While touring one of Cuba’s health facilities, I found this poster very fascinating as a physical representation of the Cuban healthcare system and its differences with respect to the American system to which I was accustomed. In the United States I haven’t come across this level of cost transparency, and this representation isn’t intended to better inform the “consumer” of the services they are paying for. Because Cuba has free universal healthcare, cost transparency isn’t really an issue for the patient themself. Rather, this graphic is intended to remind Cubans that someone is paying for their healthcare, and to be considerate of not overusing services. Indeed, Enrique Beldarrín, my professor for my “Health and Society in the Time of COVID-19 in Cuba” once relayed that too many Cubans were taking advantage of free plastic surgeries after the revolution, and subsidies had to be scaled back in response. The message “… es gratuito, pero cuesta” (it’s free, but comes at a cost) encapsulates this dynamic. From an American perspective, these figures seem shockingly cheap once converted; in the US we’re accustomed to medical expenses being some of our highest. For instance, according to the official exchange rate, a minor surgery would cost about one dollar. Not only is this a public health message; it is a political advertisement.
The Cuban government maintains an official conversion rate from dollars to Cuban pesos which is much lower than the unofficial rate (when I studied abroad there, the informal exchange rate was 250 pesos for each dollar). As a result, these figures might be inaccurate or misleading. I have mixed feelings about questioning the authenticity of the Cuban healthcare system. Often the island’s health data is called into question in order to undermine the feasibility of the country’s model of socialist medicine, or to demonize the Cuban government. Throughout a paper I wrote last semester on Cuba’s model of maternal care, I struggled to account for this nuance. Once lauded as the shining achievement of Cuban healthcare, the Pan American Health Organization indicates that the island’s infant mortality rate rose higher than that of the United States. When the reverse was true, this measure often formed the keystone of many of my sources’ arguments for the United States’ flawed prenatal care in comparison to its Caribbean neighbor. I address the controversy around this data point in this excerpt from the paper:
… the measure of infant mortality in particular has fallen under scrutiny by some scholars in the literature who allege that the Cuban government has influenced or falsified the data. For instance, Professor Katherine Hirschfeld states that during her nine months of fieldwork in Cuba at the end of the 20th century, she encountered evidence of medical repression and forced abortions (Hirschfeld 2007). Hirschfeld writes that she spoke with a doctor who provided evidence of these practices: “”What happens if an ultrasound shows some fetal abnormalities?” I asked. // “The mother would have an abortion,” the doctor replied casually. // “Why?” I queried. // “Otherwise it might raise the infant mortality rate”” (Hirschfeld 2007 pp 12). These allegations are difficult to prove or disprove given that they are predicated on the experiences of one fieldworker and her anonymous interlocutors. However, even if we accept that this case study is truthful, it does not support some of the claims that have been made by scholars who cite Hirschfeld’s account. For example, Berdine, et al (2018) cite Hirschfeld as their sole source to support their claim that “Physicians often perform abortions without clear consent of the mother, raising serious issues of medical ethics, when ultrasound reveals fetal abnormalities because ‘otherwise it might raise the infant mortality rate’” (pp 755). However, a single case study does not indicate a widespread phenomenon, and the doctor quoted by Hirschfeld does not directly imply that his statements apply to the entire healthcare system.
Other scholars have alleged that the Cuban government may inflate its infant mortality rate by neglecting to account for late fetal deaths, or by collecting data that is not representative of the entire population (Cooper et al 2006, Gonzalez 2015). Much of the literature surrounding Cuban maternal and prenatal health hinges on its infant mortality rate, without interrogating specifications of who constitutes an infant. Although Cooper (2006) acknowledges that Cuba adheres to the World Health Organization’s (WHO) stipulations for reporting infant mortality, WHO also presents infant mortality as a universal yardstick for comparing nations with varying sociocultural and economic determinants of health.
As Professor Beldarrín often asserted in class, the American perspective on the Cuban government often fabricates human rights abuses while missing the policies and practices on which the state should actually be held accountable. One such example of this dynamic is detailed in Paul Farmer’s Pathologies of Power (2003), which demonstrates how the American government decried the Cuban sanitariums created during the HIV/AIDS epidemic, while elevating their own “facilities” for Haitian asylum seekers thought to have the disease at Guantanamo Bay. In actuality, the United States provided unsanitary living conditions for the imprisoned Haitians and practiced forced sterilization (Farmer 2003). My Professor noted that, although the condemnation of the island’s HIV sanitariums was exaggerated, there was a very real controversy and polarization among the health world in Cuba about these facilities. Cubans with HIV were quarantined and treated in these facilities, ostensibly for their own safety and that of others. Because of the stigma around homosexuality during the epidemic, many patients were rejected by loved ones. Furthermore, knowledge around the transmissibility of the disease was still limited. However, this form of intervention broke a core tenet of the island’s healthcare ideology: that patients’ medical services be accessible within their communities.
All in all, as was often repeated to me by my professors, the reality of Cuba is somewhere between the official narratives of the United States and the island’s government. I remember mentioning my experience learning about the class to one of my peers at the University of Havana, who then asked if I believed that the reality of Cuban healthcare was exactly as I had been told. I responded along the lines of imagining that what was presented to me was probably not quite the case in Cubans’ daily lives, and she nodded with a grim set to her jaw. She told me that often people experience long waits for services and are no longer able to develop the same personal connections with their primary care physicians. She didn’t specify when, but this decline has likely been ongoing since Cuba lost the economic support of the Soviet Union. Moreover, it is difficult to earn a living as a Cuban doctor. As government employees, they are paid in Cuban pesos, a very weak currency in the island’s dollarized economy. Furthermore, “el bloqueo” (as Cubans call the United States’ economic sanctions) continues to take its toll on all areas of life, including healthcare. My host mother once told me that she had diabetes but could never access the needles with which to check her blood sugar. Much like the poster I reference in this post, the Cuban healthcare system is much more complicated and nuanced than one might think at first glance.
Works Cited
Cooper, Richard S., et al. “Health in Cuba.” International Journal of Epidemiology, vol. 35, no. 4, Oxford University Press (OUP), Aug. 2006, pp. 817–24, https://doi.org/10.1093/ije/dyl175. Accessed 10 Dec. 2024.
“Cuba – Country Profile.” Health in the Americas, Oct. 2024, hia.paho.org/en/country-profiles/cuba. Accessed 9 Dec. 2024.
Farmer, Paul. Pathologies of Power : Structural Violence and the Assault on Human Rights. Berkeley, University Of California Press, 2003, pp. 29–50.
GONZALEZ, ROBERTO M. “Infant Mortality in Cuba: Myth and Reality.” Cuban Studies, no. 43, 2015, pp. 19–39. JSTOR, http://www.jstor.org/stable/24487269. Accessed 13 Dec. 2024.
Hirschfeld, Katherine. “Re-Examining the Cuban Health Care System: Towards a Qualitative Critique.” Cuban Affairs, vol. 2, no. 3, July 2007, www.researchgate.net/publication/242567776_Re-examining_the_Cuban_Health_Care_System_Towards_a_Qualitative_Critique. ResearchGate. Accessed 10 Dec. 2024.
The entirety of my paper on Cuban practices of maternal and prenatal care can be accessed
here:https://docs.google.com/document/d/1ufFU0XQyRhq9Z_CATDUhhpYsebe3srV05pn_B9Lz
