Reviewed by Syd Shall
This book describes a new approach to medical education and practice that was originally developed in Cuba. This novel, Marxist approach to a worldwide problem is a striking example of the inventiveness of the Cubans to the development of socialism in their country.
Socialists say that they want to replace the contemporary system of political economy, based on the profit motive, by one in which production and exchange are predicated on the necessary and sensible needs of the population. But a critical question is: how do we get from a capitalist system to a socialist system? This book describes relevant, empirical data derived from the Cuban experience of health assistance to their South American neighbours. In particular, it addresses two key questions.
Firstly, is prior political power necessary for a serious advance to socialism? Secondly, how does one set about changing the attitudes of people? The challenge here is that we start with a population submerged in obscurantism and hostility to science. The people need to embrace science, the search for truth, and cooperation instead of competition. This book describes the author’s close observation of the implementation of this new approach to public health in a collaboration between the government and people of rural Venezuela, and Cuban medical volunteers. This type of collaboration was field-tested in Venezuela, and is being extended to Bolivia, Nicaragua and Haiti, as well as to several countries in Africa.
The author is a journalist who tells us that he has been a socialist all his adult life. He is clearly very impressed by his experience with the Cuban-Venezuelan health collaboration but he also describes the difficulties and shortcomings of the programme. He attributes the origins of the new view of medical education and practice to an initiative of Dr Che Guevara soon after the overthrow of the dictatorial regime in Cuba. Although Guevara was primarily a revolutionary he was always informed by his background as a medical doctor and gave considerable thought to the best way to solve the widespread and devastating public health problems of South America, particularly those that faced the new Cuban government in 1959. With much trial and error, and careful evaluation, it eventually arrived at a viable plan. This was adopted very quickly as a key weapon in the defence of Cuban socialism.
Castro and his colleagues decided that educational and health assistance to other countries, especially sympathetic South American countries, could contribute significantly to the defence of the new Cuban socialist state. As Cuba was driven more and more to socialism, partly forced by the profound hostility of the United States, it needed all the support it could muster. Initially, the Cubans concentrated on educational assistance but they soon realised that medical assistance to poor countries could be very valuable too. Fundamental to this approach is the recognition, sadly inadequate in other states that previously aspired to build socialism, that international collaboration and mutual support are the bedrock of a successful attempt to do this in the face of capitalist aggression. Castro and his colleagues set about training as many educators and teachers as they could, despite the very difficult situation in which Cuba found itself. Cuba now has the prestige of providing the world with what may be the most efficacious method for combating illiteracy in poor countries. Its literacy system is widely employed, and not only by those sympathetic to the Cuban social system. Because they appreciated the political value of this success, the Cubans decided to extend this approach to tackling the problems of public health. These have proved intractable in all capitalist systems; for there never has been a capitalist state, rich or poor, that has provided adequate health care for its population. The same may be noted regarding housing, education, care of the disabled or of those past working age. The best that any capitalist system has achieved was the National Health Service created in Britain after the Second World War, but which has been systematically dismantled by successive administrations since then.
The middle section of this book describes in graphic detail the evolution of the Cuban plan for better public health for the poorest parts of South America. This has had mixed results, which provides important lessons about what is needed to develop a society based on socialist principles.
What then is this novel approach? The first thing to understand is that public health in the contemporary capitalist world is a disaster – a disaster that, in the interests of profit, leads every year to millions of premature, unnecessary deaths. All medical professionals are aware that preventive medicine could save innumerable lives and would be much cheaper than our current profit-driven system. There are continuous calls for greater emphasis on preventive medicine, but very little is ever done practically, unless there is profit to be made.
The second feature of a desirable medical system, as all experts tell us, is for it to be integrated. It is wasteful of resources and lives to have a minutely divided, private health system in which each step becomes a separate problem to overcome. Finally – and again this is widely recognised as good medical practice – patients should be regarded as people, not merely as diseased hearts or livers. By extension, the physical, biological and social context in which the patient exists should be understood by the medical delivery staff. All these ideals of good medical practice have been known for generations but despite much waffle and countless mission statements, nothing serious is done about them. We can, therefore, reasonably consider the hypothesis that a desirable medical system is so antithetic to capitalism that it can never evolve in a capitalist system.
I will now turn to the empirical evidence provided by Brouwer’s book and some recent news in the technical press. The Cuban experiment in medical practice and education began about 10 years ago, following a long gestation period. Purely coincidently, an alternative, capitalist initiative to attack the dire state of health in the colonial countries began at about the same time. This initiative is called “The Global Fund to Fight AIDS, Tuberculosis and Malaria” and is the brainchild of Bill and Melinda Gates of Microsoft fame. The Fund boasts that ‘Since its creation in 2002 … [it] has become the main financier of programs to fight AIDS, TB and malaria, with approved funding of $22.4 billion.’
The Cuban plan is known as the “Medicina Integral Communitaria”. Brouwer tells us that the word ‘integral’ should be interpreted in its broadest sense. So the Cuban approach to public health is integrated communal medicine, with a heavy emphasis on prevention and on involving local populations. The Cubans recognise the critical necessity of having in place appropriate people. They take their cue from admonishments of Che Guevara that one needs revolutionary doctors with the requisite technical expertise and also the willingness to be part of a huge collective effort to raise the living and health standards of the population. The emphasis on community has several implications. Firstly, although medical personnel are central to the effort, the primary motive force should come from the local population who wish for adequate health care. Secondly, the community and the medical staff must play equal parts in making the system work. Thirdly, the medical personnel should be aware of the precise character of the community in which they work. They provide health care not just to individuals but to the entire community, and work with the community to achieve this. The emphasis on integration refers first to the patient, and then to the context (familial and social) in which the patient lives; but it also refers to the integration of all services needed to attain and maintain a healthy community. Thus, everyone involved – doctors, nurses, physical therapists, sport trainers, social care professionals and public health workers – must work together, otherwise little is achieved.
Is all this utopian? No, it can be made to work; but, as the book describes, there are two essential conditions. There must be a pre-existing political, and hence social, revolution in order that the second condition can be met. This is that there must be an abundant supply of volunteers who are prepared to sacrifice years of their lives to studying and becoming technically competent, and then they must be prepared to turn their backs on private wealth and voluntarily join a worldwide band of workers who are beginning the construction of a new and different world. The entire emphasis is on creating a new type of human being, a true homo sapiens.
The Cuban programme appears to be successful in Venezuela, in the context of a sympathetic population and government. It was not successful in Honduras where a coup d’état ejected an elected liberal conservative government that was replaced, with connivance from the USA, with a military dictatorship. The efficacy of Cuban inventiveness will be put to a serious test in the coming decade in Haiti. Here, the Cubans provided one of the biggest and most effective contingents of assistance immediately after the huge earthquake last year. None of this, of course, is reported in the capitalist press. Now the Cuban, Venezuelan and Brazilian governments are uniting to try to build in Haiti an effective public health system in the manner I have described. Recently, however, the Duvalier gang are being welcomed back by the USA and installed in government in Haiti. It is difficult to believe that these people will allow the Cuban health programme to continue. This will be a contest of strength between the Haitian people and the government.
By contrast, the Global Fund places its emphasis on providing money for the employment of private capitalist companies to supply medical aid and assistance. The assumption is that with money anything and anybody can be purchased. But the problem in poor countries such as Africa or South America is that there is little or no pre-existing framework of health care or indeed of public health.
The Cuban programme is alive and well despite facing formidable political and organisational problems. The longer it survives, the stronger it will probably become. By contrast, it was reported in early January 2012 that the French AIDS scientist and executive director of the Global Fund had resigned. An American journalist at a conservative think-tank opined, ‘this is a crucial, dangerous moment for global health’. This is hyperbole, in my opinion. What is the problem? The world economic depression means that the Fund is running out of money. Thus we see the capitalist attitude to public health: we will do something when we have spare cash. By contrast, the socialist view is that we should develop people who have the knowledge and the spiritual and mental strength to devote their lives to gradually improving the health of the poor.
The last chapters of this book venture, inadvisably, into making political comparisons between the Cuban plans and the efforts made by former states in central and Eastern Europe. Here the author’s comments are too superficial to be useful. To understand what happened in those countries requires a careful analysis of their histories from a Marxist foundation, but the author writes as if they were born and died without changing. Nevertheless, Revolutionary Doctors is an excellent book and should be required reading for every person in the health profession, no matter what country they work in. Indeed, every young person in the world would benefit from reading this book, for it is with them that the future lies.
3 April 2012