P. Sean Brotherton, Revolutionary Medicine: Health and the Body in Post-Soviet Cuba (Duke University Press, 2012), £16.99
Cuba is back in the international news. In December 2014, it was announced that relations between Cuba and the United States were “thawing”; that the 65 year US embargo would soon be lifted and diplomatic relations re-established, as evinced by the opening of the Cuban embassy in Washington in July this year. This marks the latest twist in the love-hate relationship between the US and Cuba. Settled first by Spain in 1492, Cuba was ceded to the United States in 1898 after the bloody Spanish-American War, when it came under direct US military occupation. In 1899, the US War Secretary assured the Cuban people that the occupation would be transient, but Cuba still remained victim to US puppeteering during the “Bourgeois Period” (1902-58)—from the Second US Occupation and the so-called Sugar Intervention, to involvement that culminated in an autocratic military dictatorship led by the US-backed Fulgencio Batista.
The healthcare system in Cuba in this pre-revolutionary period was iniquitous, profit-driven, urban-centred, and corrupt. Accordingly, after the 1959 revolution, public health became a key priority for Fidel Castro’s party. National policy reoriented towards the priorities of ordinary people, and one of the major accomplishments was the instatement of a national health system—providing healthcare for all Cubans, even in rural areas.
The Cuban healthcare system continues to polarise international opinion: ridiculed by the right as yet another example of how socialism fails in practice; and idolised by the left who see it as a paragon of the liberatory potential of revolution. Now, as the very idea of universal health care is in question in many countries, it is a good time to read Brotherton’s ethnography of health in modern Cuba, to help us move beyond these two (equally mendacious) caricatures, and add some nuance to our conception of this contentious island state.
The fall of the Soviet bloc in 1991 heralded a decade of economic depression and political crisis known as the “special period”, during which the double whammy of the US embargo and the lack of Soviet support meant that Cuba was no longer able to provide the services, nor guarantee the rights, that it had once prided itself on. How Cuba responded to the “special period” tells us much about the pitfalls facing what anthropologist Katherine Verdery calls “post-socialist” states. Brotherton’s book examines the long-term effects of this protracted economic stranglehold on the public health system in 21st century Cuba. In this review, I will focus on how the Cuban government encouraged the flow of professionals out of, and patients into, the country as it struggled with a crisis of identity and ideology in the face of new economic challenges.
Last year’s Ebola epidemic in West Africa elicited a sluggish response from the world’s most powerful nations, but one country delivered a surprisingly swift and substantial response: Cuba. By October it had sent 165 physicians to tackle the crisis in Sierra Leone, proportionately more than any other nation. This rapid response left many in the international community asking: “How can such a small country—and a socialist one at that—afford to send so many health workers to an overseas humanitarian crisis?”
In fact, this should not have been a source of surprise; Cuba has a long history of medical outreach to other nations in the Global South, both in times of natural disaster and during anti-colonial struggles. The result is startling: Cuba has sent more medical professionals to developing nations than all the G8 countries combined.
Before the 1990s Cuba’s medical internationalism programmes operated “as a form of medical diplomacy, or ‘soft power’ politics, bartering medical aid as a means to strengthen diplomatic ties with other Third World countries” (p172). We can think of this as the kind of gift-giving explored by the anthropologist Marcel Mauss—the exchange of goods or services between social groups in such a way that builds not only wealth but solidarity—on a national scale. Brotherton sees the early Cuban medical exchanges with allied nations in this way: “using gifts as a means to create social bonds, along with the recipient’s obligation to reciprocate, either symbolically or materially” (p172). However, Brotherton fails to explore critically the geopolitics of these exchanges fully; they cannot be understood outside the context of Soviet foreign policy and its desire to strengthen anti-US alliances.
But since the start of the “special period”, the logic of these medical missions has changed along with the political atmosphere. Now both individual doctors and the state have new ulterior motives to support these international exchanges. The humanitarian doctors (“internationalistas”) are rewarded handsomely, and often return with boosted social and financial capital that distances them—biographically and geographically—from their local patients. The end result is that these clinicians take advantage of their reputation for excellence to partake in humanitarian work in other countries, leaving their own patients without the personalised primary care the Cuban system was famed for, and that their reputations were built on.
As for the state, its conception of medical aid changed vis-à-vis the “special period”. Cuba began conceiving of its medical personnel and their expertise like any other commodity, translating “the country’s human capital, in the form of physicians, into material capital, thereby providing economic opportunities…for the cash-strapped island” (p174). Policy shifted towards “transactional humanitarianism”. The financial benefits for the Cuban government were significant—28 percent of the country’s export income in 2006 came from traded medical services and personnel.
Following the creation of South-South trade agreements (such as the ALBA agreement between left-leaning Caribbean and Latin American nations), Cuba started to exchange medical for non-medical goods. One example of such an “oil for aid” deal was a scheme called Mission Barrio Adentro whereby Cuba has sent 20,000 doctors to poor parts of Venezuela since 2000 in exchange for subsidised petrol. Brotherton asks whether this was simply an example of solidarity, or rather a demonstration that medicine too has become a tradable commodity, even in Cuba. Surely, this is not what Che Guevara had in mind when he spoke of “exporting revolution”.
But Cuba’s excess of medical capacity did not only lead to the export of personnel out of the country; it also meant that Cuba was ripe to become a honeypot for medical tourists flocking in the other direction. This became possible during the “special period”, following the revision of health priorities and policies in 1991. According to Brotherton: “Cuba’s socialist project underwent relentless changes, many of which seemed to contradict its underlying revolutionary principles” (p147).
If viewed pragmatically, the party line seems reasonable. Since the revolution, Cuba had never been entirely self-sufficient, always relying on the USSR for funds and pharmaceuticals. The fall of the Soviet bloc jolted Cuba into realising the need to gain control over the means of producing its own medical equipment and drugs. But such a project required more capital than the state could afford. So laws were changed to encourage health tourism and fund the ailing public health sector until it could be self-sustaining. This meant the creation of a parallel health sector in Cuba, targeted at rich Americans attracted by “sun and surgery” packages.
This explicit shift in health policy generated a lot of resentment among ordinary Cubans, for two reasons. First, they objected to the vast sums invested in high-tech medicine and biotechnology while their once famous primary health care centres (consultarios) were neglected and becoming unfit for purpose. Second, while the new health resorts were meant to serve only foreigners, it soon became apparent that wealthy Cubans were (unofficially) using these clinics too. This signalled the beginning of a two-tier health system (one dealing in dollars, one in pesos), after years of egalitarianism. Brotherton sums up the contradictions of such “socialist entrepreneurship” by stating that the recent two-tiering of Cuban healthcare “challenges the moral legitimacy of the socialist project, yet is necessary, on the ground, for the maintenance of the country’s crumbling health and welfare system” (p165). He wonders whether such corporate thinking marks the end of socialism, or conversely whether socialist states paradoxically “provide key spaces…in which a selective form of capitalism thrives”, whereby “the globalising neoliberal logic of a free-market ideology becomes effectively ‘territorialised’ to confined spaces that do not impinge on state sovereignty” (p167).
What lessons from the Cuban experience can be applied to other countries? Despite differing historical and political trajectories, the challenges faced by Cuba provide some lessons for other states weighing up state-run and privatised health systems. I will conclude by drawing out lessons from Cuba that apply to the UK, at the macro (national) and micro (individual) levels.
At the macro level, what is abundantly clear is the importance of self-sufficiency. The Cuban health sector made huge gains between 1960 and 1990, but one thing that was never achieved was control of the means of production, with respect to pharmaceuticals, equipment etc. Cuba proves that, without such self-sufficiency, islands of socialism cannot survive the attrition caused by the caustic waves of capitalism.
At the micro level, Cuba provides a cautionary tale. During the “special period” the state was no longer capable of providing the comprehensive cradle to grave social welfare it had before. How did this affect the everyday lives of ordinary Cubans? Brotherton’s ethnographic encounters suggest that, in the vacuum left by a shrinking health system, it is left to individual Cubans to gain access to healthcare via the informal sector (“lo informal”), whether by buying drugs on the thriving black market, getting to hospital using the illegal taxis, or using nepotism to get a job in the growing informal economy. In other words, Cuba now demonstrates the idiocy of the “big society” in full force; people do create their own informal safety net, but it is full of holes and many thousands suffer needlessly as they fall through it.
It is patently clear from the stories of the individuals interviewed in the book that such state shrinkage hurts people; that the lack of welfare is embodied, resulting in worse psychological and physical health. Just as the UK government is complicit in privatisation by stealth, the Cuban state’s response to the informal health sector is contradictory. On the one hand it disapproves of habits that could “undermine the institutions of the state by siphoning limited resources away from official channels to informal networks” (p33). But at the same time it relies on these informal practices to fill in the gaps in the system, thus allowing it still to convey a facade of a functioning state. Cuba demonstrates how the informalisation of health may help governments spend less, while patients struggle more. Healthcare may be outsourced, but suffering cannot be.