I’ve got an article in Yahoo’s special Cuba package this week on the country’s deeply paradoxical healthcare system, and I wanted to add some context and post some reference material, in case anyone’s interested.
I went into this piece with what seemed like a very straightforward idea — to look at Cuba’s exclusion from the World Bank and IMF back in the late 1980s and early 1990s, and see what it could tell us about the failures of neoliberalism and the value of primary healthcare. I know it sounds wonky, but I swear it’s actually fascinating and important.
Cuba has managed to achieve first world health indices – namely life expectancy and infant mortality rates that match or exceed those of developed countries – despite having a third world economy. Countries with comparable GDPs to Cuba tend to have much worse health stats; and countries with much better economies than Cuba are spending a gazillion times more money to achieve the same results.
By most accounts the country has accomplished this feat through the provision of free primary health care to all of its citizens, and through the augmentation of that care with a deeply integrated public health program.
Cuba was free to do this — to invest in the basics — because unlike virtually every other developing country, it was precluded from taking “structural adjustment loans” from the World Bank or IMF. Those loans came with some brutal requirements, namely that borrowers take a hatchet to their public sector spending, including on health and education. The idea, known as neoliberalism or market fundamentalism, was that if you could only improve the economies of these third-world countries, health (and education and civil society in general) would take care of itself.
Two decades on, most sane people agree that neoliberalism is bullshit. According to at least some public health researchers, the Cuban health experiment proves that in fact the opposite is true: you don’t need a first-world economy to get first-world health; you just need good primary care.
That’s what I wanted to write about. But of course, the story ended up being much more complicated than any simple assertions could accomadate.
Yes, Cuba enacted some admirable and unprecedented primary health care programs, right as the rest of the developing world was being pushed to do the exact opposite. But it’s not entirely fair to say that they did it on a shoestring budget; they had billions in support from the Soviet Union. And when that money disappeared, things got muddy fast. The paradox is not, as is often stated, “first-world health in a third-world country.” The paradox is “first-world health and third-world medical care in the same place.”
So instead of structural adjustments and World Bank malfeasance, I ended up mostly reconstructing the timeline; looking at what Cuba did when, and how each move contributed to the overall picture.
Global health has been among the saddest casualties of newsroom budget cuts. Without the resources to do in-depth reporting in far-away places, would-be global health reporters are often limited to covering only the most basic or most sensational issues. Hang-wringing glimpses at the next pandemic rise above the fray, as do any reports on the coming HIV vaccine. But not much else.
Those headline-makers are interesting and important, to be sure; but absent a wider context they tend to skew our sense of priorities. In the end, I think we talk a lot about conquering individual diseases — particularly those that pose a threat to the west — and very little about things like access to clean water and decent nutrition. I also worry that we’ve largely ceded agenda setting power to Bill and Melinda Gates — and probably in the near future to Mark Zuckerberg — not just on the ground but in the national conversation (to the extent that a national conversation even exists around global health).
The sudden interest in Cuba felt like a rare opportunity to do more because, while predicated on something boring and basic (primary health care), the paradox is inherently interesting and has already been so oversimplified and sensationalized that nuance itself seemed like a fresh take.
There was still the problem of reporting from such a distance — a deeply frustrating and anxiety-making proposition no matter how you slice it. But as luck would have it several friends and colleagues were visiting Havana right as I was working on the piece. And not only did some of them encounter the health paradox directly, they encountered it from opposite sides.
One friend was visiting his uncle in Havana when the uncle came down with what looked like Dengue fever. The friend quickly found himself in a Cuban hospital for Cubans, which is to say one that had lots of roaches and no hand soap. Multiple people, including the doctors and nurses themselves, urged him to use whatever connections he had to get his uncle to an American facility, stat.
Another colleague – an academic – was visiting the island on business for an American university, and came down with a fresh bout of a long-recurring ailment. He landed in a clinic for tourists, where he received some of the best primary care of his life. The doctor there explained why his own doc’s prescriptions weren’t working, and then quickly prescribed a new, more effective treatment. He recovered before his trip was complete.
The Yahoo piece tries to unpack how these two parallel systems came to exist on the same small island and what, if anything, we can learn from the long arc of that story. It relies most heavily on the research of nearly a dozen anthropologists, doctors and public health experts who have worked on the island in recent years.
For a really good look at what the actual interface — doctors and patients in clinics — of cuban health looks like, see this fantastic collection of ethnographies edited by Nancy Burke of UCSF and UC Berkeley.
For a good solid overview of Cuban health care from revolution to (almost) the present day, see this report by Steven Ullman of the University of Miami’s Institute for Cuban and Cuban-American Studies.
For a comprehensive look at Alma Ata, neoliberalism, and structural violence, see various chapters in this Paul Farmer Reader.
For a look at the primary health care system in Cuba and arguments on why it necessitated exclusion from neoliberal programs, and why that was good, see any of the following studies: