In 2015, an opinion piece in the Huffington Post asked what we can learn from Cuba. The author, a doctor, noted that Cuba’s infant mortality rate (4.7 deaths per 1,000 live births) not only improves on that of its Caribbean and Latin American neighbors, it is also lower than the United States’s rate (6.2 per 1,000) and is on par with countries like Canada and New Zealand.

Cuba’s health indices are a startling exception to the generally accepted correlation between state or individual poverty and ill health. Observers frequently declare that health in Cuba is “development within underdevelopment.” Cuba’s government is justifiably proud of its maternal and infant health statistics, since they represent a huge investment of financial and human capital—the result of the state’s political will. Despite supply shortages that plague the health system (due in large part to the U.S. embargo, the harshest against any country), prenatal care often surpasses international health recommendations. Women have routine prenatal checkups in neighborhood clinics. They receive a supplemented diet and are monitored for gestational diabetes, anemia, placenta previa, excessive or inadequate weight gain, high blood pressure, and preeclampsia. Women also undergo ultrasounds to identify congenital malformations, and are supposed to attend consultations with a nutritionist, dentist, geneticist, and family psychologist. Doctors make home visits to observe domestic environments, provide advice, and familiarize themselves with potentially problematic economic or social situations. Women at risk for inadequate weight gain may also be admitted temporarily into local maternity homes, which provide inpatient care until women return to normal ranges.

One rationale for this intensive investment in prenatal care is that it is solid public health policy. The Cuban state argues that such investments have significant rewards: Women in good maternal health are more likely to deliver babies of a healthy birth weight and without congenital malformations, and to carry their babies to term. Healthy infants require less curative medical care and are less likely than premature or low-birthweight babies to die in the first year of life or to suffer chronic health problems and developmental delays. This leads to greater capacities for work and education, which both enrich individuals and produce a stronger socialist society. Cuban prenatal health policy thus explicitly ties biological reproduction and the reproduction of socialism together through the language of social costs and population management. While not unique to Cuba, this approach stands in contrast to the individualist approach of health economies in which miracle stories of saving severely health-compromised babies are touted, while the considerable labor and the financial and emotional burdens of caring for children with significant health problems and developmental delays are ignored.

Yet there is more at stake than the health of the Cuban public. In 1987, Fidel Castro stated that “public health became a challenge and a battleground between imperialism and ourselves.” Statistics are not only technologies of scientific knowledge and government administration, but are also powerful symbolic representations. It is significant that maternal-infant mortality statistics are collected by the World Health Organization and other international groups as indicators of a country’s good governance and commitment to the welfare of women and children. Cuba’s excellent health statistics thus resonate far beyond their public health implications. They can be parlayed into material resources such as low-interest loans or grants from international agencies. They undergird the moral legitimacy of the socialist government at home and abroad, and are employed in the state’s efforts to assert socialism’s superiority to capitalist inequality.

For some in the United States, such extensive oversight over pregnant women raises questions about personal liberty and the role of government in health. It is true that there is significant intervention into the lives of pregnant women. The integration of Cuba’s health network with community organizations makes it difficult to imagine any woman, regardless of age, race, region, or economic status, arriving at her third trimester of pregnancy—much less entering labor—without having received prenatal care. This is not an uncommon phenomenon in America’s uneven patchwork of health and welfare services. But Cuba’s policies should also be compared with the inadequacy of prenatal care in many developing countries, where lack of investment leads to elevated maternal and infant deaths. They also compare favorably with the punitive policies of many U.S. states, where women can be incarcerated for fetal endangerment yet receive little help through services like free drug cessation treatment. That such penalties are disproportionately levied against poor and minority women should come as no surprise.

Yet the Cuban government now faces a conundrum. The socialist government made access to health care the cornerstone of its moral legitimacy. Now, health care is the benchmark by which Cubans will judge the legacy of their revolution. As Raúl Castro’s government begins to diminish state involvement in sectors from employment to agriculture, the island’s free and accessible public health services are the most tangible elements of the state’s continued commitment to its population. However, given a deteriorating public health system and the slow leak of doctors to more lucrative employment sectors, Cubans worry that this guarantee will wither in the face of dramatic social and economic changes.

Questions around the government’s role in health are fraught for American audiences, where the current debate over health care reform has underscored how deeply politicized health policies can be. For Cubans, the right of governments to intervene in health is beside the point; they argue that health care is a key responsibility that their government should be held accountable for providing. Indeed, the right question might not be what we can learn from Cuba. After all, little about their prenatal care is novel. Rather, we should ask: why haven’t we learned from Cuba?

The answer to that question confronts us with differing ideologies about the balance between individual and governmental responsibility that can inform our understanding of both our own and the Cuban health system.

Note

This post includes material that has been reworked from Elise Andaya's book, Conceiving Cuba: Reproduction, Women, and the State in the Post-Soviet Era (Rutgers University Press, 2014).