REVOLUTIONARY MEDICINE EXPERIMENTAL FUTURES TECHNOLOGICAL LIVES, SCIENTIFIC ARTS, ANTHROPOLOGICAL VOICES A series edited by Michael M. J. Fischer and Joseph Dumit P. Sean Brotherton REVOLUTIONARY MEDICINE HEALTH AND THE BODY IN POST-SOVIET CUBA DUKE UNIVERSITY PRESS DURHAM AND LONDON 2012 ∫ 2012 Duke University Press All rights reserved Printed in the United States of America on acid-free paper $ Designed by Nicole Hayward Typeset in Adobe Garamond Pro by Keystone Typesetting, Inc. Library of Congress Cataloging-in-Publication Data appear on the last printed page of this book. published with the assistance of the frederick w. hilles publication fund of yale university. To my parents, Ivan and Delcita Brotherton CONTENTS List of Illustrations / ix List of Tables / xi Prologue / xiii Preface: An Ethnography of Contradictions / xv Acknowledgments / xxv Introduction: Bodies in States of Crisis / 1 PART I. BIOPOLITICS IN THE SPECIAL PERIOD / 13 1. The Biopolitics of Health / 15 2. Expanding Therapeutic Itineraries / 35 PART II. SOCIALIST GOVERNMENTALITY, PUBLIC HEALTH, AND RISK / 55 3. Medicalized Subjectivities / 57 4. Curing the Social Ills of Society / 84 5. Preventive Strategies and Productive Bodies / 111 PART III. WE HAVE TO THINK LIKE CAPITALISTS BUT CONTINUE BEING SOCIALISTS / 145 6. Turismo y Salud, S.A.: The Rise of Socialist Entrepreneurs / 147 7. My Doctor Keeps the Lights On / 169 Conclusion: Bodies Entangled in History / 182 Coda / 191 Notes / 193 Bibliography / 219 Index / 245 ILLUSTRATIONS part i. josé martí sculpture. 13 1. Medicina tradicional y natural (mtn) pharmacy in Havana. 43 2. Huerto (garden) of medicinal plants. 48 part ii. use me. cooperate with me to keep the city clean and healthy. 55 3. A personal collection of medicines. 58 4. Elimination of poliomyelitis in Cuba. 71 5. Vaccinations against bcg tuberculosis. 71 6. Listen to this friend . ! 73 7. Parasitism: Measures of control. 73 8. Parasitism: Life cycle of Ascaris lumbricoides (roundworm). 73 9. Hygiene Is Health. Let’s Make Cuba the Healthiest Country in the World. 74 10. To a child with vomiting and diarrhea . 74 11. What do you know about your health? Infectious hepatitis. 75 12. The functions of nutrition. 75 13. For this child, we are all caregivers. 79 14. For this child who is to be born, we are all caregivers . and for you as well! 79 15. Why? You have a right to be healthy. 81 16. To smoke is to ‘‘burn’’ your health. 81 17. An mef consultorio. 88 18. Organization of the sns parallels politico administration. 91 19. Flowchart of basic health statistics. 117 part iii. in cuba there will be no shift toward capitalism. 145 20. Cubanacán Turismo y Salud. 149 21. The return of Western Union to Cuba. 151 22. Cira García International Clinic. 153 23. Hospital Hermanos Ameijeiras. 154 24. Advertisements for some of Cuba’s international clinics and research centers. 155 25. Ópticas Miramar. 158 26. mediCuba. 162 27. Advertisement for Spirulina, a vitamin. 166 28. Cubita co√ee: Lo Mío Primero. 166 29. Mission Inside the Neighborhood. 171 30. Operation Miracle. 171 31. Cuban medicine: Experience, know-how, and techniques for healing. 175 TABLES 1. Cuba’s Public Health Statistics, 2009. 87 2. Detailed Description of Risk Groups for Analyzing the Health Situation of a Community. 116 3. mef Guidelines for Assessing Socioeconomic Factors in Health Areas. 118 PROLOGUE Walking along the streets of the formerly posh suburbs of Havana, I am always struck by the contrast between the old and new, now fused together. The streets resemble a bricolage of di√erent centuries, and each house I pass seems to reveal a new style, era, or simply an invention born of necessity. Romanesque pillars painted in soothing pastel colors, now faded, complement large windows and crumbling balconies that contrast with decorative rusting ironwork and gardens in disarray. It is not uncommon to find a bust of the Cuban independence fighter José Martí standing proudly in the center of many of these gardens, an image of his head and a revolutionary slogan engraved on a small plaque partly shrouded by encroaching weeds. In contrast to this serene image is the blaring sound of American pop music coming out of 1950s-model Fords and Chevrolets with large Sony or Panasonic speakers from the U.S.-dollar store placed strategically in the cars’ rear windows. The booming, repetitive bass and synthesized voices remind me that, despite appearances, we are in the new millennium. Laundry hanging out of ornate colonial windows and the buzzing sound of pressure cookers softening the daily fare of frijoles negros (black beans) are accompanied by the shrill laughter of brightly uniformed children on their way home from school. People standing in a winding queue in front of the local bodega (ration store) converse, laugh, and share a collective sigh, as most of the daily rations fail to arrive or simply run out. Unbothered by a river of water flowing from a broken pipe in the street, people smile obligingly as a passing tourist snaps a photo of what is, for him, a novelty: Cubans lining up for bread. These are the participants in the making of history, as it passes by in a series of rhythmic beats. PREFACE ETHNOGRAPHY OF CONTRADICTIONS In a crowded theater in Havana in the summer of 2000, as I sat watching the Cuban-directed and Cuban-produced movie of the year, Un Paraíso bajo las estrellas (A paradise under the stars)—incidentally, this is also the motto of the Tropicana, the infamous Cuban cabaret that features voluptuous danc- ing girls—the audience roared with laughter and shouted comments about the unfolding drama. One part of the movie that generated a particularly vociferous response was the demise of one of the secondary characters, who, while arguing with his neighbors, slipped o√ a bridge and fell to his death, standard fare in a Cuban soap opera. What was most remarkable about this death, however, was the character’s rebirth. During his funeral, his ex-wife, a Cuban living in Spain, arrived with her arms weighed down with shopping bags and boxes and dressed in the latest designer wear. The center of attention immediately shifted from the de- ceased to the newly arrived cubana de afuera (Cuban living abroad) and her declaration that she had brought regalitos (little presents) for everybody. While the mourners surrounded her, the deceased, not to be left out of the general mayhem of gift distribution, suddenly awoke. The mourners, stunned into disbelief, began to question him. ‘‘What happened?,’’ they cried out. Responding quite matter-of-factly he stated, ‘‘When I got to Heaven, they wouldn’t let me in because the entrance fee was in divisa [U.S. dollars].’’ Rejoicing in his rebirth, the mourners silently accepted the reality that the afterlife is merely an extension of everyday life, in which access to divisa shapes lives and experiences di√erentially. The audience in the theater screamed out in jest, ‘‘Vaya, no es fácil!’’ (It is not easy!). A woman sitting next to me shook her head and grumbled, ‘‘This country is shit.’’ A man yelled out, ‘‘Oye [listen], there is nothing left in this country that isn’t in divisa!’’ In Cuba today a deep discontent runs beneath the reiteration of revolu- tionary catechisms. In myriad ways Cubans are beginning both to voice serious concerns and to poke fun at the situation in which they find them- selves. Whereas once o≈cial state rhetoric served as a political summons to rally the population, even if superficially, the conspicuous reemergence of haves and have-nots, defying the socialist discourse of egalitarianism, leaves the government exposed to widespread criticism at unprecedented levels, often in public forums. As the state continues to defend its socialist aspira- tions, individual citizens, long accustomed to the basic necessities and the few extra luxuries furnished by the revolution, are starting to feel the e√ects of a prolonged economic crisis now that this material well-being is no longer guaranteed. More important, citizens are beginning to question and chal- lenge the rebirth of a class-stratified economy in which possession of divisa indexes di√erential access to basic goods and services and to rampant con- sumerism by the privileged few who reside in the upper layer of this multi- tiered economy. Like other spheres of Cuban society, the health care system has been at the center of recent macroeconomic transformations, such as the socialist government’s pursuit of a dual economy using Cuban pesos and U.S. dollars (now substituted by pesos convertibles).∞ This book examines how these re- forms characterize some of the implicit contradictions of everyday life and, importantly, shape individuals’ experiences with institutions of the state. Nowhere are these contradictions more evident than in Cuba’s socialist health policies, which are currently undergoing revisions, experiencing con- straints, and meeting obstacles as the country’s current financial woes pose serious challenges to the state’s ability to keep the underlying principles of the socialist government intact. While many social scientists have examined public health care in Cuba, none have ethnographically explored how health reform might be analyzed in terms of larger economic and political considerations, many of them external to Cuba, as well as in terms of changing practices in the everyday lives of citizens. To address these concerns, I ground this book in what I call an ethnog- raphy of contradictions, and, in order to map such an ethnography, I advocate a theoretically promiscuous approach, one that is wedded not to a single theoretical camp or framework, but to an engagement with a diverse body of xvi Preface recent scholarship on the anthropology of the state, critical-interpretive medi- cal anthropology, and postcolonial and postsocialist studies.