Book Review

Healing the Masses: Cuban Health Politics at Home and Abroad

N Engl J Med 1994; 331:337-338August 4, 1994

Article

Healing the Masses: Cuban Health Politics at Home and Abroad
By Julie M. Feinsilver. 307 pp. Berkeley, Calif., University of California Press, 1993. $45 (cloth); $17 (paper). ISBN: 0-520-08218-4 (cloth)

This book is a political rather than a public health account of the considerable accomplishments of the Cuban health care system. The topic is felicitous for the debate about health care in the United States. At a time when new U.S. investments in global health are declining and domestic expenditures in the world's most costly health care system are being closely monitored by economists, an example of a poor, developing country that puts health first and achieves levels of health comparable to those in the United States at a fraction of U.S. per capita expenditure is revealing. Feinsilver, in this comprehensive, readable, and mostly jargon-free book, presents a case history of the development, change, and initial stages of decline of this system.

The ability of the Cuban health care system to achieve health indicators that are comparable to those of developed countries was discussed in international health circles throughout the 1980s. Certain developing countries with extremely low per capita incomes were able to achieve high levels of health throughout their populations. These successes fueled the argument that political will and health interventions, as opposed to general improvements in socioeconomic conditions, can lead to improved health. This book, in reviewing Cuban health politics, ideology, and accomplishments during the period from 1978 through 1992, discusses important elements of this achievement. The author made nine trips to Cuba during the study period, and the book represents the culmination of those years of interviews with health authorities, research in archives of documents, and peripatetic visits to the countryside.

The book began as a dissertation at Yale University, and the first chapter provides the requisite theoretical framework, paying homage to French social philosophy and a dissertation advisor. In this jargon-filled discussion, the author addresses the “mytho/logics” of Cuban health politics, citing, among others, Pierre Bourdieu. This literature may be new to health professionals, but in this case it is apt. Although this chapter does little to demystify the language of French social philosophy, the book can be read as one long example of the role of myth and symbol in health and politics. Feinsilver documents how in Cuba health, instead of an indirect goal of development, becomes the direct goal of development, symbolizing the success of the revolution, even in the face of declining living standards, and success in the fraternal and fratricidal competition that marks U.S. and Cuban relations (although disappointingly, this international political rivalry is not sufficiently developed in the book).

Health and equity are natural partners in social programs, and successful early Cuban efforts to stamp out high rates of infectious disease and malnutrition are legion. These efforts were accomplished not through primary health care and paraprofessional health workers, but through physicians based in polyclinics. The explosion in the number of physicians, the growth of tertiary and high-technology health care, and the development and export of biotechnology are themes that run through the book, with obvious parallels to the United States. In fact, primary health care reintroduces itself into Cuban medicine only through the export of physicians to other developing countries, which is used by Cuba to demonstrate its alternative to U.S. foreign-aid policy.

Following Cuba through its health transition is an important contribution of the book, if unappreciated by the author. The health transition is the third wave of major changes in health (the first two waves being demographic and epidemiologic). Jack and Pat Caldwell and others associated with the Health Transition Review argue that this transition is brought about not through changes that directly affect fertility or mortality, as in the case of the demographic transition, or changes in disease patterns, as in the case of the epidemiologic transition, but through changes in social, cultural, and political phenomena. Healing the Masses serves as a case history of this transition, tracing both the national features and the regional and international consequences that followed the sad decline in health and living standards in Cuba after the collapse of the Soviet Union and the Eastern European socialist states.

For a U.S. citizen and political scientist conscious of the long history of U.S. exploitation, invasion, and embargo of Cuba, writing about Cuba is a difficult task. As a rule, Cuban deficits in the face of this history are consistently discounted. Are the deficits due to inherent and systemic problems or to the impact of a hostile policy and embargo? As the author notes, “It has been said that researchers who go to Cuba for one week write a book. Those who go for two weeks write an article, and those who go for longer don't write anything.” I picked up this book with the normal skepticism, only to be pleased at the way the author strove for objectivity, laying out a theoretical framework, assessing Cuban health accomplishments in Cuban terms, and concluding with a critical chapter, as well as formidable notes and bibliography. (Readers may wish to purchase the book for this 78-page feature alone.)

However, the book is marred in places by a willingness to accept documentation of technical accomplishments uncritically. For example, a table comparing Cuban and U.S. infant-mortality rates for 1986 assigns Cuba a rate of 15 per 1000 and the U.S. a rate of 56 per 1000. In a chapter on community participation, the author discusses uncritically the massive outbreak of dengue hemorrhagic fever and the response to it, first reporting the Cuban assertion that the viral serotype was introduced by the United States into Cuba and then reporting that the outbreak was overcome through widespread community participation. Yes, there was participation and mobilization of the Cuban people to clean up breeding sites around their homes, but it was also participation a la Singapore, buttressed by threats of sanctions, both financial and penal, for nonparticipation. Furthermore, the low number of deaths, it could be argued, was due more to the excellent response of the health care system than to control of the entomologic source of infection. In addition, the pattern of cases followed an epidemiologic curve similar to that for other outbreaks, and the Cuban response cost a fortune. Practical elimination of the vector was achieved after the outbreak (which can be said for no other infected country in the Americas), but what were the authorities doing before the outbreak?

At least the author is suspicious of Cuba's claims for its quarantine program for people infected with the human immunodeficiency virus (HIV). A number of North American intellectuals who have visited the island have been embarrassed about having supported Cuban claims of the effectiveness of this system. Putting aside the serious ethical implications of this intervention, there are several other concerns. First, although a large proportion of the population is reported to have been tested, this number does not approach 100 percent. One suspects that many people at high risk avoid being tested at all costs, probably to the detriment of their health. Second, other Caribbean islands (with the important symbolic exception of Puerto Rico), such as Jamaica, have had very low levels of HIV infection without the onerous burden of quarantine.

Ultimately, Healing the Masses does serve to demonstrate the author's thesis about health and symbolic politics. Additional conclusions can also be drawn. Cuba's health care system, by focusing on certain narrowly defined indicators of health, has achieved great success. But with declining economic conditions and the resulting hardship, new outbreaks of disease due to malnutrition and other factors, a politically repressive regime and a gulag, uncertainty about the future, and the burden of a large tertiary care and high-technology health care system, health in a broader sense has not been achieved. The United States has certainly played a part in this outcome, both through its embargo and symbolically through the distorting mirror of U.S. and Cuban relations. At the same time, we face many similar problems in our inner cities and in underdeveloped areas of the United States. This book is a good starting point for understanding the Cuban experiment and thinking about our own.

Carl Kendall, Ph.D.
Tulane University School of Public Health, New Orleans, LA 70112

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