Revolutionary Medicine: Health and the Body in Post-Soviet Cuba available in Paperback, eBook
Revolutionary Medicine: Health and the Body in Post-Soviet Cuba
- ISBN-10:
- 0822352052
- ISBN-13:
- 9780822352051
- Pub. Date:
- 03/21/2012
- Publisher:
- Duke University Press
- ISBN-10:
- 0822352052
- ISBN-13:
- 9780822352051
- Pub. Date:
- 03/21/2012
- Publisher:
- Duke University Press
Revolutionary Medicine: Health and the Body in Post-Soviet Cuba
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Product Details
| ISBN-13: | 9780822352051 |
|---|---|
| Publisher: | Duke University Press |
| Publication date: | 03/21/2012 |
| Series: | Experimental Futures Series |
| Pages: | 286 |
| Product dimensions: | 6.00(w) x 8.90(h) x 0.80(d) |
About the Author
P. Sean Brotherton is Assistant Professor of Anthropology at Yale University.
Read an Excerpt
REVOLUTIONARY MEDICINE
HEALTH AND THE BODY IN POST-SOVIET CUBABy P. Sean Brotherton
DUKE UNIVERSITY PRESS
Copyright © 2012 Duke University PressAll right reserved.
ISBN: 978-0-8223-5205-1
Chapter One
THE BIOPOLITICS OF HEALTH
In Cuba, health care is free. But when you go to the family doctor, the clinics, or the hospitals there are generally no medications, no disinfectants, no cotton, and sometimes no needles. If you need to be admitted to the hospital, you have to bring your own sheets, a towel, and a fan because there is no air conditioner, or it is broken. For the most part, you have to find a way to get the medications you need if they are not available, which is often the case, even the most basic drugs, such as aspirin. But, yes, health care is free.... In this country, the government goes on and on about how "nobody is without access to health care from the most advanced to most basic." But, really, if it were not for the people luchando [struggling] you would really see what our health care system actually provides. We are the ones, el pueblo [the people], that make the sacrifices so Fidel can give his grandiose speeches about how wonderful our health care system is! Marianna Díaz Rodríguez, accounting assistant, born in Havana in 1951
Since the crumbling of the Soviet bloc in 1989, Cuba's socialist health care system has been affected by market-based reforms and the government's pursuit of a dual economy in U.S. dollars and Cuban pesos. These new economic reforms, complicated by the U.S. government's tightening of economic sanctions against Cuba, have undermined individual health by affecting the availability of food, medicines, and equipment. For example, the term la lucha (the struggle) joined a legion of other terms in the early 1990s within a growing body of idiomatic phrases known as cubanismo, specialized terms or phrases either invented or commonly used that have taken on new meanings in the post-Soviet context. The term la lucha addresses the multiple ways in which individuals are dealing with the widening gap between their current standard of living and the formal state apparatus aimed at addressing the material well-being of the populace. Often used in response to "How are things?," "Estoy en la lucha" (I'm struggling) has become a way of describing the personal hardships of everyday life. Díaz Rodríguez, bitterly ironic, expresses her frustration with the Cuban state's increasing problems in providing adequate health and social services. Rather than focus on Cuba's health accomplishments as defined through the widely published vital health statistics, I want to critically examine the role of individual Cubans and professionals who are luchando to achieve their health care goals and who generate these statistics. This approach requires a shift from the macro- to the micropolitics of health, which necessarily moves the discussion away from an examination of the state as an entity that acts on individual bodies toward an examination of the multiple on-the-ground social processes that shape and influence Cuba's contemporary primary health care system.
MACROECONOMIC CHANGE
One of the major differences I have noticed after the período especial is the health situation of our country. While, generally, I think things have gotten better in terms of overall health after 1993, there have been major shortages in medicines, distribution of medicine, and basic medical supplies. However, I still maintain that health, on an individual level, is still better in the 1990s, despite the economic crisis, than in the 1980s. If you look at the basic health statistics you see that individual health has actually improved, with the average life expectancy increasing. These are indicators of the health of our country. I also strongly believe these numbers are a reflection of the work of our health care professionals and their effectiveness, despite many hardships. I think one of our strongest programs in Cuba has been the maternal-infant health program. The education for maternal and infant health care has been growing steadily over the past forty years. Our infant mortality figures nationally are seven or eight [per ten thousand live births], generally below seven. This is a reflection of the strength of our primary public health programs.
In my hospital, for example, we have the majority of necessary medicines and almost all of the antibiotics, or at the least the necessary primary materials to produce them in Cuba. We receive the primary materials mainly from Europe. However, as you know, there are some lines of antibiotics that are very expensive for us to produce. If possible, we usually get some of these medicines through donation. For example, I am treating a patient now for whom I managed to get a treatment that lasts fourteen days, and the antibiotic cost U.S. $100. Now this is just one case, but you know that such an expense for the average Cuban is impossible. However, through international donations and working through socios, you can find solutions. Javier Valdéz, Director of Primary Health Care Research in Plaza of the Revolution City Hospital, born in Havana in 1963
As Valdéz notes, physicians, like individual citizens, are not immune to the struggles of everyday life in the período especial, and many of the strategies and tactics health professionals employ, such as working through socios and transnational connections, suggest that the revolutionary work ethic is now merged with a pragmatic engagement in the informal economy. With the advent of the período especial in the early 1990s, the structural reforms implemented in the face of mounting macroeconomic changes directly affected the political economy of the health sector. Buffered for over three decades by highly favorable terms of trade with the former Soviet Union and the countries of the Council for Mutual Economic Assistance, or COMECON, that had been major catalysts in the country's social development, Cuba was now faced with a severe economic crisis. This crisis was triggered and compounded by Cuba's nearly complete dependence on the Soviet Union and by the economic embargo the U.S. government had imposed on Cuba more than forty years earlier. Between 1984 and 1989, 77 percent of Cuba's export trade was attributable to sugar, and nearly 70 percent of its import–export trade was with a single country, the Soviet Union. As a result of the Soviet collapse and the U.S. embargo, between 1989 and 1993 the country's gross domestic product fell 35 percent, and exports declined by 75 percent.
In the aftermath of the Soviet withdrawal from Cuba a complicating factor was the U.S. government's tightening of economic sanctions against Cuba in the 1990s. The so-called Torricelli-Graham Act of 1992, also known as the Cuban Democracy Act, and then the Helms-Burton bill of 1996 made clear that the intent of U.S. foreign policy toward Cuba was to foster the socialist government's defeat through what U.S. Sen. Jesse Helms called "a final push over the brink." In late December 1997 Vice President Carlos Lage of Cuba estimated that the U.S. embargo and other political factors cost the Cuban economy U.S. $800 million a year, equivalent to about 20 percent of Cuba's current import bill. The economic crisis threatened the survival of the Cuban revolution, particularly in regard to its continued commitment to basic human needs. However, the economic crisis also undermined health by affecting the availability of food, medicines, and equipment, and this subsequently challenged the developments achieved in public health.
The MINSAP reports that between 1989 and 1993 the total expenditures in hard currency in the health sector went from U.S. $227 million to $56 million. In 1990 the country imported approximately U.S. $55 million in medical and pharmaceutical products, while by 1996 this figure had dropped to U.S. $18 million, a decrease of around 67 percent. An agricultural and nutritional crisis also affected the health of the population, as a critical shortage of petroleum and the growing scarcity of replacement parts for antiquated Soviet technology brought the agricultural industry to a grinding halt in the early 1990s. Food production plummeted.
An often-cited case of the nutritional crisis was the outbreak in 1993 of an epidemic of neuropathy, which caused thousands of people to temporarily lose their vision (see introduction). This outbreak was due in part to nutritional deficiencies resulting from the dropping per-capita daily food consumption, which fell from 3,100 calories in 1989 to fewer than 1,800 in 1993. In the early 1990s a decline in medical and pharmaceutical imports seriously compromised many physicians' treatment options. As a result of a reduction in therapeutic options, increasing numbers of nonfunctioning medical devices, and equipment shortages in the country's hospitals, the capacity of secondary and tertiary institutions to undertake high-technology procedures decreased markedly. For instance, the political scientist Thad Dunning (2001) studied the effects of the período especial on the ability of hospitals in the city of Santiago de Cuba to perform major surgeries. He found that between 1989 and 2000 the number of surgeries decreased by 46 percent in selected hospitals. Dunning hypothesized that this trend was reflective of the overall decrease in high-tech procedures being performed in other hospitals throughout the country.
The withdrawal of Soviet aid and the deleterious effects of the U.S. bloqueo have been linked to such negative trends as massive shortages in pharmaceutical drugs and medical supplies. In 1997 the American Association for World Health sponsored a study of the impact of the embargo on health and nutrition in Cuba. The study suggested that while 1,297 medications were available in Cuba in 1991, physicians in 1997 had access to only about 889 of them, many of which were available only intermittently. The strengthening of the embargo in the mid-1990s resulted in drastic changes in Cuba's ability to trade with foreign countries. Despite the U.S. Department of State's contention that the embargo against Cuba did not prohibit U.S. companies and their subsidiaries from selling medicines and medical supplies to the Cuban people, the same report failed to address the almost insuperable bureaucratic barriers imposed by U.S. legislation. Laws imposed by the U.S. government, which require multiple levels of bureaucratic approval to export goods to Cuba, result in inordinate delays, increased costs, and limited access to some of the most important medicines and medical products. The added expense of imports for public health due to the embargo cost the Cuban government an estimated U.S. $45 million in 1993. From this perspective, the bureaucratic obstacles put in place by the U.S. government amount to a de facto embargo on important medicines and medical supplies.
Strangely, despite the significant macroeconomic changes affecting Cuba's health sector, the country's basic health indicators continued to increase over the course of the período especial. For example, between 1990 and 2001 the infant mortality rate declined from approximately 11 to 6 deaths per 1,000 live births, and life expectancy improved slightly between 1990 and 2001, from 75.22 to 76.3. Given this seeming paradox in Cuba's health care system, I reiterate Dunning's question: "How did the health-care system, which was deeply compromised by economic contraction, nonetheless produce an improvement of basic health indicators?" (2001, 1). Dunning provides one of the most compelling attempts to explain health care outcomes by examining patterns of resource allocations in the context of state spending and Cuba's dual monetary economy. He argues that from 1989 to 1999, the quantitative success in basic health indicators can be attributed to the state's concentration on resources for "health care within the internal, Cuban-peso dominated sector" and "the expansion of the family doctor system, primary care and other low-tech but human-capital intensive investments" (2001, 1). This idea resonates with the opinions of several health professionals I interviewed, who suggested that Cuba's vital health statistics, the infant mortality rate being the most widely referenced, was an embodiment of their hard work and daily sacrifices. However, while persuasive, this argument has several limitations. The focus on resource allocation in the form of human capital is one aspect of a much more complex series of processes. The MEF program is dependent on salaried family physicians working within the peso economy, who are essentially clinicians and who in most cases have very little equipment or medicine at their disposal. The MEF physicians' primary goals are health promotion and disease prevention, and their role is to identify health problems that can be referred to more specialized institutions. In this respect, the expansion of the MEF program at best played an influential role in maintaining Cuba's basic primary health statistics, if only because of these physicians' efforts to mobilize communities around health education (for example, the education campaigns geared toward infant and maternal health).
The relationship between the increasing role of medical intervention (or between the level of expenditures in health care) and mortality and morbidity rates are questionable. Vital health statistics are influenced by several factors, including, but not limited to, nutrition, sanitation, the general standard of living, and medical care. In this respect, an analysis of Cuba's resource allocation and funding patterns neglects other important factors that occurred in Cuba from 1989 until the present, namely, the role of individual Cubans in negotiating their own health and well-being. Rather than falling prey to statistical fetishism or an analysis of the achievements of the health sector as if they existed in a vacuum, one must look beyond the raw numbers achieved in Cuba's population health profile. The período especial called into question the moral legitimacy of the state, and it had indelible social and political consequences for both the revolutionary government and the popular support citizens and health professionals gave it.
One area among many that could considerably influence the health sector was the everyday practices of individual Cubans who, during the same period, were ingeniously maneuvering through other sectors of the economy that were undergoing state reform; for example, the legalized circulation of dollars, changes in U.S. legislation allowing remittances to be sent to the island, the opening of U.S.-dollar stores, the expansion of pharmacies and international clinics that catered to tourists and Cubans alike, and changes in laws allowing Cubans who lived abroad, especially Cuban Americans, to visit their friends and families on the island. Within this broader context it becomes apparent that the very fabric of Cuban society, including the practice of medicine, was undergoing broad social and political changes.
In the following vignettes, I examine the various ways in which individual Cubans and primary health care physicians are negotiating macroeconomic changes in their everyday lives. I present the experiences of individuals in their designated health area (área de salud) that is attended to by MEF physician-and-nurse teams stationed in small clinics known as consultorios del médico de la familia. The vignettes reflect a growing reality among a number of people whose access, or lack thereof, to foreign currency has shaped their everyday experiences in the city of Havana.
(Continues...)
Excerpted from REVOLUTIONARY MEDICINE by P. Sean Brotherton Copyright © 2012 by Duke University Press. Excerpted by permission of DUKE UNIVERSITY PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
List of Illustrations ix
List of Tables xi
Prologue xiii
Preface: An Ethnography of Contradictions xv
Acknowledgments xxv
Introduction: Bodies in States of Crisis 1
Part I Biopolitics in the Special Period 13
1 The Biopolitics of Health 15
2 Expanding Therapeutic Itineraries 35
Part II Socialist Govern Mentality, Public Health, and Risk 55
3 Medicalized Subjectivities 57
4 Curing the Social Ills of Society 84
5 Preventive Strategies and Productive Bodies 111
Part III We Have to Think Like Capitalists but Continue Being Socialists 145
6 Turismo y Salud, S A.: The Rise of Socialist Entrepreneurs 147
7 My Doctor Keeps the Lights On 169
Conclusion: Bodies Entangled in History 182
Coda 191
Notes 193
Bibliography 219
Index 245