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Cuba as a “World Medical Power”: The Politics of Symbolism

Published online by Cambridge University Press:  12 October 2022

Julie M. Feinsilver
Julie M. Feinsilver*
Affiliation:
Yale University
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Although most government leaders espouse the principle of “health for all,” few pay more than lip service to the ideal by allocating adequate resources for its development. In Cuba, however, health care is a basic human right and the responsibility of the state. Cuban leaders consider health indicators to be measures of government efficacy, and as a result, health care has assumed an inordinately prominent place in Cuban government policies despite the present world economic crisis. Although affected to a lesser extent because of its integration into the Community for Mutual Economic Assistance (CMEA), Cuba has nevertheless been increasing health care expenditures in the face of economic adversity.

Type
Research Article
Information
Latin American Research Review , Volume 24 , Issue 2 , 1989 , pp. 1 - 34
Copyright
Copyright © 1989 by the University of Texas Press

Footnotes

*

I would like to thank the following persons for their comments on previous incarnations of this article: David E. Apter, Marta Cehelsky, Jorge I. Domínguez, Susan Eckstein, Kal Erikson, Robert Fishman, Günther Handl, Amy Saldinger, George A. Silver, Giorgio Solimano, and the referees and editors of LAR. I would also like to thank Neil Bennett for doing the demographic calculations. Any errors, of course, rest with the author. Funding for field research in Cuba for the larger project was provided through the generosity of the American Council of Learned Societies and the Social Science Research Council. The analyses and opinions stated herein are solely those of the author and in no way reflect those of the funding agencies or commentators.

References

Notes

1. República de Cuba, Constitución (Havana: Partido Comunista de Cuba, 1976), Artículos 48 and 49, pp. 36–37; and Ministerio de Salud Pública, Salud para todos: 25 años de experiencia cubana (Havana: MINSAP, 1983).

2. Cuba also trades with capitalist countries and is thus affected by revaluations of hard currencies, fluctuations in interest rates, and similar factors. Even Soviet trade subsidies are tied to world-market prices. See Susan Eckstein, “Capitalist Constraints on Cuban Socialist Development,” Comparative Politics 12, no. 3 (April 1980):253–74; and Richard Turits, 'Trade, Debt, and the Cuban Economy,“ World Development 15, no. 1 (Jan. 1987):163–80.

3. Republic of Cuba, Ministry of Public Health, Annual Report of the Minister of Public Health 1986 (Havana: MINSAP, 1987), 3, 18; and Granma, 29 Dec. 1986, p. 3. See also the following issues of Granma Weekly Review: 24 Jan. 1988, p. 4; 14 June 1987, p. 12; and 12 Jan. 1986, p. 3.

4. Fidel Castro, Second Period of Sessions of the National Assembly of People's Power: Closing Speech (Havana: Political Publishers, 1978), 39–41; Bohemia, 15 Sept. 1978; Granma, 31 July 1981, pp. 1, 3; Granma, 10 Dec. 1981, p. 1; and Granma Weekly Review, 11 Mar. 1984, p. 4.

5. For a historical perspective, see the first part of Small States in Europe and Dependence, edited by Otmar Höll (Boulder, Colo.: Westview, 1983), especially 14, 55.

6. Peter Shearman, The Soviet Union and Cuba, Chathman House Papers, no. 38 (London: Routledge & Keagan Paul, 1987), 33.

7. Among the many works on this topic, see H. Michael Erisman, Cuba's International Relations: The Anatomy of a Nationalistic Foreign Policy (Boulder, Colo.: Westview, 1985); Jorge I. Domínguez, “Cuban Foreign Policy,” Foreign Affairs 57 (Fall 1978):83–108; and Jorge I. Domínguez, To Make a World Safe for Revolution: Cuban Foreign Policy (Cambridge, Mass.: Harvard University Press, forthcoming). Also Cuba in Africa, edited by Carmelo Mesa-Lago and June S. Belkin (Pittsburgh: University of Pittsburgh Press, 1982); and Cuba in the World, edited by Cole Blasier and Carmelo Mesa-Lago (Pittsburgh: University of Pittsburgh Press, 1979).

8. República de Cuba, Constitución, Artículo 12, pp. 18–20.

9. Foucault's analysis of Velázquez's painting, “Las Meninas,” suggests an interesting parallel with Cuba's actions in the international sphere. The real subjects of the painting are not Princess Margarita and her various attendants in the foreground but the two sovereigns, King Philip IV and his wife Mariana, whose reflections are seen only in the mirror in the background of the scene. Although they are only visible in a small reflection, all forward-gazing eyes of the painting's subjects are turned toward them. Thus although they are not part of the group of models, the royal couple are nonetheless the focal point of the painting within the painting as well as the ones for whom the painting was created. Cuba's actions in the world arena can be perceived in the same manner: very much influenced by the United States and often staged for the benefit of the United States, even though the United States may be elided from the scene. See Michel Foucault, The Order of Things: An Archaeology of the Human Sciences (New York: Vintage Books, 1973), 3–16.

10. For an instructive interpretation of symbolism in Japanese domestic politics, see David E. Apter and Nagayo Sawa, Against the State: Politics and Social Protest in Japan (Cambridge, Mass.: Harvard University Press, 1984).

11. Pierre Bourdieu, Outline of a Theory of Practice (Cambridge: Cambridge University Press, 1987), 177, 180.

12. Ibid., 181.

13. Norman Hicks and Paul Streeten, “Indicators of Development: The Search for a Basic Needs Yardstick,” World Development 7 (1979):578–79.

14. Although Cuban criteria have not been clearly enunciated as a whole, the ones listed were culled from various official statements made over the years since the topic was first mentioned publicly. The 1987 statements allude only to the infant mortality rate and life expectancy at birth.

15. Dr. Halfdan Mahler, “Discurso pronunciado en la sesión inaugural de la conferencia ‘Salud para Todos: 25 años de experiencia cubana,’” Havana, 3–9 July 1983; Dr. Carlysle Guerra de Macedo, “Discurso pronunciado en la sesión inaugural de la conferencia ‘Salud para Todos.’” See also articles in The Physiologist 22, no. 1 (Feb. 1979):9–11; The Physiologist 22, no.6 (Dec. 1979):15–17; Nursing Mirror (Surrey, England) 153, no. 20 (11 Nov. 1981):36–38; journal of the Medical Association of Georgia 68 (Feb. 1979):99–100; Pediatric Nursing 6, no. 5 (Sept.–Oct. 1980):51–53; Science 200, no. 4347 (16 June 1978):1246–49; The Western Journal of Medicine 132 (Mar. 1980):265–71; Obstetrics and Gynecology 49, no. 6 (June 1977):709–14; and the Canadian Medical Association Journal 111 (2 Nov. 1974):991–1002.

16. Congress of the United States, Joint Economic Committee, 97th Congress, 2nd Session, Cuba Faces the Economic Realities of the 1980s (Washington, D.C.: U.S. Government Printing Office, hereafter USGPO, 1982), p. 5.

17. Prerevolutionary Cuba had urban private health services that were well-developed but unevenly distributed. Health indices were relatively good, but its statistics were neither complete nor reliable. Maldistribution of health resources was acute, with Havana siphoning off most personnel and monies, and rural areas doing without. Malnutrition, parasites, and other diseases of poverty afflicted the majority of rural Cubans. Sanitation facilities and potable water were scarce everywhere, even in the capital. After the Revolution, half the Cuban doctors fled, most of them to the United States. See Ross Danielson, Cuban Medicine (New Brunswick, N.J.: Transaction Books, 1979); Agrupación Católica Universitaria, “Encuesta de trabajadores rurales, 1956–1957,” Economía y Desarrollo 12 (July–Aug. 1972):188–213; Pan American Sanitary Bureau, Summary of Four-Year Reports on Health Conditions in the Americas, 1953–1956, Scientific Publication no. 40 (Washington, D.C.: Pan American Sanitary Bureau, 1958); and Pan American Health Organization, Health Conditions in the Americas, 1957–1960, Scientific Publication no. 64 (Washington, D.C.: PAHO 1962).

18. Granma Weekly Review, 24 Feb. 1985, suppl. p. 3.

19. Granma Weekly Review, 11 Mar. 1984, p. 4.

20. National Center for Health Statistics, Vital Statistics of the United States, 1982, vol. 2, sec. 6, Life Tables, DHHS Publication no. (PHS) 85–1104 of the Public Health Services (Washington, D.C.: USGPO, 1985), p. 6; and Granma Weekly Review 24 Feb. 1985, suppl. p. 3.

21. Granma Weekly Review, 16 Feb. 1986, suppl. p. 4.

22. “Rise in Infant Mortality Rate,” Cuba Update 7, nos. 1–2 (Winter–Spring 1986):7.

23. Granma, 23 Jan. 1987, p. 1; and Granma Weekly Review, 31 Jan. 1988, p. 9.

24. Granma Weekly Review, 25 Jan. 1987, p. 4.

25. U.S. Department of Commerce, Bureau of the Census, Statistical Abstract of the United States 1987 (Washington, D.C.: USGPO, 1986), p. 58; and World Health Organization, World Health Statistics Annual 1987 (Geneva: WHO, 1987), 80.

26. See Ruth Leger Sivard, World Military and Social Expenditures, 1985 (Washington, D.C.: World Priorities, 1985), 39, 41.

27. República de Cuba, Ministerio de Salud Pública, Informe Anual 1982 (Havana: MINSAP, 1983); and National Center for Health Statistics, Vital Statistics 1982.

28. On China's “barefoot doctors,” see David M. Lampton, Health, Conflict, and the Chinese Political System (Ann Arbor: Center for Chinese Studies, University of Michigan, 1974). On Soviet feldshers, see Mark G. Field, Soviet Socialized Medicine: An Introduction (New York: Free Press, 1967). On paramedical personnel as doctor substitutes, see OMS-FNUI, Atención primaria de salud: informe conjunto del Director General de la Organización Mundial de la Salud y del Director Ejecutivo del Fondo de las Naciones Unidas para la Infancia (Geneva: World Health Organization, 1978), 34–37.

29. Republic of Cuba, Ministry of Public Health, Annual Report 1986, 18.

30. This conservative estimate is based on a population projection using the Latin American table in Model Life Tables for Developing Countries, Department of International Economic and Social Affairs Population Studies, no. 77 (New York: United Nations, 1982). This estimate uses 10 million as the population baseline in 1985 and the number of doctors in the year 2000 pegged at a conservative estimate of 65,000. A more optimistic calculation results in one doctor for every 190 inhabitants. This figure is calculated by taking the number of doctors in 1984 (20,545) plus 50,000 who are to be trained by the year 2000, minus the 3267 doctors age 45 or over in 1979. For the population baseline, see Granma Weekly Review, 16 Sept. 1984, p. 3. For the number of doctors in 1984 and projected increase by the year 2000, see Granma Weekly Review, 18 Nov. 1984, p. 3; and for the number of doctors who were 45 and older in 1979, see Revista Cubana de Administración de Salud 8, no. 1 (Jan.–Mar. 1982):119.

31. Calculation based on 247 doctors per 100,000 population. See U.S. Department of Health and Human Services, Public Health Service, Human Resources Administration, Office of Graduate Medical Education, Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, vol. 2, DHHS Publication no. (HRA) 81–652 (Washington, D.C.: USGPO, 1981), table V.3, p. 274. This report is generally referred to as the GMENAC report.

32. Granma Weekly Review, 24 July 1983, p. 3.

33. Granma Weekly Review, 13 May 1984, p. 3; and Granma, 30 July 1986, p. 3. The dropout rate was close to 50 percent when the initial estimate was revised downward by 10,000. Since then the dropout rate has decreased. See Granma Weekly Review, 20 Sept. 1987, p. 5.

34. The Soviet Union, Czechoslovakia, and other Eastern bloc countries attempt to provide sabbaticals for their physicians, but often there are too few physicians to grant them sabbaticals when they are due. Personal communication from George A. Silver, M.D., Professor Emeritus of International Health, Yale School of Medicine, 24 Mar. 1986.

35. Granma Weekly Review, 24 July 1983, p. 3; and Granma Weekly Review, 27 May 1984, p. 4.

36. República de Cuba, Public Health in Figures 1986, 55; and Osvaldo Castro Miranda, “Recursos humanos en salud de Cuba,” Educación Médica y Salud 20, no. 3 (1986): 376–77. This periodical is published in Washington, D.C., by the Pan American Health Organization.

37. Problems have arisen when some doctors have chosen not to live in the home-offices that were built for them. See Granma, 17 Jan. 1984; and Granma Weekly Review, 19 Apr. 1987, p. 10.

38. Lilliam Jiménez Fontao and Mayra Zaldívar Lores, “Experiencia del médico de la familia en un consultorio de Plaza de la Revolución,” Revista Cubana de Medicina General Integral 3, no. 1 (1987):135; Granma, 26 May 1986, pp. 1–3; and Granma Weekly Review, 27 Oct. 1985, pp. 8–9.

39. Granma Weekly Review, 17 Oct. 1985, p. 8.

40. Granma Weekly Review, 9 Sept. 1988, p. 12; and Granma, 16 Oct. 1986, p. 1.

41. Organización Panamericana de la Salud, Informe sobre medicina familiar (Washington, D.C.: OPS, 1984).

42. Informe del Gobierno de Cuba a la Organización Panamericana de la Salud sobre las condiciones de salud pública y los adelantos logrados en el intervalo transcurrido entre la XXI y XXII Conferencias Sanitarias Panamericanas, 1982–1986 (Washington, D.C.: PAHO, 1986), p. 2; Granma, 4 Jan. 1986, p. 2; and Granma, 30 Dec. 1986, p. 3. See also the following issues of Granma Weekly Review: 6 June 1982, p. 4; 16 Sept. 1984, p. 12; 24 Aug. 1986, p. 3; 26 Oct. 1986, p. 5; 18 Jan. 1987, p. 3; 10 May 1987, p. 12; and 24 May 1987, p. 3.

43. The first Cuban heart transplant was performed in December 1985, and by May 1987, twenty heart transplants had been performed. See Granma, 4 Jan. 1986, p. 2; Granma, 30 July 1986, p. 1; and Granma Weekly Review, 10 May 1987, p. 12. Yale-New Haven Hospital's record was mentioned on ABC News (New Haven), 8 Mar. 1986.

44. Based on my personal observations in various cities throughout Cuba in 1980 and 1981.

45. César Vieira, “PAHO/WHO Interoffice Memorandum HSP/84/242/88, 6 de abril de 1988,” PAHO mimeo, p. 5.

46. See Robert Ubell, “Cuba's Great Leap,” Nature (Great Britain) 302 (28 Apr. 1983):746; Jeffrey L. Fox, “Cuba Plans a Century of Biology,” American Society of Microbiology 52, no. 5 (1986):243–48; and Marcel Roche, “Cuba: El Centro de Investigaciones Biológicas,” Interciencia (Buenos Aires) 10, no. 6 (Nov.–Dec. 1985):299–300. On Cuba's plans to export interferon, see Newswatch, 17 Mar. 1986, pp. 3–4.

47. See the article by Jon Beckwith, Professor of Microbiology and Molecular Genetics at Harvard Medical School, entitled “Cuba Report: Science and Society Are Inseparable,” Science for the People 17, no. 5 (Sept.–Oct. 1985):21. This journal is published in Cambridge, Mass.

48. For a fuller discussion of Cuba's medical research, see Julie M. Feinsilver, “Symbolic Politics and Health Policy: Cuba as a ‘World Medical Power,‘” Ph.D. diss., Yale University, expected 1989.

49. Granma Weekly Review, 10 July 1983, p. 10.

50. New York Times, 22 Jan. 1985, p. A–2.

51. Granma Weekly Review, 24 Feb. 1985, suppl. p. 3.

52. The figure for Cuba was calculated from an article describing 16,000 civilian internationalists in the New York Times, 22 Jan. 1985, p. A–2; and from the population estimate of ten million Cubans cited in Granma Weekly Review, 16 Sept. 1984, p. 3. The U.S. figures are calculated from AID and Peace Corps personnel figures of 1494 and 5200, respectively. The U.S. population figure as of 1982 was 232,309,000 according to Sivard, World Military and Social Expenditures 1985, p. 35. In 1982, AID had 1494 workers abroad, and the Peace Corps had 5200 volunteers. It should be noted, however, that AID primarily uses contractors or recipient government agencies for project implementation. See U.S. General Accounting Office, Donor Approaches to Development Assistance: Implications for the United States, GAO/ID–83–23 (Washington, D.C.: GAO, 1983), 13, 17, 19.

53. Calculation based on a total of 118,760 technicians, of which 23,075 are Cuban. See U.S. Department of State, Soviet and East European Aid to the Third World, 1981 (Washington, D.C.: USGPO, 1983), 20.

54. Calculated from Sivard, World Military and Social Expenditures, 1985, 35.

55. Central Intelligence Agency, Communist Aid to Non-Communist LDCs, 1979 and 1954–1979 (Washington, D.C.: CIA, 1980), 8.

56. Ibid., 21; and CIA, Communist Aid to Non-Communist LDCs 1977 (Washington, D.C.: CIA, 1978), 9.

57. China sent some 8,000 medical workers abroad during that period. In 1986 China had about 1,000 doctors working in forty-one countries. See China Daily, 19 July 1986, p. 3 (reference provided by Deborah Davis-Friedman).

58. Colaboración Internacional, no. 2–86 (Apr.–June 1986):5–6.

59. Julio Díaz-Vázquez, “Cuba: colaboración económica y científico-técnica con países en vías de desarrollo de Africa, Asia, América Latina,” Economía y Desarrollo 68 (May–June 1982):29.

60. The seven countries are Cape Verde, Angola, Equatorial Guinea, Guinea-Bissau, Ethiopia, São Tomé, and South Yemen. See Paul H. Grundy and Peter P. Budetti, “The Distribution and Supply of Cuban Medical Personnel in Third World Countries,” American Journal of Public Health 70, no. 7 (July 1980):718.

61. Verde Olivo 23, no. 3 (21 Jan. 1982):18–19. This magazine of the Cuban Armed Forces is published in Havana.

62. Granma Weekly Review, 28 Oct. 1984, p. 9, cited in Domínguez, To Make a World Safe for Revolution.

63. “Country's Cooperation with Ethiopia Discussed,” (article originally in Spanish in Prisma Latinoamericano, Jan. 1983, 24–26), published in English in FBIS Latin American Report no. 2661 (4 Apr. 1983):28. These reports are published by the National Technical Information Service in Springfield, Va.

64. Pamela S. Falk, “Cuba's Foreign and Domestic Policies, 1968–78: The Effect of International Commitments on Internal Development,” Ph.D. diss., New York University, 1980, 242.

65. Domínguez, To Make a World Safe for Revolution.

66. Colaboración Internacional, no. 1–86 (Jan.–Mar. 1986):19.

67. Granma Weekly Review, 17 Aug. 1986, p. 10.

68. Granma Weekly Review, 6 Mar. 1988, p. 2.

69. Granma Weekly Review, 11 Nov. 1984, p. 10.

70. Colaboración Internacional, 1–86 (Jan.–Mar. 1986):27.

71. Cuba Internacional, no. 209 (Apr. 1987):53–54.

72. Cuba Internacional, no. 184 (Mar. 1985):41.

73. Granma Weekly Review, 28 Feb. 1982, p. 7; and Granma, 28 July 1982, p. 4.

74. Granma Weekly Review, 22 Oct. 1978, p. 9, cited in Falk, “Cuba's Foreign and Domestic Policies,” p. 245.

75. Cuba Internacional, no. 215 (Nov. 1987):20–23.

76. Granma Weekly Review, 14 Oct. 1984, p. 5.

77. The report indicated that in 1977 the contingent in rural areas was considerably larger. See Granma Weekly Review, 28 Oct. 1984, p. 9.

78. “Guyana, Cuba Agree on Cooperation, Trade,” FL281730 Bridgetown, Guyana, CANA radio broadcast in English, 2104 GMT, 26 Mar. 1983; in FBIS Latin American Report, no. 2666 (14 Apr. 1983):23.

79. Granma Weekly Review, 12 July 1987, p. 8; and Granma Weekly Review, 20 Sept. 1987, p. 5.

80. Granma Weekly Review, 11 Nov. 1984, p. 5.

81. Granma Weekly Review, 18 Nov. 1984, p. 3.

82. Statement by Sen. Charles Mathias, Jr., quoted in Center for Peace and Conflict Studies, Detroit Council for World Affairs Newsletter, Spring 1985, p. 2.

83. United States Information Agency, U.S. Advisory Commission on Public Diplomacy: 1986 Report (Washington, D.C.: USIA, 1986), p. 36.

84. Central Intelligence Agency, Communist Aid Activities, 1979 and 1954–1979, p. 11.

85. New York Times, 9 June 1985, p. 6.

86. Alfonso Mejía, Helena Pizurki, and Erica Royston, Foreign Medical Graduates: The Case of the United States (Lexington, Mass.: Lexington Books, 1980), p. 34.

87. Granma Weekly Review, 21 June 1987, p. 1.

88. See the following issues of Granma Weekly Review: 13 Apr. 1986, p. 3; 2 Nov. 1986, p. 11; and 25 May 1986, p. 1. See also “Medical Brigade Help Offered to Mexico,” FBIS Latin American Report 6, no. 185 (24 Sept. 1985):Q1–2.

89. Díaz-Vázquez, “Cuba: colaboración económica,” p. 43.

90. Personal conversations with various conference participants from a number of Latin American countries, and participant observation at meetings in Cuba, 1980–1981. This claim is substantiated by travel reports published in a variety of American medical journals. Prof. Jon Beckwith, Harvard Medical School, substantiated this claim regarding biotechnology and genetic engineering specialists who attended an international conference in Cuba in early 1986. Interview conducted 26 Sept. 1986 in Boston.

91. Granma Weekly Review, 22 June 1986, p. 4.

92. Danilo Salcedo y Eduardo Joly, Informe de misión para determinar las necesidades de asistencia en materias de población (New York: United Nations Family Planning Agency, 1979), 93. Dr. Halfdan Mahler commented that “cooperation should be triangular: Cuba-WHO and Mozambique and other countries.” See Granma, 7 Aug. 1981, p. 8. Also, since 1979 Cuba has participated in the United Nations Development Program (UNDP) and the World Health Organization's International Program of Tropical Medicine, which granted Cuba more than half a million dollars for research and training programs. Because Cuba had already eradicated tropical diseases, this award can be interpreted as an instance of UNDP and WHO funding Cuba because of the multiplier effect. See Granma Weekly Review, 4 July 1982, pp. 12–13.

93. Kenneth Hill, “An Evaluation of Cuban Demographic Statistics, 1938–1980,” in Fertility Determinants in Cuba, edited by Paula E. Hollerbach and Sergio Díaz-Briquets (Washington, D.C.: National Academy Press, 1983), cited in Sergio Díaz-Briquets, “How To Figure Out Cuba: Development, Ideology, and Mortality,” Caribbean Review 15, no. 2 (Spring 1986):10. See also Sarah Santana, “Some Thoughts on Vital Statistics and Health Status in Cuba,” in Cuban Political Economy: Controversies in Cubanology, edited by Andrew Zimbalist (Boulder, Colo.: Westview, 1988), 107–18; Carmelo Mesa-Lago, “Cuban Statistics Revisited,” Cuban Studies/Estudios Cubanos 9, no. 2 (July 1979):61; and Vicente Navarro, “Health, Health Services, and Health Planning in Cuba,” International Journal of Health Services 2, no. 3 (Aug. 1972):403. For a contrary view, see Nicholas Eberstadt (of the American Enterprise Institute), “Did Fidel Fudge the Figures? Literacy and Health: The Cuban Model,” Caribbean Review 15, no. 2 (Spring 1986):5–7, 37–38.

94. Sarah Santana, “Thoughts on Vital Statistics,” 114.

95. Ibid., 115.

96. C. Arden Miller, Elizabeth J. Coulter, Lisabeth B. Schorr, Amy Fine, and Sharon Adams-Taylor, “The World Economic Crisis and the Children: United States Case Study,” International Journal of Health Services 15, no. 1 (1985):95–134, especially 123–32.

97. Recent austerity measures do not affect these programs. See Granma, 31 Dec. 1987, p. 1.

98. Granma Weekly Review, 4 Nov. 1984, suppl. pp. 3–4; and Granma Weekly Review, 25 Nov. 1984, p. 3.

99. Granma Weekly Review, 26 Oct. 1986, p. 3.

100. Granma Weekly Review, 25 Jan. 1987, p. 4.

101. United Nations, Living Conditions in Developing Countries in the Mid-1980s: Supplement to the 1985 Report on the World Social Situation (New York: United Nations, 1986), 11.

102. Interview with Dr. Roberto Capote Mir, a ranking Cuban physician and public health professor who is currently Regional Adviser for Health Systems and Hospital Administration at the Pan American Health Organization in Washington, D.C., 21 April 1987.

103. Paula E. Hollerbach, Recent Trends in Fertility, Abortion, and Contraception in Cuba, Center for Policy Studies Working Paper no. 61 (New York: Population Council, 1980), 1, 24.

104. World Heath Organization and UNICEF, Atención primaria de salud (Geneva and New York: WHO and UNICEF, 1978).

105. Susan Eckstein, “Structural and Ideological Bases of Cuba's Overseas Programs,” Politics and Society 11 (1982):104–5; Granma Weekly Review, 12 Apr. 1987, p. 4; and Granma Weekly Review, 22 Nov. 1987, p. 4.

106. Thomas McKeown, “Determinants of Health,” Human Nature (New York) 1, no. 4 (April 1978):60.

107. Ibid., 66.

108. Dr. Peter Bourne, Special Assistant to the President for Health Issues, New Directions in International Health Cooperation (Washington, D.C: U.S. White House, 1978), 47.

109. Fidel Castro, Second Period of Sessions of the National Assembly, 39.

110. Bohemia, 22 Dec. 1978, p. 46.

111. On estimated lower charges by Cubans, see Central Intelligence Agency, Communist Aid Activities 1977, p. 5. On charges to Libya and Iraq for doctors, see Helen Mathews Smith, “Castro's Medicine: An On-the-Scene Report,” M. D. 27, no. 5 (May 1983):163.

112. Granma Weekly Review, 27 Feb. 1983, p. 9.

113. Angola paid for much of its civilian assistance from the early 1980s until 1984–85, when most aid reverted to a grant status until Angola could afford to pay again. See Domínguez, To Make a World Safe for Revolution.

114. See Carlos Martínez Salsamendi, “El papel de Cuba en el Tercer Mundo: América Central, El Caribe y Africa,” in Cuba y Estados Unidos: un debate para la convivencia, compiled by Juan Gabriel Tokatlian (Buenos Aires: Grupo Editor Latinoamericano, 1984), 145; and Jorge I. Domínguez, personal communication, 24 June 1986. See also Domínguez, To Make a World Safe for Revolution.

115. See Susan Eckstein, “Comment: The Global Political Economy and Cuba's African Involvement,” Cuban Studies/Estudios Cubanos 10, no. 2 (July 1980):90; and Eckstein, “Structural and Ideological Bases,” 107.

116. Sergio Roca, “Economic Aspects of Cuban Involvement in Africa,” Cuban Studies/Estudios Cubanos 10, no. 2 (July 1980):66.

117. Calculated from Carlos Martínez Salsamendi, “El papel de Cuba en el Tercer Mundo,” 145; and from Grundy and Budetti, “The Distribution and Supply of Cuban Medical Personnel,” 718.

118. Cuba Internacional 5–87, no. 210 (May 1987):52–57; Granma Weekly Review, 7 Feb. 1988, p. 3; Granma Weekly Review, 28 Feb. 1988, p. 12; and New York Times, 29 May 1988, sec. 1, p. 4.

119. Smith, “Castro's Medicine,” 155; and Granma Weekly Review, 25 May 1986, p. 8.

120. Granma Weekly Review, 1 Mar. 1987, p. 5; and 31 May 1987, p. 4.

121. New York Times, 29 May 1988, sec. 1, p. 4.

122. Jornal do Brasil, article cited in Center for Cuban Studies Newsletter, Sept. 1986, p. 3.

123. Granma Weekly Review, 1 Feb 1987, p. 9.

124. Granma Weekly Review, 29 Nov. 1987, p. 3.

125. Granma Weekly Review, 10 Jan. 1988, p. 3.

126. Granma Weekly Review, 26 Apr. 1987, p. 1.

127. The cost of sugar production by Caribbean producers is estimated at an average 15 cents a pound and 12 cents a pound for the most efficient producers like Cuba. From 1981 through 1987, world sugar prices have been below 10 cents a pound. Average prices for 1986 and 1987 were less than 6 and 7 cents a pound respectively. See Scott B. MacDonald and F. Joseph Demetrius, “The Caribbean Sugar Crisis: Consequences and Challenges,” Journal of Interamerican Studies and World Affairs 28, no. 1 (Spring 1986):35; Wall Street Journal, 20 Oct. 1986, p. 42; Granma Weekly Review, 25 Oct. 1987, p. 1; and New York Times, 26 July 1988, p. 42.

128. Granma, 29 July 1986, p. 4.

129. Cuba missed its 7 July 1986 interest payment and sought a deferment until the end of September 1986 due to its foreign exchange crisis. Latin American Weekly Report, 24 July 1986, p. 7.

130. Granma Weekly Review, 19 Apr. 1987, p. 10.

131. Granma Weekly Review, 21 Feb. 1988, p. 2.

132. Latin America Regional Report: Caribbean, 2 Oct. 1986, p. 2.

133. It has been estimated that between 1977 and 1980, Cuba's earnings from international contracts represented 6 to 18 percent of the island's hard-currency exports. See Susan Eckstein, “Cuban Internationalism,” in Cuba: Twenty-Five Years of Revolution, 1959–1984, edited by Sandor Halebsky and John M. Kirk (New York: Praeger, 1985), 379–80.

134. Bohemia, 15 Sept. 1978, p. 39.

135. Central Intelligence Agency, Communist Aid Activities, 1979 and 1954–1979, iv, 11.

136. Central Intelligence Agency, Communist Aid Activities, 1977, p. 10.

137. John M. Donahue, The Nicaraguan Revolution in Health (South Hadley, Mass.: Bergin and Garvey, 1986); Organización Panamericana Sanitaria, “Cooperación técnica de la OPS/OMS: desarrollo de servicios de salud,” internal document URU/DHS/010/P2, 16 Nov. 1987, pp. 20–22; Novedades de Quintana Roo (Cancún, Mexico), 13 May 1988, p. 44; and New York Times, 13 Mar. 1988, p. 8.

138. Interviews conducted in various Cuban cities in 1978, 1979, and 1980–1981. According to Jesús Escandell of the Central de Trabajadores Cubanos, the main demand of Cuban workers is housing. Granma Weekly Review, 17 May 1987, p. 3. Criticisms of the health system have been raised in Boletín Especial by Equipo de Opinión del Pueblo (Holguín), 1987.

139. For a fuller treatment of the trade-offs, see Feinsilver, “Symbolic Politics and Health Policy.”

140. Stephen White, “Economic Performance and Communist Legitimacy,” World Politics 38, no. 3 (Apr. 1986):463–64.

141. Granma Weekly Review, 18 Nov. 1984, p. 3. Castro mentioned education as the second service most highly valued by the people.

142. Granma, 16 Oct. 1986, p. 1.

143. Granma Weekly Review, 10 May 1987, p. 9.

144. Granma Weekly Review, 22 June 1986, p. 3.

145. Roca, “Economic Aspects,” 70.

146. On primarily military but also civilian aid, Roca argues that the costs seem to outweigh the economic benefits; Pérez López indicates that the data are insufficient to make any definite claims; Eckstein and Pérez López both point out benefits that Roca failed to mention. See Roca, “Economic Aspects,” 67–75; Jorge F. Pérez López, “Comments: Economic Costs and Benefits of African Involvement,” Cuban Studies/Estudios Cubanos 10, no. 2 (July 1980):80–84; and Eckstein, “Comment: The Global Political Economy,” 85–90.

147. Domínguez, “Political and Military Limitations,” 28.

148. For a fuller discussion of Soviet aid, see Feinsilver, “Symbolic Politics and Health Policy.”