(Washington, DC) – The Venezuelan healthcare system is grossly unprepared for the arrival of the Covid-19 pandemic, further jeopardizing the health of Venezuelans and threatening to contribute to regional spread of the disease, Human Rights Watch and the Johns Hopkins University’s Centers for Public Health and Human Rights and for Humanitarian Health said today. Ensuring that sufficient humanitarian aid reaches the Venezuelan people is urgently needed.
As of May 25, 2020, Venezuela had 1,121 confirmed cases of Covid-19, and 10 deaths. The real number is almost certainly much higher, given the limited availability of reliable testing, limited transparency, and the persecution of medical professionals and journalists who report on this issue. Overcrowding in low-income areas and prisons, as well as generalized limited access to water in hospitals and homes, makes it likely that the new coronavirus will rapidly spread within the country. The massive exodus of Venezuelans, and the migration back and forth across Venezuela’s borders due to the pandemic, increases the risk of the virus spreading further.
“The humanitarian crisis in Venezuela and the breakdown of the health system have created dangerous conditions conducive to rapid community spread, unsafe working conditions for health personnel, and high mortality rate among patients in need of hospital treatment,” said Kathleen Page, a physician and faculty member of the Johns Hopkins University School of Medicine and the Johns Hopkins Centers. “Venezuela’s lack of capacity to confront the Covid-19 pandemic may drive people to try to leave the country, further straining the health systems of neighboring countries and imperiling regional health more broadly.”
United Nations Secretary-General António Guterres and Emergency Relief Coordinator Mark Lowcock should lead efforts to address this issue. Members of the Lima Group, the United States, and the European Union should press Venezuelan authorities under Nicolás Maduro to immediately open doors to a full-scale, UN-led humanitarian response to prevent catastrophic spread of Covid-19 in the country, Human Rights Watch and Johns Hopkins Centers for Public Health and Human Rights and for Humanitarian Health said. It is critically important for foreign governments to depoliticize aid and for the US government to ensure that existing sanctions do not contribute to the crisis or hinder humanitarian efforts.
Venezuela’s health system has collapsed. Shortages of medications and health supplies, interruptions of basic utilities at healthcare facilities, and the emigration of healthcare workers have led to a progressive decline in healthcare operational capacity. At 180 out of 195, Venezuela ranks among the countries least prepared to mitigate the spread of an epidemic in the 2019 Global Health Security Index.
In November and December 2019, a team from Human Rights Watch and Johns Hopkins Centers conducted in-depth interviews by phone with healthcare providers in 14 public hospitals in Caracas, the capital, and five states – Anzoátegui, Barinas, Bolívar, Lara, and Zulia. All but one of the hospitals provided high-complexity care. The groups also conducted follow-up interviews with some health professionals, humanitarian actors, and experts on sanctions in March, April, and May 2020.
Although the bulk of the research was conducted before the pandemic hit, the findings give strong reason for concern that the healthcare system is not only failing, but failing in ways that make it particularly ill-equipped to cope with Covid-19, especially due to routine water shortages and sanitation and hygiene failures. Developments in the country through May 2020 give further cause for concern.
The doctors and nurses interviewed said that soap and disinfectants are virtually nonexistent in their clinics and hospitals. As inflation has risen and salaries have been devalued, it has become increasingly difficult for them to bring in their own supplies. The Caracas hospitals experience regular water shortages. In remote hospitals, water shortages have lasted weeks to months. Patients and personnel are required to bring their own water for drinking, for scrubbing up before and after medical procedures, for cleaning surgical supplies, and sometimes for flushing toilets.
In a survey of healthcare providers that measured the Venezuelan healthcare system’s capacity to confront Covid-19, 31.8 percent of hospital workers reported that their hospitals lacked potable water and 64.2 percent reported intermittent access to potable water between February 27 and March 1, 2020. On May 21, a union leader reported that a survey in 16 hospitals and health centers in Caracas revealed shortages of water in 8, gloves in 7, and of soap and disinfectant in 15. Eight hospitals and health centers also lacked face masks, and 13 were reusing them. Another national survey on the impact of Covid-19 published on May 16 reported there were shortages of gloves in 57.14 percent of the health sector, face masks in 61.9 percent, soap in 76.19 percent, and alcohol gel in 90.48 percent.
The mortality rate for Covid-19 is uncertain and likely to vary according to age, underlying health conditions, and availability of treatment, among other factors. The death rate will most likely be higher than average in Venezuela, where there is no capacity for complex care due to a lack of basic X-ray equipment, laboratory tests, intensive care beds, and respirators, and where healthcare providers’ lack of access to water prevents them from washing their hands, which is vital to limiting the spread of Covid-19. Fuel shortages are increasing the difficulty for both health professionals and patients to get to hospitals and clinics, and for food to reach people in need, which could further undermine health care.
The disease also could be transmitted quickly in the community and in overcrowded prisons in the absence of basic public health protections and access to sufficient water. Infectious diseases thrive under the poverty conditions, crowded living arrangements, and malnutrition that many Venezuelans face.
The humanitarian, political, and economic crisis in Venezuela has led to the largest migration in the region in recent decades. More than five million Venezuelans have left the country, taking with them diseases that had been eradicated in the region, such as measles. The health systems of neighboring countries are already strained trying to meet the health needs of Venezuelan exiles. Although a few thousand Venezuelans have recently decided to return to Venezuela due to dire conditions in receiving countries, the exodus is unlikely to stop and the coronavirus outbreak in Venezuela will only make things worse.
Venezuelan authorities have adopted some belated measures to, in theory, attempt to respond to the pandemic. The government declared a state of emergency on March 13 and instituted a nationwide quarantine on March 17, which restricts movement and mandates closing all but essential businesses. It is enforced by police, the Armed Forces, a special police force called FAES, and armed pro-government gangs, leading to arbitrary arrests and harassment, local groups said. On March 17, the Nicolás Maduro government requested an emergency $5 billion loan from the International Monetary Fund (IMF) to combat Covid-19, which the IMF rejected, stating there was “no clarity” regarding the Maduro government’s “official government recognition by the international community.”
The Venezuelan authorities’ response is severely undermined by their failure to publish epidemiological data, which is critical to address a pandemic; their harassment and persecution of journalists, health professionals, and others who raise awareness about deteriorating conditions in hospitals, gas shortages, and the spread of Covid-19; and their unwillingness to assume any responsibility for contributing to or failing to address the health system’s breakdown, which they blame entirely on US sanctions even though the breakdown predates the sanctions.
“Foreign governments should contribute to Venezuela’s Covid-19 response by funding UN humanitarian efforts to ensure the aid is distributed apolitically,” said José Miguel Vivanco, Americas director at Human Rights Watch. “However, for aid to effectively reach the Venezuelan people, the primary responsibility lies on Venezuelan authorities under Maduro, who need to ensure full access to the World Food Programme and allow humanitarian and health workers to work without fear of reprisals.”
For detailed recommendations and additional information about water shortages, sanctions, and humanitarian aid, please see below.
Human Rights Watch and Johns Hopkins Centers for Public Health and Human Rights and for Humanitarian Health experts urge UN Secretary-General António Guterres and Emergency Relief Coordinator Mark Lowcock to lead efforts to address the humanitarian situation in Venezuela and to request that the Maduro government adopt all necessary measures, including those in this publication, to ensure that aid effectively reaches the Venezuelan people.
The Lima Group members, the US, and the European Union, as well as other countries with demonstrated influence over Venezuelan authorities, should press them to:
- Open Venezuela’s doors to a full-scale, UN-led humanitarian response that reaches the interior of the country, specifically by allowing full access to the UN World Food Programme and its partners, which have the logistical capacity to provide a significant amount of humanitarian aid nationwide;
- Enable local and international humanitarian workers to provide humanitarian aid and have access to all hospitals and other healthcare centers so that they can provide supplies and assistance;
- Allow healthcare professionals and humanitarian workers to carry out their work without reprisals, and ensure they can move freely throughout Venezuela despite quarantine restrictions by issuing and respecting special permits and by prioritizing their access to gasoline; and
- Allow independent experts to review and publish all available epidemiological data to increase transparency about the extent of the humanitarian emergency by reporting accurate counts of Covid-19 confirmed cases and deaths and by resuming regular publication of detailed mortality and morbidity reports.
All governments should fund UN-led humanitarian efforts that comply with the UN standards of humanity, neutrality, independence, and impartiality in the provision of assistance.
Given the risk of overcompliance with US financial sanctions and sanctions on Venezuela’s oil sector, as well as Venezuelans’ need for resources to address the humanitarian emergency, the US government should:
- Clearly state again that no one will be penalized for financing or supplying humanitarian aid to Venezuela in this time of a public health crisis, and repeat that humanitarian aid is exempt from sanctions;
- Limit overcompliance, including by publicly providing concrete avenues for companies and organizations to channel humanitarian aid into Venezuela without excessive bureaucratic scrutiny or delays; and
- Actively support a robust UN-led humanitarian effort in Venezuela.
Limited Access to Water in Hospitals
The rights to water and sanitation are essential components of the right to an adequate standard of living and inextricably linked to the right to health. The United Nations has emphasized that the right to water requires that water be sufficient and continuous, safe and acceptable, physically accessible and within safe reach, and affordable to all. In particular, the World Health Organization has noted that safe water, sanitation, and hygienic conditions are key to protecting human health during the Covid-19 pandemic.
Across Venezuela, households and hospitals have limited access to water. According to a World Food Programme study, 25 percent of Venezuelan households lacked sustainable access to potable water and 4 in 10 households experienced daily interruptions in their water supply between July and September 2019.
The UN Humanitarian Response Plan for Venezuela, published and carried out in the last half of 2019, estimated that 4.3 million people needed water, sanitation, and hygiene services. During the same period, the UN response plan was able to provide safe water to 310,598 people – 7 percent of the estimated need. The response plan targeted 3,719 health and education facilities during this period but reached only 253, or 7 percent; only 44 of the targeted institutions, or 1.2 percent, were hospitals or health centers.
Hospitals in Venezuela have had limited access to water since 2014 and the problem has grown more acute over the years, health professionals interviewed said. According to Doctors for Health, a nationwide network of doctors, the percentage of Venezuelan public hospitals with intermittent access to water rose to 69 percent in 2016, from 28 percent in 2014. In 2019, 70 percent reported intermittent access to water and 20 percent reported no access to water.
One person interviewed said that in their hospital access to running water varies, with water cuts sometimes lasting for an entire weekend and at other times lasting as long as five days. Another interviewee said that the government rations the water in their hospital, with access only for an hour or two twice a week. In more remote hospitals, water shortages are worse.
In large cities, water trucks bring limited amounts of water to hospitals, but it is insufficient, the health professionals said. One hospital that needs 30 trucks for a day’s operations, for example, received only 4 or 5.
Even when hospitals have access to some water, its quality is poor. The water brought by the trucks is not potable. Running water is not adequately treated and there is no way to filter or boil it in hospitals since the kitchens in many hospitals are not operational, so it is risky for hospitals to rely on it. In addition, the hospitals’ methods of collecting and storing water create contamination risks. The wells, under- and aboveground water storage tanks, and barrels used in some hospitals are – due to lack of maintenance, lack of covers, or simple unsuitability – inadequate to preserve a quality water supply.
Impact of Water Shortages on Patient Care
An immediate consequence of hospitals’ limited access to water is that healthcare workers are unable to wash their hands, which they are supposed to do before and after touching a patient. Venezuelan healthcare workers do their best to keep their hands clean, which in one neonatal unit took the form of washing their hands with condensation that fell from the air conditioner.
The lack of water, especially as it prevents hand-washing, contributes to high rates of nosocomial infections, that is, infections that originate within a hospital. These infections in Venezuela have included bacteremia, fistula infections, and pulmonary infections, and are now likely to include Covid-19, according to Johns Hopkins University members of the research team. Similarly, in 2018, the UN Office of the High Commissioner for Human Rights (OHCHR) observed that “[l]ack of water and hygiene supplies were ... causing pervasive infection problems” in Venezuela. The lack of water has also resulted in a lack of laundry service at hospitals, and healthcare workers risk bringing infections home if they mix their clothing with the clothing of their family members in the wash.
Difficulties in accessing quality water also have led medical procedures such as dialysis and surgery to be cancelled. Five healthcare providers said that dialysis patients were among those most affected by lack of water and contaminated water, and two noted drastic reductions in the number of operational dialysis machines at their hospitals due to contamination of water: from 14 machines down to 9 in one hospital and from 35 to 15 in the other. With the arrival of Covid-19 and the accompanying quarantine, patients have faced increased difficulties accessing dialysis due to gasoline shortages, blocked roads, and limitations on their movement between cities.
One hospital had, only two weeks before the interview, cancelled all scheduled surgery for a week due to the lack of water and for four additional days due to contamination of the operating room. Meanwhile, the OHCHR noted that the inability of doctors in the Venezuelan state of Zulia to perform more than a few surgeries a week, due to a combination of water shortages, energy shortages, and operating-room contamination, has led to six-month waiting lists.
Hospitals have also been partially closed because of water shortages. One doctor said her hospital’s capacity was reduced from 79 beds to 5 due in part to the lack of water. Another doctor said that limited access to water had reduced her hospital’s five or six operating rooms to two. Four hospitals have closed their labs.
One hospital reduced its services so drastically that its status changed from a level 4 medical institution to a level 1 institution – from offering the most healthcare services to the least. The hospital also abandoned its radiology section. “It is nothing more than a hallway with a waiting room where nobody is waiting,” one doctor said.
Due to general rationing of services, hospitals also prioritize certain services, such as the emergency room, and certain patients, and turn others, such as the elderly, away to die at home. Since there are water shortages throughout the country, transferring the patients to a hospital with water is not an option, several doctors said.
Even when water shortages do not prevent healthcare workers from providing services, they contribute to an unsanitary and unhygienic environment. Hospitals cannot be cleaned regularly or thoroughly due to the lack of water and cleaning materials. One hospital had to close half a floor due to unsanitary conditions. Another hospital that used to be cleaned four times every 24 hours is now cleaned half as frequently and with very little water. People interviewed reported nauseating odors, rodent infestations, and broken-down bathrooms. Two interviewees could attend only a fraction of their patients after the building where they worked closed due to sewage problems in 2018.
One hospital’s bathrooms, although closed for lack of water, were still used. Another hospital’s patients urinated and defecated outdoors instead, resulting in a noxious environment surrounding the hospital. At another hospital, in which staff, patients, and even family members urinated and defecated into makeshift containers and then disposed of the waste outside, the doctors requested portable restrooms, but the request was never filled. “It is Dante-esque,” one doctor said, “as though we are in a war but not a single bomb has fallen.”
Response of Healthcare Providers, Patients, Families
Some healthcare providers buy alcohol gel for hand hygiene themselves. A bottle costs US$3 to $5 at the unofficial exchange rate at the time of the interviews, an enormous expense considering that the monthly salaries of doctors ranged from approximately $6 to $15 then. Some also occasionally bring bottled water, soap, or toilet paper to the hospital. But many do not have the means to buy even the alcohol gel, especially nurses, who earned about $3 a month at the time of the interviews.
Many patients are also forced to take on part of the burden of promoting a hygienic environment. Patients or family members bring water for the patient to drink, for medical procedures, and even to clean the bathrooms and flush the toilets. In one major hospital, patients had to bring 25 liters of water to be admitted. In another, if the patient or the patient’s family does not provide water, their surgery is cancelled. As the OHCHR observed in its 2019 report on Venezuela, “[F]amilies of patients have to provide all necessities, including water, gloves, and syringes.”
One healthcare provider estimated that only 25 percent of patients could afford to bring water. Even for those who can afford water and the additional items required for surgery, the time taken to gather all that is needed can make the patient’s condition worse, leading to a greater likelihood of complications and prolonging recovery.
The Venezuelan government’s primary response to hospitals’ lack of water has been neglect. Several people interviewed said that for years the government has done nothing to improve the deteriorating conditions in their hospitals. During the only instance they could recall in which the Venezuelan government acknowledged the deterioration of a hospital and resolved to fix it, the government worked on the building for only one month before abandoning the project. A union representative said that government intervention in another hospital did not respond to healthcare workers’ demands for water and other necessities but instead “[A]ll they have done is fix a few lamps.”
Of the three projects targeting hospitals listed on the Water Ministry’s website, two provided a limited number of aboveground water storage tanks to the states of Vargas and Zulia, failing to address the root of the problem: the lack of a continuous supply of high-quality water. In June 2019, construction began on a third project that would increase water services at Hospital Universitario Antoni Patricio Alcalá (Huapa), but, as of March 11, this hospital still did not have a consistent water supply and had no access to potable water. Nevertheless, the Maduro government designated Huapa one of 46 hospitals and health centers for Covid-19 patients.
These isolated and half-hearted attempts to provide water to hospitals fall far short of the government’s obligation to ensure Venezuelans’ right to health, Human Rights Watch and the Johns Hopkins Centers said. The government should open its doors to humanitarian aid to improve its water system infrastructure, which has been operating at half its capacity in part due to corruption and lack of maintenance. It should also address widespread electricity shortages, which make it impossible for water systems to function properly; it should ensure that wells in the hospitals that have them are again fully operational; and it should frequently test the quality of water reaching Venezuelan hospitals and households.
Lack of Official Data; Limited Testing
Venezuelan authorities have suppressed or else failed to collect public health data that would reveal the extent of the crisis. Until 2014, when health indicators started deteriorating, Venezuela had a robust epidemiologic surveillance infrastructure that published regular and detailed morbidity and mortality reports. Then came two years of silence. In 2017, the then-health minister published data showing that infant mortality had increased by 30.12 percent and maternal mortality by 65.79 percent in 2016. She was promptly fired.
Since then, the government has not released its epidemiological data. Some doctors interviewed said that the government had also prohibited them from listing certain causes of death such as malnutrition and had forced doctors who went public with mortality data to resign.
The Venezuelan government has suppressed public health information regarding Covid-19. On March 17, the opposition-led National Assembly announced that it had created a Covid-19 awareness website, coronavirusvenezuela.info. On March 18, Venezuela Sin Filtro, a nongovernmental organization, reported that state-owned Internet provider CANTV had blocked the website and that private Internet providers had also limited access to the website indirectly by blocking another website linked to the opposition. A National Assembly representative confirmed this information to Human Rights Watch.
The authorities also have reportedly banned Covid-19 testing in a private clinic in Caracas and confiscated the results there, saying that only an official entity should conduct them. As of May 21, Venezuelan authorities claim to have conducted 697,691 tests, of which at least 16,577 were PCR tests. The vast majority are thus rapid tests that may result in false negatives during the first days after becoming infected.
Harassment and Persecution of Healthcare Workers, Journalists
Several people interviewed said that government authorities and supporters had harassed them or other health professionals or activists they knew after they had openly questioned the government’s response to the health emergency. Health professionals said they were threatened, followed, and photographed, sometimes by intelligence agents. Some doctors who participated in protests said the authorities detained and prohibited them from speaking publicly about healthcare conditions.
Government authorities have also harassed healthcare professionals who publicize information about Covid-19. On March 9, the Zulia governor announced that he would order an investigation of Freddy Pachano, a doctor at the University of Zulia, for tweeting about possible Covid-19 cases at the Hospital Universitario de Maracaibo. The governor said that if Pachano had sounded the alarm in error he would have him prosecuted.
The Foro Penal Venezolano, a network of criminal lawyers and activists that provides pro-bono legal support to people who are arbitrarily detained, reported a sharp increase in arbitrary detentions since the government declared a state of emergency on March 13, including of healthcare workers and journalists who questioned Venezuelan authorities’ response to Covid-19. Foro Penal Venezolano has also reported arbitrary arrests of political opponents and others during this time. Espacio Público, a nongovernmental organization that monitors free speech in Venezuela, documented 40 cases of people detained for criticizing the government’s response to Covid-19 as of May 16, including 17 media workers. The National Press Workers Union documented 22 arbitrary arrests and 21 instances of harassment and/or intimidation of journalists between March 16 and May 3.
On March 21, the Venezuelan special police force FAES arrested Darvinson Rojas, a journalist, after he reported on possible Covid-19 cases. The police also detained Rojas’s parents, injuring his father. Rojas’s parents were released later that night. On March 23, Rojas was charged with incitement to hatred and incitement of the public. He was conditionally released on April 2, but remains under criminal prosecution.
On March 23, the Venezuelan newspaper La Verdad de Vargas reported that a nurse had tested positive for Covid-19. On March 24, the public prosecutor’s office subpoenaed the newspaper’s editor-in-chief, Beatriz Rodríguez, as a witness in a criminal investigation of La Verdad de Vargas for alleged terrorism.
Also on March 24, FAES detained Rosalí Hernández, a journalist, as she gathered information on disinfection efforts in Catia. FAES held Hernández for 40 minutes, forcing her to delete the material she had recorded.
Venezuelan authorities have also detained healthcare workers who protest how hospitals’ shortages of water and supplies have left them unable to respond to Covid-19 effectively.
On March 17, military intelligence detained Rubén Duarte, a nurse at Hospital Central de San Cristóbal, after he demanded water, masks, gloves, and other necessities. They held him overnight.
The National Bolivarian Guard detained Julio Molino, a doctor in Monagas, on March 17 after Molino called attention to the inability of Hospital Manuel Núñez Tovar to attend to Covid-19 patients. On March 19, Molino was charged with incitement to hatred, causing panic in the community, and illegal association and placed under house arrest. Venezuelan authorities also sought to detain two of Molino’s colleagues, Carlos Carmona and Maglis Mendoza. When they could not find the two, they instead arrested Mendoza’s 17-year-old granddaughter and her 16-year-old friend and held them until late at night.
Sanctions and Humanitarian Aid
The United States imposed financial sanctions, including a ban on dealings in new stocks and bonds issued by the Venezuelan government and Petróleos de Venezuela, Sociedad Anónima, or PDVSA, its state oil company, in August 2017. They explicitly exclude humanitarian transactions. The sanctions were expanded in January 2019, but maintain the humanitarian exception.
Despite the humanitarian exception, these sanctions could exacerbate the already dire humanitarian situation in Venezuela, both due to the risk of overcompliance and because the sanctions reduce the resources available to the government to address the crisis. The extent to which the sanctions are in fact having this impact, and whether the government would have used any additional resources to help its people, is unclear. But the United States should promptly take sufficient steps to prevent negative impacts from the sanctions on the humanitarian situation, Human Rights Watch said.
One humanitarian actor told Human Rights Watch that some humanitarian transactions to Venezuela have been delayed due to overcompliance, and experts on sanctions say that overcompliance with these types of sanctions is generally a problem.
While not dismissing the potential negative impact that sanctions are having on Venezuela’s health system, it is important to note that Human Rights Watch research indicates that Venezuela’s health system collapse predates the sanctions. Likewise, imports of food and medicines decreased prior to the imposition of the sanctions, according to leading economists interviewed by Human Rights Watch.
However, in an oil-dependent economy like Venezuela’s, the rapid decrease in oil revenue since 2017 has limited the availability of government resources, according to several sources interviewed by Human Rights Watch. Experts have provided different and sometimes conflicting explanations for the decrease in revenue, including sanctions and mismanagement. The price of oil, which reached its lowest level in years in March, also affects revenue.
There is no guarantee that Venezuelan authorities under Nicolás Maduro, who have contributed to the health system’s collapse, have been implicated in high-level corruption, and have used oil revenues to, for example, shrink PDVSA’s $6.5 billion debt with the Russian state oil company Rosneft, would have used oil revenue to provide humanitarian assistance to the Venezuelan people, Human Rights Watch said.
Although still very limited compared to the magnitude of the need, the number of humanitarian organizations operating in-country and the amount of aid reaching Venezuela has increased in recent months. According to the latest situation report on Venezuela from the UN Office for the Coordination of Humanitarian Affairs, the 2019 Humanitarian Response Plan for Venezuela – the first for the country – received $75.9 million, or 34 percent, of the $223 million it required. The UN Global Humanitarian Overview 2020 estimated that $750 million would be needed for a 2020 Humanitarian Response Plan for Venezuela, $72.1 million of which would be set aside for Covid-19 response under the new UN plan to deal with the coronavirus outbreak. These efforts remain underfunded. A special appeal made in April to deal with Covid-19 in Venezuela called for 61 million dollars for three months; it has received 14 million. Foreign governments could help to address the humanitarian crisis in Venezuela by funding these efforts, Human Rights Watch and the Johns Hopkins Centers said.
The United States, the European Union, Canada, and some Latin American governments have also imposed unrelated, targeted sanctions against Venezuelan officials and members of security forces implicated in human rights violations, corruption, or drug trafficking. These targeted sanctions do not appear to have impacted the humanitarian situation in the country, though the sanctioning governments should remain vigilant to ensure that remains the case.