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  • Published in Book Reviews

As the privatisation of the NHS moves closer Ralph Graham-Leigh assesses a recent book on the successes of the Cuban healthcare system.

Steve Brouwer, Revolutionary Doctors: How Venezuela and Cuba are Changing the World’s Conception of Health Care (Monthly Review Press 2011), 256pp.

Steve Brouwer tells the story of the Cuban healthcare system which has developed since the 1959 revolution, its role as a revolutionary tool, and its export and impact on other countries, particularly Venezuela.

The author situates the roots of the system in the Cuban revolutionary tradition. It is based on the basic principle that all people deserve good healthcare, and the Guevaran view that providing international healthcare is an expression of solidarity and a way to spread revolutionary consciousness. Finally it also based on the concept of ‘Our America’, the solidarity of Spanish-speaking America, as expressed by Marti, the late nineteenth-century Cuban nationalist.

Brouwer explains how the Cuban medical system differs from standard ‘Western’ healthcare systems. The Cuban system is focused on primary care, preventative medicine and a holistic approach encompassing physical, psychological and social wellbeing. Doctors are relatively low paid, and are embedded within the community, living in similar conditions to the patients. They are drawn from a wide variety of backgrounds and provide local community-based care, including in poor or remote areas neglected under other medical systems. This partly resulted from necessity; for example the focus on preventative medicine was inspired by a lack of sophisticated medical equipment and pharmaceuticals. Moreover, many pre-revolution-trained doctors declined to practice for lower pay in poor neighbourhoods, necessitating educating new doctors from non-elite backgrounds. Brouwer describes the Cuban healthcare system as generally successful, citing Cuba’s very good health indicators, such as a lower infant mortality rate than the United States, and a much higher proportion of doctors per head than in Western countries.

The book explores how the Cuban regime has used medical assistance to increase ties with Latin American neighbours and sympathetic regimes throughout the world. Cuba has built up a significant and generally well-regarded capacity to respond to humanitarian disasters, such as the 2010 Haitian earthquake, and even offered medical assistance to the US after Hurricane Katrina (unsurprisingly the Bush administration declined this offer). Although Brouwer does briefly cover Cuba’s medical involvement in countries such as Angola, Pakistan, East Timor, Honduras, Nicaragua and Bolivia, his main focus is on Venezuela. Brouwer lived in Venezuela and bases a good portion of the book on his experiences of the Chavez regime’s attempt to set up a Cuban-style health system, ‘Barrio Adentro’ (‘inside the neighbourhoods’).

The underlying story is an inspiring one of revolutionary success against significant obstacles, of Guevara’s vision of revolutionary medicine being realised, and of an alternative to the US medical system, which encourages specialisation in lucrative fields to the detriment of the majority’s health needs. But Brouwer’s style and structure obscure the story rather than enlighten it.

Firstly, the book is a narrative rather than an analysis, and the narrative thread is confusing, with jumps between Venezuela and Cuba, between time periods, and between reportage from the author’s personal experiences, and historical background. The overall historical and political context is only established in the last three chapters, where the book explains the history of US intervention in Cuba and Venezuela, the ongoing campaign of US misinformation against Cuba and the Chavez regime, and US attempts to sabotage Cuban overseas medical programmes – ranging from encouraging overseas Cuban doctors to defect to the US, to supporting local reactionary forces who physically attack them. The lack of context in the earlier sections means that the author’s personal experiences seem to occur in a vacuum, and a reader with little prior knowledge of Cuba and Venezuela would find it hard to evaluate those experiences.

Secondly, the author appears to approve unquestioningly of all actions and policies of the Cuban and Chavez regimes, which given the lack of context, made the first half of the book a heavy read. For example, a decision by Chavez is described as ‘characteristically bold’, and the 1984 Cuban goal of having 75,000 doctors by 2000 is brilliantly described as being adjusted downwards to 65,000 in 1986 ‘in the interest of accuracy’ (p.61). All Cuban medical trainees are entirely happy and eager with no hint of any concern that would be natural for a young person about to embark on a long posting in a foreign land, while Cuban medical training is extremely high-tech, as demonstrated by the use of DVDs. Brouwer actually does inadvertently explain his unwillingness to criticise the Cuban or Chavez regimes in the penultimate chapter, when he describes the ongoing US campaign against these regimes. It is understandable that he may be disinclined to voice any criticism which would contribute to the weight of opposition propaganda. However this explanation comes at the book’s end, and the author’s uncritical style does detract from the story of Cuban medicine’s significant achievements.

It was only the need to write this review that meant I finished the book, but I am glad to have done so, as the last three chapters provided the much-needed context which meant that it ended up as a useful and informative read on the subject. However, there is undoubtedly an interesting and inspiring critical analysis waiting to be written on this subject.