Healthcare without Borders

The premise of this book, that publics in industrialized nations have overlooked Cuban medical internationalism, is indisputable. To correct this, John Kirk details the proactive Cuban presence in the aftermath of environmental catastrophes in developing nations, the country's vast medical pedagogical reach, and its robust partnerships in specific projects, such as biotechnology and eye surgery provision. Kirk objects to the labeling of Cuba's medical internationalism as a form of diplomacy, which, according to him, implies a strategic will to promote a political agenda. Instead, since its first mission following the Valdivia earthquake in Chile in 1960 and until its recent one during the West African Ebola crisis in 2014, Cuba has pursued a different approach to providing help that emphasizes quick responses, service to the neediest populations, and cooperation with local political patrons. Moreover, medical outreach by Cuba has assisted governments with which it had no diplomatic relations and even those opposed to the Cuban Revolution.The book's sources privilege sympathetic press coverage and official publications. Although archival and fieldwork evidence are scant in the text, Kirk has carried out many interviews with internacionalistas returning to Cuba. The resulting narrative is rich in statistics, especially numbers and types of consultations provided per mission. While this quantification is useful, the book's contribution would have been stronger had it addressed the broader relevance of the data. The experiences of hundreds of internacionalistas over 50 years are boiled down to a homogeneous, if admirable, blend of skill and abnegation, and thus we come away with little understanding of variations in the circumstances that have shaped internacionalistas' careers. We have few details, for example, about what drove them to this kind of work, how they lived within the communities that they served, or how these experiences have altered later practice.Without this analytical due diligence, most of the 11 chapters become a repetitive enumeration of Cuban accomplishments. While Kirk notes the gratitude of aid-receiving governments abroad, missing is an account of how local institutions adopt, adapt, or reject Cuban aid or grapple with the ethical and political implications of these interventions. The complexity of these negotiations over knowledge and resources is the subject of excellent scholarship in the history and social study of medicine today. It was surprising not to find a discussion of recent works on Cuban health care (save for Julie Feinsilver's Healing the Masses) or, more important for HAHR readers, the historiography of medicine in Latin America.Equally surprising was the characterization of Latin American medical experts as either followers of the Cuban way or reactionary leaders of professional medical societies. Kirk's depiction of the latter as wealthy doctors jealous of losing status and patients is quite negative but relies more on proclamation than demonstration. The views of the vast middle ground of medical personnel are unacknowledged, along with their ambiguous attitudes toward their own balkanized organizations, or the simple fact that their labor in the private sector is not merely a function of greed but an economic necessity that does not preclude effective action to address the social determinants of their patients' health. This brand of social medicine, with all its limitations, has been a Latin American staple since the 1930s, long before Fidel Castro came to power. One need not be a fan of the Federación Médica Venezolana, which Kirk singles out for attack, to reject the book's Manichaean stance on the medical cultures of Latin America.Opposite the critics of the internacionalistas stand the graduates of the Cuban Escuela Latinoamericana de Medicina (ELAM), established in the late 1990s to train health personnel. Let there be no misunderstanding: ELAM is a treasure and, as Kirk argues, a valuable source of revenue for Cuba even as the school maintains its commitment to low fees for those unable to afford them. However, it is quite another thing to claim, without corroboration, that ELAM trainees perform more detailed exams or listen to patients more actively than medical trainees elsewhere (p. 47), or that ELAM's emphasis on socioeconomic health risks is unique (p. 54). A simple review of medical curricula in the United States can illustrate the widespread interest in the latter topic. More provocative is the finding that ELAM has nurtured the growth of relatively novel specialties such as disaster medicine, which warrants further research.I respect Kirk's ethic of acompañamiento, his bearing sympathetic witness to a worthy cause, which extends to his donating of the book's proceeds to MEDICC, an organization that promotes US-Cuban health sector cooperation. However, portraying Cuba's medical internationalism as a singular model of virtue and high performance gets in the way of explaining the significance and nuances of the record. The reader cannot doubt the sincerity of Kirk's esteem, but I fear that defining Cuba's medical internationalism as the sum of its missions abroad will appeal more to metrics enthusiasts than to the broad public that the topic deserves

Diplomacy · Health care · Internationalism (politics) · Outreach · Political science · Politics · Premise · Public relations · Sociology · Cuban History and Society · Law