To be published in Cuban Affairs Vol. 2, Issue 3-July
2007
Institute
for Cuban & Cuban-American Studies, University of Miami
Re-examining the Cuban Health Care System: Towards a Qualitative
Critique. Katherine
Hirschfeld
Introduction
Based
on such key statistical indicators as infant mortality, longevity, infectious
disease rates, and provision of health services, Cuba appears far superior to
neighboring countries. The vast majority
of scholarly analyses of Cuba’s health care system have been positive, and the
Cuban government continues to respond to international criticism of its human
rights record by citing this praise for its achievements in health and medicine
(Chomsky, 2000; Limonta and Padrón, 1991; Weiner, 1998). In fact, some scholars continue to argue
that despite the debilitating economic crisis brought on by the collapse of the
Soviet Union, Cuba’s health system remains superior to neighboring countries
such as the Dominican Republic (Acosta, 1997; Chomsky, 2000; Whiteford, 2000;
Whiteford and Martinez, 2001).
My own research, however, suggests that the
unequivocally positive descriptions of the Cuban health care system in the
social science literature are somewhat misleading. In the late
1990s, I conducted
over nine months of qualitative ethnographic and archival research in
Cuba. During that time I shadowed
physicians in family health clinics, conducted formal and informal interviews
with a number of health professionals, lived in local communities, and sought to
participate in everyday life as much as possible. Throughout the course of this
research, I found a number of discrepancies between the way the Cuban health
care system has been described in the scholarly literature, and the way it
appears to be described and experienced by Cubans themselves. This paper will provide a brief overview of
several of these issues, with the goal of offering a more balanced and
ethnographically informed portrait of the Cuban health care system. A final section will discuss these issues in
the context of the assumptions social scientists have historically made
regarding the nature of health and health systems in socialist countries.
The Formation of a Critical
Perspective: A Short Fieldwork Vignette
Conducting
qualitative ethnographic research in Cuba is not easy. North American anthropologists have
historically been viewed with suspicion by the Cuban government, and in some
cases research permission has been revoked for individuals who took a critical
perspective or inadvertently broached the issue of political dissent (Lewis,
1977; Rosendahl, 1997). In my own case,
the overwhelmingly positive portrayal of Cuba in the medical anthropology and
public health literature meant that I arrived on the island with very favorable
expectations. I never anticipated my
research would evolve into a critique.
After
just a few months of research, however, it became increasingly obvious that
many Cubans did not appear to have a very positive view of the health care
system themselves. A number of people
complained to me informally that their doctors were unhelpful, that the best
clinics and hospitals only served political elites and that scarce medical
supplies were often stolen from hospitals and sold on the black market. Further criticisms were leveled at the
politicization of medical care, the unreliability of health data and the
overall atmosphere of secrecy surrounding the prevalence of certain infectious
diseases such as HIV and tuberculosis.
Anecdotes of medical malpractice and bureaucratic mismanagement seemed
common. The Cuban health care system, as
described by Cubans in informal speech, seemed quite different from the Cuban
health care system as described by North American social scientists and public
health researchers. This is not to say
that Cubans had nothing positive to say about their health care system, only
that negative personal experiences also seemed common. Intrigued by this discrepancy between the
academic literature and my fieldwork observations, I began informally
collecting information on patient dissatisfaction and complaints.
Doing Critical Research
Unfortunately,
research exploring negative aspects of the Cuban health care system cannot be
undertaken with methodological rigor.
Public criticism of the government is a crime in Cuba, and penalties are
severe. Formally eliciting critical
narratives about health care would be viewed as a criminal act both for me as a
researcher, and for people who spoke openly with me. As a result it can be very
difficult for foreign researchers or other outsiders to perceive popular
dissatisfaction, and few Cubans are willing to discuss dynamics of power and
social control in a forthright manner.
Conversations on these topics can be quite cryptic, and meanings are
deliberately obscured.
Eliciting
critical narratives regarding the health care system therefore necessitated
informal research methods, and much of the information I gathered on these
topics is fragmented and anecdotal.
This should not be taken to mean that the data are insignificant. To the contrary, it is worth pointing out
that a number of the conclusions social scientists have previously made about
Cuba and the Cuban health care system have not been based on any ethnographic
or qualitative research. When social
scientists interested in health care have gone to Cuba, their research appears
to have been of short duration and most likely mediated through the use of
government-provided translators or guides (3). As Paul Hollander has pointed out, short term
“hosted” visits to socialist countries have historically resulted in painfully
inaccurate assumptions about the nature of life in these societies (Hollander,
1998).
In
order to obtain more reliable information about negative experiences in the
health care system, I abandoned my formal research agenda and my role as a
researcher and instead strove to learn from an insider perspective by taking on
a “membership role” (Adler and Adler, 1987).
As a number of anthropologists and sociologists have demonstrated,
research on politically sensitive topics necessarily limits one’s
methodology. The data gained from
informal participation in sensitive areas, on the other hand, while not as
analytically rigorous, can provide a wealth of insight that more distanced or
objective methods may not (Ferrell, 1998).
In
my case, abandoning a formal researcher role and taking on a membership role
meant that I spent more time in my social role as visiting student and adopted
daughter in a Cuban household than I did in my formal role as scholarly
researcher. In this context I became
much more aware of peoples’ expressions of dissent and dissatisfaction as well
as the local idiom for discussing politically sensitive topics. Instead of formal interviews, I carried on
ordinary conversations with people in the course of everyday events such as
waiting in food lines and social visits.
I was carefully never to ask politically sensitive questions, but simply
listened to people and gently probed for more information when they volunteered
this information themselves. Much to my
surprise, people seemed quite willing to discuss these kinds of issues off the
record.
These
experiences led me to conclude that any foreign researcher who did not strive
to take on a membership role could easily draw a number of erroneous
conclusions even from ostensibly confidential interviews in Cuba. People simply would not voice negative
opinions in the context of researcher-interviewee interactions. Questionnaire data would be similarly
unreliable. In fact, most Cubans I spoke
with informally seemed to view questionnaires as tools to elicit popular
reiteration of the party line. As one
friend stated, "We know we're supposed to be moving toward democratic
reforms and be able to speak out, to criticize.
But people are still scared. Any
kind of survey or opinion poll makes them afraid. No one will say what they really think."
My
increased awareness of Cuba’s criminalization of dissent raised a very
provocative question: to
what extent is the favorable international image of the Cuban health care
system maintained by the state’s practice of suppressing dissent and covertly
intimidating or imprisoning would-be critics? Obviously it is not possible to empirically
answer such a question. It is, however,
important that the question be asked, if only rhetorically. Previous research in anthropology and public
health theorizing the nature of socialist health systems has not typically
addressed issues of authoritarianism, dissent or social control in socialist
countries (1). The possibility that
favorable health indicators may be produced by very different means in Cuba
than in other countries--means that individual doctors and patients experience
negatively-has not been examined.
The
main goal of this paper will be to correct this imbalance by exploring (and
implicitly validating) two key areas of criticism Cubans commonly make of their
health care system in informal speech:
1) material shortages and inefficiency; and 2) authoritarianism and the
criminalization of dissent. Ultimately
I will argue that Cuba (like the former Soviet Union) could be more usefully
thought of as an “ideocratic” state, where political power is used to support
and defend Marxist ideology. As
retrospective studies of the Soviet health system have shown, this unique configuration
of ideology and power can produce very favorable health statistics, but can
also lead to subjectively negative experiences for individual doctors and
patients.
Material Shortages and
Inefficiency
One of the most readily apparent problems with
the health care system in Cuba is the severe shortage of medicines, equipment,
and other supplies. This problem is by
no means limited to the health sector.
Cubans often have tremendous difficulty obtaining basic consumer goods
and other necessities, including food.
In the official Cuban media and in much of the social science and public
health literature in the United States, these shortages are described as
resulting from the U.S. trade embargo (Barry, 2000; Garfield and Santana, 1997;
Garfield and Holtz, 2000; Nayeri, 1995; Simons, 1996). This assertion is not entirely incorrect--the
U.S. trade embargo certainly exacerbates material shortages on the island.
When
speaking informally, however, many Cubans state that their government
deliberately maintains economic policies that create material shortages that
exacerbate the effects of the embargo.
There is some logic to these statements.
A number of Cuba’s economic privatization efforts do not appear to have
been designed to alleviate material shortages for the Cuban populace, but to
increase hard currency earnings for the Cuban government (for a
complete overview of this argument, see
Crabb, 2001). As one friend jokingly
described,
What we have here is a mixed
economy. People call it
‘socio-cap.’ It’s not socialism, and it’s
not capitalism. Instead it’s the worst
of both. There is inequality and poverty
[of capitalism]. And also long lines
[for food and other goods] and inefficiency [of socialism]. We still have nothing to eat. (4)
A
number of key sectors of the economy (such as health) remain governed by
centralized planning, which inevitably leads to chronic material shortages and
inefficiency. In a centralized economy,
forces of supply and demand are inevitably out of balance, leading to
overproduction of some goods and underproduction of others. As a result of these shortages and
inefficiencies in the formal, planned economy, black markets (or informal
economies) emerge as an alternate source of goods and services (Eckstein, 1994;
Perez-Lopez, 1995; Verdery, 1996). These
kinds of illicit economic activities undermine the effectiveness of centralized
planning and exacerbate the inherent inefficiencies of the system. Furthermore, the formal economy could not
function without this parallel black market, given that planners simply could
not insure the necessary supplies of raw materials.
This
pattern is quite apparent in Cuba. One
study, for instance, has estimated that the average Cuban household spends
between fifty and seventy percent of its income on black market goods
(Eckstein, 1993:142). During my field
research I observed an overwhelming popular reliance on the black market or
informal economy to satisfy basic consumer needs, including health needs. Nearly everyone I knew was to some extent
dependent on goods and services procured via informal reciprocity networks of
friends and relatives (usually referred to as “socios”). The popular term
for this practice is “sociolismo,” a
term Cubans jokingly use to describe the lived reality of their socialist
system.
A Cuban friend, alternately amused and
exasperated at my naivety regarding these issues, described the relationship
between the formal and informal economies to me rather more
bluntly as follows,
It works like this. If my brother is well-connected politically,
he can get a good job in a tourist hotel.
Not only does he get to earn some American dollars, he also gets access
to the hotel’s storeroom [which represents a supply of desirable consumer goods
that are unavailable to most Cubans].
One day he may walk away [steal] with some towels for his neighbor, who
has none. Say the neighbor works in a
factory bottling beer. To repay his socio he’ll smuggle a case of beer out
of the factory and give it to the hotel employee. The hotel employee will then trade the beer
to the maid for a supply of soap, which he’ll either give to his socios or sell on the black market. Everybody does it. It’s the only way to survive.
In
my experience, the health sector often appears to be characterized by these
kinds of informal exchange networks. In one of my study communities, for
instance, no one used the formal health sector at all for commonplace medical
complaints (colds, flu, muscle strains, arthritis) for the duration of my
fieldwork. Instead, socios were tapped for medical consultations, surgical supplies,
dental equipment, pharmaceuticals (often sent by relatives from Miami) and folk
advice, while the local family doctor clinics were often bereft of both
patients and supplies. Two short case
studies illustrate these dynamics.
Case 1:
Pepe's Tooth (as told by Pepe)
When one of my wisdom teeth started
coming in it hurt terribly so I made an appointment with a friend of mine who's
a really good dentist to take it out.
Well, when we first tried to schedule it there weren't enough materials
available, so we had to put it off for a while, until he could hoard back
enough stuff [surgical materials]. First
there weren't any needles. Then no
sterile water, then no surgical thread.
About three or four months went by before we could actually do the
surgery. He had gradually stashed things
away as he found them, and then, since he was a friend of mine, he had me come
in on a Saturday when the clinic was closed to do it.
Case 2:
Sylvia’s Tooth (as told by Sylvia)
They [the dentist] tried to give me
acupuncture instead of anesthesia when I had a tooth pulled. These two nurses poked needles in my head,
but I don't think they really knew what they were doing...As soon as the dentist
started to work on my tooth I let out these screams, screamed like crazy, and
they still stood there talking... Luckily a nurse friend of mine was working in
the next room and she came and gave me a shot [of Novocain]. 'Here' she said, as she pulled the syringe
out of her pocket, 'I saved this back for you.' Thank God she showed up.
These
two cases illustrate the necessity of having strong social networks in
Cuba. Without socios to procure supplies even routine medical or dental
procedures can be difficult or impossible to endure. Furthermore, this form of theft is commonly
accepted and carries no moral stigma.
Unfortunately,
these practices serve to bankrupt the formal economy, leaving it almost an
empty shell, while much of the actual business of medicine (diagnosis, treatment,
and obtaining pharmaceuticals) is conducted through personal networks of socios using pilfered medical
supplies. A number of reports from the
former Soviet Union illustrate a similar pattern (Feshbach and Friendly, 1992;
Ledeneva, 1998; Knaus, 1981). As
Ledeneva (1998:29) has described,
Getting into a good hospital, a hospital
already filled to capacity, or the hospital with the right specialization for
one's illness still required blat
[the Soviet equivalent of sociolismo]. Surgical operations at the best medical
centres were, and still are, organized by blat: 'When I had this problem my friend arranged
that I be hospitalized in the regional clinic where he worked and not in the
city hospital to which I was affiliated.'
To arrange an appointment with a well known doctor also implied a
personal contact or acquaintance.
Doctors were important people with whom to cultivate relationships
because, in addition to providing access to hospital beds, blat with the doctor could sometimes make the difference between
whether he or she listened seriously to the patient and gave a good diagnosis
during a visit or only dealt with the matter perfunctorily.
In
such a situation, it is easy for the Cuban government to point to the empty
shell of the formal health sector as evidence of the negative impact of the
U.S. embargo. Again this is not to say
that the embargo has no health costs, only that a true assessment of the costs
of the embargo cannot be reckoned without also measuring the medical goods and
services circulating in the informal economy.
Unfortunately, economic transactions in the informal economy are
difficult to assess, and the Cuban government is not likely to encourage such
lines of inquiry.
The Politicization of Health and Health Care
Many
Cubans (including a number of health professionals) also had serious complaints
about the intrusion of politics into medical treatment and health care
decision-making. There is no right to
privacy in the physician-patient relationship in Cuba, no patients’ right of
informed consent, no right to refuse treatment, and no right to protest or sue
for malpractice. As a result, medical
care in Cuba has the potential to be intensely dehumanizing.
To
elaborate, these values (privacy, autonomy and individualism) form the
cornerstone of medical ethics as understood in most Western health systems
(Brock, 1987). Privacy and autonomy
underlie the practice of informed consent, as well as other legal codes that
ostensibly protect patients from potential abuses (unwanted treatment,
inappropriate treatment or untested experimental treatment) of modern
medicine. Legislation giving patients
these rights was enacted in the United States as a deliberate response to the
perceived excesses and ethical lapses of medicine in the 1940s and 1950s.
A
number of scholars have argued that the notion of privacy, or an autonomous
realm of personal thought and behavior, is even key to the Western conceptions
of selfhood and identity
(Bryant, 1978; Goffman, 1960; Ingham,
1978; Lifton, 1961; Shweder and Bourne, 1984; Young,
1978).
As Shweder and Bourne have stated,
We find it tempting to argue that
Western individualism has its origins in the institution of privacy--that
privacy promotes a passion or need for autonomy, which, for the sake of our
sense of personal integrity, requires privacy (p. 194).
In
Cuba, however, values such as privacy and individualism are rejected by the
socialist regime as “bourgeois values” contrary to the collective ethos of
socialism. Given these dynamics it is
not surprising that several noted Cuban dissidents, as well as North American
psychiatrists interested in the psychological dimensions of socialism have
described the subjective aspects of life in socialist regimes in terms of a literal
assault on the self. These scholars have
described tremendous emotional and psychological trauma resulting from these
dynamics (Arenas, 1994, 1993; Kleinman
and Kleinman, 1986; Kleinman, 1986; Lifton, 1956; 1961).
As
a result of this devaluation of autonomy and individuality, the health care
system in Cuba is often quite paternalistic and authoritarian, and politics
intrude into medical practice in a number of subtle and overt ways. The
eradication of the private sphere means that all activities, whether in the
household, community, or clinic become the object of medical-political
scrutiny. Cuban family doctors are
expected to attend to the “health of the revolution” by monitoring their
neighborhoods for any sign of political dissent, and working closely with CDR
officials to correct these beliefs or behaviors. Family doctors are also expected to report on
the “political integration” of their patients, and to share this information
with state authorities. Political
integration refers to such activities as participation in volunteer labor
brigades, membership in mass organizations as well as exemplary work
records.
The
extent to which family doctors actually engage in political (or economic)
surveillance of their patients appears highly variable—some doctors appear
eager to win political points by informing on their patients while others
struggle to maintain at least some confidentiality. In one clinic, for instance, I observed
several patients unselfconsciously confide potentially "subversive"
activities or sentiments (mostly involving household activities in the informal
economy) to their family doctor, who appeared to sympathize accordingly. It was clear that the relationship of trust
and caring between these doctors and their patients was forged out of their
mutual ability to protect these confidences.
On
the other hand, I also observed one physician who considered it part of his
duty to the revolution to use his intimate knowledge of patients and their
families to further the agenda of the government. He was unpopular, and many people in his
medical district chose to pursue their health care exclusively in the informal
economy--his clinic was often empty. The
use of socios as health professionals
both strengthened kin or friendship bonds within these informal networks, as
well as allowing patients to subvert the political aspect of a formal medical
visit with a militant doctor.
The
intrusion of politics in medical care is also illustrated by the militaristic
rhetoric used in Cuban medical textbooks and other health publications
detailing the ideology and practice of socialist medicine. This military model strongly emphasizes
discipline, hierarchy, and complete obedience to political authority for all
doctors. One introductory textbook, for
instance, (Rigol et al, 1994:28) described the role of the
"revolutionary" doctor as emblematic of "un militante de la salud" ("a health
militant"). Another source revealed
that the standard medical school curriculum includes several semesters of
mandatory classes in "preparación militar"--or military training (MINSAP,
1979). This training is designed to
underscore the role of the physician in the "war" against imperialism
and underdevelopment. One description of
the ideal revolutionary doctor included such personal traits as
"simplicity, modesty, and honor" as well as "patrioticmilitary
preparation necessary for the defense of the revolution and socialism on the
national or international scale" (MINSAP, 1979:39).
Two
short case studies are useful in illustrating the authoritarian and
paternalistic dimensions of the Cuban health system:
Case #1:
Reproductive Choice
The Cuban Ministry of Health [MINSAP]
expects physicians to structure their clinical interventions to achieve the
Ministry’s annual health goals. As with
other sectors of the economy, MINSAP sets statistical targets that are viewed
as the equivalent of production quotas.
The most carefully guarded of these health targets is the infant
mortality rate. Any doctor who had an
unusually high rate of infant deaths in his or her jurisdiction would be viewed
as having failed in a number of critical respects.
One of the family doctors I worked with
in Havana was quite politically militant and took these health goals very
seriously. One day during my clinic
observations I observed her scheduling an ultrasound for a pregnant woman.
"What happens if an ultrasound shows some
fetal abnormalities?" I asked.
"The mother would have an
abortion," the doctor replied casually.
“Why?” I queried.
"Otherwise it might raise the infant
mortality rate.”
Case Study #2: Medical Malpractice
One family doctor told me that she once
led an instructional seminar for medical students at the University of
Havana. During the seminar they reviewed
several problematic cases, one of which involved a patient who had died due to
mistakes made by a doctor. The case was
included as a warning to the students to be careful in following established
treatment protocols and surgical procedures.
After the seminar, one of the medical
students approached the doctor and told her that after reading the case file,
she realized that the patient in the case study was actually a close relative
of hers. She said that the doctors who
treated him told her family he had died of natural causes, and she was very
traumatized to find he had actually died from malpractice. The doctor running the seminar sympathized
with the student’s grief and anger, but told her it would be better if she kept
quiet and made no complaint against the hospital. To do so would be to risk being labeled a
political dissident or a counterrevolutionary.
The student reluctantly concurred.
In the first case, the patient is granted no
autonomy to make her own reproductive choices.
The clinical sphere is not a private space where doctors and patients
discuss medical options and come to a joint decision on how to proceed. Instead, the clinic is a political space and
decisions are often made according to the larger statistical and political
goals set by the national Ministry of Health.
There is no right to privacy in the doctor-patient relationship to
protect clinical medicine from this type of political intrusion.
The
second case also illustrates the disempowerment of individual patients that
results from the devaluation of individuality and autonomy. Collusion between physicians to cover-up
medical mistakes is not uncommon, and has been documented in a number of health
systems, including the United States and Japan (Langlie, 2002; Larimer,
2001). The key difference in the Cuban
example concerns the right of patients or family members to publicly criticize
their doctors and assert a right for compensation in known cases of
malpractice. Such a course of action
implies a notion of individual rights, and a willingness to assert those
rights. In the Cuban system, patients
are not accorded individual rights in this way, and any attempt to assert
otherwise would likely result in some form of political sanction.
Problematizing the State
These
issues--the criminalization of dissent, the denial of individual rights, and
the eradication of the private sphere--are in my opinion, fundamental in
understanding the dissatisfaction and negative experiences that doctors and
patients often report in Cuba. Previous
analyses of the Cuban health care system, however, have focused almost
exclusively on statistical health indicators and have not examined these
issues. This oversight is significant,
and merits some discussion.
Historically
medical anthropologists have not problematized the nature of power in
revolutionary socialist societies.
Instead, most of these scholars have maintained a definition of
“socialism” that implicitly
characterizes these regimes as progressive and egalitarian (Singer and
Baer, 1989; 1995; Singer, 1990; Singer, Baer
and Lazarus, 1990). Power relations have
not been discussed in these analyses, even in the post-Soviet era. Correspondingly, the criminalization of
dissent in Cuba and other revolutionary Marxist regimes has received little (if
any) attention. What is a
dissident? What is a
counterrevolutionary? Examining these
questions provides some insight into the darker aspects of socialist regimes
and socialist health systems, and offers a potential explanation for the
discrepancy between the laudatory tone of the scholarly literature and the
criticisms voiced by individual doctors and patients I spoke with in Cuba.
In
official Cuban government rhetoric, dissidents or critics are defined as
“reactionaries” or enemy agents devoted to subverting the egalitarianism and
social justice of the revolution. Their
activities and beliefs are defined as political treason, and their criticisms
are often dismissed or rejected as “imperialist propaganda.” There is no possibility of legitimate dissent
within the socialist system. This
position has often been implicitly validated by the social science and public
health literature on Cuba, which has not traditionally acknowledged or analyzed
the criticisms dissidents have made regarding the Cuban health care system (5).
Are all dissidents in Cuba
reactionaries and enemy agents seeking to discredit the government? My own ethnographic experience, as well as a
number of published narratives (Arenas, 1994; Llovio-Menendez, 1988; Mendoza
and Fuentes, 2001; Valladares, 1986) suggest otherwise. In many cases it appears that the label of
dissident is used to penalize or discredit anyone who challenges the
authoritarianism of the state or attempts to assert individual rights in the
face of what can be extremely dehumanizing conditions. An ethnographic example is useful in
illustrating these dynamics:
Ethnographic Vignette:
Who are the Counterrevolutionaries?
The niece of a friend in Santiago was
admitted to a special school for young artists in Havana. While she was there it was common knowledge
that the staff of the school was stealing food intended for the students and
selling it on the black market. As a result
the students were often forced to survive on reduced rations. One week the students were left with nothing
to eat but white rice and they spontaneously erupted into a loud demonstration
of protest. Government officials quickly
arrived on the scene and demanded, “Who are the counterrevolutionaries who have
organized this demonstration!?” Students
were interviewed one by one and pressured to inform on their classmates--to
reveal covert ‘imperialists’ who were ostensibly responsible for the
protest.
Eventually the situation was resolved and no one was arrested, but the
students remained cowed for the remainder of their time in the institute. My friend sighed after recounting me this
story. “Can you imagine? Nothing but white rice for an entire week...”
This
anecdote reveals the way dissent is constructed by the revolutionary government
in Cuba. Anyone who speaks out or
protests is vulnerable to being labeled a counterrevolutionary regardless of
the actual circumstances or seeming legitimacy of the complaints. This pattern appears common to all socialist
countries. Not only is dissent
prohibited but great effort is put forth to discredit those who voice
criticism, claim dissident status, or attempt to emigrate (see Parchomenko,
1986).
Theorizing the Socialist
State: “Ideocracy” and
Health
A number of political theorists have attempted
to explain these dynamics by examining the relationship between Marxist theory
and state power in socialist regimes.
These theorists have linked the criminalization of dissent and the
eradication of the private sphere to the extreme progressivism of Marxist
revolutions (Buber, 1996; Luow, 1997; Kolakowski, 1977; Talmon, 1960). In other words, revolutionary movements are
predicated on a belief in the collective unity and rightness of “the
masses.” The singularity of the
revolutionary vision, and its presumed historical irreversibility means that
those who speak out in opposition subsequently become defined as "traitors"
or "enemy agents" seeking to undermine the historical destiny of the
nation. The mandate for unity and
collective progress towards a utopian future effectively outlaws dissent. Critics of the regime are subsequently viewed
with great hostility, as serving to impede the collective, predestined progress
of the nation (and humanity) as a whole (Talmon, 1960:113). These
theorists have gone on to assert that these dynamics result in the creation of
“ideocratic” states. According to
Remington (1988) in an ideocratic state, political power is used to maintain
the legitimacy of revolutionary ideology--a practice that includes aggressively
policing speech and other cultural productions.
In other words, in a socialist regime--ideological dissent or deviant beliefs are equated with political
treason and heavily criminalized.
In this sense Marxist revolutionary movements
differ from other kinds of utopian philosophies (such as religious or
millenarian movements, for instance) in that the coercive powers of a secular,
rational, state are deployed to police dissent and bring the
projected utopian world into being.
Vaclav Havel has described this configuration of ideology and power as
follows,
[Under socialism] reality does not shape
theory, but rather the reverse. Power
derives its strength from theory, not from reality, and inevitably power begins
to serve the ideology rather than the other way around. Not only does this ideology guarantee power
in the present, but it increasingly becomes the guarantor of its continuity
(quoted in Gleason, 1995:185).
These
observations illustrate the necessity of including state power as a variable in
analyses of socialist health systems.
Understanding the relationship between ideology and power in a socialist
state provides an useful explanatory model for the discrepancies between the
positive image of Cuba as reported in international social science and public
health literature, and the negative experiences and criticisms reported in
informal speech by many doctors and patients.
In an ideocratic state, political power is
used to maintain the legitimacy of the ruling doctrine--in this case, Marxist
theory. If Marxist theory predicts that
health and health care delivery will improve in a revolutionary regime, then
political power will be used to insure that this pattern becomes manifest in
the revolutionary state. These efforts
can take several forms. On the one hand,
great emphasis is often placed on constructing hospitals and health facilities,
and equalizing access to health resources.
Many early Soviet and Cuban publications, for instance, emphasize this
element of concern for health and health planning, and health statistics were
often used to illustrate the superiority of the socialist regime (Berman, 1953;
Sweezy, 1949; Hollander, 1997).
On
the other hand, “revolutionary” health efforts can also include such practices
as deliberate manipulation of health statistics, aggressive political intrusion
into health care decision-making, criminalizing dissent, and other forms of
authoritarian policing of the health sector designed to insure health changes
reflect the (often utopian) predictions of Marxist theory. All of these practices have been extensively
documented for the former Soviet Union and China
(Cockerham, 1999;
Feshbach and Friendly, 1992; Fitzpatrick, 1999; Garrett, 2000; Guillemin, 1999;
Hoch, 1999; Lifton, 1976; Knaus, 1981; Tulchinsky and Varavikova, 1996). During
the Soviet era, however, the true extent of these practices was virtually
unknown in the West. Western social
scientists interested in the question of socialist health frequently cited
favorable health statistics from the USSR, China, and Cuba, but did not look
critically at the ways state power was used to create and maintain these health
indicators. In some cases it is likely
that the socialist system did genuinely improve health and health care
delivery. In other cases, it is likely
that state power was used in a way to as to give the illusion that such
positive changes were taking place by imprisoning dissident physicians,
intimidating would-be critics, and manipulating health statistics.
Conclusions: Socialism, Public Health, and Social Science
In
the introduction to this paper I raised a somewhat radical question: to what extent is the favorable international
image of the Cuban health care system maintained by the Cuban government’s
practice of suppressing dissent and covertly intimidating or imprisoning
would-be critics? The goal of the
paper has not been to answer this question so much as to argue for its
relevance in assessing the Cuban case.
When speaking informally, Cubans often make critical comments about
their experiences in the health care system.
To my knowledge, however, these locally articulated criticisms are not
included in social science or public health articles on the Cuban health care
system. As a result of this omission,
the scholarly literature on Cuba implicitly validates the point of view of the
Cuban government--that shortages are caused solely by the U.S. trade embargo,
and that that the complaints of dissidents are not legitimate. The ethnographic data and analysis presented
here are intended to challenge these assumptions. I have tried to illustrate that material
shortages are endemic to all centralized, planned economies, and that in
addition to devoting resources to hospital construction and expansion of the
health sector, ideocratic states often use very authoritarian tactics--tactics
that individual doctors and patients can subjectively experience very
negatively--to create and maintain favorable health statistics. When issues of
state power and social control are factored into the analysis, it becomes
possible to see how Cuba’s health indicators are at least in some cases obtained
by imposing significant costs on the Cuban population--costs that Cuban
citizens are powerless to articulate or protest, and foreign researchers unable
to empirically investigate.
At this point, it is important to clarify that
taking a critical perspective toward Cuba and Cuban health care does not imply
a casual dismissal of the ideals of the Cuban Revolution or the compelling
rhetoric of social progress and equality that has accompanied Cuba’s health
initiatives. As Peter Berger has pointed
out, “a critique is not an attack, but rather an effort to perceive clearly and
to weigh human costs” (1986:71). My
primary goal in this work, therefore, has been to use ethnographic data to
illustrate some of the human costs of Cuba’s “socialist health and health
care,” and to challenge the case for Cuban exceptionalism with respect to some
of the problems that have been described for other socialist health systems
such as the former
Soviet Union.
Notes
1.
There is a small but
significant body of literature in medical anthropology devoted to exploring the
relationship between capitalism, socialism, health and health care. This subfield is usually referred to as
“critical medical anthropology” and its focus is outlined in the works of Baer,
Singer and Johnsen (1986), Baer (1989; 1990), Singer (1990), Singer and Baer
(1989; 1995), and Baer, Singer and Susser (1997). Other noted social scientists and health
professionals have also contributed to this literature and shaped the approach
of critical medical anthropologists, including Howard Waitzkin (1983), and
Vincente Navarro (1976; 1978; 1986; 1989) and Ray Elling (1989). The focus of this scholarship has typically
been applying Marxist critiques to health conditions and health problems of
capitalist countries and capitalist health systems. The socialist alternative to capitalist
health and medicine is usually described by these scholars in rather idealistic
terms, based on the predictions of Marxism rather than empirical investigation
of health conditions in socialist states.
2.
Given the sensitive nature
of such comments, extra care has been taken to insure confidentiality. All names in this paper are pseudonyms, and
in some cases genders, ages and geographical locations have been changed to
further conceal identities. Phrases
marked as direct quotes were not tape recorded.
Instead I made notes to myself in my field notebook as soon as possible
after the interview or conversation took place.
3.
To my knowledge,
Scheper-Hughes, (1993) and Waitzkin and Britt (1989) offer the only two medical
anthropology studies of the Cuban health care system based on firsthand visits
and qualitative research. Unfortunately,
these authors provide little or no information describing the circumstances of
their research, their research methods or the duration of their time in
Cuba. Another work that deserves mention
here is Julie Feinsilver’s (1993) Healing
the Masses. While this book offers a
very engaging and complete analysis of Cuban health policy, it does not include
qualitative community research or clinic observations.
4.
A short overview of Cuba’s
recent economic reforms will better contextualize this remark. After the fall of the Soviet Union the severe
economic crisis in Cuba forced new economic reforms. Farmer’s markets were legalized, along with a
number of small business operations, such as family-run restaurants, bicycle
repair, and so forth. The holding of
American dollars was legalized until recently, and the state developed a dual
economic policy. Economic centralization
and rationing were kept in place for most goods and services but at the same
time hard currency markets were opened offering a number of specialized goods
that were unobtainable elsewhere. Most
Cubans, however, (especially those outside of the city of Havana) have excluded
from participation in the privatized sectors of the economy, which are largely
restricted to political elites. In
recent years even these limited reforms have been reversed, privatization has
diminished, and the economy has become recentralized in many sectors.
5.
Despite the claims of
Waitzkin and Britt (1989) that even “skeptical observers” have found nothing to
criticize in the Cuban health care system, there is a small but compelling body
of dissident literature in which criticism of health conditions and the health
care system figures prominently. See
Brown and Lago (1991), Eberstadt (1986), Mendoza and Fuentes (2001), Smith and
Llorens (1988). For more general
critiques (including Marxist critiques) see Edwards (1993), Halperin (1994),
Human Rights Watch (1990), Llovio-Menedez (1988), Timmerman (1990).
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About
the Author
Katherine
Hirschfeld is Assistant Professor at the University of
Oklahoma. She has a B.A. in
Anthropology from the University of
Massachusetts and a PhD in Anthropology from Emory
University. Hirschfeld has worked as a consultant for the
Carter Center in Atlanta, the Pan-
American Development Foundation, and the
United States Agency for International
Development. Her book, Health,
Politics and Revolution in Cuba Since 1898 was published by Transaction
Press in 2007.
