What does health activism mean in Venezuela\'s Barrio Adentro program? Understanding community health work in political and cultural context

AMY COOPER Saint Louis University

What does health activism mean in Venezuela’s Barrio Adentro program? Understanding community health work in political and cultural context Launched in 2003 by the leftist government of Hugo Ch´avez, Venezuela’s Barrio Adentro (Inside the Poor Neighborhood) health care program is deeply dependent on local community health workers to implement and administer clinics and various health initiatives. Based on ethnographic research conducted between 2006 and 2009, this article analyzes the experiences of Barrio Adentro community health workers (promotores) in a workingclass neighborhood in Caracas, the capital city of Venezuela. My research reveals that community health workers understood their relationship to the state as fraught, but fundamentally collaborative. In contrast, they viewed local residents as the main threat to achieving their community health goals, based on perceptions that some residents were apathetic or politically opposed to the government’s programs to promote social change. In situating this analysis in the broader social and historical context, I show how community health workers represent one of the most significant forms of state-supported activism in a country that has radically expanded social and political participation for historically marginalized groups in the name of “21st century socialism.” I argue that the state’s antineoliberal discourse, substantial investment in public health care, and employment of Cuban doctors distinguish community health work in Barrio Adentro from the experiences of community health work in other areas of Latin America, where community participation has also been framed as a form of empowerment but often serves as a mechanism to devolve state responsibilities for health care onto local communities. In focusing on the broader social, political, and economic context that gives meaning to Barrio Adentro activists, this analysis offers insights that may be applied to community health initiatives in other settings. [Community health workers, public health, medical anthropology, Venezuela, Latin America]

n this article, I develop an ethnographic analysis of community health workers’ experiences in state-led health programs in Caracas, Venezuela. Venezuela offers a unique case study of the relationship between community health workers and the state because since the early 2000s, the leftist government has expanded opportunities for community-based activism as part of a larger restructuring of political life. Many scholars have analyzed state-supported grassroots political participation in 21st century Venezuela (Fernandes 2010; Martinez et al. 2010; Schiller 2013; Smilde and Hellinger 2011), but few have studied community activism around health care, even though health care has been one of the most popular areas of activism under President Hugo Ch´avez (Mahmood et al. 2012). Unlike many forms of community activism in Venezuela that have long operated independently from state influence, activism around health care has largely been state-led since 2003 and was tied to the expansion of primary health clinics in poor neighborhoods. Founded in 2003 as a cornerstone of the government’s attempt to develop “21st century socialism,” the Barrio Adentro (Inside the Poor Neighborhood) program offers free health care provided by physicians in neighborhood settings. The program, which includes diagnostic, pharmaceutical, and rehabilitative services, transformed people’s access to medicine by instituting thousands of clinics in historically marginalized and underserved neighborhoods. Across Venezuela, this network of free clinics modeled after Cuba’s community-based Family Doctor Program became metonymic of the democratically elected leftist government itself. However, Barrio Adentro clinics have been able to function only with support from unpaid community health workers. Community health

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ANNALS OF ANTHROPOLOGICAL PRACTICE, Vol. 39, No. 1, pp. 58–72, ISSN 0094-0496, online C 2015 by the American Anthropological Association. All ISSN 1548-1425.  rights reserved. DOI: 10.1111/napa.12063

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workers organized themselves into local Health Committees (Comit´es de Salud), each of which was affiliated with a Barrio Adentro clinic. Although health volunteers I knew complained that more residents should work on health committees, activism in support of state health reforms has been extensive. For example, in a 2006 study of 11 different barrios, 56 percent of the 500 residents surveyed said they took part in some kind of community organization in their barrio. Nearly half of this group said they had served as a Barrio Adentro community health worker, meaning that approximately 25 percent of all the people surveyed had done community health work (Hellinger 2011:55). According to one report, in the five years after the institution of Barrio Adentro, more than 8,500 Health Committees had been founded by local residents (Armada et al. 2009). I focus on the experiences of voluntary community health workers in Barrio Adentro clinics, particularly those living in the workingclass neighborhood of Santa Teresa. My research reveals that promotores, or community health workers, understood their relationship to the state as fraught, but fundamentally collaborative. In contrast, they viewed local residents as the main threat to achieving their community health goals, based on perceptions that some residents were apathetic or politically opposed to the government’s programs to promote social change. I argue that community health work in Venezuela represents one of the most significant forms of state-supported activism in a country that has radically expanded social and political participation for historically marginalized groups in the name of socialist revolution. The state’s antineoliberal discourse and substantial investment in public health care distinguished community health work in Barrio Adentro from experiences of community health work in other areas of Latin America, where community participation was framed as a form of empowerment but often served as a mechanism to devolve state responsibilities for health care onto local communities.



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M e t h o d s a n d fi e l d s i t e

My argument is based on data collected during 15 months of ethnographic fieldwork in the summer of 2006 and between January 2008 and February 2009. I conducted participant observation and in-depth interviews in the Santa Teresa neighborhood in central Caracas, and carried out research with volunteers in other parts of Caracas and at the secondary and tertiary levels of the public health system. Research on promotores was part of a larger project examining the sociopolitical effects of government health interventions for historically marginalized Venezuelans. Ethnographic research allowed me to obtain detailed, nuanced information about community health workers’ experiences and perceptions, based on my observations as a participant in community health work and on data collected from interviews I conducted after developing trust and rapport with local residents.1 The colonial-era neighborhood of Santa Teresa is located in the city center, just blocks from the capital. Its 20,000 residents are socioeconomically diverse, with an average income slightly higher than that of the city’s poorest barrios. Most residents described their neighborhood as working class or lower middle class, although some residents pointed out that there was a significant amount of poverty behind closed doors. For example, one community health worker named Gabriella challenged the idea of Santa Teresa as middle class, claiming that the neighborhood’s multistory apartment blocks were in fact ranchos verticales, or “vertical shanties.” In Santa Teresa, I conducted daily participant observation with promotores, health professionals, and patients in Barrio Adentro clinics and other state-led programs (such as health fairs, exercise clubs for older adults, and door-to-door health censuses). I trained and worked with community health workers as if I were a member of their Comit´e de Salud, or Health Committee, which included a 13-week training course for promotores with a Barrio Adentro doctor in the fall of 2008. I

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got to know the most active members of Santa Teresa’s two Health Committees and spent much of my fieldwork conducting sustained, daily research with them. Although Comit´e de Salud membership was somewhat fluid and not all members were actively volunteering during the period of my research, I got to know 15 community health workers participating in Santa Teresa’s Comit´es de Salud during 2008.2 This article is based on formal, in-depth interviews with 14 community health workers in addition to data from informal conversations and participant observation. What community health workers do

Health workers in Santa Teresa took significant responsibility for the functioning of state health clinics. They shared a sense of efficacy and a commitment to improving local social problems. Although tensions existed between community health workers and state institutions and officials, promotores in Santa Teresa characterized the relationship as more collaborative than antagonistic. Community health workers rarely expressed a desire for autonomy from the state. On the contrary, they often expressed a desire for more support and a stronger state presence in health care. The work of Health Committee members was necessary for Barrio Adentro clinics to function. According to government directives, each primary care clinic should have a Health Committee comprising 10–15 members (actual numbers may vary). The main task of each volunteer was to assist in the everyday functioning of clinics, usually one day a week. They kept a running list of patients waiting to see the doctor (many of whom arrive before 8 am and wait their turn), chatted with patients (casual conversations and providing information about health and social services), organized medications, bandages, and vaccines, and cleaned the clinic. Some volunteers learned to weigh patients, take blood pressure, and administer injections. Because of concerns about crime and safety in Santa Teresa, community health workers also worked as gatekeepers for 60

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the clinic, unlocking the outer metal gate to allow patients to come and go. Health Committee members also worked outside the clinic. They acted as liaisons between the doctor and community members, escorting doctors on house calls and conducting neighborhood censuses to identify undiagnosed health problems. Community health workers assisted at irregularly scheduled Jornadas de Salud, weekend health fairs in community plazas and parks (see Figure 1). These events were one-off medical clinics open to passers-by and anyone who could not attend a clinic during working hours. Promotores at these events kept track of the patients waiting to be seen, led health promotion “chats” (charlas), and handed out health information. Because most community health workers had not worked in these kinds of settings before, they took free government courses in social work, biomedical care, and health promotion and prevention. One such course focused on a different topic related to the health of poor urban communities each week (e.g., diabetes, high blood pressure, smoking, teenage pregnancy) and practiced ways of engaging community members in discussions about accessing health care and making healthy life choices. The course I took was led by a Cuban doctor twice a week in one of the neighborhood’s two Barrio Adentro clinics, in which health workers sat in plastic chairs around the doctor’s desk and shared insights about the designated themes for that week. We were expected to distribute official health information (pamphlets, etc.) and lead health “chats” with small groups of neighbors, school students, and other local acquaintances as part of the training. Many promotores joined Health Committees before their neighborhood had its own clinic. These individuals often took the initiative to get a clinic built after months of hosting a government-employed doctor and administering a makeshift clinic in a resident’s home or shared community space. Although their efforts to get clinics built involved struggles with government officials and with

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Volunteers and state workers calculating participants’ BMI (body mass index) at an open-air health fair, Caracas. Photo by Amy Cooper.

FIGURE 1.

residents opposed to the government and its health programs, my interlocutors expressed pride in their role establishing primary care clinics. For example, Clara coordinated a Health Committee in the barrio of 23 de Enero when municipal authorities assigned two doctors to her neighborhood. She told me:

Where did the first Cuban doctors go when they arrived? Here to my house. Here were doctor Ariadne and doctor Eduardo. I gave them my food, what we could give, and toothbrushes, and face cream, all of that. When we settled on the placement and construction of the health clinic, the Health Committee had to forestall the opposition, even though there were only a few here who opposed its construction. But we achieved it. And during the construction period, in this little self-made house of my sister’s, where you’re sitting right now, was where the doctors saw their patients. That was in 2003.

Although the state promised to build clinics, government officials sometimes left residents to take charge of their construction. For example, the Ministry of Health published a manual in the early 2000s titled “You Can Supervise the Popular Clinic in Your Community.” The detailed manual guides volunteers with no background in construction work through the oversight of such a project, starting with procedures to petition the government to commission a clinic. It states:

In this manual you will learn about everything that a popular clinic should have. The mission is to observe the norms of each of these things step-bystep. On each page you will find drawings that show the appearance of each room in the clinic, accompanied by all that should be inside of it: electrical sockets, lighting, windows, showers, sinks, etc . . . as well as the external finishings, the functioning of all the services, in total, all that the popular clinic needs to be completely operational 61

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before being turned over to the Ministry of Health . . . (Ministerio de Salud n.d.:2). The manual explains that community health workers should supervise the contractors hired by the government to ensure they completed their work according to plan. When I began research in Santa Teresa in 2006, their Barrio Adentro clinic was a makeshift space inside the parish council building. When I returned in January 2008, a dedicated clinic had been built half a block from the original clinic. Lilian, the former coordinator of Santa Teresa’s Health Committee, described how they had “struggled” to get the state to build their new clinic. This involved repeated visits with municipal health officials requesting permits and construction crews to build the clinic at the site chosen by volunteers. She was excited to show me photos of herself with other community health workers, posing in hardhats in front of the clinic at different stages of construction. Motivation to become a community health worker

Most community health workers I knew had not engaged in sustained activism or volunteer work before joining a Health Committee in the early 2000s, and none had previously worked in health care. The community health workers in Santa Teresa during this period were all women, as were nearly all of those I met in other parts of Caracas.3 The gendered quality of community health activism is common in Latin America, as in other parts of the world (Nading 2013; Paley 2001). In Santa Teresa, the typical volunteer was an unemployed or underemployed middle-aged mother (14 of the 15 members I knew in the neighborhood were between 41 and 58 years old). Not all had completed high school. Community health workers’ economic situations reflected the class diversity of this neighborhood. Some lived in small condominium apartments and could afford to take a vacation from time to time, while 62

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others were unemployed and living in precarious housing situations. However, none of them considered themselves to be the poorest of the poor in this community. “Opportunities”

Many community health workers described their work in terms of oportunidades, or opportunities. This referred to the chance to improve the health and vitality of their community, as well as the opportunity to personally improve one’s own situation, specifically, to experience social and political demarginalization. When asked why they became community health workers, promotores said that the state’s material investment in social services motivated them to want to support these developments. They also said they were motivated by a public discourse of social justice and empowerment for the poor to support government health projects unfolding in their neighborhoods. For example, community health worker Carolina told me: It was our president [Hugo Ch´avez] who opened our eyes. He constantly told us and emphasized that, “you all have power, you have to claim the rights that belong to you. Everyone has a right to health, to education . . . ” He put the institutions there and he told us, “You have a right to this.” Carolina explained that the President’s discourse motivated her to take up new opportunities for claiming rights and empowering oneself, no matter what one’s age. According to Carolina, Ch´avez also “put the institutions there” via massive state investment in health and education programs. Carolina signed up for a new high school equivalency program, where she met Mari´angela and through her became involved in a state-led community activism group (not specifically focused on health) founded after Ch´avez was elected president. When the government sent a Cuban doctor to Santa Teresa in 2004, this activist group morphed into a Health Committee. They let

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the doctor live in their homes and organized a makeshift clinic space for him. Later, they successfully petitioned the government to build a Barrio Adentro clinic in their neighborhood. While Carolina seemed introverted and soft-spoken, her friend Mari´angela exuded selfconfidence and a sense of righteousness about community health work. Mari´angela was one of the only people I knew in Santa Teresa who spoke openly about her role in building a socialist society (others tended to speak euphemistically, probably to lessen the potential for political controversy in the highly polarized neighborhood). Through her physical presence and speech, Mari´angela embodied her own claims to empowerment via her participation in local social projects. She told me:

Before Ch´avez I was ‘non-participatory’: I did not participate. I dedicated myself to my house, to my work, to my son, to my husband. But there wasn’t this opportunity before; there was nothing to stimulate you. Presidents came and went, they did their own jornadas [health fairs] using their personnel from government institutions. But to give participation to the pueblo, to let you be the protagonist of your own destiny, so you could be the one who helps to solve problems? This is thanks to the president [Ch´avez] because this national project involves the inclusion of the excluded.

Mari´angela claimed that before Ch´avez became president, mobilizing to address inequality or other social problems was not something that ordinary people in Santa Teresa did with their lives; instead, they focused on their homes and families. Even if one wanted to, she claimed, there were no opportunities to participate in community activism in this neighborhood before Ch´avez. Elected neighborhood official and community health worker Lilian made a similar point when she told me:



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This is an opportunity that they gave to us so we could organize ourselves, you see? Because before, this didn’t exist. Before they didn’t taken into account whether someone wanted to be involved. Before what happened was the Mayor’s office would bring their own personnel to vaccinate and so on, but they didn’t take the community into account, there weren’t many [community] organizations. At times I pressed volunteers, suggesting that they could have organized among themselves without government support (histories of poorer barrios in Caracas show this was quite common), but they corrected me, claiming that they needed the structures and funding around which to motivate and focus their actions. What drew people to community health work were the actual programs the government put in place to provide services, material benefits, and substantive opportunities to be a part of a process of empowerment and social change. As Carolina explained, “[I became a volunteer] when the president started to change everything, to make sure that things get to the people who were most in need, like doctors . . . people having access to the things that they had never had the opportunity for before.” Magdalena, a community health worker of Afro-Venezuelan descent, told me she decided to volunteer with the Health Committee after her first visit to the Barrio Adentro clinic where she not only received free medical services for the first time in her neighborhood but also reported that it was the first time a doctor spent time engaging her in a conversation about her health. She said, “[That experience of seeing the Barrio Adentro doctor] completely changed me, my way of thinking. I received a benefit, so I participate in the community.” Although Magdalena was an idealistic person, often describing her vision of a future in which Venezuelans had full access to education and health care, she was also a pragmatist who was unwilling to sacrifice time and effort on 63

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community activism in the absence of a demonstrable commitment to health on the part of the state. Community health workers and the state

Although the relationship between community health workers and state institutions was not free from tensions, the Health Committee members I knew viewed this relationship as collaborative, beneficial, and necessary. Tensions I observed included a sense of frustration over the need to struggle for government services, the idea that nongovernmental organizations could more effectively manage some aspects of health care, and problems related to the fact that Health Committee work was unpaid. However, promotores were adamant that the state was morally and legally responsible for guaranteeing the health of the Venezuelan people by instituting national health reforms such as Barrio Adentro. They also agreed that the most appropriate role for the state was to support projects that community health workers proposed. In other words, they claimed to enjoy the freedom to petition the government for services they deemed necessary, rather than having the government institute services in a standardized manner, without regard for local needs. Among volunteers, I observed a sense of empowerment regarding what they had accomplished. Unsurprisingly, community health workers understood their role in the state health system not as supplementary, but as essential to its functioning. For example, one worker named Enrique said, “Without the cooperation [of local residents], we would not have pulled off this project [Barrio Adentro].” At the same time, I observed a sense of frustration that promotores often struggled with the government to obtain services that were guaranteed by law.4 Sometimes construction on a project stalled or stopped completely, and community health workers had to push for a resolution. They were not always successful. For example, a secondary-level health facility 64

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offering rehabilitation services (Barrio Adentro Salas de Rehabilitaci´on Integral) was under construction in a disused office building in Santa Teresa in 2006, and the work was still incomplete when I finished fieldwork in early 2009. Community health workers commonly expressed frustration that this project seemed to have been abandoned; it was unclear to them why this was so. Another area of potential concern for Barrio Adentro community health workers was the degree to which they and their work were tied to the state. While they viewed themselves as community activists, Health Committee members were also agents of the state. I rarely observed community health workers in Santa Teresa complain about their interdependence with the Venezuelan state. On the contrary, volunteers commonly wore their bright red government-issued Barrio Adentro t-shirts and baseball caps with pride (and encouraged me to do so, too). However, one health activist, Lilian, frequently expressed a desire to extend her work beyond the confines of state programs. She often talked to me about founding a care home for the elderly—an independent, not-for-profit stand-alone building that would be located in a bucolic area at the limits of the city, where older adults could live or visit. Lilian said she planned to ask the state for funding, but would insist that the project remain independent from the state. This was during a period in which Lilian had been feeding and advocating for an elderly couple who were destitute and nearly homeless, living in a run-down hotel in Santa Teresa, a few blocks from Lilian’s apartment. They seemed to have no family to care for them, and were in need of medical attention. Lilian escorted them to doctor and hospital visits. She made them soup and pungent herbal teas that she delivered to their room, which was empty of furnishings except for a bed, their few belongings kept in plastic shopping bags, and a framed photo of the Venezuelan saint of biomedicine and mystical healing, Jos´e Gregorio Hern´andez. One day, Lilian and I visited a nearby government asilio (elderly care home), where I

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watched Lilian try to secure a permanent place for this couple to live. She and an administrator spoke past each other of needs, limitations, human rights, and state responsibilities as the administrator tried to explain they simply could not take them in. Lilian’s frustration was palpable. She told me that if she could build an independent elderly care home (with government funding), she could avoid some of the bureaucracy and limitations she encountered when dealing with state officials. Lilian herself was an elected official in her parish, but she felt that the government was failing this elderly couple, who deserved to live out their days in dignity. Lilian’s desire to exert independent control over her future casa de abuelos (grandparents’ house) suggests the existence of tensions between state officials and promotores (even promotores who were employed by the state in other capacities, like Lilian) in exerting autonomy over local health projects. I did not observe this tension explicitly articulated by health volunteers in Santa Teresa beyond what I could glean from Lilian’s plans for the casa de abuelos. This is not to claim that such tensions were not present, but rather that they were not a constant or salient part of community health workers’ relationship to the state at that point in time. Instead of articulating the need for independence from the state, health volunteers articulated the need for the continuation of training, medical personnel, supplies, and financial resources, and viewed state institutions as the only viable source for these resources. Volunteers saw state health projects as vitally important, and wanted to have their say in them and ensure their success. I am not suggesting that carving out autonomy from state institutions was not a central concern in other neighborhoods or that it was not an issue worthy of attention. In Caracas neighborhoods with histories of strong grassroots activism, self-governance, and resistance to state intrusion, issues of autonomy in state-sponsored projects were subject to significant negotiations (Fernandes 2010; Martinez



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et al. 2010; Smile and Hellinger 2011). However, with the exception of Lilian’s talk of the home, a desire for independence from the state was not articulated by my interlocutors. Another tension common to community health work in general is the potential for it to be perceived not as empowering, but as exploitative for the workers. More than 30 years ago, the World Health Organization’s Alma Ata Declaration popularized the idea of enlisting community health workers to improve public health outcomes (World Health Organization [WHO] 1978). Community participation has been a goal of international public health planning since the 1970s, imagined both as a means to improve health care and as a potentially radical form of democratic empowerment (Kahssay and Oakley 1999; WHO 1978, 1986). While such projects offer a compelling vision of local democratic participation, in practice community health workers have been burdened with the responsibility of managing public health care with insufficient support. This was the case with community participation projects that swept Latin America in the 1980s and 1990s. Such projects used a discourse of local democratic empowerment to describe what amounted to the devolution of state responsibility onto individuals and communities (Morgan 1993, 2001; Ugalde 1985). Facing international pressure to impose austerity measures and reduce social spending, government officials saw community participation as primarily a cost-cutting mechanism, a way for state institutions to pass off their historical responsibility to provide health care. When local participants made demands for increased government support for health care and sanitation services, they were met with indifference or even repression (Heggenhougen 1984; Paley 2001; Zakus 1998). Reviewing the history of community participation programs in Latin America, one sociologist pessimistically suggested of the region that, “the only future of democratic participation programs is violent confrontations,” (Ugalde 1985:48). Nearly 30 years later, a democratically led shift to the left across Latin 65

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America offers opportunities to develop new models of community health work. The Venezuelan government has described Barrio Adentro and other social programs as antineoliberal measures that heal the damage done by austerity policies of the 1980s and 1990s. Although the Venezuelan state asks for voluntaristic participation in their public health projects, it does not do so in tandem with a devolution of state investment in health. As Pfeiffer and Rachel Chapman note in a review article on structural adjustment and public health, “the new Venezuelan approach to primary health care, Misi´on Barrio Adentro, represents massive investment in multisectoral health for the poor and flatly rejects structural adjustment,” (Pfeiffer and Chapman 2010:159). The government’s investment in health reform since 2003, including over 6,000 new clinics and 40,000 health professionals providing free services (many from Cuba on renewable two-year contracts), has improved access to medical care and gained widespread popularity. These achievements were not won by previous Latin American experiments in community participation that unfolded amidst shrinking government investments. While using volunteer workers cuts costs for Barrio Adentro, I did not encounter anyone during my research who suggested that community health workers enable the state to shirk its responsibilities for providing health care. Such a claim would have made little sense during a period when the state was investing in health infrastructure and services on an unprecedented scale. In the context of government programs whose stated aims included transforming Venezuelan society into more of a participatory democracy, the claim that Health Committees were meant to empower local residents was convincing to those who supported the leftist government. However, the fact remains that Barrio Adentro community health work was unpaid, and only rarely were health workers converted to paid positions within the government. As a result, women often stopped volunteering for financial reasons. For example, Carolina par66

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ticipated in irregular Health Fairs and trained with me in the promotores seminar to brush up on her skills, but quietly told me one day that she could not spend a full day per week in the clinic anymore—she needed a job, she had two young girls to think about. Providing monthly stipends could prove popular and would certainly ease women’s burdens. This idea has been applied to other state social programs such as Misi´on Madres del Barrio, which was meant to pay up to 80 percent of minimum wage to mothers in extreme poverty who worked in the home (Baribeau 2006). Yet that program has been critiqued for providing “handouts” to poor women while not ensuring that participants fulfilled the training and other services obligations of the program. A few of Santa Teresa’s community health workers made this very critique of Misi´on Madres del Barrio. Among Health Committee members I knew, the idea of voluntarism was highly valued. Volunteers valorized the idea that they were doing good works for their fellow residents. A broader shift in these women’s economic circumstances from one of financial precariousness to relative security would undoubtedly help establish the conditions under which women (and men) could more readily participate in community health work. The utopia and reality of community health work

Volunteering in Barrio Adentro represented an opportunity for neighborhood residents to achieve their vision of community health. Mari´angela told me that working as a health volunteer was about more than providing medical services; it was about promoting social equality and social justice. As she explained: My part of the volunteer work was in dentistry: assisting Doctor Ricardo with patient care . . . They taught me how to wash the tools, how to clean them, seal them up, organize them, to have them sterilized and ready to use . . . For me it was a wonderful experience. Why?

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Because it’s helping others, helping those in need . . . [With Doctora Evalina], the two of us would frequently make door-to-door visits to the pensiones [transient hotels]. That was where we witnessed the reality of the poverty, providing medical attention to so many pregnant women, as well as little kids, with illnesses . . . We are living in a country with a national project of socialism, which is not that everyone should be rich or everyone should be poor, but that there is an equality . . . in access to health, housing, education.

The majority of Santa Teresa’s community health workers described themselves as previously excluded from political life, usually due to their social class position, but also due to gender and racial inequalities. They viewed their work in Health Committees not only as a form of volunteerism for less fortunate others, but as an opportunity to transform the sociopolitical order. The cross-cultural variability of community health workers’ experiences and roles (Arvey and Fernandez 2012) is particularly evident when comparing this case study to recent scholarship on community health workers in other settings. The Venezuelan promotores I got to know viewed themselves primarily as activists rather than as health services liaisons or as caregivers. Community health workers valorized the role that local communities played in promoting social change. Health workers in Santa Teresa positioned themselves and the local community as the main actors in the process of social change and envisioned the wealthy petro-state as the proper source of resources for their local projects. As Mari´angela told me, “one has to have the mentality of wanting to resolve all this hardship, basing your work on the resources that the state assigns to the projects you propose.” For Mari´angela, the state should facilitate local projects, but not control them. The Venezuelan state was seen as possessing oil wealth that it should redistribute to people,



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because these resources belonged to the people (Coronil 1997). In discussing poverty, homelessness, untreated medical conditions, and other social problems in their neighborhood, volunteers acknowledged the partiality and incompleteness of Ch´avez-state projects such as Barrio Adentro. However, rather than blaming the government for not fulfilling its sweeping promises to eradicate poverty, disease, and class hierarchies, community health workers noted that local communities needed to be involved as well. Promotores and other residents in Santa Teresa frequently reiterated the need for communities to work together rather than relying on the state. There was a strong sense that without community involvement, even concerted state efforts to resolve social problems would fail. As one resident pointed out, the civil authorities alone could not solve problems of drugs and homelessness in the parish: “[the state] needs the help, the support of the community, because if there is no support, if we can’t unite, then there will never be any resolution.” However, in Santa Teresa any discourse of a united community was more prescriptive than descriptive. The neighborhood’s population was close to evenly divided between people who could be identified as la oposici´on (the opposition, i.e., those opposed to Chavez’s government) and those who identified as chavistas or Ch´avez supporters.5 Venezuelan society has been politically polarized by antagonisms between la oposici´on and chavistas for over a decade. In a neighborhood like Santa Teresa, political tensions constantly posed a threat to community health workers’ efforts. Community health workers, who tended to support the government, often cited political polarization as a reason why community organization seemed difficult in Santa Teresa. As Gabriella said: In this neighborhood [Santa Teresa], the people are very closed, they don’t engage with other ideologies and their opposition is radical. We went out into the 67

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streets and we wear our [red] t-shirts and [they think] “ah, no, you are Chavistas.” But I come from a neighborhood called La Vega [a nearby barrio] and I have a vision that everyone in the world works together in solidarity. My mother helped us see that life is not only my house, my space where I live, but it’s also outside all of this, in all spaces. So I carried this vision inside of me. Gabriella claimed that political life was about much more than party-based electoral politics. Yet even while eschewing party affiliations, she suggested that different approaches to life mapped onto different political identities. She associated members of the opposition with closed-mindedness and a refusal to engage with different points of view. In contrast, she subscribed to a politics that emphasized solidarity and collaboration in public space. Gabriella suggested that chavistas were more committed to improving their communities than members of the opposition. She also suggested that residents of the city’s impoverished barrios, like La Vega, were more willing to participate in community organizing and share the responsibilities of community work than neighborhoods that were not poor enough to be thought of as barrios. Many community health workers complained that those who opposed Ch´avez did not want to contribute to government-led health projects, regardless of their goals. Carolina agreed that neighborhood politics were fraught in Santa Teresa, but she blamed the large European immigrant population for the community’s failure to unite around social problems. Many Italians, Spaniards, and Portuguese immigrants moved to Caracas in the 1950s and 1960s under government-sponsored work programs, settling in central Caracas neighborhoods like Santa Teresa. Carolina said: In Santa Teresa, the people are very apathetic, everyone is in their own world. Many foreigners live here, Europeans, 68

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and they’re that way. They are inside their houses, and nothing else matters. Whatever has to be done is left to others, if they see a problem in their own community they ignore it, they wait for someone else to solve the problem, they critique but they don’t do anything. But sometimes institutions don’t respond and you have to unite to resolve the problems . . . I believe that in the barrios people are more united, they work more for their community. It’s easier to organize people that live in poor areas than in middle class areas . . . because [in middle class areas] the majority are opposition, and they don’t believe in this.

Carolina invoked national identity and class position to explain why, in her view, Santa Teresa has not achieved the levels of community activism that she saw as ideal. In addition to blaming the neighborhood’s immigrant families for a lack of community spirit, Carolina conflated class position, political position, and willingness to collaborate on community projects. She claimed that poor people “are more united” and “work more for their community,” while middle-class people affiliate with the opposition and “don’t believe in” community work. Notice that like Gabriella, Carolina idealized the city’s poor barrios as unified and committed to community work. In imagining the ideal community, Santa Teresa’s health volunteers did not look to a universal concept of community for inspiration. Nor did they to aspire to a comfortable and relatively safe middle-class existence in Caracas’ eastern suburbs. Instead, they idealized social and political life in the city’s barrios, poor and historically marginalized neighborhoods with mostly informal housing that are seen to have even higher levels of crime than the rest of the city. In talking to me and to each other, they described the barrios as authentically Venezuelan communities where neighbors socialize in public space and engage in relations of interdependency and reciprocity. Santa Teresa’s

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volunteers referred to barrios as politically empowered communities where residents organized themselves and successfully petitioned the government for resources and services. One of Lilian’s refrains throughout my fieldwork was to ask if I had “seen how things were being done in the barrios,” and to promise to bring me with her on trips she was planning to different nearby barrios (which she did on numerous occasions). Located west of Santa Teresa, the barrio of 23 de Enero was most frequently identified by health volunteers as the exemplar of “community” in Caracas. 23 de Enero was famous for its leftist radicalism, which took diverse forms over the latter half of the 20th century, including armed resistance to the state, self-policing, cultural and social programs, and semiautonomous local governance (Fernandes 2010). A story I heard on more than one occasion during my fieldwork concerned a Barrio Adentro clinic in 23 de Enero where the residents rose up against health authorities and took over the clinic to protest against its doctors for allegedly refusing to see patients outside of office hours (I also visited this clinic where I heard this history firsthand from promotores who worked there). This clinic was well known among community health workers I met, who spoke of it with respect for being completely under the control of the community, even to the point of deciding which doctors will work in the clinic (normally government officials decide). Among community health workers in Santa Teresa, admiration of the city’s barrios was so pronounced that it sometimes devolved into romanticization. Once while traveling to a barrio in Catia, Lilian stuck her head out the window of the pickup truck we had hired to drive us into the hills, drawing deep breaths and pointing at the houses residents had made from tin and breeze blocks. She announced, “people are happier up here in the cerros— they don’t have to pay apartment complex bills, and the air is fresher.” Cerros are especially precarious barrios in which people build their homes into steep hillsides that are



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vulnerable to mudslides in heavy rains. Regardless of the accuracy of Lilian’s claim that barrio residents are happier than other city residents, the valorization of barrios reveals health workers’ anxieties about their own community lacking wholesomeness, social unity, and political effectiveness. The barrios were important to volunteers because they served as a model against which to judge community life and politics in working-class Santa Teresa. Idealizing poorer communities in Caracas gave promotores in Santa Teresa a concrete model of what they were working toward, a more “natural” or “Venezuelan” society that was communal, unified, and politically engaged. This model of community vitality led them to locate the primary threat to their work in their own neighborhood, rather than in an apathetic or overbearing state apparatus.

Conclusion

The Barrio Adentro primary health program was instituted with massive levels of state investments and local participation. This differs from the neoliberal period of the 1980s and 1990s, in which Latin American governments sought voluntary community participation in health, often while implementing austerity measures in health spending. The fact that community participation was sought as an enhancement of, rather than a substitute for, the state provision of health care meant that community health workers in Santa Teresa tended to view their relationship with the state as collaborative rather than antagonistic. Perhaps one of the reasons community health workers in Santa Teresa did not seem particularly concerned about gaining autonomy from state health institutions was because they viewed the state as the appropriate and well-intentioned provider of medical services to the population. Other researchers have observed that Latin American health activists commonly demand increased 69

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state involvement in health care, and critique governments that portray health care as the responsibility of individuals or NGOs (Biehl 2007; Nading 2013; Paley 2001). Not only did most Venezuelans agree that the government should ensure universal access to health care, but survey research suggests that some viewed state-guaranteed access to health care as one of the most important features of the country’s democratic system (Hellinger 2011:43). In my fieldwork, I repeatedly observed Venezuelans reading and quoting from the 1999 constitution, particularly the sections on social rights. Many seemed to feel significant ownership over the ideas in the constitution and viewed them not as empty promises, but as viable goals to be reached through collaboration between organized communities and state institutions. In terms of challenges faced by community health workers in Santa Teresa, my research reveals that one of the most significant challenges was the fact that they were not paid for their work, especially since most workers were unemployed or underemployed. Even though many held the idea of voluntary community labor in high esteem, Venezuela’s oil wealth (which directly funded much of Barrio Adentro) could have allowed for some kind of remuneration, as other government social programs offered monthly stipends to participants. The other challenge I identified in my research was related to concerns that the community was not united in support of their work. Community health workers critiqued Santa Teresa’s residents for apathy, political opposition, and a misplaced focus on their personal lives rather than community revitalization. They idealized social activism and community life in the nearby barrios, which subverted popular discourses that stigmatized barrios as sites of criminality and poverty. This analysis shows that how community health workers understand their relationship to the state depends on historical and cultural models of the state that are particular to a locality or region. Whether community health workers privilege autonomy or interdependence from state institu70

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tions is shaped by many factors, such as the perceived political will of the government and the degree to which the state is expected to serve as the guarantor of the nation’s health. This research also shows how community health workers calibrate their efforts against the state’s efforts. Santa Teresa’s community health workers were motivated to join Health Committees when the state evidenced its promises of universal health care by instituting clinics, doctors, and prevention programs. While driven by their desire to enact social change, they were also guided by a keen sense of rights and justice, including a conviction that it was the state’s responsibility to invest in health care and provide the resources to allow them to work on health in their community. Future research in this setting could enrich these findings by examining how community health workers’ experiences have changed after the death of Hugo Ch´avez in 2013, given the material and affective investment of successive Ch´avez administrations in the Barrio Adentro health program. It is unclear how ongoing political polarization has affected community health work in the post-Ch´avez era, but it has likely led to a worsening of tensions in communities like Santa Teresa that are divided between pro- and antigovernment supporters. This would make the daily work of community health workers more difficult, and may contribute to rising pessimism about the ability of community health work to achieve positive social change. Domestic economic instability, due in part to volatility in global oil prices, could make it more challenging for poor and working-class Venezuelans to devote themselves to voluntary labor such as community health work. In a setting where community health work is strongly affiliated with certain political leaders and administrations, political polarization and changing support for political leaders could have dramatic effects for community health workers. In focusing on the broader social, political, and economic context that gives meaning to Barrio Adentro activists, this research offers insights that may be applied to community

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health initiatives elsewhere. One line of my analysis focused on the factors driving community health worker recruitment and retention in Barrio Adentro. While promotores were inspired to participate because they felt they were improving community health and wellbeing, their efforts were ultimately guided by a strong sense of reciprocity vis-`a-vis the state and its efforts to improve community health. Perceptions of political will at the level of state institutions played a major role in encouraging my interlocutors to become promotores. Community health workers persevered in their efforts, even in the face of perceived community apathy, based on the conviction that they were ultimately contributing to state-supported processes of social demarginalization and empowerment. They expected their work to be reciprocated, not by financial rewards or even the gratitude of the community, but by a sustained state commitment to social justice via investment in government social programs. Organizations seeking to recruit community health workers in other settings may or may not find that local residents view participation as part of a reciprocal relationship with governments, NGOs, and public–private partnerships. Understanding—and responding to—the culturally specific expectations that drive community health worker participation could help health initiatives achieve positive outcomes. Notes

Acknowledgments. I would like to extend my deepest gratitude to the Barrio Adentro community health workers who participated in this research project. Thanks also to Jennifer Cole, Tanya Luhrmann, Judith Farquhar, Simon May, Jonathan Rosa, Keisha-Khan Perry, Jay Sosa, Pinky Hota, Christine El Ouardani, and participants of the Irmgard Coninx Stiftung Berlin Roundtables on Health Politics in an Interconnected World, whose comments improved earlier versions of the article. This research was funded by grants from the FulbrightHays DDRA program, the Tinker Foundation, The University of Chicago, and Muhlenberg College.



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1. Participants in this study were selected based on snowballing sampling and convenience sampling. 2. I have known seven of these individuals since 2006. 3. Sujatha Fernandes, who conducted ethnographic research on community activism in Caracas during this period, estimated that over 90 percent of community health workers were women (Fernandes 2007). 4. The 1999 Constitution, instituted soon after Hugo Ch´avez was elected president, guarantees the right to health care. 5. Political identities were far more complex than this, but this core dichotomy is widely recognized. References cited

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Workers. Medical Anthropology Quarterly 27(1):84–102. Paley, Julia 2001 Marketing Democracy: Power and Social Movements in Post-Dictatorship Chile. Berkeley: University of California Press. Pfeiffer, James, and Rachel Chapman 2010 Anthropological Perspectives on Structural Adjustment and Public Health. Annual Review of Anthropology 39:149–65. Schiller, Naomi 2013 Reckoning with Press Freedom: Community Media, Liberalism, and the Processual State in Caracas, Venezuela. American Ethnologist 40:540–554. Smilde, David, and Daniel Hellinger 2011 Venezuela’s Bolivarian Democracy: Participation, Politics, and Culture under Ch´avez. Durham: Duke University Press. Ugalde, Antonio 1985 Ideological Dimensions of Community Participation in Latin American Health Programs. Social Science and Medicine 21(1):41–53. World Health Organization (WHO) 1978 Declaration of Alma Ata. Report on the International Conference on Primary Health Care, Alma-Ata, U.S.S.R. Geneva: World Health Organization. 1986 Ottawa Charter for Health Promotion. http://www.who.int/healthpromotion/ conferences/previous/ottawa/en/, accessed August 30, 2010. Zakus, J. D. 1998 Resource Dependency and Community Participation in Primary Health Care. Social Science and Medicine 46:475– 494.