Thursday, September 1, 2011

Steve Brouwer, Revolutionary Doctors

In Revolutionary Doctors: How Venezuela and Cuba Are Changing the World’s Conception of Health Care,

Steve Brouwer talks about the misrepresentation of the ALBA countries in the corporate media, noting that “they have an even more effective way to hurt the images of Cuba, Venezuela, and the ALBA nations: when it comes to Cuban/Venezuelan cooperation and medical internationalism in the region, they do not report the news at all. That is, they can generally be relied upon never to publish or broadcast favorable stories that feature the extraordinary accomplishments in health care and education” (KL 3193-3198). He illustrates this with the paucity of positive coverage of Cuban and Venezuelan medical efforts in Haiti surrounding the 2010 earthquake, acknowledging that a few reports managed to slip through. I had seen a couple of these, but even before that I had read in a little in alternative sources about these accomplishments and was very interested in both Cuban medicine and in how the new Latin American constitutions that put the right to health care front and center were playing out. Until I read Brouwer’s book, I wasn’t aware of the extent of the transformations, the reach of the programs, or the breadth of cooperation amongst countries.

Almost every chapter of Brouwer’s book begins with a quotation from Che Guevara, most from his 1960 “On Revolutionary Medicine.” He gives an account of the development of Cuban medicine from the revolution to the present, particularly the cooperation between the Cuban and Venezuelan governments in building the latter’s health care system since Hugo Chávez was first elected and their work in other poor countries in Latin America and the Caribbean and around the world. These systems and projects are radically transforming the way medicine is taught and practiced in a large part of the planet, and form part of larger visions of social change.

Health care in Cuba was dramatically transformed from immediately after the revolution. From the ‘60s, medical school graduates became part of a free public system. The Cuban approach was further developed as a result of the 1978 international Alma-Ata conference, which put together guidelines for “new health delivery systems built around the primacy of primary care, with family practitioners trained to integrate medical treatment with public health initiatives and preventive education.” While these goals were SAPped by the IMF in many countries, they remained the basis for the Cuban system, which emphasized the provision of health care to poor communities.

The Cubans also revolutionized medical education. Since the 1990s, medical students have done a 3-year residency in family medicine prior to specializing. Instead of the Flexnerian model used in the US and elsewhere, the program of study that continues to include classroom instruction is combined with an extensive program of experiential learning in which students apprentice to experienced doctor/teachers attending to patients in family medicine settings right from the start. The content of the curriculum (which makes use of DVDs and other technology) remains the same as elsewhere, but is combined in novel interdisciplinary courses. Throughout, the curriculum includes a Community Health and Medicine component, which involves such subjects as the history of health, epidemiology and hygiene, community intervention and health analysis, Latin American political thought, medical ethics, community rehabilitation, administration, disaster medicine, and the principles of medical research. Cuba’s Latin American School of Medicine (Escuela Latinoamericana de Medicina, or ELAM), opened in 1999 and now trains students from over 20 countries, most from poor families, who are expected to return to work in their communities. Nurses and other medical professionals receive similar community-based instruction.

Doctors often do residencies in community medicine in poor countries. Cuba sends large numbers of doctors, nurses, and other medical specialists to work in countries around the world – 185,000 worked in 103 countries through 2008. These professionals go abroad for shorter-term disaster relief efforts (the highly experienced Henry Reeve Medical Brigade) and longer-term (usually two years at a time) efforts aiding in the development of the primary health care systems of other countries. Cuban medical specialists, who’ve been working in Haiti for years and, as noted above, were among the most important responders after the 2010 earthquake are now helping Haiti (re)build its health care system.

Cuban medical personnel have been central to Venezuela’s efforts in this direction. Articles 82-86 of Venezuela’s popular 1999 constitution guarantee the right to proper medical care. From the beginning of the century, and financed with oil revenues after 2003, the government began building a network of social missions to improve conditions and avenues for participation for poor and working people, urban and rural. The massive social spending on these projects operated in the context of substantial reductions in inequality:
Among the many non-cash sources of income supplied through the social missions and not accounted for in assessing income redistribution are free health care, free education programs, free food for millions of children at school and the most impoverished adults, heavily subsidized food available at more than 15,000 Mercal food stores, tens of thousands of free neighborhood recreation and sports programs, free housing grants or interest-free loans, and free work-training programs. In addition there are a great many public works that often benefit poor and working-class people more than the rich, such as the new subway and bus lines added to the Caracas public transportation system. (KL 1142-1146).
Central in the social missions has been Barrio Adentro, which began delivering primary care in poor areas throughout the country in 2003. Through this system doctors (as well as dentists, nurses, sports specialists, and other medical professionals) go to live and work in poor communities – the name means “inside the neighborhood.” Barrio Adentro has consisted of four phases: the creation of a network of clinics for primary care, the formation of a network of secondary clinics, improvements to the existing hospitals, and the building of a set of hospitals specializing in research into and treatment of special problems.

The community health program got off to a slow start in Venezuela, but received a shot in the arm with the arrival of thousands of Cuban medical professionals. Hosted – and often guarded – by local health committees, the doctors lived in sparse and difficult conditions among the communities they served, working long hours and continuously available to serve people’s medical needs. According to Brouwer, “Their services are available to all Venezuelans for free at almost 7,000 walk-in offices and over 500 larger diagnostic clinics, and they have been very effective in meeting the needs of 80 percent of the population that had been ill-served or not served at all by the old health care system” (KL 158-162).

But the Cuban doctors have done more than provide primary care. They've helped Venezuela to construct its own system of health care through teaching, training, and mentoring thousands of Venezuelan medical students. Through the Comprehensive Community Medicine program (Medicina Integral Comunitaria, or MIC), medical students are taught and trained in their home communities by experienced doctors. The Venezuelans, who study for six years in the methods developed in Cuba, followed by a two-year residency in community medicine, will replace the Cuban workers.

Medical education is part of a broader effort at enhancing access to education at all levels. Through Mission Sucre, for example, people have been able to study a range of fields at the university level. As medical students are instructed in the “socio-medical sciences,” so social science students study community issues, including public health problems:
[E]very student who is matriculating in social science has to work as part of a team that identifies a problem or concern of a local community. Aside from their conventional course work, the student’s team has to build their final thesis around a problem identified in meetings with this community, then researches the social science literature for analysis of this particular problem, and concludes with written and audiovisual material that suggests possible solutions for the community (KL 2207-2210).
Through ALBA (the Bolivarian Alliance for the Peoples of the Americas, which includes Venezuela, Bolivia, Ecuador, and Nicaragua), the Cuban/Venezuelan model continues to spread in Latin America and the Caribbean as well as Asia and Africa. Brouwer reports that
Fidel Castro, speaking at the first graduation of doctors from ELAM in 2005, announced the solution: Cuba and Venezuela were going to join forces to educate 100,000 more doctors over the next ten years: 30,000 Venezuelans, 60,000 coming from other countries in Latin America and the Caribbean, and another 10,000 from nations in Africa and Asia.
The community medicine and experiential-tutorial methods developed in Cuba and Venezuela are spreading to other countries, notably Bolivia. Connected to this, Miracle Mission (Misión Milagro), funded by Venezuela, has provided free eye surgeries to more than a million and a half people throughout the region.

Brouwer offers statistical evidence of the effectiveness of these programs, at home and abroad. As noted above, though generally invisible in the corporate media, the Cubans’ key role in disaster relief efforts like the humanitarian responses to Hurricanes George and Mitch in 1998 and the Haitian earthquake in 2010 is recognized by many.

Despite brief declines during the “Special Period” of the mid-1990s, and despite a lack of resources, Cuba’s domestic health statistics have continued to improve:
Cuba’s egalitarian medical system is the envy of most developing countries, and many developed nations as well. Its medical performance, as measured by global statistical standards such as infant and child mortality rates and adult longevity, bears this out, as does an educational system that has been able to produce more physicians per capita than any other nation on earth. By 2009, Cuba had 74,880 physicians, or one doctor for every 150 citizens, compared to one for every 330 in Western Europe, and one for every 417 in the United States. (KL 752-756).
Cuba has twice as many doctors per capita as the US, and “[a]s of 2008, there were twenty-five medical schools in Cuba, and 29,000 Cuban students of medicine, who were just a small fraction of the 202,000 students enrolled in all medical fields, among them dentistry, nursing, medical technology, and rehabilitation.”

The old system still exists for the 20% of Venezuela's population that can afford it, but When Chávez was elected in 1998, more than two thirds of the population - 17 million people - lacked access to regular medical care. Half of the population was living in poverty (the lower fifth in extreme poverty), childhood malnutrition was a major problem, and higher education was out of reach for large numbers of people. According to Brouwer:
The increased medical attention paid off quickly in human terms during the first ten years of the revolution, as infant mortality fell from 19 to 13.9 deaths per 1000 live births between 1999 and 2008 and the mortality of all children under five fell from 26.5 to 16.7. Postneonatal mortality was cut by more than half, falling from 9.0 to 4.2 deaths per 1000 live births. The life span of the average Venezuelan increased by 1.5 years between 2000 and 2009.
The number of students in higher education has tripled since 1998 (“[S]ome of the most popular [fields of study] are social science, computer science, agro-ecology, law, nursing, sports training, scientific technology, and education”). There have been similar advances in Nicaragua and Bolivia in health, literacy, and education.

Brouwer says that the major participants and many leaders in the local health committees along with other neighborhood organizations are women, and that this participation has been enabling and encouraging women to be politically active and involved. Almost three quarters of the students in MIC are women (many with extensive family obligations), and Brouwer suggests that the Cuban doctors (since 1999 more than half of Cuban doctors have been women) have served as role models.

These systems have promoted, amongst medical workers, students, and communities, an appreciation of the environmental and social character of health and illness, and made them more able to address these problems and to participate in public health campaigns (as students have done with vaccinations, removing breeding areas for disease-carrying mosquitoes, and sex education). Brouwer also talks about a “general rejuvenation of the internationalist and revolutionary spirit in Cuba” stemming from these efforts (KL 1886-1887).

He suggests that “both nations have gained considerable respect from many other countries and international organizations, not only for the very real accomplishments of their programs, but also for the generosity, dedication, and competence demonstrated by individual doctors, nurses, teachers, and technicians” (KL 2974-2976). Other countries have been inspired to start similar programs, and to cooperate with their efforts (e.g., last year the Australian government announced that it would join with Cuba to work in Haiti and East Timor).

The success and public support gained by these efforts have enabled them to withstand organized opposition. Efforts in Honduras and Guatemala were initially threatened, then earned the praise of even some in the upper classes following public protest to keep them going, and have been promoted under more welcoming leadership. They came under attack again, however, after the coup in Honduras:
In the aftermath, soldiers harassed medical staff and threatened to close down the Garifuna hospital. The founder of the hospital, Dr. Luther Castillo, who had been the first Garifuna to graduate from ELAM, had to go into hiding to escape persecution and was forced to abandon the country. In 2010, he served as the coordinator of the first large contingent of ELAM graduates in the Henry Reeve Brigade when they rushed to Haiti to serve as medical volunteers after the earthquake. In Guatemala, the Cuban presence also provoked controversy and considerable opposition from right-wing elements (KL 718-722).
The rightwing opposition has been equally active in Venzuela and Bolivia:

In 2008, ORVEX, the Organization of Venezuelans in Exile, which was funded by rich expatriates in Miami, managed to issue the most outrageous reaction when it released a short film titled La Universidad del Terrorismo Patrocinada por del Gobierno de Venezuela. According to this piece of disinformation that appeared on YouTube, “a university of terrorism” had been created at the Latin American School of Medicine (ELAM) in Havana, where terrorist doctors were being prepared to attack the entire Western Hemisphere under the patronage of Hugo Chávez and the Venezuelan government. These verbal assaults on Barrio Adentro and Cuban medical training were accompanied by the refusal of some cities and states, still under the control of the political opposition, to allow the deployment of Barrio Adentro physicians (KL 2415-2421).

When Cuban doctors started treating the impoverished Bolivian majority, there were negative responses from local elites and protests from the Bolivian medical association that were similar to defamatory campaigns mounted in Venezuela and other parts of the Americas. They either disparaged Cuban doctors as inept, unqualified practitioners who could only disrupt health care delivery or portrayed them as immensely clever political/military agents who would brainwash the public with communist propaganda. Within a few months, as word of the quality of care circulated among grassroots communities, this kind of criticism dissipated. It was followed in some areas, such as the wealthy department of Santa Cruz, by direct actions by right-wing political forces that were assisted in their anti-government and separatist activities by officials and contractors of the U.S. State Department. Some with violent tendencies, emboldened by this support, decided to mount physical attacks on Cuban medical personnel.
As the above suggests, “local” opposition has been supported and encouraged by the US government. I’ve written about US interference in the region and its “war on ideas” propaganda many times before, but little could be more revealing of the callousness and cynicism of those in power in this country than the government’s actions in the context of these effective humanitarian efforts.

After refusing entry to the 1500+ of the highly trained Henry Reeve Brigade ready to fly to the Gulf Coast to aid in disaster relief after Hurricane Katrina in 2005 (a month later the Brigade flew to Pakistan following the earthquake there), in 2006 they tried to disrupt Cuban efforts abroad through the Cuban Medical Professional Parole Program, “a law specifically designed to lure Cuban doctors, nurses, and technicians away from their foreign assignments by offering them special immigration status and speedy entry into the United States” (KL 192-195). (Brouwer suggests that this has proved largely futile, that the percentage of people not returning to Cuba has been consistently very low, and that this small number is overwhelmed by the numbers willing to replace them or to serve on subsequent postings.) In 2008, the US embassy in Bolivia attempted to recruit Peace Corps volunteers and Fulbright scholars to spy on Cuban and Venezuelan doctors and other humanitarian workers.

Unlike in Honduras, the US-supported coup attempts in Venezuela and Bolivia have not been successful. In Haiti, though, after the kidnapping of Aristide, “The U.S. Marines overran the new Aristide medical school, chased out the doctors and students, and used the facility as their military headquarters. The medical school would remain closed until the spring of 2010, when, with aid and personnel supplied by ALBA, classes began once again” (KL 2930-2932).

Brower describes the shadowy government and corporate entities involved in US propaganda and other destabilization efforts. It would be one thing to suggest that these medical and humanitarian projects are themselves used as propaganda by the governments involved (which wouldn’t, of course, preclude real humanitarian commitments). But to try to discredit, sabotage, and shut down programs that are bringing desperately needed medical care to millions of poor people and training hundreds of thousands of medical professionals is despicable.

Brouwer offers a well-written and informational account - some sources better than others - including firsthand observations and perspectives from those involved (though perhaps too few and a bit superficial). I have some criticisms, though. First, the distinction he makes between the Cuban and capitalist (which he sometimes calls "European" models is rather strange. It holds for the US, but many European countries have health care systems that resemble the Cuban model in important ways. Second, to say that Brouwer is sympathetic to these governments would be an understatement. He does make a few criticisms, but the problems he notes explicitly – bureaucracy and low-level corruption – minimize the larger problems with the Cuban system especially, to which he barely alludes. He quotes Cintio Vitier - “a trench is not a parliament” – in suggesting that the embattled governments, due to hostility from without, haven't previously been able to realize a socialism characterized by the level of openness they would otherwise wish. While it is true that these movements and governments have been embattled, this by no means accounts entirely for the authoritarianism of the Castro regime (and would by no means justify it if it did), supposedly now able to begin to return to a more “authentic” socialism. The problems with Marxism as a political program were there from the start, and Brouwer’s own quoting of Chávez quoting one of Kropotkin’s letters to Lenin from 1920* shows that the best of what is now happening is a new flourishing of anarchist practices that had been marginalized, violently or otherwise, during the twentieth century (indeed, Kropotkin’s “Appeal to the Young” is likely as relevant as Guevara’s work). It is unnecessary and probably counterproductive (even in a continuing trench situation) to idealize things in this way. These programs are humanistic and effective. They are saving lives and changing societies for the better.

*He describes Chávez “explaining that socialism had to be a liberating process that allowed poor and working people to be the protagonists in building a new society and pursuing their own self-development. In one nationally broadcast talk in 2009, he quoted from a letter that the famous Russian anarchist, Peter Kropotkin, wrote to Lenin: ‘Without the participation of local forces, without organization from below by the workers and peasants themselves, it is impossible to build a new life’”(KL 3307-3311).

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