¡Salud! (DVD, 2006), a documentary film by Connie Field, 93 mins., distributed by MEDICC (saludthefilm.net)
In many countries in the Americas, debates over the practice and meaning of health care have taken on new political momentum. Should health care be a commodity whose price is determined by the market? Or is it a human right that should be allocated according to principles of solidarity and social justice? In the United States, as we face exponentially rising health care costs and a growing proportion of the uninsured and under-insured, even modest health care reform has become a highly contentious issue. Whether considered in a national or global context, the issue of health disparities is already a key political issue for the 21st century.
Supporters of public health care often hold up Cuba as an example of what can be accomplished, even in a context of limited resources, with political will and the commitment of sufficient financial and human capital. Cuba’s superb health statistics—equal to, and sometimes better than, those of the United States—are an accomplishment of which Cuba is justifiably proud. They form a cornerstone of the socialist state’s claims to a moral legitimacy superior to that of capitalist states, particularly the United States. Given the polemics that surround Cuba, arguments about the veracity of Cuban health successes are a primary vehicle through which Cuba supporters and critics debate the socialist government’s mandate.
While Michael Moore’s Sicko brought Cuba’s universal health care system into the U.S. public awareness, Connie Field’s beautifully shot and well-paced documentary, ¡Salud!, tells the lesser-known story of Cuba’s history of medical internationalism. The film begins by highlighting the statistics that describe global health inequalities: In Europe, a woman has a one-in-4,000 chance of dying in childbirth; in Africa it is one in 16. In Canada, average life expectancy approaches 80 years; in Haiti, it is 52. Through personal testimonials, the film then introduces us to some of the problems of health care access in four countries where Cuban doctors have been deployed—the Gambia, Honduras, South Africa, and Venezuela. A Venezuelan woman, describing a doctor’s refusal to promptly treat her asphyxiated baby, sets the tone of the film, declaring: “To deny you medical attention is to deny your right to life, and the right to life is universal.”
After the 1959 revolution in Cuba, the government developed a free and accessible public health care system that has been central to Cuba’s vision of an egalitarian society. A key node in the system has been the network of family doctors who live in the communities they serve. This both allows patients continual access to health care and gives doctors an intimate knowledge of individual, familial, and neighborhood risk profiles. While the medical budgets of many developed countries reflect their emphasis on costly curative medicine, Cuba achieves comparable health indices with a fraction of the cost by focusing on community-based preventative care.
Since the first Cuban medical mission in 1963 (to Algeria), more than 100,000 of the country’s health professionals have served in 103 countries. Whether this “health diplomacy” reflects Cuba’s policies of international solidarity or strategic political positioning (or both) is a hotly contested question. Whatever their intentions, Cuban health missions have been extremely effective in helping poor countries confront their often daunting health care needs. As one health policy expert, interviewed by Field, aptly points out: “If this were the kind of international relations that every nation practiced, this would be a better world.”
Following the day-to-day experiences of Cuban doctors serving abroad, the film explores the role of Cuban doctors in alleviating systemic health inequalities. In South Africa, which suffers from a massive brain drain of trained physicians and a health system still mired in the legacy of apartheid, Cuban doctors fill the gap in the country’s public safety net that overwhelmingly serves the country’s poor black majority. When the Gambian government established its first national health care system in 1996, it turned to Cuba for both advice and the personnel to staff clinics in previously unserved poor rural areas. Thanks in part to Cuban doctors’ efforts in preventing malaria, cases dropped from 600,000 in 2002 to 200,000 in 2004. Moving to Latin America, the film then documents the work of Cuban doctors in Honduras after the devastation of Hurricane Mitch in 1998, as well as the massive Barrio Adentro project, which has staffed thousands of clinics in poor areas of Venezuela with Cuban doctors.
But it is not just medical expertise, the film argues, that makes Cuban doctors such good ambassadors for their country; it is their deeply held solidarity with the poor and the marginalized. While doctors in some countries, most notably Venezuela, have protested Cuban doctors’ presence, they often work where local doctors—usually from the upper social classes and accustomed to certain comforts—refuse to go. Arguing that doctors who themselves hail from underserved areas are more likely to serve their communities, in 1999 Cuba established the Latin American School of Medicine, which provides students from 27 countries with a free medical education. Whether they fulfill this promise, however, as the medical anthropologist Paul Farmer concludes, depends ultimately on whether health care is framed as a right for all, regardless of the patient’s ability to pay, or as a commodity to be sold to the highest bidder.
The film also presents some of the difficulties that Cuban doctors face during their missions, which usually last at least two years. Doctors encounter foreign cultures and frequently difficult living and working conditions; while most persevere, about 2% defect during their service, often opting to join their well-paid counterparts in the private sector rather than continuing in the public system. (Indeed, the administration of George W. Bush implemented a program promising expedited U.S. visas to Cuban doctors who defected in Venezuela.) Doctors must also endure long separations from their family, often leaving behind young children.
Despite these challenges, Cuban doctors volunteer for international service in startling numbers. In 2005, for example, some 20,000 of them—about one quarter of Cuba’s health personnel—were serving in Venezuela. While a strongly held sense of social solidarity undoubtedly underlies this service, the film perhaps downplays the economic motivations of international service for both the state and for individual doctors. Doctors in Cuba make between $20 and $25 per month; working overseas, they may earn between $150 and $375 a month, and their salaries rise to $50 a month after their return to Cuba. Given the economic hardships that face many Cuban families, the opportunity to earn extra money without abandoning their profession or permanently leaving their country—as occurs in the brain drain faced by many developing countries—is appealing to many of them.
At the same time, while other missions have principally taken place in poor and under-resourced countries, the Cuban government now also relies heavily on the thousands of barrels of subsidized oil provided daily by the Venezuelan government in exchange for the work of Cuban doctors. The departure of so many doctors and the consequent closure of numerous neighborhood clinics has also affected the Cuban medical system; since 2006 (after this film was completed), the family doctor system—famous for installing a doctor on every urban block—has been reorganized as a network of more dispersed clinics staffed by a limited team of doctors and nurses who attend to a greater number of patients. (Although this has not had an impact on Cuban health indices, many Cubans who had become used to immediately accessible medical service are unsatisfied with this change.) While such observations do not diminish the role of solidarity and humanism that motivates both doctors and the state, they do point to a new impetus for medical service in the context of post-Soviet Cuba’s economic challenges.
Although ¡Salud! is too long to be shown in its entirety in most undergraduate classes, it moves briskly and will appeal to anyone interested in Cuba and the politics of health. The film offers an excellent introduction to, and overview of, Cuban understandings of health care as social justice.
Elise Andaya teaches anthropology at the University at Albany (SUNY). She is completing a book manuscript on reproductive politics, gender, and kinship in post-Soviet Cuba.