[This entry responds to a post from Free Thoughts blog. FT reprints an article by a Dr. Ferrer who photographs struggling Cuban hospitals to smear the “regime.” Like almost everyone who ever says anything about Cuba, the blogger knows nothing about the subject. But the article made WordPress’s “hot posts” and I needed an excuse to write about this.]
Prologue: Dirty Pictures Aren’t an Argument
Ferrer’s pictorial shares the limits of all such “anecdotal” evidence: Totally divorced from context, we can’t see if there are any factors which might mitigate the severity of the problems depicted, or indicate whether they are isolated or representative of general phenomena. For instance, is the hole in the wall (pictures #14 and #15) in an unused wing of the hospital? Might it have been repaired shortly after? Is it part of a construction effort? For all we can tell from the pictorial, it could be the only damned hole-in-the-wall in the history of Latin America. At worst, Ferrer proves that Cuban health care is imperfect. There is no system of medicine in the world of which a similar pictorial could not be constructed: The notorious “First World” Walter Reed VA hospital makes for a more damning one.
This is something to keep in mind when faced with snapshots of “bad things.” However, in most of these photos it isn’t clear what bad thing is even being alleged, unfairly or not: Photo #1 depicts a puddle on a balcony; #’s 9 and 12 show medical personnel at work under pretty normal conditions. Where unambiguously bad things are depicted—again, that hole in the wall—it is unclear how these are necessarily medically-impacting: If I went downtown to St. Jude’s Children’s Hospital and put my shoe through the wall, the quality of care there would not have to decrease at all.
Mopping this up should be a real priority for a country that has to make its own anticoagulants
Asking Cuba to Make Bricks Without Hay
In fairness, maybe the point is not that bad things like holes in walls of themselves decrease the quality of medical care, but rather that a hospital’s failure to board holes is an index, a sign, of more general deficiencies. By a similar logic, we would avoid a restaurant with a leaky roof not because we fear water in our food, but because we have to wonder what else is wrong that we cannot see. But consider some factors special to the Cuban case:
Cuba qualifies as a poor country. We could talk about the causes, but this condition long predates the revolution. As such, things like dingy walls, dented furniture and backlogged repair orders—even Ferrer’s “alarming deficit of medicines”—are to be expected. Enduring the strictest embargo in the history of the world merely compounds this. Ferrer’s critique chastises Cuba for bearing the marks of poverty—which just amounts, absurdly, to asking it not to be poor.
As a rule, a country’s economic and social indicators tend to closely correspond. That is, a country’s aggregate wealth is the surest predictor of its citizens’ average standard of living. But this formula breaks down when we get to Cuba, whose social indicators far outstrip what its GDP would lead an observer to expect. Cuba boasts, for instance, 1/14th the per capita wealth of the U.S. but very nearly equal rates of life expectancy and literacy. (This, of course, blows the rest of Latin America out of the water.) This kind of divergence is simply not found anywhere else in the world. The point is that if there is any country in which dingy walls, etc., could coexist with decent health care, it is Cuba.
With this in mind: Surely the question is not whether Cuba is poor, but how well it does for being poor—how well it manages and prioritizes the sparse resources it does control. No catalog of deficiencies such as Ferrer’s could hope to answer this question. (Any more than, say, listing all the days I didn’t take my kid to the zoo will tell you if I’m an involved father.) What is needed, rather, is the specific balance of what is deficient against what is supplied; and both factors balanced against what is possible to achieve. (Maybe I took junior to the fair all of those days instead of the zoo; maybe there is no zoo near my home; maybe I can’t afford the zoo due to my disabled status but have lovingly replicated it with paper animal cutouts for my child’s home play. Again, context is all-important here.)
Neither let us downplay the effects of the embargo on health and medicine in particular. The horrors have been documented by every medical authority who has bothered to investigate the question—UNESCO, UNICEF, AAWH, WHO, the British parliamentary Health Select Committee, Oxfam and a ton of other NGOs. The AAWH report (beautifully summarized here) concludes the embargo is taking “a tragic human toll” on Cubans, having “closed so many windows that in some instances Cuban physicians have found it impossible to obtain lifesaving machines from any source, under any circumstances. Patients have died.” The tightening of the embargo in the 1990s forced a shortage of anesthetics and antibiotics, lowering the number of surgeries from 885,790 in 1990 to 536,547 five years later. Now, Cuba receives less than half of all new patented medications. Note that all such studies praise the “regime” for mitigating the harsh effects they document. In 1989, when Cuba had much less of its own money to invest in health care, the World Health Organization (WHO) called this system “a model for the world,” adding, “A humanitarian catastrophe has been averted only because the Cuban government has maintained a high level of budgetary support for a health care system designed to deliver primary and preventive health care to all of its citizens.”
Cubans themselves express a wide basic support for the health care system. A recent Gallup poll indicates 75% of Cubans have “confidence in [their] country’s health care system.” 96%—nearly all—say that “health care in Cuba is accessible to everyone.” (Compare this with the 2/3 of Americans who poll in favor of a national health care system, much closer to the Cuban one.)
“Tourism Apartheid?,” i.e., Jesus. Grow the Fuck Up.
Ferrer seems concerned less with what he sees as the weak points in Cuban health care than with the fact that these weak points coexist with strong points. He laments “[t]he official policy of APARTHEID imposed by the Cuban regime…The few existing hospitals and polyclinics which have adequate conditions and resources are exclusively for the use of foreigners and members of the governing elite.”
First, Ferrer’s amplified language distorts what amounts to a fairly ordinary situation. Cuba has a “two-tiered” economy wherein both pesos and dollars are national currency.¹ For global-economic reasons beyond Cuba’s direct control, the dollars are unit for unit worth more than the pesos. Certainly, Cubans with pesos to spend are more limited on what they can get and where they can get it than Cubans or “foreigners” with dollars to spend. This fact, while unfortunate, should no more distress Ferrer than the fact that Cubans with fewer pesos are more financially limited than Cubans with more pesos, or that foreigners with fewer dollars are more limited than their richer foreign counterparts. The “exclusive[ness]” here is a part of every national economy in the world, real or imagined, present or historic. Cuban medicine in particular is hardly to blame for the general characteristics of trade.
On a couple counts, Ferrer is just dead wrong. Despite Bush’s best efforts, plenty of Cubans have the requisite “foreign capital” and there is simply no evidence that some “facilities are exclusively for the use of foreigners and members of the governing elite” [my emphasis]. Nor does the “inequality” among peso-holders and dollar-holders break down along “ordinary Cubans versus ruling elite” lines—for one, nothing like a Cuban “ruling elite” has ever been shown to exist (See “The Myth of Cuban Dictatorship” by Charles McKelvey). Not that Ferrer attempts to provide evidence for any of these claims.
Yes, nobody can absolutely guarantee that no Cuban has been ever “steered” from a health care facility just for being Cuban. A friend of mine who has been to Cuba many times relates an incident where some Cuban friends, met at a Radical Philosophy Association (RPA) conference in Havana, were hesitant to follow him up to his hotel room to continue an evening’s socializing. They were mildly fearful of being mistaken by hotel staff, or maybe cops, for haranguing tourists for money. However, it was late and it seems like they might have come up otherwise. Perhaps something similar occurs with health care facilities patronized by tourists. (“Health tourism” is the actual term for people who come to Cuba from abroad for medical care.) Fear of “hassling the tourists” is pretty universal to vacation havens. There is no evidence of a systematic, “regime”-engineered “policy” driving it, and the phenomenon doesn’t require us to postulate one.
It could still be asked why the Cuban “regime,” along with every other “regime” whose nations have tourists, doesn’t do something about this problem. In Cuba’s case, this is not clearly an option. Cuba courts tourism because it has to. It needs foreign currency, and investment in the tourist sector (along with biotech) has been deemed the least capital-intensive way to attract it. I’m reminded of an old movie in which a father loses his job, forcing the family to take in a boarder. At dinner, the mother gives the largest pork chop to the guest. She has to reach right over the youngest child’s plate to do this, which leads him to frown miserably as the chop passes him by. (This is interrupted by a stern parental glance.)
Ferrer, a Cuban, is like the young child in the movie, upset at the special treatment of the boarder but uncomprehending of the uncontrollable factors that make it necessary. The Italian author of “Free Thoughts” blog and other Western critics of “tourism apartheid” are like a snooty neighbor who accuses the movie parents of child abuse. The proper response for this situation is sympathy, not contempt for policymakers. (The analogy breaks down in two places: First, there are few “surly children” in Cuba; even the most critical accounts admit that most Cubans regard “dollarized” facilities as helpful or at least necessary. Second, none of Cuba’s actual neighbors are very snooty, as the national “households” of the U.S. and Latin American countries still have far more inequality than Cuba’s.)
Nor are the dollar and peso “sectors” of the economy nearly so distinct as a term like “apartheid” would suggest: Given the “unified” character that state-management lends to Cuban medicine, there is a unique opportunity for these dollars to feed back into the health care apparatus, aggrandizing even those sectors most likely to be patronized with pesos. Most of the dollars end up in government banks, where they are then used to purchase imports of needed and wanted items for local consumption. Many Cubans work in the tourist sector, where they receive dollars directly as tips. Globalsecurity.org notes: “The socialist peso economy applies to most Cubans, providing them with free education, free health care, universal employment, unemployment compensation, disability and retirement benefits and the basic necessities of life: food, housing, utilities and some entertainment at very low cost. The free-market dollarized economy operates in the tourist, international and export sectors, and substantially sustains the socialist economy” [my emphasis].
Cuba’s de facto economic “apartheid” compares favorably to the explicit form found in the U.S. Virtually nobody, even the super-rich, solicits medical care in the “free” way in which they might obtain a can of Coke. The medical infrastructure is not a collection of storefronts which might be “popped ‘round to” with cash on the barrelhead. For the 90% of insured Americans who are in some kind of “managed care” program, access to any medical service or product is mediated by multiple contracts holding among employers, insurers and other third party administrators, primary and specialist physicians. Patients may be “steered” by an employer toward an HMO or PPO, and by provider networks and “gatekeeper” physicians when treatment is sought. Of course, the for-profit character of the system “steers” the less wealthy away from better—as more expensive—care. The difference is that the American version exists to make wealthy people wealthier, while the Cuban version, again, exists for the survival of Cubans.
Those Charitable Bastards
Ferrer continues: “Thousands of doctors and other health professionals, as well as essential medical resources, are diverted from public health and directed to political missions in countries such as Venezuela, Bolivia, Nicaragua and Ecuador. To this end, thousands of tons of medicines, medical equipment and indispensable resources are donated. Missions carried out at the expense of increasing the deprivations suffered by Cubans.”
Assuming this is true, can we say that it’s wrong? Are Cubans more important than Venezuelans or Bolivians (whose own “deprivations” would “increas[e]” if the “[m]issions” fall off)? Should charity never substantially cost the giver? Just what is the argument here? Again, Cubans seem to support this, and proudly. Anyway, the main export here is labor, and Cuba can probably spare that, boasting twice the per capita doctors of the U.S. and, depending on the year, the most per capita doctors of any country. And Cuba gets plenty of aid back from Venezuela, anyhow (e.g., cheap oil), if that’s what’s important.
¹ Technically, in 2005 the “convertible peso” replaced the dollar but for practical purposes is equivalent to it.