1 A Contradictory Paradox: Discourses on Cuban Healthcare and Development Ari Coopersmith Advisor: Christy Schuetze Swarthmore College Department of Sociology/Anthropology April 2017 2 Contents Acknowledgements Preface ........................................................................................ 3 Introduction: "Distorted Development" ............................................................. 9 Chapter 1: "Revolutionary Medicine" .....................................................2 0 Chapter 2: The Cuban Health Paradox and Development Economics .............. .56 Chapter 3: The Cuban Health Paradox and Biopolitics ................................ so Conclusion: Looking Towards the Future ............................................. 100 Bibliography ............................................................................... 104 Acknowledgements: A sincere thank you to my Major and Thesis Advisor, the recently tenured Professor Christy Schuetze; to all my professors, the Sociology/Anthropology Department, and everyone else at Swarthmore; to my family; my friends; my classmates; and to the Cuban people from whom I learned so much. I feel very grateful that you are all part of my life and that you have all made this thesis possible. 3 Preface: The Cuban Health Paradox "Vivimos como pobres y morimos como ricos," or "we live like the poor and die like the rich." So goes a common saying among Cubans, which many Cubans evoke to contrast the nation's general health status with access to material resources as a whole. This saying was repeated to me by Cubans from many different walks of life when I lived in Havana from January to May 2016, studying at the University of Havana and learning about Cuban healthcare, history, literature, and economics. In Cuba, scarcities are common, but medical care is widespread. Most Cubans cannot access Wifi without first purchasing internet access cards (which many cannot afford) and traveling to special parks designated as Wifi zones (generally in cities)--speaking to loved ones, reading the news, or updating Facebook while sitting on curbs or park benches, but only when it is not raining. While almost no Cubans have Wifi in their homes, virtually all Cubans can access primary care physicians for free, who visit the homes of their patients. I met many Cubans who struggled to come up with the money to buy enough food to sustain themselves, yet who had free access to pharmaceutical drugs and medical care. One acquaintance of mine had been undergoing free ARV treatments for HIV, and had also been harassed by the police for vocally criticizing government policies on topics such as censorship. He expressed gratitude to the government for his HIV treatment and also profound discontent towards the government for his treatment as a political dissenter. I met several Cubans who had studied subjects like biochemistry or computer science at an undergraduate/graduate level, but instead had entered the tourist industry as taxi drivers or 4 tour guides because the salary of government jobs, even in high-level academic positions, was not enough to support their families. I heard of professors struggling to pay for their own public transportation to the location of their lectures. However, college and graduate education, including medical education, is free. My undergraduate classmates at the University of Havana received small stipends to attend and many will go on to graduate or professional school. I once visited a friend who worked at an elementary school, and a school administrator there gifted me several history textbooks because there was a surplus; meanwhile, the same school administrator moonlighted as a dance teacher for tourists because his job did not pay enough to make ends meet. I once played a pick-up basketball game at a park in Havana with somebody around my age--21 years old. Because of his age, goofy demeanor, and because he was just hanging out in the park, I assumed that he was, like me, a young adult still in school. I was surprised to learn after the game that he was a medical student who had already served a year in the military, and that after the game he would walk directly from the park to his house to shower, and then to a rotation in a cardiology unit at a Havana hospital. The point here is that in many cases, the social class occupied by Cuban doctors involved a level of community integration that I had not experienced in the United States. It is commonly known in Cuba that killing a cow without government permission is illegal--even if you are a farmer who owns that cow, and are slaughtering it for its meat--and one can be sent to prison for it. This is because the government guarantees milk to all children under five, and takes this right extremely seriously. Whether or not this law is enforced is one issue, 5 but the pervasion of this knowledge in Cuba exemplifies how Cuban public health practices are also connected to state control over its population. I met one man who worked in the maintenance sector of a hospital, making about $20 per month and struggling to sustain himself. He expressed to me a sentiment that several others had repeated to me before: that the government and the Revolution, despite being founded on an admirable ideology, had generally failed him. He said that the Revolution had ended decades ago because the nation's politics and living conditions were not being revolutionized, but were stagnant, and that he did not feel free or safe expressing his criticisms of the government. He thought that he lacked the relative economic security, opportunities for socioeconomic mobility, and political freedoms that he perceived to be enjoyed by many of his neighbors 50 miles to the north (in the U. S). However, he told me that despite the economic and political constraints he endured, he was happy that at least the Cuban government had gotten it right on public health; that structures such as the state and global politics had caused him hardships, but access to medicine was not one of those hardships. Cubans obviously hold a wide range of unique opinions and experiences regarding the state, the Cuban Revolution, and healthcare. The above examples illustrate encounters I had with Cubans who experienced poverty and limits on political freedoms, and also a robust public health system, administered by the same central state. In this way, geopolitical economics (the embargo in particular), and the Cuban state, come to be seen by many Cubans as influential in their lives, for better and for worse. 6 The combination of an effective public health system with extreme economic and political challenges has intrigued and confused Western commentators on Cuba, particularly those from the United States. "Cubans live like the poor, and die like the rich" is also a phrase often co-opted by these Western commentators on the Cuban healthcare system, usually used to express surprise that Cuban healthcare does not follow trends normally associated with "rich" and "poor" countries. The Cuban healthcare system has lent itself to a commonly used concept among non-Cuban development experts, governments, public health academics, and mainstream media: the idea of the "Cuban health paradox," in which the paradox lies in a misalignment of Cuban public health with paradigms of international development--paradigms that emphasize the importance of economic growth and political freedoms for promoting national progress in a general sense. The Cuban health system is often the subject of side-projects for U. S. or Canadian doctors or public health experts who take guided tours of the country. Many of these experts have found themselves delighted or inspired by the health system and sometimes publish informally-written color pieces on it for medical journals. Press, perhaps looking for compelling one-off stories, sometimes publish articles on the Cuban health paradox, in which Cuba's healthcare system becomes newsworthy or intriguing, if only on a slow news day, because of its departure from dominant notions of health care and development. The stories often contrast Cuba's 1950s cars and crumbling buildings as symbols of backwardness and underdevelopment with Cuba's domestic and international healthcare efforts as symbols of progress. Ethnographers and public health experts have also travelled to Cuba, seemingly intent on dispelling the idea that Cuba is a "utopia" for healthcare, focusing instead on the authoritarian aspects of Cuban 7 medicine. Public health literature coming out of Cuba is not necessarily widely read outside of the country. The Cuban model of health care tends to be taken by the world as a quirky example of public health in a poor, politically turbulent, and supposedly "underdeveloped" country. As a student of medical anthropology and a pre-medical undergraduate at Swarthmore College, I traveled to Cuba with a program facilitated by Sarah Lawrence College because I was interested in studying the Cuban healthcare system. I lived a Havana neighborhood called Vedado and directly enrolled at the University of Havana. I took classes at the University's Center for Cuban Economic Studies (CEEC), the Cuban University for the Arts (ISA), and the Center for Demographic Studies (CEDEM), where I also undertook a faculty-tutored research project on the effects of the U.S. embargo on public health in Cuba. In addition to academic work, I was able to speak with medical professionals, scholars, and Cuban people about the healthcare system. I wanted to investigate how Cuba had managed to overcome the associations that had been part of my forays into public health and development economics (through the lens of critical anthropology): that economic instability and a history of colonialism correlated with poor health, manifesting in poor population-level health indicators. I found that most Cubans I spoke with--both academic experts and those not involved with healthcare or politics by trade--tended to link healthcare in Cuba more to the philosophies of populism, Revolution, and even nationalism than to the types of theories I had studied in anthropology that linked poverty with poor health due to structural inequality, and put even less emphasis on economic theories that promote the efficacy of free markets to efficiently produce and allocate resources. In writing this thesis I felt that the Cuban healthcare system needed to be described from an anthropological perspective, not only as an international anomaly, as an inspiring rebellion 8 against neoliberalism, as an authoritarian dictatorship, or as part of a global communist movement, but as connected to an alternative development philosophy associated with the Cuban Revolution. I hope to bring to light the ways in which the Cuban healthcare system is portrayed by outsiders as paradoxical by presenting and analyzing a selection of illustrative examples from u.s. mainstream media, publications and policies of the government and international development organizations, and public health literature, showing how the the idea of the Cuban health paradox is based on particular neoliberal-oriented development paradigms to which Cuba does not conform. I will trace the Cuban healthcare system to its historical roots in social revolution and elucidate its basis in an ideology of development which opposes globally-dominant neoliberal development paradigms. 9 Introduction: "Distorted Development" North American monopolies ... have dedicated themselves to strengthening their colonial possessions and to perfecting their system against intrusion by old and new imperialist competitors. All this resulted in a monstrously distorted economy which has been described by economists of the imperialist regimes with a phrase demonstrative of the profound charity that they feel for us. the inferior human beings ... They give to all the peoples ofA merica ra] decorous and smooth name--the 'underdeveloped. ' What is underdevelopment? A dwarf with an enormous head and a swollen chest is 'underdeveloped' in the sense that his weak legs and short arms do not match the rest ofh is torso; he is the product of a malformation which has distorted his development. This is what we are in reality, countries that are colonial, semicolonial, or dependent. Ours are countries with distorted economies because of imperialist policy which has abnormally developed the industrial or agricultural branches to complement the imperialists' own complex economies. 'Underdevelopment' or distorted development brings along a dangerous specialization in raw materials that holds over our people the threat of hunger. We, the underdeveloped, are also countries of monoculture, of a single product, of a single market. A single product, the uncertain sale of which depends on a single market that imposes and fixes conditions, holds the great formula of imperialist economic domination as expressed in the old and eternal Roman precept, 'divide and rule. ' -Ernesto Che Guevara, 1961: "Cuba: Exceptional Case or Vanguard in the Struggle against Colonialism ?" Iterations of the idea of development have underscored histories and debates surrounding Cuba since the era of Spanish colonialism, and remain relevant to Cuba today. Guevara pointed out that discourse among imperialist powers (scholars, governments, and international development experts) in the 1950s deemed Cuba and other Latin American countries "underdeveloped," in reference to their economic structures, and their populations' access to basic needs (e.g. nutrition, housing, education, healthcare). Guevara contended that the common conception of "underdevelopment" failed to recognize that economic imperialism, not inherent "inferiority," has distorted the economic development of post-colonial nations, including Cuba. 10 Further, he argued that economic distortion of post-colonial nations has served imperialist corporate interests, and is responsible for economic "development" of imperialist countries in terms of access to cheap labor, raw materials, and markets for refined goods. Lastly, he asserted that neoliberal standards of development that conflate freer markets and more foreign investment with higher standards of living and health tend to encourage the very type of economic distortion that is later referred to as "underdevelopment." Guevara meant the "United States" when he referred to "imperialists." He argued that in terms of U.S.-induced economic exploitation and "distortion," Cuba resembled other Latin American nations, and, in line with Marxist-Leninist philosophy, that socialist, anti-imperialist revolutions were inevitable in these countries as well. On the subject of promotion of capitalism as a means of national progress or development, the Latin America scholar Aviva Chomsky (2015:10) points out: It makes little sense to ask whether capitalism or socialism 'works' better. In the United States, capitalism seems to work remarkably well: our standard of living is higher than anywhere else in the world. But other countries, just as capitalist as our own, are not faring so well. Ifwe use Haiti or Sierra Leone as our measuring stick, capitalism seems to be quite a failure as an economic system. Conversely, a heavy dose of socialism has not doomed Sweden or Norway to economic collapse, nor to authoritarian excesses. In a world historical view, what 'works' best seems to be having been a colonial power, while what 'works' worst is having been colonized. (2015: 10) In this passage, Aviva Chomsky channels Guevara, and the ideology of the Cuban Revolution, in pointing out that free market capitalism, often lauded by economists as a prerequisite for improving quality of life on a national level, has alternatively been a tool of oppressors in colonial and post-colonial nations in the form of justification for exploitation by