Che Guevara (Image via RottenTomatoes.com)
The Lancet, Volume 378, Issue 9807, Page 1910, 3 December 2011
doi:10.1016/S0140-6736(11)61830-8
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Revolutionary Doctors: How Venezuela and Cuba are Changing the World’s Conception of Health Care
Monthly Review Press, 2011
Pp 256. US$18·95. ISBN-9781583672396
Giving a speech in 1960, the year after the Cuban Revolution, Che Guevara spoke of the role of medicine in the new Cuba, telling supporters “our task now is to orient the creative abilities of all medical professionals toward the tasks of social medicine”. InRevolutionary Doctors, Steve Brouwer assesses the accomplishments of those who were to follow Che’s prescription, tracing the development of Cuba’s systems of health care and medical education since the revolution, together with the role of medicine in the country’s relations with the outside world.
Brouwer examines the relationship between Cuba and Venezuela over the past decade, as the latter country’s own democratic Bolivarian Revolution—named for Simón Bolívar who helped to liberate much of Latin America from Spanish colonial rule—has attempted to build a system of universal free health care as part of a wider project of social change.
Brouwer lived for a year in rural Venezuela, encountering medical students, doctors, and other health professionals in communities where none had existed just a few years earlier. Mission Barrio Adentro (“inside the neighbourhood”) began initially in early 2003 as a small programme in the Libertador district of Caracas; it was intended to provide free primary health care to poor communities, previously underserved or without any regular access to health care. However, the reluctance of Venezuelan doctors to take part in Barrio Adentro, and to live and work in poor urban barrios or rural areas, led the mayor of Libertador to bring in physicians from Cuba to staff the new local clinics.
Barrio Adentro was soon adopted nationally, with Venezuelan President Hugo Chávez making a deal that would provide Cuba with discounted petroleum in exchange for doctors and other health professionals, most of whom would come to Venezuela on rolling 2-year placements. The project became the cornerstone of a series of social welfare missions funded directly by revenues from the nationalised oil industry. By the autumn of 2004, Barrio Adentro had expanded to a nationwide network of 13 000 doctors, together with nurses, dentists, and other health-care workers, who staffed small local clinics across the country.
Barrio Adentro would not have been possible without the thousands of Cuban medical professionals who have taken part since 2003, but this approach was clearly unsustainable in the longer term. Soon after the project took off, efforts were made to integrate Venezuelan doctors into the system: residency programmes were provided for recent graduates and medical students were sent to study at the Latin American School of Medicine (ELAM) in Havana. Most important, however, has been the establishment of a 6-year comprehensive community medicine programme, Medicina Integral Communitarian (MIC). This programme teaches thousands of new primary care physicians outside the traditional university setting and gives veteran Cuban doctors an additional role as teachers, with their new students, most of whom remain within their own communities, observing and supporting the work of the Barrio Adentro doctors in between attending formal lectures. Brouwer’s first-hand account of MIC is informed by his interviews with doctors, medical students, and their families, as well as his visits to patients’ consultations and classes for medical students.
Cuban experience of health care has had a strong influence on developments in Venezuela. The emphasis on primary care and prevention as the basis of “health for all”, as reflected in the Alma-Ata Declaration in 1978, has been central to medicine in Cuba since the revolution and has led to improvements in many health outcomes, despite low income and international isolation. Cuba’s commitment to medicine has also served as the basis for a powerful form of positive health diplomacy—its international medical brigades have provided disaster relief in the region and elsewhere around the world. ELAM, which was established after the hurricane relief effort in 1998 to train doctors committed to providing care for their underserved communities around the continent, has proved central to these efforts in recent years.
Brouwer is not an impartial observer, however. He clearly supports the developments he describes, and is open about his own socialist politics. While no bad thing, it does tend to mean critical engagement is limited and at times defensive. But Brouwer largely succeeds in what he sets out to do: he relates how revolutionary doctors, motivated by solidarity with the poor, have lived up to Che Guevara’s aspiration, in Brouwer’s words, of “combining the humanitarian mission of medicine with the creation of a just society”.
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