Marc Margolis: Venezuela's Health Crisis
Is the Hemisphere's Problem
The horror of Venezuela's hospitals
As more than 3 million refugees ferry pathogens across borders, the Americas'
worst humanitarian crisis risks becoming a hemispheric emergency.
It's hard to cross a plaza or park in metropolitan South America without running into “The Liberator” Simon Bolivar, sword raised atop a bronze horse. But who remembers Arnoldo Gabaldon? The Venezuelan epidemiologist fought malaria with maps, field laboratories, quinine and armies of door-to-door fumigators, making Venezuela a pioneer in eradicating malaria in densely populated areas.
Gabaldon would be sweating in his bed netting today. Half a century on, Venezuela is a hothouse for malaria again, but also communicable miseries from HIV/AIDS to Zika. Forgotten diseases such as diphtheria and measles rage . Leprosy, tuberculosis and typhoid fever are back, alongside emerging mosquito-borne viruses, such as dengue, Zika and chikungunya. New HIV infections jumped 24 percent from 2010 to 2016.
Now the worst humanitarian crisis in the Americas risks becoming a hemispheric emergency, as nearly 3 million Venezuelan refugees and migrants ferry their pathogens across the continent.
Venezuela's failing health is no surprise: The disastrous Nicolas Maduro government has made the economy and national infrastructure a shambles. Serial blackouts and scarce supplies have devastated hospitals, where nursing staff are forced to ventilate intubated patients manually and to reuse disposable surgical gloves. A third of Venezuelan physicians have left the country since 2014, according to the Venezuelan Medical Federation.
Add to that the toll of global human folly: Severe droughts likely linked to disruptive climate change have forced Venezuelans to store water at home, a perfect swarm for aedes aegypti, the mosquito that spreads dengue, chikungunya, yellow fever and Zika. By 2016, all four strains of dengue were circulating countrywide. Venezuela's per person funding for populations at risk of contracting malaria was the lowest in the Americas after Peru and French Guiana. So depleted is primary care that pregnant Venezuelans prefer risking their lives and fleeing the Bolivarian republic to giving birth at home.
But when such migrants travel, they also carry ills that Venezuela's neighbors thought they'd beaten. After logging just one case of measles between 2008 and 2015, Brazil reported more than 10,000 infections last year . Most patients bore D8 genotype measles, the dominant strain circulating in Venezuela. The Venezuela epidemic has also been linked to outbreaks in Argentina, Colombia, Ecuador and Peru.
The World Health Organization reckoned that a Venezuelan malaria outbreak was responsible for 84 percent of the increase in infections in the Americas in 2017. Venezuela alone kicked in 53 percent of all reported cases regionally in 2016 and 2017.
“The human exodus has become a disease exodus. Contagion is one of our most prolific exports,” Venezuelan infectious disease pathologist Alberto Paniz-Mondolfi, a member of the Venezuelan National Academy of Medicine, told me. Like many of his colleagues working in precarious conditions, Paniz-Mondolfi improvises. To speak to me, he had to go to a clinic in central Venezuela powered by natural gas, a safeguard in a country pockmarked by blackouts.
Fortunately, Venezuela's neighbors are better prepared to deal with dangerous outbreaks. In recent decades, many have made strides in fighting debilitating and lethal diseases. But Venezuela's collapse has also left health professionals in the dark; the Ministry of Health stopped publishing its once-respected health bulletin in 2016. For Venezuela's neighbors, that disappearance makes evaluating and treating refugees a deadly guessing game.
“We see cases of encephalitic disease on the Brazilian border that appear to be viral, but no one knows for sure,” said Aileen Chang, an arbovirus researcher at the George Washington University School of Medicine, who has studied the Venezuelan crisis. “For malaria, you draw blood and look for parasites under the microscope. When you have a virus and don't know what it is or does, and have no cheap, quick way to diagnose, then you're completely unprepared.”
Dealing with viruses like dengue is especially vexing. Spread by highly adaptable mosquitoes that breed in still clean water, bite by day and flourish in crowded quarters, dengue travels well and is wondrously adapted to chaotic urban Latin America. Six epidemics hit Venezuela from 2007 to 2016, compared with four epidemics in the previous 16 years, according to a recent study in The Lancet Infectious Diseases.
Venezuela's statistical blackout and chronic underreporting of infections also mean that the country's accelerating outbreaks point to a wider threat. “Mosquitoes move a couple of hundred meters over their lifetime. But people travel hundreds of kilometers if they're walking, thousands if they travel by boat, bus or plane,” said Donald Shepard, a health economist at Brandeis University's Heller School.
What's worse is that many people — including most of those infected with dengue and up to 80 percent with malaria — carry disease but do not fall ill. “When people move they take bugs with them, even if they don't know it,” said Duane Gubler, an expert on emerging infectious diseases, and emeritus professor at Duke-NUS Medical School, Singapore. “Viruses mutate as they pass through humans, sometimes increasing the fitness of the virus and creating epidemic potential.”
Not surprisingly, dengue and malaria are flaring on the Colombian border, a no-man's land where outlaws lurk, wildcat miners dig for gold and then take their winnings and contagions back home, and holdout guerrillas from the Revolutionary Armed Forces of Colombia and the National Liberation Army roam. “It's a hard place to work if you're a physician or health worker,” said Martin Llewellyn, who studies vector-borne diseases at Glasgow University. “It's an open sore right on a critical border.”
When contagions spread, so does misery. Dengue alone cost $18.42 billion globally in 2016 — double the burden from 2013 — due to death, poor health, disability, and treatment and rehabilitation, Shepard found in a recent study. And Venezuela did not even make his top ten most afflicted nations.
Fortunately, scientific advances are bringing promising new tools. A dengue vaccine is undergoing advanced clinical trials, and mosquitoes weaponized to carry virus-inhibiting Wolbachia bacteria are in the works. Science alone will not stop the emergency, however. “The best mosquito control tool could be implemented in a country without health infrastructure, and it will fail,” said Gubler. “The refugee problem might go away in a few years, but the real problem — the movement of viruses and contagions through modern transportation — will still be there.”
Bottom line: Venezuela's dysfunction has become a life-threatening export as well a risk to regional stability and prosperity. “We are doctors, academics and researchers. We can't invoke invasion or international intervention,” said Paniz-Mondolfi. “But without infrastructure, medical supplies and electricity, we can't do our job. World authorities should recognize the emergency in Venezuela before it becomes a continental tragedy.”
Encouragingly, diplomacy in the Americas is more robust than ever before, with virtually all of Venezuela's neighbors pressuring the Maduro regime to stand down, allow in more humanitarian aid and attenuate the suffering. Let's hope they succeed: The best monument Latin America could build to Arnoldo Gabaldon would be to restore his home-grown legacy.
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