Latin American social medicine across borders: South–South cooperation and the making of health solidarity

ABSTRACT

Latin American social medicine efforts are typically understood as national endeavours, involving health workers, policymakers, academics, social movements, unions, and left-wing political parties, among other domestic actors. But Latin America’s social medicine trajectory has also encompassed considerable between-country solidarity, building on early twentieth century interchanges among a range of players who shared approaches for improving living and working conditions and instituting protective social policies. Since the 1960s, Cuba’s country-to-country solidarity has stood out, comprising medic exchanges, training, and other forms of support for the health and social struggles of oppressed peoples throughout Latin America and around the world, recently via Misión Barrio Adentro in Venezuela. These efforts strive for social justice-oriented health cooperation based on horizontal power relations, shared political values, a commitment to social and economic redistribution, bona fide equity, and an understanding of the societal determination of health that includes, but goes well beyond, public health and medical care. With Latin America’s left-wing surge now receding, this article traces the provenance, dynamics, impact, challenges, and legacy of health solidarity across Latin American borders and its prospects for continuity.

KEYWORDS:

• Medical internationalism
• Latin American social medicine
• Cuba
• Venezuela
• South–South health cooperation

Over the past few decades, South–South health cooperation based on left-wing solidarity has thrived among various countries in Latin America (as well as other ‘Global South’ settings). These efforts both draw from and transcend longstanding Latin American social medicine (LASM) ideas and practices by incorporating social justice values into official foreign (health) policy. Here we lay out the origins of and connections between LASM and social justice-oriented health cooperation and examine the latter’s contemporary practices, principles, perils, and prospects, focusing particular attention on the role of Cuba.

Forerunners of social medicine (and its cross-border prospects) in Latin America

LASM – notwithstanding this regional label (Tajer, 2003) – is often examined as a collection of simultaneous, albeit communicating, national endeavours (Franco, Nunes, Breilh, & Laurell, 1991; Hartmann, 2016; Waitzkin, Iriart, Estrada, & Lamadrid, 2001a). To be sure, in Latin America, as elsewhere, social medicine has taken on different characteristics and trajectories in distinct contexts and time periods, as shaped by political movements, social conditions, and the role of medical experts, among other factors (Borowy & Hardy, 2008; Brown & Birn, 2013; Carter, 2018; Cueto & Palmer, 2014). Here we loosely define social medicine as a realm of study, practice, and activism based on an understanding of health and disease as inherently rooted in social and political conditions and reflecting relations of power.

Especially in recent decades, there has been a vibrant parallel ambit to domestic experiences of LASM that is transnational, intergovernmental, and cooperative, in which government actors championing social medicine ideas have exchanged insights, expertise, experiences, and resources as a matter of official diplomacy based on mutually-held leftist values and aspirations for more egalitarian societies, and in some cases countering global capitalist power. Elsewhere, we have dubbed this endeavour social justice-oriented South–South health cooperation (SJSSC; not exclusive to Latin America). SJSSC is based on an understanding of the social and political underpinnings of health and disease (even as the content of cooperation may be biomedical) and a commitment to public, primary health care as a universal right.

The descriptor ‘LASM across borders,’ while also fitting, does not necessarily encompass official state actions in the way that SJSSC does. Brazil’s ‘structural cooperation in health’ approach also overlaps with SJSSC given its attention to horizontal decision-making, institutional strengthening, and fostering sovereign capacity (Buss & Ferreira, 2010), but it ‘does not perforce challenge the political and economic status quo’ (Birn, Muntaner, & Afzal, 2017, p. 8). SJSSC pursues either shared socialist or social-democratic political principles: the first invoking an anti-hegemonic, anti-capitalist vision; the second an egalitarian approach that seeks to reform more than upend global capitalism.

Why have social medicine across borders – and SJSSC – unfolded so vibrantly in Latin America? While challenging to answer in an abbreviated fashion, here we track a few antecedents to contemporary developments in solidarity-oriented cooperation. These include: 1) an overlapping trajectory under – and struggles against – colonialism and subsequent forms of imperialism and repression; 2) longtime medical and health cooperation that was not necessarily social medicine-oriented but nonetheless helped forge mutual understanding among states and health and social welfare professionals; 3) labour militancy and social and political movements advocating working class, and sometimes rural agrarian, social welfare justice that spilled across the region (if often coopted or displaced by populist regimes); and 4) professional and political curiosity about, and/or commitment to, socialism and social medicine approaches implemented in the Soviet Union.

Typically traced to mid-nineteenth century Europe, when a wave of uprisings challenged state repression and the brutal working and living conditions of the Industrial Revolution, social medicine was crystallized in the thinking of Rudolf Virchow, who famously called for a devastating typhus outbreak in the impoverished Silesia region of Prussia to be addressed as a political and social problem, and who himself participated on the Berlin barricades of 1848 (Anderson, Smith, & Sidel, 2005; Waitzkin, 2006). Virchow’s precepts were subsequently espoused, adapted, and reshaped across Europe and other regions (Brown & Birn, 2013; Porter, 2006), including Latin America (Iriart, Waitzkin, Breilh, Estrada, & Merhy, 2002).

Under Iberian rule, long before Virchow, the region even experienced a harbinger of sorts to social medicine in the figure of Eugenio Espejo, an erudite physician in colonial Quito of Indigenous background. Espejo’s upbringing in a pauper institution, and the fact that his ancestors were enslaved, undoubtedly moulded his sensibilities. Commissioned in 1785 by the city’s administrative council to identify a means of preventing frequent outbreaks of smallpox, Espejo pinpointed deficient sanitary and social conditions, as well as inept and self-interested colonial medical and religious authorities (Breilh Paz y Miño, 2001; Espejo, 1993). Like Virchow six decades later, Espejo was a political radical accused of subversion by imperial authorities, the former internally-exiled, the latter repeatedly imprisoned and persecuted by the Spanish Viceroy, along the way disseminating his anti-imperial convictions in Bogotá.

Beyond percolating ideas around social and political influences on health, a confluence of political, scientific, and professional factors in the 19th and 20th centuries shaped the region’s receptiveness to social medicine more directly. Well before notions of Latin America as a region with shared features, problems, opportunities, and political leanings solidified under the Cold War (Bethell & Roxborough, 1993), visions of Latin American distinctiveness emerged. First, a wave of liberation movements from 1810 to 1825, largely marshalled and inspired by revolutionary Simon Bolívar, resulted in the creation of independent republics across the region (except for Spain’s Caribbean colonies), with Brazil remaining under imperial control until 1889. While European re-invasion of Mexico, internecine and inter-state wars, and border disputes persisted for over a century, the colonial legacy – and the Bolivarian movement for South American sovereignty/independence (Bolívar, 2003), together with ongoing shared experiences of European and North American economic domination and US political interference – helped engender a sense of regional identity and destiny. This was particularly the case among urban elites (with professionals and upper classes in Spain’s former colonies speaking a common language), who were central to the state-building process (del Castillo, 2018).

By the late nineteenth century, tenets of Pan Americanism (regionwide cooperation, often, but not always, driven by US interests), as well as Latin American variants without US participation, burgeoned. A flurry of associations and meetings around political, commercial, cultural, technical, and scientific issues – facilitated by the rise of steamship and rail transport and communications advances – began to take shape, engaging multiple actors (García & Marichal, 2004; Sheinin, 2000). While most of these interchanges sought to further business and investment agendas across liberal republics, certain more radical ideas also flourished, drawing from the growing influence of Marxist ideas, anti-imperial struggles, and by the early twentieth century, the labour movement and new socialist political parties (Meade, 2016).

In the health, social welfare, and medical arenas, proliferating interactions stemmed from both the professionalisation of scientific disciplines – involving new journals, associations, scholarly networks, and conferences in areas such as hygiene and sanitation medicine, demography, eugenics,¹ and child well-being – and from the need to address conjoined health issues (Birn, 2005). These pressing and palpable problems included cross-border outbreaks (Chaves, 2009), domestic epidemics, infant mortality, and occupational diseases generated by miserable living and working conditions, urbanisation, migration, and heightened trade (Almeida, 2006).

Cooperative efforts to confront these issues were mostly hatched by those representing dominant political and commercial concerns. The Pan American Sanitary Bureau, founded in 1902 and for decades operated out of the US Public Health Service, held quadrennial regional congresses attended by high-ranking government officials in a position to negotiate legally binding international agreements, including the landmark 1924 Pan American Sanitary Code governing disease notification and epidemic control among all American republics (Cueto, 2007). For decades, it focused almost exclusively on safeguarding commercial interests, failing to respond to other priorities such as infant and maternal mortality (Birn, 2002). While Latin American sanitary treaties and most professional interchanges rarely constituted leftist solidarity, they did pave the way for intergovernmental and expert cooperation, and, occasionally, alternate players with more progressive views wielded influence.

Organised working class and other movements fighting for better living and working conditions were also salient to LASM across borders (and SJSSC later on). Struggles for health justice and social security involved a complex array of agrarian and industrial unions, Indigenous peoples, women militants, and other social movements. Mobilised against powerful and entrenched political and economic elites, these groups formed alliances with an assortment of leftwing political parties within their own countries, but also in communication with and inspired by militancy throughout Latin America (Carr, 2014; Chomsky, 2011; Herrera González, 2013). Activists pushed for social protections – including state-run health programmes – in several waves, starting in the Southern cone countries and extending to virtually the entire region by the late 1940s (Mesa-Lago, 1978; Ortúzar, 2013). With domestic reformers eyeing gains in neighbouring countries, legislative advances were peppered with solidarity at regional medical and welfare venues (Guy, 1998; Ramacciotti, 2015) and through (nationalist-minded) engagement with the social medicine-oriented League of Nations Health Organisation and the more middle-ground International Labour Office (Borowy, 2009; Carter, 2018; Derecho Internacional Público, 2014; Weindling, 2006).

However, protective legislation was typically passed under populist or authoritarian, rather than socialist, regimes, as in Argentina, Brazil, and Chile, following Bismarck-style carrot-and-stick approaches of benefits for selected groups (while rejecting universal rights) even as repressive policies against labour and social activism were retained. In most settings, social security systems remained partial and heavily stratified, with urban industrial workers and civil servants enjoying the greatest benefits, while dependents and rural and informal workers lagged far behind (García, 1981; Marquez & Joly, 1986; Mesa-Lago, 1985). Coopting of social medicine ideas was evident in Uruguay, too, where advocates of ‘childhood social medicine’ marshalled adoption of a ‘Código del Niño.’ The code spelled out children’s rights to health, welfare, education, housing, and other elements of well-being, but it came under a 1930s dictatorship, with the heavy hand of a repressive regime bent on disciplining juvenile ‘delinquents’ (Birn, 2012).

The early twentieth century founding of communist and socialist political parties in many Latin American countries served as a small yet relevant political harness for some social medicine activists (Angell, 1998; Concheiro, Modonesi, & Crespo, 2007; Löwy, 2007; Spenser, 1999), as did umbrella Popular Front coalitions motivated by the ‘Second International’ (international proletarian movement) and its Soviet successor Comintern, together with the USSR’s social policies implemented following the Russian Revolution.² Starting in the 1930s, numerous Latin American experts – envisioning a Soviet welfare state utopia and seeking a blueprint for domestic reforms – were keen to witness the USSR’s wide-reaching social policy accomplishments firsthand. Dozens of medical and public health professionals from Argentina, Brazil, Chile, Colombia, Cuba, El Salvador, Mexico, Uruguay, and Venezuela travelled to the Soviet Union (see, for instance, Zeno, 1933), a trend that accelerated after World War II (Viel, 1961). The books and popular articles these visitors penned about Soviet public health services, medical schools, and research institutes upon returning home entered into lively national and regional debates about how to shape policies and institutions, particularly as Latin American countries were positioning themselves in the Cold War (Rupprecht, 2015). Latin American nurses, physicians, and other medics were also active ‘comrades in health’ in the 1936–1939 Spanish Civil War, among the thousands of civilian volunteer health workers with the international medical brigades supporting the Republican cause against Franco’s fascists (Baumann, 2009).

The larger political context and transnational interchanges engendered translation of ideas around both social medicine and socialised (or state) medicine into further political agendas. In mid 1930s Mexico, for example, the nicolaítas, a group of radical physician-advisors to socialist-leaning president Lázaro Cárdenas, elevated their proposals to government policy through the creation of mandatory physician service to rural areas and the resurrection of Ejidos (land collectives redistributed and returned to Mexico’s large and increasingly organised peasant population) involving strong rural and community medicine components (Carrillo, 2005; Kapelusz-Poppi, 2001). Around the same time in Peru, social medicine practitioners sought to extend rural health campaigns to Indigenous populations in a community-based and more respectful manner than prior coercive interactions (Cueto, 1991).

It was in Chile that LASM came to political power most boldly (Waitzkin, 2005; Zárate Campos & Godoy Catalán, 2011). Salvador Allende, a social medicine devotee and committed socialist, rose to prominence in the 1930s: first as a medical student leader, and then as a young health minister for the Popular Front coalition elected in 1938 (Allende, 1939; Labra, 2000), setting the wheels in motion for Chile’s milestone 1952 National Health Service (SNS) (Illanes, 1993). Allende, by then a Senator, helped shepherd the SNS proposal into law, convinced it would help ‘prevent the tremendous injustices that arise due to the existence in this country of distinct social strata’ (Allende, 1951, p. 1525). Both Allende and the SNS would become embroiled in Cold War ideological rivalries (Berlagoscky, 2013). In 1970, after multiple attempts – and embodying Virchow’s idea of politics as (social) medicine at a grand scale – Allende was elected president on a platform of nationalisation and redistribution; the conservative physicians’ association was among his fiercest opponents. Allende was deposed in a US-backed military coup in 1973, with dictator Augusto Pinochet systematically dismantling the SNS. Medical radicals (including social medicine advocates) were among the tens of thousands of Chileans tortured, executed, or ‘disappeared’ and the hundreds of thousands more forced into exile.

LASM across borders and Cuba’s SJSSC

The targeting of health leftists in Chile was not an isolated episode. The authoritarian regimes that swept across Latin America during the Cold War sidelined social medicine aspirations and subjected its advocates to persecution (Waitzkin, Iriart, Estrada, & Lamadrid, 2001b). These circumstances helped spur the founding of two key organisations: Associação Brasileira de Saúde Coletiva (ABRASCO), the Brazilian collective health movement, launched in 1979 amidst the 1964–1985 dictatorship and so-named to challenge the legitimacy of the repressive state to address the people’s health; and the Latin American Social Medicine Association (ALAMES), begun in 1984 to foster solidarity and scholarly and policy interchange among leftist health professionals and academics and support those exiled. ABRASCO provided scaffolding to decades of political struggle to realise Brazil’s unified national health system and social redistribution measures. Its members served in a range of policy (and prior to that, shadow policy) positions after the dictatorship ended (Lima & Santana, 2006), including in Brazil’s South–South health cooperation. Today, both ABRASCO and ALAMES continue to hold periodic conferences, host publications, and participate in global health forums and domestic health and social policy activism (Granda, 2008). ALAMES consists of a network of social medicine academics and practitioners, albeit with palpable tensions, particularly around support for different varieties of leftist politics (e.g. socialist vs. social democratic). Various ALAMES members have been involved in building socially just health systems in locales such as Paraguay, Venezuela, and Mexico City (Laurell, 2003). ALAMES principles call for ‘promot[ing] alliances for a radical defense of life among movements’ (Torres Tovar, 2007); its members are most proud of the organisation’s solidarity with revolutionary efforts, including ALBA³ (Franco Agudelo, 2009). Despite being the region’s most vibrant forum for LASM across borders, ALAMES has not incorporated SJSSC as an explicit part of its agenda.

Even before these developments, Cuba became the region’s foremost champion of SJSSC, embarking on health solidarity efforts just a year after its 1959 revolution and heralding continuous engagement within and beyond Latin America (Cassells, 2016; Ojeda Medina, 2010). A few years earlier, the Soviet Union, German Democratic Republic, Romania, and other Eastern European countries had become involved in ‘proletarian’ health solidarity in North Korea and Vietnam (Hong, 2015; Iacob, 2017), making socialist health cooperation an instrument of the Soviet bloc’s Cold War foreign policy, analogous to the disease campaigns and population control efforts operated by the US bloc (Packard, 2016). But Cuba’s endeavours differed from the strategic alliance-making of the East–West geopolitical rivalry.

Before tracing Cuba’s trajectory, a few conceptual points are merited. SJSSC differs from conventional development assistance for health (including mainstream South–South cooperation) in various ways. First, unlike most aid channels from high-income countries and multilateral agencies, it does not compromise sovereignty by imposing conditions as a quid pro quo for receiving aid. Indeed, SJSSC (not considered aid) is exercised on as equal terms as feasible, reducing, if not eliminating, power and resource differentials between parties. SJSSC responds to national and local demands for equity and draws from social rights approaches based on health-related human rights, for example in relation to universal, public comprehensive health care (Medicus Mundi, 2010). Thus, agenda-setting for cooperation is carried out mutually, decreasing overall dependency. Second, SJSSC cooperation aims to be transformative: for example, training local primary health care practitioners counteracts the brain drain; and investing in social infrastructure hand in hand with government agencies helps create lasting and equitable means of addressing human needs. Third, SJSSC seeks to be counter-hegemonic, that is, resist corporate, neoliberal capitalist forces as part of the project of building societies based on health and social justice, ideally following a bottom-up participatory approach of community-based democracy (Birn, Muntaner, et al., 2017).

Cuba’s South–South medical cooperation began in 1960, when the government dispatched a team of emergency medicine experts to Chile in the aftermath of a major earthquake, even as half of Cuba’s doctors were decamping to the United States and other countries. Disaster relief would continue to serve as a major component of Cuban health cooperation – enhanced by the establishment of its own civil defense system following a devastating 1963 hurricane.

Meanwhile, a more social medicine-oriented approach was underway, as articulated by Argentinean physician-turned-revolutionary Ernesto ‘Che’ Guevara, who famously fought side-by-side with Fidel Castro, later joining liberation movements in Congo and Bolivia. Echoing Virchow, he came to see political struggle as an extension of social medicine:

integrating the doctor or any other health worker into the revolutionary movement [is essential], because … the work of educating and feeding the children … and … of redistributing the land from its former absentee landlords to those who sweat every day on that very land without reaping its fruits—is the grandest social medicine effort that has been done in Cuba (Guevara, 1960, p. 119).

In 1963 these ideas translated into Cuba’s medical solidarity with Algeria, following its protracted war of independence from ruthless French colonial control (Gleijeses, 1996; Hatzky & Stites Mor, 2014; Johnson, 2015). A delegation of several dozen doctors, nurses, dentists, and technicians spent a year caring for the injured and working with Algeria’s revolutionary government to rebuild health services for its shattered population. The next year, a replacement team of medics arrived, with similar missions participating in liberation movements in North Vietnam, the Congo, Guinea Bissau, Angola, and so on. Fidel’s propensity to always say ‘yes’ to requests, regardless of the cost or consequences, at times angered the Soviets, who saw Cuban cooperation as trespassing on or distracting from their own efforts (Kirk, 2015).

One seeming paradox of Cuban domestic policies and SJSSC also marked Soviet approaches: because societal underpinnings of health were addressed through universal rights to housing, sanitation, employment, nutrition, education, elimination of poverty, and so on, the health sector focused more narrowly on medicine. The social and political dimensions of health were considered self-evident achievements of the socialist system; thus, the Soviets accorded priority to showcasing technological prowess and deploying universal access to biomedical care in their cooperative efforts (Venediktov, 1977). For Cuba, too, the social justice spirit of its approach to health has manifested in its advocacy of equitable, universal access to what is largely a biomedical approach, following a community-based, preventive care emphasis, both at home (Navarro, 1972) and abroad (Feinsilver, 2010).

Initially, Cuban cooperation was motivated by reciprocity with (and gratitude to) countries/peoples that had provided support during Cuba’s revolution and/or that were engaged in similar struggles. Later, Cuba anchored both the domestic right to health care and a commitment to medical internationalism in its 1976 Constitution.

Other important solidarity activities involved supporting those targeted by authoritarian regimes across Latin America from the 1960s onwards. This involved rehabilitating leftist revolutionaries injured in Central America’s violent civil wars in the 1980s, including medical comrades from Latin America and beyond who joined in El Salvador’s prolonged struggle for a just society (Genaro & Gato, 2017). In the more hopeful situation across the border, a large Cuban medical brigade arrived just days after Nicaragua’s 1979 Sandinista revolution, a steady presence in providing primary health care to long overlooked populations (Anderson, 2013; Garfield & Williams, 1992).

Another leading form of Cuban SJSSC has been its role in training medical personnel (Kirk & Erisman, 2009), which accelerated after the end of the Cold War. Since its founding in 1998, Cuba’s Escuela Latinoamericana de Medicina (ELAM) has trained more than 26,000 students from throughout the Americas and globally – 123 countries in total (Loewenberg, 2016). Much of this training is free of charge for those coming from low-income countries (low-income and racialized backgrounds in the case of US students). ELAM thus constitutes Cuba’s unique antidote to physician brain drain: trained in primary health care, tens of thousands of newly-minted physicians have now returned home to serve their communities.

Over time, Cuba’s SJSSC – primary care provision and disaster relief to the tune of over 140,000 medical professionals serving across Latin America and in more than 100 countries, millions of cataract surgeries performed through ‘Operación Milagro,’ and establishment of almost a dozen medical schools abroad, in addition to its ELAM hub in Havana – has extended well beyond settings with active anti-hegemonic movements. Expanding since the demise of the Soviet Union, Cuba’s cooperation with settings ‘where no doctor has gone before’ has made a significant impact around the world (Huish, 2013).

The principles, practices, and commitment to health equity domestically and to internationalism (or proletarian internationalism) (Brown & Birn, 2013; Featherstone, 2012) – with roots in socialist diplomacy constitutionally enshrined – are widely invoked as drivers of Cuba’s health care cooperation (De Vos, De Ceukelaire, Bonet, & Van der Stuyft, 2007; Fitz, 2012; Kirk, 2015). Others cite humanitarian solidarity as the motor of the scope, reach, and durability of Cuba’s health cooperation, which has arguably saved millions of lives and improved many more. In Guatemala alone, a stunning 35 million medical consults have been carried out spanning 15 years, serving millions of patients ‘whose lives have been changed’ by Cuba’s programmes (Kirk, 2015, p. 273).

That said, Cuban SJSSC has also faced critiques. Domestically, the 50,000+ Cuban medical personnel (over half doctors) working in 66 countries in 2014,⁴ resulted in physician shortages and resentment in parts of Cuba (Brotherton, 2013). There have also been defections, greatly exacerbated by the US State Department’s ‘parole’ programme, which has incentivized over 1000 doctors to abandon Cuba (Kirk, 2015).

Mainstream responses to Cuba’s SJSSC have been to ignore it (Novotny, Kickbusch, & Told, 2013), dismiss it (see Fitz, 2016), or cite it as a typical case study of soft power influence (Nye, 2009), in which health serves as an instrument of self-interested foreign policy (Kickbusch, 2011). To be sure, there are controversies surrounding Cuba’s endeavours. Whereas in the past there was no quid pro quo, since 2006 under Raúl Castro over half of countries pay for medical services and training, bringing in over $8 billion annually in hard currency (Cuba’s largest source of income – triple the earnings from tourism) (Benzi & Zapata, 2017). In Honduras doctors objected to the Cubans’ presence but succumbed to pressure from populations left underserved. In 2014 Brazilian medical elites similarly protested the contracting of over 11,000 Cuban doctors to provide primary care where local doctors were ‘unrecruitable’ (Lidola & Borges, 2017; Walker & Kirk, 2017). Concerns about the low and deferred pay of internationalist doctors (cited as slave labour by some) have led to salary improvements (Oliveira et al., 2015).

A crucial question remains: how much of Cuba’s SJSSC is truly social medicine-oriented? One facet has to do with its focus on disaster relief and medical training. Arguably, the problems faced by very low-income countries – such as the Central American countries struck by Hurricane Mitch in 1998, which killed or injured tens of thousands and displaced several million people – in dealing with sudden disasters makes long-term, infrastructure-oriented disaster relief a social medicine endeavour (as opposed to short-term charitable or humanitarian aid in this domain) (Buss & Ferreira, 2010). As far away as Pakistan, Cuban solidarity recovery and rebuilding efforts after the 2005 earthquake deeply inspired local populations, who reported having never witnessed such sustained, egalitarian attention from their own government or any other (Akhatar, 2006). Cuba’s role in Haiti following the 2010 earthquake similarly stands apart: while other countries met with donor fatigue ex post facto, Cuban medics had already spent 11 years there engaged in cooperative and infrastructural activities, a situation downplayed by international media (Huish, 2013). In West Africa’s 2014–2015 Ebola crisis, too, Cuba responded almost immediately with hundreds of health personnel, while the World Health Organization (WHO) and US government dithered.

By any account, Cuba’s medical coverage at home and abroad are nothing short of extraordinary, even as accusations of propaganda or spying persist and many doctors may be as interested in adventure, earning cash, and advancing skills as they are in altruistic solidarity. Yet Cuba’s internacionalistas, much as they might disparage the situation at home, have repeatedly recounted how shocked they were at the misery they saw abroad, including diseases they had only read about in textbooks (Garfield & Williams, 1992; Kirk, 2015).

Misleadingly, some consider Cuban medical solidarity to be the ‘world’s best kept secret’ (Kirk, 2015). Yet it is hardly a secret to over 100 appreciative countries or to the US State Department actively monitoring these efforts. Still, Cuba’s SJSSC is deliberately overlooked by most mainstream (Northern) observers, a classic ‘threat of a good example’ (Chomsky, 1992; Melrose, 1985).

Of late, the most well-known instances of Cuban medical cooperation have been in the Americas – especially Venezuela, Haiti, Central America, and Brazil, as well as a remarkable intersectoral door-to-door project to identify and address the health and social needs of hundreds of thousands of persons with disabilities in Ecuador (the Manuela Espejo mission; see Monje Vargas, 2013) and Bolivia.

Contemporary SJSSC: expanding cooperation and integration against the grain

Cuba’s early medical solidarity endeavours did not go unnoticed by its ideological opponents. The 1961 Charter of Punta del Este, which launched the US-led Alliance for Progress – a development approach aimed at preventing the proliferation of Cuba-like revolutions across the region – stimulated some inter-American efforts (excluding Cuba) around health planning and realisation of such goals as water and sanitation coverage, infectious disease control, and maternal and child health improvements. By 1978, and responding to the G-77’s call for a New International Economic Order (stemming from a Third World movement against neocolonialism), the United Nations formally sought to stimulate technical cooperation between ‘developing’ countries. But this effort took place in the context of authoritarian regimes and debt crises, not as an expression of social solidarity (Birn, Pillay, & Holtz, 2017). Still, in the 1960s and 1970s, many Latin American governments set up foreign cooperation offices, creating an institutional framework that would serve subsequent, if politically divergent, objectives.

Since 2000, in conjunction with the Pink Tide (the wave of left-leaning governments elected in Central and South America), the region came to serve as a bona fide counter-hegemonic force in global (health) politics. For example, Latin America is the first and only subcontinent to have committed to remain free of nuclear arms (Musto, 2017). Three main developments made the expansion of SJSSC within Latin America possible: (1) from 2000 to 2015, over half of the region’s 20 countries (plus Puerto Rico) elected social democratic or socialist governments with strong labour party and social movement backing that has reduced poverty and income inequality and expanded access to public health and social services (Cornia, 2014; Lustig, Lopez-Calva, Ortiz-Juarez, & Monga, 2016); (2) the rise in commodity prices enabling allocation of substantial sums to South–South cooperation generally and internally to social medicine-oriented reforms (e.g. Brazil, Venezuela) (Wilpert, 2007); and (3) Cuba’s (re-) insertion into a new era of engagement in the region, driven by its economic and political relations with Venezuela (Morris, 2014; Muntaner et al., 2008).

Although such endeavours have been negatively affected by the 2008–2012 world financial crisis and, more recently, a shift in government regimes and policies (e.g. in Brazil, Argentina, Paraguay), other countries have sought to continue – some more effectively than others – to support SJSSC goals (Bolivia, Ecuador, Uruguay, Cuba, Nicaragua, El Salvador, and Venezuela), albeit amidst economic and political instability in many settings (Petras & Veltmeyer, 2016).

The emergence of Brazil as an economic powerhouse among middle-income countries (Prashad, 2013) helped spur the region’s social medicine efforts domestically and across borders, partially building on Cuba’s SJSSC model. Under president Lula’s back-to-back Workers’ Party administrations starting in 2003, Brazil’s ‘structural cooperation’ involved training, health policy and health systems support, and ‘horizontal’ interchange with key counterparts in Latin America and former Portuguese colonies (Ciência & Saúde Coletiva, 2017; Ferreira, Hoirisch, Fonseca, & Buss, 2016; Santos & Cerqueira, 2015). It has operated dozens of projects in sub-Saharan Africa – many coordinated by Fiocruz, Brazil’s national health institute – ranging from capacity building for health care personnel (e.g. physicians, lab technicians), to disease control efforts, HIV drug donations, and an ARV factory in Mozambique (Carrillo Roa & Silva, 2015; Santana, 2011).

Like Cuba, Brazil has sought to prioritise the interests and needs of LMICs and refrained from imposing conditionalities – in some ways challenging the dominant political order – but its aggressive investments in African mining, construction, and other industries run parallel to its health diplomacy (Alden, Chichava, & Alves, 2017; Garcia & Kato, 2015; Ventura, 2013), with private corporate priorities trumping social solidarity. Within Latin America, Brazil’s role has been more social medicine-oriented, focusing, for example, on equitable public health policy. Moreover, its leadership in challenging the pharmaceutical patent regime effectively resisted one of the most powerful corporate sectors in global health (Chan, 2015). Since 2014, however, Brazilian government commitment to South–South cooperation has cooled, and along with economic and political crises, civil society coordination and support has also lessened (Gómez & Perez, 2016).

Beyond bilateral efforts, the social justice orientation of many Latin American governments and their grassroots political movements (Harnecker, 2015; Karan & Sodhi, 2015) led to the creation of new organisations that favour SJSSC. Key among them are the Union of South American Countries (UNASUR), which has a permanent South American Health Council (involving member country health ministries) that strives for regional health care integration.⁵ Heeding social medicine values, UNASUR has developed a mutual agenda emphasising universal access to health care and medicines, equity, and action on the social determinants of health. Its health research institute oversees research in these areas and helps craft common policies around disease surveillance, human resources for health, health systems development, health promotion, unified regional positions vis-à-vis WHO (Herrero & Tussie, 2015), and has rallied against the privatisation of medical care (Feo, 2012).

Even with much larger and well-financed players now participating, Cuba continues to be the most important SJSSC actor in Latin America (as well as around the globe) in terms of the volume and solidarity orientation of its health cooperation (Beldarraín Chaple, 2006; Feinsilver, 2010; Fitz, 2016; Huish, 2013).

The threat of a good example: Barrio Adentro and Cuba-Venezuela SJSSC

Among the best-known examples of contemporary SJSSC is Misión Barrio Adentro (Inside the Neighbourhood), a primary health care programme developed under late Venezuelan president Hugo Chávez in 2003 to respond to the demands of poor urban and peri-urban slum residents chronically shunned by most physicians who prefer to serve wealthier patients (Castro, Gusmão, Martínez, & Vivas, 2006). Enabled by an agreement with the late Fidel Castro to furnish approximately 30,000 physicians – in return for much needed fuel supplies – plus thousands of other Cuban nursing and allied sciences professionals, including physical education specialist and dentists (Alvarado et al., 2006; Muntaner, Salazar, Rueda, & Armada, 2006), this exchange has had a combined ideological, political, and economic basis (Muntaner et al., 2008).

As is typical of Cuba’s medical solidarity programmes, doctors are not treated as privileged consultants but are integrated into the neighbourhoods they serve, often living with local community members, who themselves help to plan and build health care clinics. Not wanting to generate reliance on Cuban health professionals, the agreement between Chávez and Castro also incorporated a training component for 10,000 Venezuelans from humble roots to receive medical and nursing education in Cuba before returning to practise in their communities. In order to further reduce dependence on Cuba, in 2010 the Venezuelan government launched an ambitious effort to train community physicians and nurses from low-income backgrounds in Venezuela: several new medical and nursing schools were established with Cuban support (Mahmood & Muntaner, 2013). As of March 2015, almost 19,000 Venezuelan physicians had graduated with degrees in Integral Community Medicine and begun working at Barrio Adentro facilities throughout the country (MPPS, 2015).

All told, according to Cuban officials, between 2003 and 2015 Barrio Adentro cared for more than 53 million patients, treating 1.7 million life-threatening emergencies amidst a quadrupling of health care facilities. Since its inception, Barrio Adentro has been integrated with other social programmes targeting nutrition, medications, poverty reduction, employment, and health education among other areas, enabling referrals and coordination across sectors (Castro et al., 2006; Muntaner, Chung, Mahmood, & Armada, 2011). Together, these efforts contributed to infant mortality declines from 21 deaths/1000 live births to 14; malnutrition reductions from 21% to 14% of the population (and accelerated child growth rates), and an increase in access to clean water from 80% to 94% of the population (Curcio, 2017).

It is important to note that the social medicine dimensions of Barrio Adentro reside in their integration into a larger commitment to public (non-market), universal, gratis, equitable social services in the context of overturning Venezuela’s prior neoliberal capitalist state. In that sense, Cuban–Venezuelan SJSSC has centred on greatly expanded access to primary care for the majority of residents and training for prospective medical practitioners (especially from low-income communities) to ensure that the Barrio Adentro programme can last. Additionally, community support is managed at the local level by ‘comités de salud’ and ‘consejos comunales.’

Notwithstanding the technical orientation of the programme itself, Barrio Adentro’s initial leaders were aligned with the Latin American Marxist social medicine tradition represented by Salvador Allende, which seeks transformation of the capitalist social structure. Indeed, physician advocates of this tradition held high-level positions in Venezuela’s Ministry of Health, early on producing scholarship on the role of imperialism and class power in shaping health inequities (Armada, Muntaner, & Navarro, 2001; Armada, Muntaner, Chung, Williams-Brennan, & Benach, 2009).

This helps explain why the content of Venezuelan physician training (like its Cuban counterpart) has not focused significant attention on the social determinants of health or policies aimed at reducing health inequities (MPPS, 2013): these dimensions are understood to be addressed by the overall political commitment to policies advancing well-being and diminishing economic and social inequities. In this context, a focus on biomedical and behavioural dimensions does not replace political and social understandings of health but is corollary to the larger societal commitment to human welfare and equality. Advocates of Cuba’s SJSSC hold that providing support for the attainment of universal access to public, comprehensive, and equitable medical care shared among sister nations is the epitome of solidarity (Fitz, 2012). Yet some believe that a vision of social medicine that appears apolitical and centred on individual care risks ignoring social injustice and may end up conflated with mainstream humanitarian cooperation approaches (Saney, 2009).

The fate of the Barrio Adentro programme (and of the Venezuelan state) cannot be understood without an account of ongoing internal and external opposition and the effects of Venezuela’s ‘resource curse’ – being an export-oriented country with the world’s second largest oil reserves (Amin, 2014; Spronk & Webber, 2015). One useful distinction is between the ‘early years’ (Armada et al., 2009) – before the 2008 global financial crisis dramatically lowered the price of oil – and the aftermath of the crisis, which is still generating political and economic turmoil. The first years witnessed an impressive surge in access to health care, reaching about 17 million more Venezuelans than before (some 60% of the population at the time) and improvements in several avoidable causes of child hospitalisation and mortality (Aguirre, 2010; Armada et al., 2009; Castro et al., 2006; Ubieta Gómez, 2007). In 2005, Chávez expanded the programme to cover diagnostic and medical technology and rehabilitation centres, also ensuring emergency primary care access around the clock (Aguirre, 2010; Castro et al., 2006).

Well before the recent unrest, news of abandoned primary care centres and defecting Cuban doctors was used by opponents of Venezuela's Bolivarian government to discredit Barrio Adentro and announce its imminent demise (e.g. Ceaser, 2007). While instances of defection, neglect, and corruption undoubtedly occurred to some extent, as in most health care systems (Birn, Pillay, et al., 2017), that they have been gleefully cited as an SJSSC failure by the mainstream anti-Cuban press (e.g. the Miami Herald) and newspapers with economic interests in Venezuela (e.g. El País, El Universal) casts doubt on such claims. Still, some of these journalistic concerns (Carroll, 2013) have also been voiced from within the Bolivarian camp (Feo Istúriz, 2017), albeit in a more nuanced manner.

In spite of the popularity of Barrio Adentro among Venezuelans (Walker, 2015), certain problems are evident. The relationship between the Cuban mission and Chávez was hermetic, often alienating not only mainstream Venezuelan doctors but even those supportive of the programme, who had little input into its policies. A further challenge has been the inability to integrate Barrio Adentro into the existing state public health system (the two operate in parallel) and to fund community health workers who currently work as volunteers (Cooper, 2015).

Without discounting the damage caused by shortages of medications and corruption and poor maternal and child health outcomes, since 2015 other problems affecting medical supplies, equipment, health care infrastructure, and personnel can be traced to a protracted ‘civil war’ conducted via hoarding, boycotts, and deliberate outside interference (Bolton, 2016; Curcio, 2017; Hetland, 2017). Due to these external factors, Barrio Adentro has not become the stable institution that it was meant to be, with members of the opposition even reportedly destroying some Barrio Adentro facilities (Watsup Americas, 2017).

Political scientists critical of the Bolivarian Revolution have found parallels between Chávez and charismatic populists who governed Latin American countries in the mid-twentieth century (e.g. Getúlio Vargas in Brazil and Juan Perón in Argentina), as well as contemporaries including Bolivia’s Evo Morales and Ecuador’s Rafael Correa (Huber & Stephens, 2012; López-Maya & Lander, 2011). All of these leaders have engaged in populist and anti-capitalist rhetoric, direct contact with poor and working classes, and strong control of state institutions. At the same time, their de facto policy records have been less egalitarian than promised, representing class compromise, continuation of capital accumulation among elites, and inadequate changes to the tax structure. Chávez’s populism may also reflect the difficulties of establishing strong welfare state institutions in many extractive economies (Acemoglu & Robinson, 2013). Yet unlike some leftwing populists of Latin America’s past, Chávez strove to implement long-term policy changes (e.g. Barrio Adentro), with institutionalisation undergirded by a strong political party pursuing these political objectives beyond its tenure (Huber & Stephens, 2012). It is too early to tell whether the beleaguered Bolivarian Revolution will achieve these historical ambitions (Ellner, 2017). Still, importantly, Chávez’s support for a socialist programme mounted rather than retreated after the 2003 coup attempt against him (Gott, 2011; Wilpert, 2007), expressed in a range of comprehensive universalist health policies (Barrio Adentro, plus dental and eye care, services excluded from some national health systems in the Global North). This redoubled commitment distinguishes Chávez from the typical ideological contradictions of populist leaders, whose pledge to public programmes often diminishes after they have consolidated their power.

In sum, Barrio Adentro embodies the virtues of SJSSC: an exchange of low-cost Venezuelan oil for Cuban expertise in primary care and intersectoral action for health. That the programme survived the Great Recession years, the violent boycott of the Venezuelan opposition, and declining oil revenues is in itself proof of the resistance of Cuban–Venezuelan solidarity, further sustained by the ongoing training of thousands of doctors and continued presence of clinics in poor neighbourhoods. Moreover, the grassroots support for the programme remains strong. Barrio Adentro’s popularity as the centrepiece of Venezuelan social protection (Muntaner et al., 2011) provides ample justification as to why the Bolivarian government has continued to enjoy electoral support from the country’s poor, working class, and sections of the middle class (Ulmer & Chinea, 2017).

Still, a key question is whether the cooperation can endure amidst the unrelenting hostile national, regional, and global context against the Bolivarian Revolution and whether Barrio Adentro’s adaptation of Cuba’s health care system remains relevant as an SJSSC exemplar for other settings seeking equity and health justice.

Conclusion – SJSSC at a crossroads: a reversion to LASM across borders?

In the wake of conservative forces gaining control of major countries in the region (Brazil, Argentina, Chile), with others embattled (Venezuela, Ecuador, El Salvador, Nicaragua, Uruguay), the foreseeable future for SJSSC in the region is uncertain. Might Cuba, given its own changes towards a market economy, continue to hold the torch, or will SJSSC in Latin America revert to the domain of civil society cooperation (LASM across borders) as part of an ongoing large-scale struggle against global capitalism and imperialism?

Returning to Barrio Adentro, despite current turbulence, Venezuela’s prior trajectory under Chávez – and the country’s ongoing commitment to universal, community-based public health care for millions of previously disenfranchised people perennially ignored by physicians and politicians alike (Walker, 2015) – helps demystify why so many Venezuelans are seeking to preserve the Chavista legacy even in the face of still unfolding political and economic problems. This remarkable, though certainly not flawless, programme is one of the most dynamic instances of SJSSC in recent years – all the more so because Venezuela has long been capable, resource-wise, of meeting population health needs (Buxton, 2016).

In seeking to explain why the region’s experience of SJSSC has been both longstanding and fruitful, it is useful to briefly compare it to BRICS countries’ (Brazil, Russia, India China, South Africa) engagement in cooperation. Brazil’s dual model of social justice actions combined with mainstream foreign aid/foreign policy objectives, illuminates this question. BRICS cooperation, like SJSSC approaches, seeks long-term sustainability, sovereignty, and horizontality in decisionmaking. But Brazil, like China (which also stresses the lack of conditionalities in its aid), India, and Russia, also treats South–South cooperation as an avenue for advancing capitalist development and corporate interests (Garcia & Kato, 2015; Ventura, 2013).

Notwithstanding deleterious political conditions, perhaps there remains hope: the new players and expanded activities of recent decades, at least partly generated by ‘barrio democracy’ (Canel, 2010), suggests that SJSSC aspirations may help drive a long-term effort for current and future generations to mobilise their energies, skills, imagination, and commitment in favour of social (medicine) justice and in solidarity with the struggles of the pueblos of Latin America and well beyond.

Acknowledgements

We are grateful to the anonymous reviewers for their stimulating, thoughtful, and thorough suggestions and to Mariajosé Aguilera for her editing expertise.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Funding for this research was provided by the Canadian Institutes of Health Research [CIHR grant # EOG-126976] Ethics Office. This funder had no other role in the writing of the article or in the decision to submit for publication. The ideas expressed herein are the authors’ alone.

Notes

1. As in other countries, many Latin American public health specialists and social medicine adherents in the early 20th century also advocated different forms of eugenics, mostly favouring ‘positive’ measures to foster healthy reproduction and child-rearing (Leyton, Palacios, & Sánchez, 2015; Miranda & Vallejo, 2005; Stepan, 1992; Turda & Gillette, 2014).

2. In 1926 anarcho-feminist Menshevik turned Bolshevik Alexandra Kollontai, the First People’s Commissar for Social Welfare, became the Soviet Ambassador to Mexico. Her short-lived and controversial stay animated Mexico’s post-revolutionary discussions around social welfare; however, Mexico’s increasingly influential Communist Party was banned in 1929.

3. The Alianza Bolivariana para los Pueblos de Nuestra América (ALBA – originally Bolivarian ‘Alternative’) for the Americas) was created in 2004 and now includes Venezuela, Bolivia, Cuba, Ecuador, Nicaragua and several Caribbean island states.

4. This would be equivalent to 25% of US doctors involved in overseas cooperation.

5. Other new regional bodies whose relation to health is more indirect include ALBA and the 33 country-strong Comunidad de Estados Latinoamericanos y Caribeños (CELAC), which maintain explicit goals of Latin American and Caribbean integration and reducing US influence in the region.