Estifanos Debasu, a water, sanitation, and hygiene specialist with Doctors Without Borders/Médecins Sans Frontières (MSF), provided this account of responding to malaria and other health needs in the Venezuelan state of Bolívar, where the country's economic and political crisis is taking a heavy toll on the health system.

Growing up in Ethiopia, I hadn't heard much about Venezuela in my life. I remember being told at school that it was one of the richest places in South America, where everything was free, but that is pretty much it. I came to learn a lot more about this country in the past few years, when it was hit by a severe political and economic crisis and when the situation eventually made the headlines internationally. So when I boarded a plane to Caracas in May, I knew that the situation there was going to be different from what I had been told as a kid. I just didn't know how critical it would be.

I was sent to Venezuela by MSF on an assignment that was rather straightforward: I had to assess the most pressing needs in terms of water, sanitation, and hygiene—my field of specialty—in an area close to our medical activities. From Caracas, I headed straight to Bolívar state. There, MSF works in Sifontes, a mining area at the center of a malaria crisis.

Fifty years ago, Venezuela was one of the leading countries in South America in the battle against malaria. But the current crisis affected Venezuela's health system deeply, while making people more vulnerable to diseases. For example, informal mining activities increased during the collapse of the Venezuelan economy as more people started to put their trust into gold, coltan, and diamonds rather than the overly inflated Venezuelan currency, the bolívar.

In Bolívar state, the Sifontes mining area had become the epicenter of a malaria crisis. As soon as I set foot there, I understood that this place was perfect for mosquitoes to swarm: it was full of stagnant water and hosted thousands of people living in precarious conditions (some even sleeping in hammocks under trees). Many people would easily get infected by the disease, and the population in this area had long been highly mobile, which meant that malaria could spread quickly.

Much more needs to be done

What immediately struck me was that the population in Sifontes was aware of the risks that malaria posed, they just could not necessarily afford to prevent or treat it. Indeed, bed nets to protect oneself from the mosquitoes were extremely precious. Until last year, people had to spend four or five grams of gold to buy one. When MSF started intervening in Bolívar state, in collaboration with the Ministry of Health, and distributed tens of thousands of mosquito nets for free in 2018 and early 2019, the costs of the bed nets sold on the market went down tremendously.

In partnership with local health authorities, MSF continued a comprehensive approach to malaria in Sifontes including health promotion, spraying of houses to fight mosquitoes, malaria testing and treatment, and care for patients with severe malaria. In a few months, we witnessed a drop of malaria cases in Bolívar (not only due to our action, but also to other factors, such as the change of season).

Much more needs to be done to ensure that people living in Bolívar can be treated properly for malaria and many other health conditions.

During my time in and around Sifontes, I visited one of medical facility which MSF supports in treating malaria. It was a 12-bed health facility serving a population of tens of thousands of people. The place was barely functioning: when available, water was scarce, and electricity was also a huge issue. A few weeks before I arrived, the staff told me that they had even had to stop working for days, because a corpse was kept in an open room of the building with no air conditioning. Nobody had the equipment to collect it and remove it properly. Waste management was nonexistent. I could see rats going in and out of the building, needles on the ground and piles of untreated medical waste just outside of the facility.

"Never in my life had I seen such an alarming situation"

My visit to a second hospital in Bolívar, a few days later, only confirmed my growing concern. It was a referral facility for smaller hospitals and health centers in the region. As soon as I stepped in the hospital, I noticed that the floors hadn't been cleaned for months, and there were blood stains everywhere. Water taps were not working at all, except for one outside the facility. Piles of medical waste could be seen next to the back entrance.

I asked one of the doctors: "What do you do with it?" He sighed and answered: "Fifteen years ago, there used to be centralized waste management. But now, we just put it outside, with the rest of the trash." I was shocked. Never in my life had I seen such an alarming situation. It wasn't that these people were not doing their job properly; medical and paramedical staff were doing their best to provide clinical care to the patients. But the hospital was just dysfunctional because what was needed, such as basic water provision, just wasn't available anymore.

Water quality and waste management are usually not the first thing that comes to mind when a country is facing a political and economic crisis. But in Bolívar state, I could see the direct impact it could have on the health of its population. In the Sifontes mining area, health facilities were in a poor state, malaria-carrying mosquitoes were all around and the risk of water contamination was almost inevitable. Many persons I talked to were complaining of stomach pain and diarrhea and I was surprised there hadn't been a huge outbreak yet of waterborne diseases.

MSF subsequently decided to increase our support in the two medical facilities I had visited and to drill wells for people to access safe water in the vicinity. This is a small step, but it still means something. This year, we are also expanding our activities in other states of the country. And I hope that we'll be able to do even more in the upcoming months or years, because the people of Venezuela desperately need it.

MSF has been working in Venezuela since 2015. Teams currently work in the capital, Caracas, and in Bolívar, Sucre, Amazonas, and Anzoátegui states. From 2016 to early 2018 we also provided medical care in Maracaibo, in the northwest of the country.

MSF is an international, independent medical humanitarian organization. Our work in Venezuela is funded exclusively by private donations from individuals around the world.