Cuban Healthcare provides a stimulating overview of the possibilities of a healthcare system free of the profit motive, but lacks some critical distance, argues Caitlin Southern
Don Fitz’s Cuban Healthcare: The Ongoing Revolution covers a wide range of topics including medical and sanitary advances prior to the 1959 revolution such as viral disease inoculation and suppression, lessons learned from medical and military missions overseas and the challenges of developing a well-functioning healthcare system in the face of international hostility.
While occasionally vague and uncritical of any Cuban innovations, it is a valiant attempt to draw a comprehensive picture of the medical development of the island and the concurrent development of internal and external solidarity movements. It mentions how the legacy of the revolution and Che Guevara’s vision of a post-capitalist government is allowing Cuba to tackle the Covid-19 pandemic in a more coherent and humane manner than countries with fragmented and competitive public-health systems.
The language used can be a little repetitive in places while the overfamiliar use of ‘Fidel’ and ‘Che’ throughout the text to refer to Castro and Guevara are somewhat jarring and suggest that Fitz is not a purely academic researcher. It is interesting as an introductory text to the topic and to begin to study the role of Cuban medical interventions in other countries but has limitations as a comprehensive study.
Alternative models of health care
The importance of community care and dedicated local health teams is a clear thread running through the book, with the emphasis on preventative medicine and the links to wider social issues being explicitly made. The significance of a holistic approach to wellbeing is well contrasted to the somewhat splintered approach demonstrated in many countries with more resources. A coherent holistic attitude to medicine and social care is one which as activists we should aspire to, even if the Cuban model is not necessarily the ideal one in practice.
Fitz comes across as being a little dismissive of the concerns of doctors that the ‘Family Medicine’ approach to healthcare is less than perfect however, with their view that it causes a lack of specialisation instead turned to his argument that healthcare goes beyond the medical and into the social realm. This is true but to discount the views of people who work daily in the system in order to continue to push his utopian ideal comes across as both high-handed and ignoring inconvenient facts. The concerns could have been further explored to establish whether the practice of doctors living within the communities they serve can have a negative impact on clinical care.
While Fitz notes that the Cuban revolution was a primarily middle-class and peasant affair he doesn’t see this as a hindrance to the development of a workers’ state, conceptualising the revolution and resulting society and healthcare system as socialist. This starting point, while flawed, informs the arguments and evidence presented in the book as a whole.
The text relies heavily on the personal testimonies of medical workers who lived through the revolution and mostly foreign medical students studying in Cuba at the Latin American School of Medicine (ELAM). Students who are reliant on the state for their education and maintenance are unlikely to be critical of the system, while any public protest from doctors would be quickly seized on by mostly hostile foreign media. While not critically undermining the arguments of the work it would be useful to examine these testimonies in a more dispassionate manner.
The text mentions that governments and medical associations in countries hostile to left-wing ideas are often unwilling, or flatly refuse, to recognise Cuban medical degrees. This is ascribed by Fitz to political issues rather than being genuine concerns over the quality of teaching, which appears from the evidence and conclusions of the book to be geared towards providing medical students with practical experience of care provision rather than training them to pass exams. If this is indeed the case, then the Cuban method of teaching should be more widely embraced to reduce the tendency to view patients as customers and the treatment process as a business transaction.
Fitz seems to feel that the lack of widespread advanced diagnostic machinery in Cuba is a bonus rather than a hindrance as it demonstrates that human knowledge can render much of this machinery obsolete, a bonus for the environmental movement as the manufacture, distribution and use of them is a contributory factor in the continuation of polluting industries.
The descriptions of the medical and military missions to Africa in the 1960s and ‘70s, that were until fairly recently kept secret, warrant a serious study in themselves. Here they serve to underline the ability of Cubans to adapt under pressure and their willingness to serve the revolution. The link between these missions and the recruitment of international students to ELAM is mentioned, although as well as ideological motives for attending, the attraction of free medical education when it is usually cripplingly expensive is not understated.
The development of battlefield medicine and its application in a civilian setting helped to prepare Cuba for the difficulties that arose following the fall of the USSR and the ramping up of US aggression in the 1990s. By encouraging doctors and healthcare staff to push their limits while coping with limited supplies, Fitz feels that the reduction of consumption is also a positive model for combatting the excessive waste in the medical systems of various countries, particularly the USA.
Fitz argues that Cuban medical care is both cheaper and better than that of the USA, largely due to the need to develop under US trade embargoes and the lack of private profit driven companies. Comparative tables of child mortality and life expectancy rates with the USA are provided and show a rough parity of results between the affluent USA and the embargoed Cuba, with the argument that Cuban medicine is equal to or better than that of the USA even with the artificial restrictions placed on the nation by these outside forces being a notable refrain.
The difference in attitudes between doctors trained in Cuba and those trained elsewhere in travelling to isolated areas and remaining in disaster areas to continue providing assistance when others have left is heavily emphasised, with the remarkable note that Cuban aid teams formed a special brigade to assist in the wake of Hurricane Katrina. That their assistance was refused demonstrates the continuing hostility of successive American governments to allowing any positive publicity for the Cuban administration.
The focus on egalitarianism is interesting as it shows the commitment to ending the classist and racist attitudes inherited from the pre-revolutionary period, as well as widening women’s access to the medical discipline. While mentioning that certain attitudes such as homophobia have impacted on healthcare, the overall theme of the book is to demonstrate the massive strides taken in Cuba to provide comprehensive universal care.
Overall the book is a good starting point for a study of the challenges that are found when practising medicine on a humanitarian basis rather than with the profit motive seen in capitalist societies, but it paints an overly rosy picture of the Cuban medical system. The need for an international solidarity approach that respects individual cultures rather than imperialistically imposing their own is another point on which the comparison with the US shows Cuba in a favourable light. The subject warrants further study as each chapter could form the basis of an entire book.
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