 534million medical consultations (14). Since Chvez came into power in 1999, approximately 650,000 patients

have received expensive medications for free to treat 119 pathologicalconditions, including cancer, AIDS, osteoporosis, schizophrenia, and otherserious ailments (26).



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Over the past seven years, 24,000 homeless adults and children have receivedessential services through a specialized anti-homeless program known as

Misin Negra Hiplita(27). Venezuela now boasts the largest intensive care unit in Latin America, with

46 beds, 32 for adults and 14 for children (28). Essential medications, such as insulin, antibiotics, and therapies for malaria

and Chagas, are heavily subsidized below market value and made availablethrough a network of public drugstores (29).

Misin Milagro, an eye care program developed in 2004, has restored sightto 1.5 million Venezuelans suffering from cataracts or other eye diseases (30).

POPULAR DEMOCRACY AND ECONOMIC

RESTRUCTURING

An integral part of understanding Venezuelas commitment to increased socialspending and improved public health infrastructure involves the intense politicalparticipation that characterizes the countrys democratic institutions and systems.This includes, for example, the forming of 30,000 communal councils, whichare charged with determining local needs, overseeing progress, and empoweringindividuals to be active agents in bringing about desired changes (31). Stronginstitutions and councils have increased the Bolivarian governments willing-ness and responsiveness in serving its citizens. In 2011, for example, heavytropical rains left a staggering 100,000 people homeless. In the short term, theseindividuals were sheltered temporarily in all manner of public buildings andhotels (32, 33). In the long term, the Bolivarian government launched a compre-hensive housing program, building 346,000 homes in 18 months to addressthis housing shortage (34). Not unlike other democratic states, Chvez and hissocialist government have far from eradicated social problems in Venezuela(e.g., high crime rates). However, what differentiates Venezuela is that its citizensrecognized that the actions of the Bolivarian government were intended to benefitthe marginalized and not a small group of elites. Venezuelans who were sociallyexcluded in the past were engaged to be active participants in the countrysdemocratic process and social development. To the extent that Venezuelanssupported Chvezs socialist agenda, they shared a strong ideological preferenceto use government resources to improve the living conditions of low-income andmarginalized populations.

The Bolivarian governments commitment to egalitarianism has raised con-

cerns about the economic sustainability of redressing deep inequalities. AlthoughVenezuelas economy is characterized by low debts, high petroleum reserves,and a large amount of savings, Western economists, who oppose Chvez, repeatad nauseam that Venezuelas economic development is unsustainable and willstagnate once oil revenues cease. Despite the fact that Venezuela boasts one of thelargest oil reserves in the world (i.e., 500 billion barrels), similar dire predictions



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are not levied against other oil-rich economies such as Canada or Saudi Arabia.Critics are also quick to argue that investing oil revenues to achieve social goals,as opposed to profit-driven capitalist ones, is misguided, wasteful, and unpro-ductive. Often missing from these critical appraisals is the fact that the Bolivariangovernment has built a new industrial and agricultural infrastructure sinceChvez came into power. Because previous administrations had neglected suchfoundational investments, Venezuelas economy under Chvez has benefitedfrom the improved infrastructure, which has contributed to steady economicgrowth even during the current global financial crisis (10).

Another development that reflects the sustainability of Venezuelas economycan be seen in its increasing diversification in generating revenues. Since thestate strengthened its capacity to collect taxes, it now generates revenue from tax

collection in addition to the sale of oil. Diversifying revenues not only increasedthe nations wealth, but also created new opportunities to distribute income andwealth more equally among social classes. In fact, the main source of incomein the 2013 national budget, which amounts to 396,406 million bolvares,was derived from non-oil and gas sources, which accounted for more than thepetroleum income (35).

Economic milestones during the Bolivarian Revolution include significantreductions in the national unemployment rate (11.3% to 7.7%) and total publicdebt (30.7% of gross national product to 14.3% of gross national product)(36). In terms of external debt, Venezuelas economic burden in 2012 was51.3 percent of GDP. Given that the average external debt among EuropeanUnion nations is 82.5 percent of GDP, Venezuelas economy appears to becomparatively stable (37).

Since 1999, Venezuelan co-operatives have grown in number and have beenstrengthened by local, endogenous economies (38). Since 2004, the countrysGDP per person has grown by an average of 2.5 percent annually (10), and itsoverall GDP has increased by an impressive 24 percent (37). Such economicfigures would arouse envy among any Organisation for Economic Co-operationand Development country in North America or Europe. According to Weisbrotand Johnson (10): [t]he predictions of economic collapse, balance of paymentsor debt crises and other gloomy prognostications, as well as many economicforecasts along the way, have repeatedly proven wrong Venezuelas currenteconomic growth is sustainable and could continue at the current pace or higherfor many years.

According to Global Finance, Venezuelas unemployment rate is 8 percent.

In 2011, the Venezuelan economy defied most forecasts by growing 4.2 percentand was up 5.6 percent in the first half of 2012. It has a debt-to-GDP ratiocomfortably below the United States and most European nations. Its inflationrate, an endemic problem for many decades, has fallen to a four-year low of13.7 percent in 2012. Even The Wall Street Journal reports that Venezuelasstock exchange is among the best-performing stock markets in the world, reaching



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an all-time high in October 2012, while Venezuelas bonds are some of thebest performers in emerging markets (9).

UNITING LATIN AMERICA AND CURBING THEINFLUENCE OF WASHINGTON

The socialist politics of Chvezs government have not only spearheadedradical change in Venezuela, but have also inspired other Latin Americannations (e.g., Nicaragua, Ecuador, and Bolivia) to elect progressive governments.Growing support and backing for leftist movements in this region is somewhatunexpected given the extent of foreign interests and influence. For example,Chvez was still able to be re-elected last year despite the enormous financial

and strategic help that U.S. agencies and their allies gave to opposition partiesand the right-leaning media. Since 2002, Washington, D.C., has channeledUS$100 million to opposition groups in Venezuela, US$40 million to US$50million of which was distributed last year alone (39). Nevertheless, the majority ofvoters still supported Chvez, disregarding the negative rhetoric that was dissem-inated through Venezuelas 95 percent privately-owned, anti-Chvez media (40).

The tide of progressive change unfolding among Latin American nations iscollectively building the necessary infrastructure for a genuinely independent SouthAmerica. With support from political integration organizations such as the Bank ofthe South, CELAC, ALBA, PETROSUR, PETROCARIBE, UNASUR,MERCOSUR, and TELESUR,the example of Venezuela demonstrates to the rest ofthe world that there are real and feasible alternatives to instituting more equalityand developing economically in the 21st century (41). Following a different modelof economic development that diverges from the finance capitalist-led austerityeconomics in Europe, Venezuela and other Latin American nations have been ableto grow steadily and invest in social equality while lowering debt levels.

THE FUTURE OF BOLIVARIANISM WITHOUT CHVEZ

During the preparation of this manuscript, Chvez passed away on March 5, 2013,leaving the future of the Bolivarian Revolution in serious doubt. Questionsabound, including who will succeed Chvez as president; whether his politicalparty, the Fifth Republic Movement, will maintain its popular support; and whatdirection 21st-century socialism will head toward under new leadership. Althoughit is too soon to predict the short- or long-term future of Bolivarianism, the

egalitarian ideals that Chvez championed are far too significant to end with hispassing. In this sense, the example of Venezuela since 1999 carries a heightenedsense of importance given its achievements to date and its uncertain future.

The political and social changes that have taken place in Venezuela are neitherabstract nor intangible. In concrete terms, Chvez and his Bolivarian govern-ment have invested heavily in the social determinants of health, which have



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dramatically improved the living conditions of many Venezuelans. At the sametime, Chvez successfully and dynamically engaged Venezuelans to actively par-ticipate in the political process to achieve the countrys egalitarian goals (42).This new model of development has had a phenomenal impact all over LatinAmerica, including Colombia of late, and the left-of-center governments thatare now the majority in the region see in Venezuela the catalyst that has broughtmore democracy, national sovereignty, and economic and social progress (43).

Applying a neoliberal lens to understand the experience of Venezuela doesnothing to dispute the facts of reduced poverty and improved public health.Unresolved debates on whether the Bolivarian Revolution is guided by socialismor whether Chvezs movement is revolutionary or reformist are moot discus-sions at the end of the day, given that progress has been achieved. This is exactly

what infuriates critics within Venezuela and detractors from neocolonialistcountries. For example, the supposedly objective and empiricist magazine,The Economist, has not and will not publicize data that speak to Venezuelasachievements, preferring instead to repeatedly predict the imminent collapse ofits economy. The Spanish publication, El Pais, decidedly ignores stories abouttrends toward greater equality and better health. Instead, it devotes its pages toanti-Chvez diatribes by a journalist who served as one of the main architectsof the Caracazo (in 1989, 3,000 protesters were slaughtered for voicing dissentagainst austerity measures in Caracas).

It has become clich for academics to implicate a lack of political will asthe explanation for why effective policies or interventions are not implementedto reduce social inequalities in health. Although a solid knowledge base on why

some people are healthy and others are nothas been established, it is widelyaccepted that taking real action on the social determinants of health is oftenthwarted by insufficient levels of political will. However, in the case of Venezuela,we have a unique and current example of what happens when political will ispresent and policies committed to alleviating human suffering are implementedin a short timeframe. Paying more attention to the past achievements of theBolivarian Revolution will augment our understanding of how egalitarian politicshas the power to transform unequal societies into more equal ones.

Acknowledgments An abridged version of this article was originally publishedinCounterpunch, December 1416, 2012. This work was supported, in part, by aNational Research Foundation of Korea grant funded by the Korean government(MEST) No. 2012S1A5A8022889.

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Direct reprint requests to:

Haejoo ChungDepartment of Healthcare Management

College of Health ScienceKorea University, 704 Justice HallJeongneung 3-dong, Seongbuk-guSeoul 136-703, Republic of Korea

[email protected]


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