In 1967 Ernesto “Che” Guevara was murdered in a remote area of Bolivia after he was captured and tortured by CIA agents who then ordered a poor Bolivian solider to pull the trigger. Che was a revolutionary and a doctor who pioneered a new vision of medicine. He imagined a doctor who was an activist, who left the office and worked in the communities where the patients lived. Steve Brouwer, in Revolutionary Doctors, tells us that the Bolivian solider used by the CIA to kill Che experienced firsthand the fruits of revolutionary medicine when his eyesight was restored, forty years later, by Cuban doctors. Misión Milagro/Miracle Mission, a joint program of the Cuban and Venezuelan governments, has restored the sight of over a million people in Latin America since 2004. Che’s idea was that socialism would create new bodies, new men and women unfettered from the legacies of colonialism, slavery, and underdevelopment – strong healthy people who would create new possibilities through their labor and activism. This book illustrates how Cuba and Venezuela are changing medicine, the body, and socialism.
The Cuban revolution transformed the health experience of the poor majority. This was accomplished through massive public health campaigns and the creation of a state-run universal healthcare system. By the late 1980s, the result of these policies and programs was to change the Cuban body – to create new men and women. These were still poor people, but their bodies did not pay the cost of their poverty. But then, with the fall of the Soviet Union and Eastern Bloc, the country went into a severe economic crisis. There were massive shortages of food, clean water, electricity, and gas. Cuba declared a “Special Period in Time of Peace” and implemented emergency measures for economic recovery. Under such conditions, it would not be surprising to see a dramatic increase in death rates due to infectious disease, malnutrition, and contamination. That is not what happened. There were some increases in mortality during the first years of the crisis, especially among vulnerable populations of young children, pregnant women, and the elderly; however, these mortality rates were quickly controlled and in a few years health indices began to improve once again. Today the majority of Cubans die from diseases of affluence – heart disease and cancer – not those of poverty like infectious and parasitic diseases. Cuba’s economic and health indices challenge conventional understandings of the relationship between poverty and health.
The Cuban revolution created new models for social and economic development based on ideals of internationalism and solidarity. Since the beginning of the revolution, Cuba responded to health emergencies in Latina America and Africa and assisted countries building a public health infrastructure. As Brouwer points out, Cuba made these commitments in difficult circumstances – during a brain drain when half of their doctors left Cuba for Miami and there was no one to teach in the medical schools. Cuba sent emergency medical brigades to Chile in 1960, to Algeria in 1963, and even to Somoza-controlled Nicaragua after the 1972 earthquake. Two examples of solidarity are particularly moving – Cuba’s efforts in Africa and in Haiti. Cuba assisted newly independent Algeria in setting up a public health infrastructure; stood with Patrice Lumumba in the Congo when the US turned its back; joined with Amílcar Cabral’s struggle against Portuguese rule in Guinea-Bissau; and, most significantly, joined with the MPLA in Angola, uniting against South Africa and the CIA. Brouwer details Cuba’s 16-year commitment in Angola that helped end Apartheid and create a new Africa.
When the catastrophic earthquake struck Haiti on January 12, 2010, the health crisis was already well underway. With less than 2,000 Haitian doctors to serve the nation’s nine million people, the 344 Cuban doctors that were in the country before the earthquake were often the only ones available in rural areas. The Cuban doctors, along with 547 Cuban-trained Haitian doctors, were backed up after the earthquake by the Henry Reeve Brigade (named after a US doctor who joined the Cubans in their war for independence against Spain), which was formed in 2005 as an emergency response team. Brouwer describes how the Cuban-led teams were the largest and best organized in Haiti. He shows the flexibility of the Cuban model. They were able to respond, assess the situation, and make decisions quickly, such as bringing the 185 Haitian medical students studying in Cuba to Haiti – getting them on the ground and helping people. The Cuban-led teams had local knowledge, were integrated in the communities, and could communicate in Creole. The Cuban effort led to a new accord in which Cuba pledged to assist Haiti in building a primary healthcare system for the whole country – not just the earthquake zone.
Brouwer shows the health inequalities that existed in Venezuela in 1998 when President Chávez was elected. Although a strong public health infrastructure was built in Venezuela during the 1960s, it deteriorated due to corruption and lack of funding. It was a two-tiered system, with private clinics and plastic surgeons serving the middle and upper classes. Doctors didn’t want to live in the countryside or work in the public sector; 17 of 24 million people were underserved. Cuban-Venezuelan medical cooperation began on December 15, 1999, when Venezuela suffered a powerful rainstorm that resulted in massive flooding, mudslides, and loss of life. In response, the Cuban government sent doctors to Venezuela as part of a humanitarian aid package. Meanwhile, the new constitution guaranteed healthcare as a right. Venezuela started designing a primary care healthcare system they called Barrio Adentro – Inside the Neighborhood. The government called on the country’s doctors to volunteer in the system – only 29 participated. Cuba agreed to fill in the gap. At its peak there were 23,000 Cuban doctors working in the program.
Barrio Adentro is based on the concept of preventive community/family medicine developed in Cuba. It is designed around a consultorio popular (family doctor’s office) located in each neighborhood. All services are free and are provided by a doctor and nurse team, usually a Cuban doctor and a Venezuelan nurse. Specialized secondary health services were taken out of the hospitals and brought into the communities through Diagnostic Centers (CDI) and Rehabilitation Rooms (SRI) to treat health emergencies, diagnose and treat chronic conditions, and attend to long-term injuries and conditions complicated by years of neglect. These services were in direct response to the needs of the population – adults with speech impediments who had gone a lifetime without speech therapy, a man with a broken hand not set properly and in constant pain for seven years, people whose bodies had been torn apart by car accidents and violence. Venezuelans who were turned away from private healthcare clinics because of lack of funds for emergency appendectomies were saved by free services offered in the CDI.
The power of Brouwer’s book is that he explains the structure and policy of both the Cuban and Venezuelan programs and then details what they look like on the ground. Cuba’s dedication to internationalism and solidarity is not limited to emergency-response; they train doctors at their School of Latin American Medicine (ELAM) in Cuba. Brouwer explains how this school works, who goes there, and how these medical students and recent graduates (over 10,000 since the school began in 1998) are making health services available to the underserved in urban and rural areas of Latin America, the Caribbean, Africa, and the United States. He details the new medical curriculum used to train Cuban and Venezuelan doctors – socializing them from the first day of medical school in the revolutionary vision of medical practice. In place of the traditional medical education which begins with a focus on the basic sciences and then moves to the clinical sciences, the training of Cuban and Venezuelan doctors focuses on interdisciplinarity, integration, and participation. In the case of Venezuela, Brouwer brings us into the neighborhoods, where we see local people organize health committees, earn high school and university diplomas, work in community kitchens, and receive training to operate small businesses.
This is a grassroots movement that only works because it is built from the ground up in a participatory process. The system is not without its weaknesses (which Brouwer discusses); it is also not without enemies. There is fierce resistance from doctors who are invested in a private system of medicine for their own financial gain, and from the upper middle and upper classes who seek to “divorce” themselves from the poor majorities of their countries. Following in the footsteps of Che, the revolutionary doctor is motivated by love, has a vocation for healing, and rejects the commodification of health and medicine. Cuban and Venezuelan medical systems are not just about healthcare, they are social development programs that have as their goal the transformation of the body, the community and the global south through the practice of 21st Century Socialism.
Sociology Department; Women and Gender Program
Dominican University, River Forest, Illinois