Health, Politics, and Revolution in Cuba Since 1898

Katherine Hirschfeld

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9780765803443
• eBook ISBN:
  9781351516099
• Topic: Medicine
• Subtopic: Health Care Delivery

Challenging many of the assumptions scholars have made about the Cuban Revolution's impact on healthcare, this volume recounts one anthropologist's quest to discover the truth behind the complicated relationship between Cuba's revolution, politics, and healthcare system. Katherine Hirschfeld became interested in Cuba in the mid-1990s, after reading numerous laudatory books and articles describing the Castro regime's achievements in health and medicine. Cuba's population health indicators seemed to be far superior to those of neighboring countries, the national health costs low, and medical care free at point-of-service to the entire people. Historical records indicated that most of these positive health trends resulted from the changes instituted by Castro in 1959. Few of these authors, however, had actually spent time on the island. Thus, Hirschfeld found that academic writing on Cuba was often long on praise, but short on empirical research about what exactly had changed in Cuban medicine since 1959.After much bureaucratic wrangling, Hirschfeld managed to secure permission to conduct long-term ethnographic research in Cuba, where she lived with families from Havana and Santiago, conducted clinic observations, interviewed doctors and patients, and was treated in a Cuban hospital during an epidemic of dengue fever. The reality of the Cuban healthcare system turned out to be different than the scholarly ideal: it was bureaucratized, authoritarian, and repressive, and most people preferred to seek healthcare in the informal economy rather than endure the material shortages, red tape, and political surveillance of the public sector. Written in the form of a first-person narrative, Health, Politics, and Revolution in Cuba Since 1898 not only critically reevaluates Cuban healthcare after the 1959 revolution; it includes chapters detailing Cuban health trends from the Spanish-American War (1898) through the fall of Fulgencio Batista in 1959 and into the

Part one

The Ethnographic Encounter

1

Fieldwork

I first traveled to Cuba in the summer of 1995, full of curiosity and high hopes for my research project. This preliminary trip was immensely successful. Like many foreigners I fell deeply in love with the warmth and vitality of Cuba. All of the officials I spoke with seemed enthusiastic and supportive, and everyone (from university professors to random strangers on the street) seemed eager to talk about health. After three weeks of preliminary research, I returned to the United States and quickly convinced my dissertation committee that conducting long-term fieldwork in Cuba was a feasible research goal.

After completing my doctoral exams, I returned to the island in the winter of 1996, expecting to stay for at least a year of long-term fieldwork. The majority of the research was to be carried out in Santiago (Cuba’s second largest city) located on the eastern end of the island. My visa was arranged through the University of the Oriente, and friends in Havana introduced me to an elderly widow in Santiago who would rent me a room. I liked Lydia¹ at once—she was warm and feisty and full of boisterous laughter. Her children lived in a neighboring province, and she continually told me how grateful she was to have some company in the house. I enjoyed her company too, and was very touched by her efforts to introduce me around the community and integrate me into her social world. By the end of January, 1997 I was comfortably settled and eager to begin my research.

The Field Site

The city of Santiago has always been quite different from Havana both culturally and geographically. It is older, less urbanized and moves at slower pace. One American observer in the 1920s in fact, described the cosmopolitan atmosphere of Havana as, “rather like Paris, a city of definite attraction where smart people go to be amused” (Woon, 1929:28). Santiago, on the other hand, was inevitably described as, “ancient,” “retrogressive,” “colonial.” or “charming” (Terry, 1929; Woon, 1929).

In some ways these characterizations still hold true. Santiago remains a remarkably beautiful city, and Orientales (i.e., people from eastern Cuba) continue to define themselves as culturally distinct from Habaneros. The two regions, in fact, maintain stereotypes of each other somewhat reminiscent of those that prevail between people from the Deep South and people from the northeast in the United States. Orientales describe Habaneros as supercilious, overly concerned with fashion and appearances, and too hurried to properly enjoy life. Habaneros in turn characterize Orientales as slow, backwards, and forever prone to forgoing work or ambition in favor of eating well and sitting comfortably on their porches engaged in social visits and frivolous conversation.

The city itself has grown dramatically since the 1950s, but nearly all of this growth has taken place at the periphery. The historic urban core and the port area have remained unchanged practically since the colonial era, and traveling outward from the city center feels something like time travel. From the colonial downtown, the architecture gradually changes from traditional Spanish design to the American-influenced art deco of the early Republican period, to “modern” American-style suburbs built in the 1940s and 1950s, and finally to the prefabricated socialist housing blocks of the present regime.

The first American-style suburb was constructed in Santiago was the neighborhood of Vista Allegre. This neighborhood was originally built to showcase the elaborate mansions of early sugar barons and other provincial elites at the beginning of the twentieth century. Today many of these houses have been taken over by the government for use as day care centers, provincial ministries and other government offices, or have been subdivided into apartments.

Beyond Vista Allegre are the more traditional 1950s style suburbs that represent the last (and most modern) phase of urban development in Santiago prior to the Revolution. The neighborhood of Sueño, for instance, was built in the late 1940s and early 1950s. These houses were designed by an American developer and are reminiscent of the low, one-story, postwar suburban housing commonplace in any southern U.S. city. Since this style of housing represents the last phase of construction from before the Revolution, the houses of Sueño are still viewed as “new” and “modern” and thus highly desirable (although they are in reality quite decrepit, having had little in the way of maintenance for the past forty years).

On the outermost edge of the city, about five miles from the city center are endless miles of low concrete apartment buildings divided into various districts named after either heroes of Cuban Independence or of the 1959 Revolution. The “Distrito José Marti,” contains almost a quarter of Santiago’s total population. These concrete-block and cement structures were constructed as part of the revolutionary plans for urban development and reflect the socialist aesthetic in architecture and urban planning.

Santiago Soundscape

The timeless rhythm of life in Santiago is most readily conveyed not with a visual overview of the city, but through a description of the soundscape. Unlike the traffic noise and bustle of Havana, Santiago still feels and sounds quite agrarian—people keep livestock in their patios to supplement their state rations. Even in the “modern” barrio where I lived, I always woke to the sound of squealing pigs and crowing roosters, the cries of street vendors and the slow clip-clop of their horse carts up and down the city streets.

One vendor in particular, always startled me out of sleep with his sharp morning cries of “Perejil! Perejil! [parsley]” It echoed through the neighborhood with surprising resonance. “Perejil! Perejil!” Further away I could barely make out a long, drawn out, almost agonizing cry of “Caaaaaatrrrbbooonn” [charcoal]. (Upon hearing him, Lydia would always complain, “Dios mio, that’s not a sales pitch, it’s a lament!”) And on a nearby street another vendor sang rhythmically over and over again, “Ajo! Ajo un peso ajo! [‘garlic! for one peso, garlic!’].”

These vendors passed through the barrio nearly every morning, yet for some reason, they seemed to walk primarily in the streets surrounding my house. This meant that although I could always hear them, it was many months before I saw them. Their cries floated around the neighborhood, seemingly disconnected from any corporeal beings, to the point where I began to imagine them as some sort of exotic tropical birdcalls. The sharp, resonant, “Perejil perejil!” the distant, anguished, “Carbbooooonnn” the languorous singsong, “Ajo, ajo un peso ajo” repeated over and over, echoing across streets and over lawns, sometimes near, and other times only faintly discernible in the distance.

By mid-morning the outdoor sounds were often superseded by the rattle and clamor of the kitchen. The sharp hiss of the pressure cooker, the rhythmic pounding of garlic cloves in a wooden mortar and pestle, loud laughter accompanying the inevitable exchanges of gossip through kitchen windows. Lunch is still the biggest meal of the day in Santiago, and the lack of modern kitchen equipment means that the senior woman of the house must devote the better part of the morning to preparing a full almuerzo. Even minimal meals still require a significant time investment—rice and beans must be painstakingly picked through by hand, day after day, to remove tiny rocks, and most kitchen equipment is old and scarcely functional.

In the highly desirable and ultra modern house where I lived, for instance, the kitchen was equipped with a 1955 GE electric stove, a 1956 GE electric blender, a newly purchased Italian-made refrigerator (a recently retired 1955 GE model sat in the corner, converted into a storage cabinet). Of the original four burners on the electric stove, two were completely defunct, and of the remaining two, one had only the outermost rings of the heating element left, and the other worked only at the highest temperature setting. A portable kerosene stove sat on one counter and was often used in place of the deteriorating electric stove, or when there were power outages. The kerosene stove had to be used sparingly though, since kerosene was often unavailable. An ancient thermos sat in a central position on the countertop, holding the day’s supply of coffee, flanked by two tiny chipped espresso cups that dated from the 1940s. The top to the thermos had long since disappeared and been replaced by an equally ancient piece of cork wrapped in an old rag.

The stifling heat of the afternoon made it impossible to avoid falling into a languorous siesta after lunch. In many ways, the siesta was my favorite part of the day. The heat rose up in waves from the pavement outside, and the little concrete house itself seemed to buckle and sway under the onslaught of the sun’s rays. Lydia emitted seismic snores from the back bedroom, providing a soothing bass line to the percussive clatter of my ancient blue 1960s electric fan as it turned in its tiny arc of breeze. I lay in bed looking out at the little stone patio, breathing the hot afternoon air, listening to the steady metallic whir of the fan as drowsiness overtook me.

Often I would wake an hour or so later to hear a visita arrive. The custom of the formal social visit has eroded somewhat in Havana, but remains quite strong in Oriente. Visitas were so common during my time in Santiago, in fact, that I can scarcely remember a day without at least two (usually more) drop-in visitors. This was in addition to the regular, established presence of neighbors, who often ducked in and out of the house at will, either to watch the nightly television soap opera, or to simply to sit and talk during a lull in their daily chores. At times, entire days seemed to consist of little more than one long, endless (and often hilarious) conversation, punctuated by the gentle creak of the cane rocking chairs moving back and forth across the cool tile of the shaded front porch.

The exclusive use of rocking chairs (the heat makes upholstered furniture impractical), and the overwhelming emphasis on sociability, humor and conversation gave most afternoons a tranquil feel. Cuban-American writer Margarita Engle aptly described this sensation in her book Singing to Cuba,

He led his mother to another rocking chair facing mine. Then he found one for himself, and looking around the room, I realized that rocking chairs were the only seats available. They were scattered all over the room, big, imposing rocking chairs. As I child I had always loved hammocks and rocking chairs. I had associated them with stability, with relaxation, patience and a dreamy state of mind found only in the very young and the very old (Engle, 1993).

The “dreamy state of mind” Engle talks about is an apt description of the way these visits often passed. The sun-soaked quality of the late afternoon, the gentle motion of rocking chairs, and the ebb and flow of dialogue and laughter all combined to create a faraway sense of lassitude and repose. People spend hour after hour immersed in the gentle sway of rocking chairs and endless flows of conversation with little motive other than the simple pleasure of each other’s company.

Often these conversations took on a delightful dreamlike quality themselves, as people reinvented their frustrations with bureaucracy and food shortages into wildly comic narratives of improvisation and derring-do. Over time I would come to think of these storytelling sessions as emblematic of the special magic I most admired in Cubans—the unique cultural alchemy whereby they were able to transform their daily ordeals of suffering and deprivation into shared laughter and wit. The line between comedy and tragedy is rarely absolute in any context, and Cubans seem to navigate this boundary with exceptional agility and skill.

At night, the world often took on a surreal quality since practically the entire city, without fail, watched the same television soap opera at nine, followed by the evening movie at ten. The spatial closeness of the houses, and the fact that doors and windows were often left open to catch whatever meager breeze might be available, meant that any pedestrian walking through the streets was confronted with the singularly unusual auditory sensation of hearing the same sound track emanating simultaneously (and at high volume) from every house on the street.

Ethnographic Vignette: Getting Oriented

Early one morning, shortly after my arrival in Santiago, I set out on my bicycle in search of the provincial Ministry of Health office hoping to track down a list of recent health statistics for my neighborhood. I had gotten directions from a neighbor, but still managed to get lost in the unmarked streets near the Moncada Barracks. Eventually I found myself at a side entrance of the provincial hospital, where I spied a man and a woman in white lab coats chatting in front of the door.

“Excuse me,” I said hesitantly, pulling up to them on my bicycle. “Can you tell me where to find the local office of the Ministry of Public Health?”

“Oh look! Now what did I tell you?” the woman exclaimed to her friend, laughing. She was tall and had light coffee-colored skin. Her long hair was stylishly done in numerous tiny braids. The man she was with smiled sheepishly. “I told you,” she repeated, giving him a playful tug on the sleeve. “And look at the beautiful bicycle!” she said in awe. “With velocidades [speeds] and everything And the color. . . . “ My 18-speed mountain bike (a glorious metallic purple) inevitably became object of much jealous admiration wherever I stopped. It stood out from the bedraggled one-speed Chinese models that populated the streets of Santiago like a sleek Mercedes in a parking lot full of Yugos. They spent some moments remarking on the beauty of it. “And what’s your name?” the woman with the braids asked me.

“Mary Katherine,” I replied.

“Ah, Meryl! like Meryl Streep!” she seemed delighted. Meryl Streep is wildly popular in Cuba, the one American actress that all Cubans can instantly identify. The reasons for this are obscure.

“Well, not exactly, it’s actually Mary, not Meryl—” I began, only to be interrupted.

“And with green eyes too!” the woman nodded knowingly to her friend. He seemed shy and reticent. “See! I told you.” She said smugly to him, then turned to me again. “Meryl, do you drink wine?” she asked suddenly.

“Um, yes.” I said hesitantly. I was beginning to wonder if I would ever find the Ministry of Health. The thought of reading through health statistics, though, suddenly seemed quite dull in comparison to the unexpected turns of this particular conversation.

“Ai, pero mira Tomds,” she exclaimed again, shaking her head. “Gentefina! Pero fina, te lo digo!”

“Gente Fina” means literally “fine people” and is used generally to refer to those perceived as aristocratic. From the context, I inferred that a taste for wine together with having green eyes and a marvelous bicycle of velocidades were sufficient to classify me as “gentefina.”

“Ah, Meryl, you don’t know how perfectly timed your arrival is, here on your lovely bicycle of velocidades,” she said.

“Well, I’m very glad,” I said back to them. “Although I don’t quite understand why. And do you know where the Ministry of Health is?”

They laughed even harder. The man finally spoke. “You see . . . “ he began, but trailed off. “It’s just that I was telling Marisa . . . well, I’ve been out here explaining a terrible problem to her. I’ve been suffering so terribly. Oh, Meryl,” he placed his hand on my arm, suddenly serious.”Meryl, in my heart . . . in my heart,” he stammered “In my heart, I feel all the pain of Christ on the cross . . . “ He went on in this way for some time, describing deep emotional suffering with lyrical intensity, the way one might confide in a very intimate friend. I found myself awash in sympathy, in part out of sheer awe at the poetic way he chose to articulate his angst.

After a long, meandering preamble, I finally managed to deduce that his wife of seven years had recently been unfaithful to him, and he felt caught in a terrible dilemma. On the one hand, the rules of machismo demanded that he throw her out (and even give her a beating in the bargain). On the other hand, he very much wanted to forgive her and continue their relationship because he still loved her. He and Marisa, both doctors in the hospital and old friends from medical school, had stepped out for a moment to discuss what should be done. And Marisa had advised him to at least separate from his wife, but not to lose hope because at any moment someone new and wonderful could come into his life. It was at that moment that I pulled up on my marvelous shining bicycle of velocidades—seeming proof of Marisa’s prophecy.

After such a propitious introduction, I felt it would hardly be polite of me to simply demand directions to the Ministry of Health and leave. We spent the better part of an hour standing by the back door of the hospital, suddenly immersed in an entirely unexpected and intimate sociality, something that I would soon...

Table of contents

• Cover Page
• Half title
• title
• copy
• Contents
• Acknowledgements
• Introduction
• Part One: The Ethnographic Encounter
• Part Two: History Revisited
• Bibliography
• Index