Duke University Press, 2012
288 pgs., US $24.95 (paperback)
Reviewed by Amy Cooper (University of Chicago)
In Revolutionary Medicine, P. Sean Brotherton presents a rich ethnographic analysis of health and medicine in Cuba since the late 1990s, examining state medical institutions, the everyday practices of doctors, and the pragmatic strategies of Havana residents seeking biomedical care amidst growing social and economic inequalities. The book is based on fieldwork conducted across a ten-year period, during an economic crisis known as the período especial or special period that began with the collapse of the Soviet Union in 1989 and was exacerbated by the tightening of U.S. economic sanctions on Cuba during the 1990s. In the field of health care, immense shortages in pharmaceuticals and medical equipment compromised the ability of the Cuban state to guarantee universal health care, which for decades had been promoted as a basic right. Starting in the 1990s, Cuban citizens long accustomed to freely accessible biomedicine from a highly developed network of state doctors, clinics, and hospitals suddenly found themselves having to struggle (luchar) to meet their own health needs. Broader socioeconomic transformations occurring at the same time allowed some Cubans to access money to buy desired and costly foods and medicines in an emergent dollar-based economy, while others were left to make do in a peso-based economy marked by scarcity and shortages. Brotherton shows how, over the past ten years, Cubans have navigated the uncertainties of daily life with ingenuity, anxiety, and some measure of resentment at the growing inequalities that have become a fixture of contemporary life on the island.
Revolutionary Medicine is divided into three sections. In the first part, Brotherton presents intimate and compelling vignettes of individuals whose lives are structured around obtaining and trading pharmaceuticals and medical supplies, self-diagnosing, self-medicating, and navigating complex social worlds of socios (personal contacts) to resolve different medical needs. In doing so, he shows how ordinary Cubans respond to the therapeutic vacuum caused by the collapse of the Soviet Union and the expansion of the U.S. economic embargo in the 1990s (33). Brotherton’s interlocutors often express bitterness about the deterioration of the Cuban state health system in recent years and the fact that they have to spend so much time and money on health care. From these examples, Brotherton shows how many of Havana’s residents deeply value Cuba’s longstanding guarantee of comprehensive biomedicine and experience the contemporary transformation of their public health system as a loss and a betrayal by the state.
However, even as they insist on medical care as an entitlement of citizenship, Brotherton argues that Cubans agentively respond to macroeconomic changes by taking responsibility for their own bodily health. Brotherton shows how, in addition to seeking out biomedicine by engaging in expanding informal markets of care with one’s personal contacts or socios, Cubans are also increasingly seeking out alternative forms of healing, such as in the syncretic spiritual practice of Santería and Chinese-inspired practices like acupuncture (Chapter 2). This complex array of individual bodily practices at times replaces the state’s medical system, at times undermines it (as is the case when individuals siphon drugs and medical supplies from state institutions to trade on the black market), and at times undergirds it, lending it further legitimacy. Brotherton argues that the proliferation of unofficial forms of care-seeking served to maintain population-level health indicators, for in spite of the ravages of the special period, infant mortality and life expectancy actually improved during the 1990s. These indicators, in turn, serve as a source of national and international legitimacy for Cuba’s primary health system.
Brotherton’s informants often maintained impressive home pharmacopoeias, and those with access to U.S. dollars spent nearly ten times more money on drugs and medical products each month than the average state worker’s monthly salary (29, 57). He argues that if we want to understand why Cubans invest so much time and money seeking out health care in a context of relative scarcity, we must understand the historical construction of what he calls “medicalized subjectivities.” Part II describes the historical context of medicine and state health care in Cuba from the pre-revolutionary period to the present day, part of Brotherton’s broader analytic goal of conducting a “genealogy of individual bodily practices” in contemporary Havana (4). Chapter 3 explains how the provision of health care as a basic human right became a priority of the revolutionary Cuban state from the early 1960s, and traces the impressive developments of public health campaigns and institutions through the early 1980s in expanding medical coverage and addressing longstanding population-level health problems, particularly communicable diseases and problems of malnutrition.
In the early 1980s, as Brotherton explains in Chapter 4, the Cuban state revolutionized its system of polyclinics into a unique framework known as the Programa del Médico y la Enfermera de la Familia- the Family Doctor and Nurse Program or MEF. Starting in 1984, the MEF program placed doctors and nurses in community clinics where they were meant to serve as the front line for treating medical problems in the neighborhood, and were also tasked with collecting and mobilizing detailed information about each individual and family in the area (a process known as dispensarización) to address a broad range of health risks, including those based on lifestyle choices (86). Chapter 5 provides specific examples of how health risks are imagined, made intelligible, and incorporated into public health interventions, looking at the individual and systemic factors that limit the practices of dispensarización in the community as well as the work of anti-dengue campaigns and HIV/AIDS prevention.
Providing evidence of the many ways in which public health campaigns and medical education shaped people’s everyday experiences across decades of life on the island, Brotherton shows readers how “years of state-sponsored public campaigns, politics, and practices had resulted in highly medicalized understandings of what constitutes health and physical well-being… [individuals became deeply] invested in a biomedical culture in which medicalized understandings of the body were constantly couched within larger conceptual framings of scientific advancement and socialist modernity,” (58). This has multiple implications that Brotherton draws out through his ethnography. In effect, “medicalized subjectivities” accustomed to the provision of cradle-to-grave biomedical care inform the emergence of “pragmatic subjectivities” (31) that respond to state biomedical scarcity by engaging in informal and unofficial medical care seeking.
In addition, as Brotherton suggests throughout the book, the construction of medicalized subjectivities was also a politically significant process, as access to biomedicine was inextricably tied to experiences of citizenship and political belonging. This may help explain why patients and doctors sometimes reject contemporary attempts by the Cuban state to incorporate traditional and natural medicine (or MTN) into state-run clinics (Chapter 2). As Brotherton points out, the use of herbal and home remedies was widespread before the Cuban revolution and did not necessarily disappear in subsequent decades. However, state officials sought to marginalize non-biomedical forms of healing, discursively figuring physicians as true medical authorities and encouraging the population to rely on biomedical doctors for proper diagnoses and treatments (72). The advent of the special period and immense pharmaceutical shortages led the state to reassess its position on the use of traditional and natural medicine, which it now actively promotes. Yet as Brotherton suggests, many Cubans remain skeptical of state attempts to replace biomedical drugs with “natural” formulations, likely due to both their sense of entitlement to biomedicine as well as to the historically inculcated preference for it (at least when they visit a doctor’s office).
The third part of the book focuses on two other major changes in the Cuban medical system in recent years, both of which point to Cuba’s growing role in transnational medical exchanges. Chapter 6 examines Turismo y Salud, S.A. (“Tourism and Health, Inc.”), a public-private partnership that emerged in the mid-1990s when the Cuban state turned to foreign tourism and private investment as a way of recovering from economic crisis. This fast-growing “health tourism” industry is run by the state and serves foreign clients who travel to Cuba for diagnostic and treatment “vacations” for a range of medical issues. These are private clinics that technically exclude Cuban citizens because they require a foreign passport for access, but as Brotherton shows, Cubans find ways to get around this policy by having a foreigner accompany them to the clinic or by using socios to gain unofficial access. State officials have claimed that nearly all the profits from the health tourism venture gets reinvested in the state health care system (156); nevertheless, Brotherton shows us that many of his informants view “the reemergence of a parallel, profitable, private sector health care system operating within Cuba’s socialist economy,” (156) as a grave injustice, since “the very government that for many years had preached nurturance and access to health care as a right was now participating in and promoting an economy of haves and have nots,” (159). In effect, Cubans with access to dollars can avail themselves of Turismo y Salud, S.A. and obtain pharmaceuticals and medical supplies that people feel should be freely available in state-run public clinics, but are not.
In Chapter 7, Brotherton examines another transformation of the Cuban health system in recent years, the departure of a massive number of community doctors to work in medical missions abroad since the mid-2000s, mostly in Venezuela’s Misión Barrio Adentro (“Inside the Neighborhood” Mission). Like with Turismo y Salud, S.A., the impetus for this change was largely economic. While Cuba has long promoted its own brand of humanitarianism and internationalism by sending medical professionals to work for brief stints in medical aid missions in poor countries, and even at times collecting payments from countries in a position to pay (like Libya and Iraq), the contemporary agreement between Venezuela and Cuba to effectively trade large quantities of oil for medical labor is operating at an unprecedented scale- over 20,000 Cuban medical professionals are currently living and working in community settings across Venezuela (174). Cuban doctors now undergird a community-based system of primary care in Venezuela, though ironically their departure from Cuba debilitated the family doctors program there and many community clinics have closed as a result (180). Brotherton focuses on Havana residents’ reactions to the loss of doctors from their neighborhoods, noting that their anger and resentment at losing the doctors far outweighs their sense that the international agreement has produced material benefits in their lives (as promised by state officials).
Early on, Brotherton tells readers that Revolutionary Medicine is an “ethnography of contradictions,” (xvi) a rather fitting phrase here. In the book, one can trace a number of contradictions that structure daily life and the experience of health care in Havana, as well as contradictions within informants’ own narratives and patterns of bodily practices around health. Perhaps the most obvious of these is the proliferation of informal and profit-based forms of medical practices within a nominally socialist state that continues to promote expectations for universal public health care. As part of this we have a related paradox, that it is the very proliferation of these unofficial health practices that buttresses the seemingly fractured but still functioning official health system.
Another set of contradictions has to do with Havana residents’ experiences of family doctors. We learn early on that some informants view the family doctors as “useless” because their clinics often lack necessary medications, supplies, and equipment, meaning that, as one doctor put it, they “cannot solve even the most basic problems,” (22, 108). We also learn that many people who have access to pharmaceuticals and medical supplies from unofficial sources seem to have no qualms about self-diagnosing and self-medicating for any number of ailments (28-29). Yet, at the same time, we read about residents who see the doctors as lifelines, community leaders, and invaluable local sources of care. In addition, Brotherton’s informants seem universally resentful that the Venezuelan medical mission has “bought” “their” family doctors (180), which seems to contradict a valuation of those same doctors as “useless.” Some readers may wonder at these apparent discrepancies, which could possibly be explained by different informants’ social and economic positions (i.e., people with access to dollars may find the family doctors less relevant than people who rely wholly on them for care). It may also be the case that people’s attitudes toward family doctors are shaped not only by the practices of doctors in providing physical care, but by the larger symbolic meanings of doctors in this setting, as metonymic for the entire state health care system and historically portrayed as “revolutionary heroes” (88). Brotherton shows how residents resent the loss of doctors in their community not only because they need them for medical care but because the presence and absence of doctors communicates important things about the state’s longstanding promise to care for the people’s medical needs. Indeed, one of the best things about this book is that it does not strive to analytically resolve all the paradoxes of daily life and health practices in Havana, but rather allows readers to consider the multiple realities that shape actual individual experience in this setting.
Deftly avoiding the polemics that characterize much writing on contemporary Cuba, Brotherton analyzes the complex and at times contradictory meanings and practices of health and the body in contemporary Havana with great respect for the vastly different points of view of his informants. The book does a brilliant job of demonstrating the productive relationships between individual bodily practices and macro-level socioeconomic change. Brotherton makes valuable contributions to analytic understandings of medically mediated citizenship, subjectivity, and the limits of individual agency and state authority in a context of ongoing economic crisis. Revolutionary Medicine would be an excellent stand-alone text to read in graduate or undergraduate courses in Latin American studies, medical anthropology, global health, or the medical humanities.