The virtues of repression: politics and health in revolutionary Cuba

Cuba is a country of contradictions. It has high levels of absolute poverty and low levels of relative poverty. It is a poor country1 with very strong health indicators. Even with the adjustments to life expectancy and infant mortality ratios as suggested by Geloso and colleagues, Cuban health indicators are excellent by global standards. In addition, the regime has promised and fulfilled human rights in the areas of social entitlements to health care, education, food, and housing, while it has consistently violated human rights as political and civil rights. Cubans tend to be intensely critical of their government’s failure to respect human rights, allow economic freedom, and permit political dissent, yet simultaneously proud of the Revolution’s anti-imperial stance, vis-à-vis the USA in particular, as well as its rejection of a version of life that valorizes capitalist bourgeois consumption. In the field of health, as Geloso and colleagues point out, Cuba has achieved high levels of population health through possible manipulation of data (although this is not unique to either Cuba or authoritarian regimes) and coercive public policies. If Cuba is manipulating the data to produce more favorable health indicators in order to achieve nationalistic goals, what does this mean? At best, the manipulation creates inaccuracies and masks health system weaknesses, and fails to acknowledge the means through which gains are achieved. The analysis of Geloso and colleagues suggests that this is a problem primarily attributable to poor, authoritarian regimes that have significant power to manoeuver meagre resources. Some of the evidence that they provide includes the ratio of late foetal deaths to neonatal deaths, which is much higher in Cuba than in other countries in the region and elsewhere. But other indicators are not mutually determinant. For example, there seems to be no relationship between infant mortality and maternal mortality, although both indicators can be considered to serve as proxy measures, which is to say that they reveal complex socio-political dynamics and multiple underlying factors. The contextual factors mentioned by the authors suggest that Cuba’s health indicators are artificially improved or enhanced by the circumstances of deprivation. Thus, it appears that there are virtues of both repression and scarcity. At worst, manipulation of health data reveals that impressive health indicators are achieved through coercive measures, such as state-imposed quarantine for infectious diseases (as in the early years of the AIDS epidemic), internment in hogares maternos, or forced abortions. On one research trip to Cuba a woman told me that she had been pregnant and going to regular health check-ups (which are mandatory). During one such visit, the health practitioner who examined her told her that she was not pregnant after all, but that she had developed a uterine cyst, which had to be removed. The cyst was removed, but the woman was convinced that this was a mistake, that she had been pregnant, and that the foetus was removed. In her opinion, this confusion and tragic error was the result of medical incompetence. Her regular doctor was out of the country on a medical diplomatic mission and the replacement was poorly trained. She blamed the government for sending its doctors abroad and leaving Cubans to suffer at home. Many other women who participated in my research complained about the consequences of Cuba’s medical internationalism for similar reasons (Johnson 2016, p. 174). The Cuban government’s possible manipulation of data and propensity to take advantage of the circumstances of deprivation to bolster health outcomes (such as few cars that result in few traffic fatalities or the years of the Special Period that limited caloric intake and required people to walk long distances to find food, supplies or work) also reveal that there is a high cost paid by citizens for the achievement of impressive health indicators. In the areas of maternal and infant health, it appears that this cost is borne most heavily by women. This is a brutal reality, one that reveals yet another contradiction. Pregnant women are well cared for. They receive extra rations and are provided with services and medical care that are not available to the rest of the population, but they are under continuous surveillance and have absolutely no options. They cannot deviate from the medical protocols established by the regime and they have no choices to make concerning where to give birth or who will attend—they will all give birth in the regional maternity hospital with an obstetrician in attendance. A woman with “good connections” and enough money can secure her preferred doctor throughout pregnancy and at the birth, and can arrange for a c-section without having to endure labour for the period of time prescribed by the state. Cuban women are proud of their country’s achievements in health care, but insist that this is fulfilment of their inalienable human right to health and not the product of political benevolence. They deplore the poor conditions in hospitals, lack of choice, and disruptions to domestic health care as a result of the regime’s international priorities. Another consequence of the government’s fixation with health indicators and their nationalistic value, and with Fidel Castro’s obsessive need for global admiration (which appears to have abated somewhat under Raúl Castro’s reign), is that it masks the difficult realities of life. Although health achievements are laudable, they are only one component of a fully realized human life. The women I met while conducting research explained that beyond their nationalistic pride and gratitude for not having to suffer what their counterparts elsewhere in Latin America suffer (in terms of high rates of disease and infirmity, and limited if any access to health care services), caring for babies and children in Cuba is almost impossible. One participant effectively expressed the sentiments of many others: ‘The reality is that children are in need after they are born and for this reason many women decide not to have children, [because] they are not guaranteed what they need’ (Johnson 2016, p. 176). Another participant explained that, ‘with our creativity and idiosyncracies we try to do what we can’ (177). Such assessments demonstrate that health indicators themselves do not address the main challenges of daily life, and that the goals of nationalism do not always serve domestic populations. And yet it is impossible to dismiss Cuba’s achievements in health care as insignificant. They are questionable and costly and intensely political. They are important props of national identity that cast many shadows. Despite the consternation expressed in the Geloso commentary and in this response, it is wrong to come to a single conclusion about Cuba. The country is too complex for that. This is Fidel Castro’s legacy. A country of poverty, human rights violations, political authoritarianism, that is propped up by excellent health status for its population (even if its indicators are manipulated for nationalistic purposes), full access to education, and an anti-imperialist stance that plays well to its own citizens and which has likely had positive, protective effects on individual and population health. It is tempting to dismiss Cuban achievements because of countervailing patterns of political repression, but this conclusion oversimplifies the complexities of Cuban politics and the lived experiences of Cubans. Research was funded by a grant from the Social Sciences and Humanities Research Council of Canada, Standard Research Grant #410-2009-0049. Conflict of interest statement. None declared.

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