How Venezuela and Cuba Are Changing the World’s Conception of Health Care
Revolutionary Doctors, a new book by author Steve Brouwer and published by Monthly Review Press, gives readers a first-hand account of Venezuela’s innovative and inspiring program of community health care, designed to serve—and largely carried out by—the poor themselves. Drawing on long-term participant observations as well as in-depth research, author Steve Brouwer tells the story of Venezuela’s Integral Community Medicine program, in which doctor-teachers move into the countryside and poor urban areas to recruit and train doctors from among peasants and workers.
Where Do Revolutionary Doctors Come From?
The campesinos would have run, immediately and with unreserved enthusiasm, to help their brothers.
—CHE GUEVARA, “On Revolutionary Medicine,” 1960
Even though he came to Cuba with a rifle slung over his shoulder and entered Havana in 1959 as one of the victorious commanders of the Cuban Revolution, he still continued to think of himself as a doctor. Five years earlier, the twenty-five-year-old Argentine had arrived in Guatemala and offered to put his newly earned medical degree at the service of a peaceful social transformation. Dr. Ernesto Guevara was hoping to find work in the public health services and contribute to the wide-ranging reforms being initiated by President Arbenz, but he never had much opportunity to work as a physician in Guatemala. Within months of his arrival, Arbenz’s government was brought down by the military coup d’état devised by the United Fruit Company, some Guatemalan colonels, the U.S. State Department, and the CIA.
Che never lost sight of the value of his original aspiration—combining the humanitarian mission of medicine with the creation of a just society. When he addressed the Cuban militia on August 19, 1960, a year and a half after the triumph of the revolution, he chose to speak about “Revolutionary Medicine” and the possibility of educating a new kind of doctor.
“A few months ago, here in Havana, it happened that a group of newly graduated doctors did not want to go into the country’s rural areas and demanded remuneration before they would agree to go. . . .But what would have happened if instead of these boys, whose families generally were able to pay for their years of study, others of less fortunate means had just finished their schooling and were beginning the exercise of their profession? What would have occurred if two or three hundred campesinos had emerged, let us say by magic, from the university halls? What would have happened, simply, is that the campesinos would have run, immediately and with unreserved enthusiasm, to help their brothers.”
Since then, Cuban medicine and health services have been developed in a number of unique and revolutionary ways, but only now, nearly fifty years later, has Che’s dream come to full fruition. Today it is literally true that campesinos, along with the children of impoverished working-class and indigenous communities, are becoming doctors and running, “with unreserved enthusiasm, to help their brothers.”
While this is happening on the mountainsides of Haiti, among the Garifuna people on the Caribbean coast of Honduras, in the villages of Africa and the highlands of Bolivia, it is occurring on the grandest scale in the rural towns and city barrios of Venezuela. When I was living in the mountains of western Venezuela in 2007 and 2008, I witnessed the emergence of revolutionary doctors every morning as I walked out the door of our little tin-roofed house. The scene would have delighted Che:
As the sun rises above the mountain behind the village of Monte Carmelo and the white mist begins to lift off the cloud forest, four young campesinos walk along the road in their wine-red polo shirts with their crisp, white jackets folded up under their arms to protect them from the dust. At 7 a.m. they wave goodbye to the high school students who are waiting to begin their classes in three rooms at the women’s cooperative and then hop aboard the “taxi,” a tough, thirtyyear-old Toyota pickup truck that often packs twenty or more people in the back. They travel down the winding mountain road, through the deep ravine at the bottom, and up the hill on the far side of the valley to the larger town of Sanare, where they are going to work all morning alongside Cuban doctors in neighborhood consulting offices and the modern Diagnostic Clinic.
Around 7:45, four more medical students from the village, already donning their white jackets, walk by our house, past the plaza and the little church, and gather in front of a small concrete block building called the ambulatorio. About the same time, they are joined by three more medical students who emerge from Carlos’s bright blue jeep,“the Navigator,” one of the other vehicles in the taxi cooperative that serves the village. These students from Sanare pull on their white jackets, hug their compañeros, and wait for Elsy, a health committee volunteer who is studying to be a nurse, to unlock the gate to the ambulatorio, the walk-in clinic that offers Barrio Adentro medical service.
As I stroll by, I see the prospective patients sitting on the benches of the small, covered patio in front of the entrance door. They are waiting for Dr. Tomasa, the family medical specialist. Two chirpy teenage girls sit next to Dr. Raul’s dentistry room and grin with perfect-looking smiles. “What could be wrong with your teeth?” I ask.
“Nothing,” responds one of them, “Dr. Raul is giving us another checkup.” Another checkup? Their parents never had a single checkup when they were young—consequently, there are many people over forty or fifty who have very few teeth.
By 8 a.m. one of the medical students stands behind the simple wooden counter, performing receptionist duties. Another shuttles back and forth to the file shelves, organizing and updating medical information that is kept on every family in the community. A third chats informally with the waiting patients, entertaining their small children, and informally inquiring about their families’ health. The other four students stand alongside Dr. Tomasa in the consulting office, watching her take family and individual histories and give examinations. They also fetch medicines, take temperatures, and weigh healthy children who are accompanying their mothers. Today, like every day, Dr. Tomasa says to her students, “Por favor, more questions. This is how we learn. You can never ask too many questions.”
Monte Carmelo is a small village that stretches along a single paved road on a mountain ridge in the foothills of the Andes in the state of Lara. Before Hugo Chávez assumed the presidency of Venezuela in 1999, the road was unpaved and the high school did not exist. According to the 2007 census, its population consisted of 129 families and approximately 700 individuals, nearly all of them supporting themselves by working small parcels of land by hand, or with horses and oxen. That same year nine residents of Monte Carmelo were medical students. Eight were studying Medicina Integral Comunitaria (popularly known as MIC), an intensive six-year course that in English is usually called Comprehensive Community Medicine. A ninth village resident was studying medicine in Cuba. Two more young women from a neighboring hamlet were also in medical school. They were part of a group of sixty-seven students in this agricultural region who were becoming doctors of medicine.
The students are a diverse lot: some are nineteen or twenty years old and have recently finished high school; others are closer to thirty and have young children; a few are even older. Some young mothers have recently completed their secondary education through Mission Ribas, one of the Bolivarian social missions that bring adults back to school on evenings and weekends. All of the students are enthusiastic about their role in fostering good health and introducing reliable medical care into the fabric of their community and the larger world. And many of them dream of emulating their Cuban teachers and one day serving as internationalist physicians themselves in remote and impoverished parts of the world.
This experiment in training new doctors in MIC would be worthy of international attention even if the program was limited to the 67 students in this remote coffee-growing region in the state of Lara. But in fact they represent only a tiny fraction of a gigantic effort to transform medical education and health care delivery throughout all of Venezuela. Nearly 25,000 students were enrolled in the first four years of MIC in 2007 2008, and by 2009 and 2010 they were joined by more students, swelling the ranks of students enrolled in all six years of MIC to approximately 30,000. This is almost as many as the total number of doctors who were practicing medicine in all capacities in Venezuela when Hugo Chávez was elected president in 1998.
One unique aspect of MIC is that the students in Monte Carmelo do not have to leave the campo, the countryside, nor do students in the poorest neighborhoods of Venezuelan cities have to desert their barrios in order to attend medical school. Medicina Integral Comunitaria is a “university without walls” that trains young doctors in their home environments. This is not a short-term course for health aides or “barefoot doctors,” but a rigorous program designed to produce a new kind of physician. Every morning during their years of study, the MIC students help doctors working in Barrio Adentro attend to patients’ illnesses and learn to comprehend the broad public health needs of their communities. And every afternoon, they meet with their MIC professors in a series of formal medical classes that constitute a rigorous curriculum and include all the medical sciences studied at traditional universities.
The MIC education program could not exist without Barrio Adentro, the nationwide health system that first began delivering primary care in 2003 thanks to an enormous commitment of expertise from Cuba. From 2004 to 2010, Barrio Adentro continually deployed between 10,000 and 14,000 Cuban doctors and 15,000 to 20,000 other Cuban medical personnel—dentists, nurses, physical therapists, optometrists, and technicians. 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.
Obviously, Cuba cannot afford to devote so many of its medical personnel to Venezuela indefinitely, nor does the Chávez government want to depend on foreign doctors forever. So when Barrio Adentro was being launched in 2003, Cuban and Venezuelan medical experts devised a new program of medical education that will enable Venezuela to keep its universal public health program functioning permanently. Starting in 2005, the Cuban doctors were asked to perform a rigorous double duty: not only did they continue treating patients in Barrio Adentro clinics, but many of them also began teaching as professor/tutors for the MIC program in comprehensive community medicine. The goal of MIC is to integrate the training of family practitioners into the fabric of communities in a holistic effort that meets the medical needs of all citizens, makes use of local resources, and promotes preventive health care and healthy living.
The Cuban mission in Venezuela is possible because over the past half-century, Cuba has developed a vision of medical service that goes far beyond its own borders. Cuban health workers, in addition to providing free health care for all their fellow citizens, have transformed themselves into a “weapon of solidarity,” a revolutionary force that has been deployed in over 100 countries around the world. Since 2000, however, the Cuban commitment has increased substantially because the Bolivarian Revolution in Venezuela has contributed its own enthusiasm, volunteers, and economic resources. Through various agreements of cooperation, Cuba and Venezuela have embarked upon a number of projects in other fields such as education, agriculture, energy, and industrial development, and then have extended these cooperative ventures to other nations, particularly within ALBA, the Bolivarian Alliance for the Peoples of Our America, which includes Bolivia, Nicaragua, and Ecuador as well as the small Caribbean island nations of Dominica, Antigua and Barbuda, Saint Vincent and the Grenadines.
Of all these ambitious undertakings, delivering medical services is by far the most prominent. In order to extend universal health care to the poor and working classes in way that is compatible with the new, egalitarian vision of these societies, many more physicians are needed. With this in mind, Cuba is educating more doctors at home even as it trains tens of thousands in Venezuela. In 2008 there were 29,000 Cubans enrolled in medical school, plus nearly 24,000 foreign students (including more than one hundred students from the United States) studying at the Latin American School of Medicine in Havana or at the schools of the New Program for the Training of Latin American Doctors that are located in four other provinces.
An Army in White Jackets
I first became aware of the magnitude of this medical revolution in 2004 on my first trip to Venezuela. When Dr. Yonel, a young Cuban dentist working in a barrio of Caracas, informed me there were more than 10,000 doctors working in Venezuela, I exclaimed, “Un ejército de medicos! An army of doctors!”
Dr. Yonel smiled and replied, “Un ejército de paz. An army ofpeace.”
Clearly the collaboration of the rejuvenated Cuban Revolution and the nascent Bolivarian Revolution was yielding impressive results. And a growing number of countries in the Western Hemisphere, long under the yoke of wealthy conservative minorities or military authoritarians who were dependent on capital and political instruction from the North, were no longer willing to listen to the United States when it told them to shun Cuba and Venezuela. Since its long-standing economic blockade of Cuba was failing to deter these developments, the United States tried to launch a disruptive dissident movement in Cuba and assist a coup d’état in Venezuela. When these efforts failed, the U.S. government imposed more draconian economic and travel restrictions on Cuba in 2004 and funded various schemes to undermine both revolutionary governments. In 2006, the United States stooped to an especially low level when it attempted to directly sabotage Cuba’s humanitarian medical missions by creating the Cuban Medical Professional Parole Program. This was 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.
These antagonistic efforts did not succeed in diminishing the international solidarity and prestige that Cuba and Venezuela were acquiring around the world, nor did it keep them from expanding their programs of humanitarian medical aid and international medical education. In 2007, a young Chilean, a member of the third class graduating from the Latin American School of Medicine in Havana, spoke at her commencement and told her classmates: “Today we are an army in white jackets that will bring good health and a little more dignity to our people.”
By 2010, Cuba and Venezuela further demonstrated their capabilities by being among the most prominent providers of both emergency and long-term aid to Haiti after its devastating earthquake. Brazil, the economic giant of Latin America, signaled its admiration by announcing that it would be delighted to join Cuba in a partnership to create a new public health system in Haiti. José Gomés, the Brazilian Minister of Health, explained why his country was choosing to work with the Cubans on such a significant and demanding project: “We have just signed an agreement—Cuba, Brazil, and Haiti—according to which all three countries make a commitment to unite our forces in order to reconstruct the health system in Haiti. . . . We will provide this, together with Cuba—a country with an extremely long internationalist experience, a great degree of technical ability, great determination, and an enormous amount of heart.”
For Cuba, Venezuela, and by extension their allies in ALBA alliance, these triumphs throughout the first decade of the twenty-first century were more than diplomatic coups, they were moral victories. They demonstrated the power of social solidarity and humanistic concern for other people, values in stark contrast with the materialistic, self-centered, and aggressive behavior of the advanced capitalist societies.
This book aims to acquaint the reader with the ways that revolutionary doctors and health care workers have developed into major protagonists of socialist change and are defining what that change should look like. Chapters 2 through 4 offer some glimpses of Cuba’s international medical missions, their profound impact on various parts of the world, and their relation to the overall development of Cuban health care over the past fifty years. Chapters 5 through 8 describe how a new public health system, Barrio Adentro, has been created in Venezuela, and how new Venezuelan doctors are being educated to assume responsibility for this system in the future. This description is based on my own observations of day-to-day interactions of doctors, medical students, health committees, and the members of the communities they serve. Finally, the last four chapters illustrate how capitalist cultures and imperialist forces are resisting the development of revolutionary medicine and revolutionary consciousness, while the emerging socialist cultures are pressing forward with new ideas and creating the patterns of practice and commitment in daily life that are producing the revolutionaries of the future.