Revolutionary Health: State Capacity, Popular Participation and the Cuban Paradox

Abstract

Drawing from findings in ‘state capacity’ and ‘social capital’ literatures, this article adopts a new framework for exploring the puzzle of Cuba's health outcomes, which are widely recognised as being extremely positive given the country's developing status, and the external crises it has faced in recent decades. The findings presented in this article emerge from five years of research, including nine months of fieldwork in Havana. It is argued that Cuba's health outcomes are partly attributable to an unusually high level of popular participation and cooperation in the implementation of health policy. This has been achieved with the help of a longstanding government with clear health goals and enough political influence to compel the rest of the community to prioritise them. On the other hand, the degree of public negotiation or participation in health policy decision-making was found to be minimal, and this carries consequences that undermine certain aspects of health care quality in Cuba and threaten the sustainability of the public health system.

Keywords:

• health
• Cuba
• state capacity
• social capital
• second economy

Notes

 1. The complete findings of my research appear in: Elizabeth Kath, Social Relations and the Cuban Health Miracle, New Jersey, Transaction, 2010.

 2. Jerry Spiegel and Annalee Yassi, ‘Lessons from the Margins of Globalization: Appreciating the Cuban Health Paradox,’ Journal of Public Health Policy, 25:1, 2004, pp. 85–110; Connie Field, ¡Salud!, http://www.saludthefilm.net/ns/index.html, 2007, accessed 27 September, 2010.

 3. Sarah Lunday, ‘Old-Fashioned Doctoring Keeps Cubans Healthy,’ Los Angeles Times, 9 July 2001; Spiegel and Yassi, ‘Lessons from the Margins’; Julie M. Feinsilver, Healing the Masses: Cuban Health Politics at Home and Abroad, Berkeley, U of California Press, 1993; Ross Danielson ‘Medicine in the Community: The Ideology and Substance of Community Medicine in Socialist Cuba,’ Social Science and Medicine, 15C, 1981, pp. 239–47; Linda. M. Whiteford, Laurence G. Branch and Enrique Beldarrain Chapel, Primary Health Care in Cuba: The Other Revolution, Lanham MD, Rowman and Littlefield, 2008; and for further references see Kath, Cuban Health Miracle, p. 1.

 4. Michael Moore, Sicko, http://www.michaelmoore.com/sicko/index.html, 2007; John S. Yudkin, Gemma Owens, Fred Martineau, Mike Rowson and Sarah Finer, ‘Global Health Worker Crisis: The UK Could Learn from Cuba,’ The Lancet, 371:9622, 2008, pp. 1397–99; Wilbert J. Keon, ‘Cuba's System of Maternal Health and Early Childhood Development: Lessons for Canada,’ Canadian Medical Association Journal, 180:3, 2009, pp. 314–16; Sabra Lane, ‘Learn from Cuba's Health System, PM Told,’ ABC News, 16 March 2010, http://www.abc.net.au/news/2010-03-15/learn-from-cubas-health-system-pm-told/365436, accessed 26 September 2011.

 5. Lisa Climan, ‘A Pat on the Back for Cuba,’ Dollars and Sense, 5 July 2001.

 6. ‘UNDP Highlights Human Growth in Cuba,’ Escambray Digital: Newspaper of Sancti Spiritus Province, Cuba, 22 March 2007.

 7. David Koch, 2010, ‘Hospitals Friendly to Newborns and their Mothers are Widely Realized in Cuba,’ UNICEF, http://unicef.org/infobycountry/cuba_53057.html, accessed 26 September, 2010.

 8. Lee T. Dresang, et al, ‘Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine’, Journal of the American Board of Family Practice, 18, 2005, pp. 297–303; K. Swanson et al, ‘Primary Care in Cuba: A Public Health Approach,’ Health Care for Women International, 16:4, 1995, pp. 299–308; Howard Waitzkin, et al, ‘Primary Care in Cuba: Low- and High-Technology Developments Pertinent to Family Medicine,’ Journal of Family Practice, 45:3, 1997, pp. 250–58; Tim Anderson, ‘Social Organisation and Infectious Disease: The Mexican and Cuban Health Systems Compared (Working Paper)’, Sydney University, 2005; Tim Anderson, ‘The Structuring of Health Systems and the Control of Infectious Disease: Looking at Mexico and Cuba’, Pan American Journal of Public Health, 19:6, 2006, pp. 423–31.

 9. D. S. Iatridis, ‘Cuba's Health Care Policy: Prevention and Active Community Participation,’ Social Work, 35:1, 1990, pp. 29–35; Mervyn Susser, ‘Health as a Human Right: an Epidemiologist's Perspective on the Public Health,’ American Journal of Public Health, 83:3, 1993, pp. 418–26.

10. Feinsilver, Healing the Masses.

11. Aviva Chomsky, ‘The Threat of a Good Example: Health and Revolution in Cuba,’ in Jim Yong Kim, et al (eds), Dying for Growth: Global Inequality and Health of the Poor, Munroe ME, Common Courage Press, 2000; Feinsilver, Healing the Masses; Spiegel and Yassi, ‘Lessons from the Margins’.

12. Tom Calma, Social Justice Report 2005: The Indigenous Health Challenge, Canberra, Australian Human Rights Commission, 2005.

13. United Nations Development Programme, The Human Development Report, http://www.undp.org/ 2006, 2009; UNSD (United Nations Statistics Division), Millenium Development Goals Indicators, http://mdgs.un.org/unsd/, 2009; WHOSIS (World Health Organization Statistical Information System), http://apps.who.int/whosis/, 2009.

14. I discuss the reliability of Cuba's health statistics in Kath, Cuban Health Miracle, pp. 12–15.

15. Francis Fukuyama, ‘Social Capital, Civil Society and Development,’ Third World Quarterly, 22:1, 2001, pp. 7–20; Robert Putnam, Bowling Alone: The Collapse and Revival of American Community, New York, Simon & Schuster, 2000; James S. Coleman, ‘Social Capital in the Creation of Human Capital,’ The American Journal of Sociology, 94: Supplement: Organizations and Institutions, 1988, pp. 95–120; see also Kath, Cuban Health Miracle, p. 31.

16. Fran Baum, ‘Social Capital: Is it Good for your Health? Issues for a Public Health Agenda,’ Journal of Epidemiology and Community Health, 53:4, 1999, pp. 195–96.

17. Michael Woolcock, ‘Social Capital in Theory and Practice: Where Do We Stand?’ Paper presented to 21st Annual Conference on Economic Issues, Department of Economics, Middlebury College, 7–9 April 2000, p. 7; Australian Productivity Commission, Social Capital: Reviewing the Concept and its Policy Implications, Canberra, 2003, p. 20.

18. Pierre Bourdieu, ‘The Forms of Capital,’ in Handbook of Theory and Research for the Sociology of Education, J. G. Richardson (ed.), New York, Greenwood Press, 1986; Coleman, ‘Social Capital in the Creation of Human Capital,’ pp. 95–120.

19. Peter Evans, Dietrich Rueschemeyer and Theda Skocpol (eds), Bringing the State Back In, Cambridge, Cambridge UP, 1985; Leonardo Burlamanqui, Ana Célia Castro and Ha-Joon Chang (eds), Institutions and the Role of the State, Cheltenham, Edward Elgar, 2000; Bob Jessop and N. L. Sum (eds), Beyond the Regulation Approach: Putting Capitalist Economies in their Place, Cheltenham, Edward Elgar, 2006; Linda Weiss (ed.), States in the Global Economy: Bringing Domestic Institutions Back In, Cambridge, Cambridge UP, 2003; see also Kath, Cuban Health Miracle, p. 53.

20. Charles Polidano, ‘Don't Discard State Autonomy: Revisiting the East Asian Experience of Development,’ Political Studies, 49:3, 2001, pp. 513–27, p. 513.

21. I discuss the study's theoretical dimensions in more detail in Kath, Cuban Health Miracle, pp. 30–71.

22. This framework draws from state capacity literature generally but especially Michael Mann, The Sources of Social Power, Vols. 1 and 2, Cambridge, Cambridge University Press, 1986 and 1993.

23. Interviews were conducted in Spanish and translated by the author. All interviewees' names have been coded to maintain anonymity.

24. Waitzkin et al, ‘Primary Care in Cuba,’ pp. 250–58.

25. Interview with Herrera, Director of Obstetrics in a Maternity Hospital, Havana, 22 September 2004.

26. Andrés Oppenheimer, Castro's Final Hour: An Eyewitness Account of the Disintegration of Castro's Cuba, New York, Touchstone, 1993, p. 160.

27. Interview with Ramírez, Representative of the Cuban Ministry of Public Health (MINSAP), Havana, 6 September 2004. A libreta, or ration book, entitles Cubans monthly to basic food supplies.

28. Julie. M. Feinsilver, Healing the Masses, p. 29; and Patrick Pietroni, Cuban Health Care System and its Implications for the NHS Plan, London, UK House of Commons Health Select Committee, 2001.

29. Katherine Hirschfeld, ‘Sociolismo and the Underground Clinic: The Informal Economy and Health Services in Cuba,’ Cuba in Transition, 16, 2006, pp. 335–50.

30. Interview with Almeida, Cardiologist (Sub-Specialty in Pregnancy), Havana, 2 August 2004; see also Sarah Lunday, ‘Old-Fashioned Doctoring Keeps Cubans Healthy,’ Los Angeles Times, 9 July 2001.

31. Interview with Almeida, Havana, 2 August 2004.

32. Interview with Castillo, Medical Specialist and ‘Basic Work Group’ (GBT) and Supervisor at a Policlinic, Havana, 20 September 2004.

33. Interviews with Herrera, Havana, 22 September 2004; Valdes, Specialist in Internal Medicine, Havana, 2 August 2004; Castillo, Havana, 20 September 2004.

34. Interview with Ramírez, Havana, 6 September 2004.

35. Interview with Castillo, Havana, 20 September 2004.

36. Interview with Ramírez, Havana, 6 September 2004.

37. Interview with Valdes, Havana, 2 August 2004.

38. MINSAP, Estadísticas de Salud de Cuba, http://www.dne.sld.cu/index.htm, 2007.

39. Nor is the media an effective outlet for registering complaints about health services, given that virtually all media is state owned and operated.

40. Feinsilver, Healing the Masses.

41. A. Domínguez, ‘Stimulating Community Involvement through Mass Organizations in Cuba: The Women's Role,’ International Journal of Health Education, 20:1, 1977, pp. 57–60.

42. As Raúl Castro has stated, Cuba's leadership defines the country's civil society as its mass organizations (Nelson Amaro, ‘Decentralization, Local Government and Citizen Participation in Cuba,’ Cuba in Transition, 6, 1996, pp. 262–82, p. 273). The Communist Party's official description of Cuban mass organizations holds them as autonomous, a portrayal that has come under constant scrutiny.

43. Amaro, ‘Citizen Participation in Cuba’; Constitución de la República de Cuba, Havana, Ministerio de Justicia, 1999.

44. Arnold August, Democracy in Cuba and the 1997–98 Elections, Havana, Editorial José Marti, 1999, p. 387.

45. Haroldo Dilla Alfonso and Gerardo González Núñez, ‘Participation and Development in Cuban Municipalities,’ Ottawa, International Development Research Centre, http://www.idrc.ca/fr/ev-54437-201-1-DO_TOPIC.html, 1997.

46. Dilla Alfonso and González Núñez, ‘Participation and Development’; see also their ‘Successes and Failures of a Decentralizing Experience,’ in P. Brenner, M. R. Jiménez, J. M. Kirk, and W. M. LeoGrande, A Contemporary Cuba Reader: Reinventing the Revolution, Lanham MD, Rowman & Littlefield, 2007.

47. Feinsilver, Healing the Masses, p. 80.

48. Geraldine Lievesley, ‘The Latin American Left: The Difficult Relationship between Electoral Ambition and Popular Empowerment,’ Contemporary Politics, 11:1, 2005, pp. 3–18, p. 10.

49. Feinsilver, Healing the Masses, p. 81.

50. Interview with Ramírez, Havana, 6 September 2004.

51. Feinsilver, Healing the Masses, pp. 81–82.

52. Giselda Sababria Ramos, ‘Participación Social en el Campo de la Salud,’ Revista Cubana de Salud Pública, 30:3, 2004.

53. Rafael Hernández and Haraldo Dilla, ‘Democracy and Socialism: Political Culture and Popular Participation in Cuba,’ Latin American Perspectives, 18:2, 1991, pp. 38–54, p. 53.

54. see Fidel Castro, ‘History Will Absolve Me,’ Castro Internet Archive, http://www.marxists.org/, [1953] 2001.

55. Sergio Díaz-Briquets, ‘How to Figure out Cuba: Development, Ideology and Mortality,’ Caribbean Review, 15:2, 1986, pp. 8–42.

56. Interview with Herrera, Havana, 22 September 2004.

57. Pierre Sean Brotherton, ‘Macroeconomic Change and the Biopolitics of Health in Cuba's Special Period,’ Journal of Latin American Anthropology, 10:2, 2005, pp. 339–69.

58. Julie M. Feinsilver, ‘The Cuban Threat: Medical Diplomacy,’ Scoop, http://www.scoop.co.nz/stories/WO0611/S00005.htm, 2006; Julie M. Feinsilver; C. Loose, ‘The Cuban Solution,’ Washington Post, 23 July 2006. There is some debate around the motives underpinning Cuba's health missions. Some refer to the missions as ‘medical diplomacy’ intended to win Cuba support from abroad that translates into more tangible benefits, and others argue they are driven by humanitarian, not pragmatic, motives (John M. Kirk and H. Michael Erisman, Cuban Medical Internationalism: Origins, Evolution and Goals, Palgrave, 2009). I would argue that there are likely to be both humanitarian and pragmatic motivations involved.

59. Oppenheimer, Castro's Final Hour, p. 161.

60. For details of such cases see Kath, Cuban Health Miracle, pp. 109–10.

61. Mary Katherine Crabb, Socialism, Health and Medicine in Cuba: A Critical Re-Appraisal, PhD Thesis, Emory University, 2001, p. 172.

62. Crabb, Socialism, Health and Medicine, p. 72.

63. Interviews with: Blanco, University Professor of Sociology (specializing in public health), Havana, 20 July 2004; Valdes, Havana, 2 August 2004; and Fernández, Social Worker from Havana's National Centre for Sexual Education (CENESEX), Havana, 20 July 2004.

64. Interview with Valdes, Havana, 2 August 2004; and Herrera, Havana, 22 September 2004.

65. Interview with Valdes, Havana, 2 August 2004.

66. Cuba's educational levels are high, however.

67. Julie M. Feinsilver, ‘Cuba as a ‘World Medical Power’: The Politics of Symbolism,’ Latin American Research Review 24:2, 1989, pp. 1–37, p. 17.

68. Interviews with: Arango, Representative of the Federation of Cuban Women (FMC), Havana, 7 October 2004, Castillo, Medical Specialist and ‘Basic Work Group’ (GBT) Superviser at a Policlinic, Havana, 20 September 2004; Díaz, Former Family Doctor (still living in Cuba), Havana, 1 October 2004; Espinosa and Raíz, Representatives of the National Commission for Social Prevention and Attention (CNPAS), Havana, 7 October 2004; Ramírez, Havana, 6 September 2004, González, Social Worker at a Maternity Home (Hogar Materno), Havana, 21 September 2004.

69. For a detailed discussion of this phenomenon see Kath, Cuban Health Miracle, pp. 127–60.