Venezuela is in the middle of an unprecedented, state-made, complex humanitarian emergency. The public health crisis, which is just a symptom of the larger unraveling that is unfolding, has reached extreme levels. Essentials like soap and gloves have vanished from hospital floors. Life-saving medications are sometimes only available on the black market and cost half a month’s wages. Food is scarce and people are dying – dying of starvation, dying of AIDS, dying of long-eradicated diseases like diphtheria. The Global Fund, for its part, is idling.
These are some of the conclusions of a new report from ICASO and Acción Ciudadana Contra el SIDA. ACCSI is a Venezuelan organization working to ensure effective and coordinated strategies to protect, promote and defend the human rights of people living with HIV (PLHIV) and other key and vulnerable populations.
The report, Triple threat: Resurging epidemics, a broken health system, and global indifference to Venezuela’s crisis, which is based on a desk review, key informant interviews and a local emergency consultation with affected communities, paints a sobering picture of the breadth of the devastation in the once thriving oil-rich nation. “People are dying because they do not have treatment. People are dying of preventable and curable diseases. People are dying for lack of political will. I have been living with HIV for 30 years. I think I am going to die soon,” said one key informant living with HIV.
Crisis at a glance
In 1961, the World Health Organization declared malaria eradicated from 68% of Venezuela’s malaria zone. The report estimates that in the first four months of 2017 there were over 900,000 new notified cases of malaria. This represents 67% more cases than in the entire previous year. Medication is difficult to access and drug resistance is increasingly becoming a serious issue.
On the AIDS front, the report notes that HIV prevalence is higher than the regional average (0.6% compared to 0.5%). The number of AIDS-related deaths has risen by nearly three quarters, from 1,900 in 2011 to 3,300 in 2015. In 2016, there were 6,500 new infections. Widespread stockouts of antiretrovirals (ARVs) have been reported in all 23 states, contributing to an increase in drug resistance.
Key and vulnerable populations are disproportionately impacted by the crisis. For example, there has been a resurgence in vertical transmission of HIV due to the inability of mothers to access baby formula as a substitute for breast milk. In addition, the report cites academic studies that have found that certain indigenous groups, like the Warao, have a “dramatically high” HIV prevalence; and though the data is sparse due to the lack of a prevalence study on key populations, self-reported prevalence among men who have sex with men is at 6.6%.
Experts who spoke to ICASO said that unpublished information suggests that there has been a rapid increase in tuberculosis incidence, although the lack of data makes it difficult to fully ascertain the extent of the problem. As with the other two diseases, lack of testing and examination capabilities, treatment interruptions and drug resistance are significant issues. Indigenous people, diabetics, PLHIV and prisoners are among the most affected groups.
Why the hold up?
The report describes the efforts of advocates to convince the Global Fund to provide assistance, and the response from the Fund. The Global Fund’s first (and long delayed) response to the desperate pleas of Venezuelan community advocates was to decline to provide assistance. Despite the raging economic crisis in Venezuela, and skyrocketing inflation rates, the Global Fund said that because Venezuela was still classified by the World Bank as a high-income country, based on GNI per capita thresholds, the country was not eligible for funding. In February 2017, a month after the initial refusal, the Global Fund offered an olive branch. The Fund said it would provide assistance to obtain competitive pricing for commodities, consider a multi-country malaria grant, and work on medicine procurement with the Pan American Health Organization (PAHO). This did not placate the advocates.
Before, at and after the May 2017 meeting of the Global Fund Board, the delegations from civil society and Latin American and the Caribbean continued to press the Fund to find a way to channel resources to the country, but were met with roadblocks at every turn: Official prevalence rates are too low, emergency funds are only for eligible countries, the most affected populations for which reliable data is available (the Warao indigenous group) do not fit into the Global Fund’s definition of key populations.
The report describes how advocates tried in vain to get a decision that would apply specifically to Venezuela, to bypass the hurdles created by the many rules and exceptions in the Global Fund’s eligibility-related policies. While the Board expressed “continued concern about the resurgence of malaria, shortages of critical commodities for HIV and TB, and broader health crisis in Venezuela and its impact on the region,” it only committed to participating in a regional response. The report laments that the regional response has yet to materialize.
The way forward
In their report, ICASSO and ACCSI set forth a number of actionable recommendations for the Global Fund, the international community and the government of Venezuela. With respect to the Global Fund, the report made the following recommendations:
1. In the short term (next three to six months) the Board should immediately instruct the Secretariat to take the following actions:
a) Convene a meeting of all relevant regional U.N. and NGO partners to develop a comprehensive regional response that directs humanitarian aid to organizations that are working in the country, including through PAHO, UNAIDS, and NGOs and faith-based organizations that have a proven track record and access to those most in need.
b) Reprogram unspent funds in regional civil society grants to support Venezuelan NGOs to provide aid and to continue to monitor and report on the situation.
c) Direct fund portfolio managers working in neighboring countries to assess the current impact of Venezuela’s health system’s collapse on neighboring countries, and reprogram funds to meet urgent needs on the borders, particularly with regard to malaria.
d) Convene and support Venezuelan NGOs to develop a funding request that can provide immediate relief, and monitor and report on stock-outs through use of the multicounty grant mechanism or the NGO rule.
2. Over the longer-term (18-24 months) the Global Fund Board should:
a) Draw on the Venezuela case to review and simplify eligibility criteria to better align with the Global Fund Strategy, which focuses on combating the three diseases among “key and vulnerable populations disproportionately affected by the three diseases.”
b) Review the criteria used to determine which countries can access the emergency fund to ensure that countries with similar circumstances to Venezuela fit its eligibility criteria.
c) Establish an appeals process for non-eligible countries and disease components.
What this report and the Venezuela case highlight are some of the limitations of using gross national income per capita (GNIpc) as an absolute yardstick for development. For starters, the World Bank’s method to convert local currency into U.S. dollars uses the official exchange rate. According to a recent Reuters article, “the bolivar has lost well over 99% of its value in the past three years” and the minimum monthly wage amounts to less than $1 a day using the parallel black-market rate. And of course, GNIpc tells us nothing about the level of inequality or the degree to which wealth is concentrated in the hands of the elites. In addition, income metrics were not designed to capture disease-specific considerations or reflect a government’s ability and willingness to address health needs.
In addition to formulating and enacting a comprehensive national response for Venezuela, the Global Fund and its partners must develop a regional response to contain the fallout that is already being felt along Venezuela’s borders with neighboring countries. People, especially people in distress, are mobile. So are mosquitoes. Responding to the crisis in Venezuela protects the Global Fund’s investments in neighboring Colombia and Guyana and the rest of the region. Without this, the goal of ending the epidemics by achieving the objectives in the Fund's Strategy 2017-2022 could be in jeopardy.
It is time for the Global Fund to stop saying WHY it cannot help, and to start saying HOW it is going to help.