In August 1964, exiled physician Dr Antonio Maceo received a letter from a Cuban fan of his radio show ‘El Médico y Usted’. The writer had long suffered from lupus and had thus pursued diverse treatments, including physical therapy, to no avail. He went on to detail the improvisational measures he had devised to treat his condition, grounded in the increasingly scarce pharmaceutical scene of early 1960s Cuba. Finally, he got to his point. ‘They've told me’, he began, ‘that in the United States there's a variety of Prednisone [an anti-inflammatory] that contains 16 mg’. In contrast, the ‘only variety available in Cuba’ was a tablet of 5 mg, of which he took two daily. ‘Do you think it'd be good for me to take the [16-mg. Prednisone]?’, he asked, pointedly.Footnote 1
This fan would join listeners across the Americas in incorporating ‘El Médico y Usted’ into his health-seeking practices. Launched in 1963, the radio programme ran continuously for the next two years and generated a robust correspondence from all over the hemisphere. In daily ten-minute broadcasts, Dr Maceo provided information about a wide variety of ailments and health practices, ranging from alcoholism to measles, osteoporosis and nervous disorders. A distinguished generalist who had pursued his education in Paris and Havana, Maceo had worked as a medical practitioner and health bureaucrat in Cuba before leaving for exile in 1960. But Maceo was not just a physician, and his show reached well beyond medical concerns. As a prominent member of the exile community (and the grandson and namesake of the renowned Cuban patriot), Maceo had long played a central role in Cold War politics, even being tapped to briefly lead the Cuban Revolutionary Council, a US-sponsored exile organisation. ‘El Médico y Usted’, which ran on the infamous Radio America network, formed part of US government efforts to wage cold war on the cultural front – in this case, through medicine.
The appeal of this discourse stemmed directly from the Cold War politicisation of health throughout the Americas. In early 1960s Cuba, drug scarcity had become a glaring effect of that politicisation, as Fidel Castro's government moved to expand and improve public health programmes across the island. Those plans quickly brought the revolutionary state into conflict with the US pharmaceutical industry, which had played a leading (though not exclusive) part in drug sales to Cuba. Before the Revolution, US medications had been a pervasive presence on the island's medical scene, and many middle- and upper-class Cubans were as attached to US brand names as their North American counterparts. That brand loyalty rendered the sudden disappearance of US medications from Cuban pharmacies both structurally problematic and personally traumatic. By the mid-1960s, pharmaceuticals from the Soviet bloc and other sources would help to plug the gap. But for some Cubans those drugs remained decidedly inferior to the ones they had come to know ‘before’.
This article charts the emergence of pharmaceutical scarcity as a political touchstone and popular language in early 1960s Cuba, as US politicians, Cuban officials, drug companies, leftist sympathisers with the Revolution, and individual Cubans on both sides of the Florida Straits interacted with the unprecedented absence of well-known drugs. This constellation of actors together comprises a transnational ‘therapeutic culture’ of the kind sketched by Arthur Daemmrich in his study of ‘pharmacopolitics’.Footnote 2 In the United States, the period under consideration spans major shifts in the pharmaceutical arena, with the expansion and eventually government regulation of the drug market. Yet new pharmaceutical regimes did not act on a blank patient canvas: by the 1970s, the politicisation and marketisation of medications in the United States would lead patients to claim a new political role as ‘policy actors’ with a consumer inflection.Footnote 3
The ‘therapeutic culture’ of early revolutionary Cuba was similarly in flux, forming something of a palimpsest of drug practices. Though we know far too little about the history of popular pharmaceutical attitudes in Cuba, anecdotal accounts point to widespread self-diagnosis and self-medication both before and after 1959.Footnote 4 Health practices themselves were dizzyingly diverse, ranging from medically orthodox to herbal and spiritual remedies. Mid-century Cubans, we might posit, were cosmopolitan participants in the island's multicultural medical marketplace, in which US brand-name drugs played an increasingly prominent role leading up to the Revolution. Yet this was soon to change, influenced by major political touchstones of the early 1960s, from the imposition and tightening of the US embargo to ransom negotiations over the Bay of Pigs prisoners. Over time, these battles resulted in a shift away from US drug options and toward Soviet and generic ones. A heterogeneous past and an increasingly politicised present would thus shape the pharmaceutical landscape of early revolutionary Cuba, both from above and from below.
This article traces those transnational struggles over medical provisioning, situating them in a Cold War context of health politics and diplomatic tensions between Cuba and the United States. From New Left activists who saw in pharmaceutical scarcity an apt vehicle for their own political solidarity, to US and Cuban officials who sought to clarify the terms of the embargo, macropolitical struggle was often waged in and through medicine: drug wars for a Cold War age. Yet such events are only partially responsible for the language of shortage that would quickly envelop medications. The notion that formerly available drugs were suddenly ‘gone’ was, in some cases, an accurate factual claim. Yet it was also necessarily an ideological assessment: a measure of revolutionary failure, perhaps, or of US intransigence. For others still, shortage was precisely the wrong conclusion: access to the pre-1959 market of US goods was, after all, far from universal. While some Cubans aired their grievances over the absence of beloved products, others, particularly in the island's underserved rural areas, undoubtedly welcomed the opportunity to enter a socialised health system.Footnote 5
We cannot easily recreate a snapshot of pharmacy shelves and what they might have contained in early 1960s Havana, let alone in Camagüey or Santiago. What we can see, however, is how a diverse network of interlocutors learnt to argue through drug shortage, to assess the successes or shortcomings of revolutionary change in these increasingly weighty terms. On a structural level, this history encompasses the transition in Cuba from a capitalist pharmaceutical regime to a socialist one. Yet the implications of this shift exceeded the strictly commercial or even political. As a generation reared on brand-name medications gave way to one that spoke a language of generics, pharmaceuticals also become a privileged arena for the elaboration of new social mores – and revolutionary body politics.
Drug Crisis (?): Revolutionary Health, New Left Solidarity, and Cold War Backlash
We should not be surprised that medicine had quickly assumed such a central political role in revolutionary Cuba. A group of psychologists seeking to measure popular sentiment about the Revolution in its earliest years discovered that the factor that most distinguished conservatives from radicals in Cuba was none other than socialised medicine, which thereby bested the ‘nationalisation of public services’, central planning, the ‘participation of the government in economic life’, the ‘existence of strong sindicatos’, and the ‘guarantee of an adequate standard of living’.Footnote 6 Statistically, then, socialised medicine was the single most divisive issue separating those who supported the Revolution from those who dissented from it. This was a striking point of departure for the changes soon to come in the area of public health.
While early revolutionary policy focused most intently on the expansion of health services to rural areas, changes also were undertaken at the very heart of the island's medical infrastructure in Havana. One of the earliest battles was waged over the prices of medications, previously set – or, as it turned out, rarely restrained – by North American pharmaceutical interests in Cuba. In fact, a US Senate Subcommittee would be established in 1959 to investigate price fixing in the industry. Pharmaceutical companies in the United States responded to those hearings by politicising their commitment to free enterprise in light of Cold War tensions. As Dominique Tobbell suggests: ‘The industry argued that any challenge to the system of free enterprise not only threatened the country's international fight against communism but, potentially worse, invited socialism into the domestic political economy’.Footnote 7 Invoking the threat of socialised medicine on the home front, industry giants pledged to fight communism abroad through aid missions and donations for ‘those developing nations deemed susceptible to communism’.Footnote 8
As the US Senate debated the merits of the pharmaceutical free market, the Cuban government took dramatic action on this front. In March 1959, officials decreed a 15 per cent reduction in the price of medications produced within Cuba and a 20 per cent reduction for foreign drugs. These cuts would only deepen over the course of the next year, amounting – according to one pharmacist – to a 50 per cent cut by January 1960.Footnote 9 The unambiguous aim was to expand pharmaceutical access for Cuba's poor, but the measures also formed part of a broader programme of economic radicalisation. Over the course of 1960, hostilities between the Cuban government and US pharmaceutical companies would culminate in the nationalisation of drug production on the island, thereafter managed by a number of state agencies, including INRA, the Ministerio de Industrias, the Ministerio del Comercio Interior, and the Medicuba Company. Drug production would not be centralised again until January 1963.Footnote 10 In the interim, pharmaceutical production was largely managed by state bureaucrats, some without training in this area.
Indeed, the politicisation of medicine was generally the norm, prompting internecine battles at the Colegio Médico Nacional and Havana's medical school, as well as the exodus of large numbers of medical professionals. Meanwhile, the nationalisation of health facilities continued apace, though not without concessions to physicians willing to abide by revolutionary governance.Footnote 11 Though a politics of medical nationalism drove early efforts to expand Cuban drug production, available facilities and personnel ultimately could not fill the gap. The US embargo imposed in early 1962 would explicitly exclude medication and in principle allowed for humanitarian donations of drugs and food to the island. Yet shortages had nonetheless become rampant, with recent exiles pointing to ‘empty shelves in drug stores’, with even ‘serums and aspirin unavailable’.Footnote 12 Some members of leftist solidarity circles speculated that this was due to an unofficial boycott implemented by US pharmaceutical companies, while, on the opposite end of the political spectrum, others blamed Castro for ‘hoarding’ medications. In either case, by February 1962 the Cuban government moved to implement ‘controls’ on the distribution of drugs.Footnote 13 Restrictions on drug circulation would thereafter coexist with a number of popular strategies for obtaining medications.
One point of access would come from an unlikely source. In October 1961, a small band of activists in New York City had organised a ‘provisional committee’ dedicated to ‘Medical Relief for Cuba’. Some of them maintained overt connections to other solidarity organisations of the period, especially the Fair Play for Cuba Committee (FPCC), established in April 1960 in New York City in response to escalating tensions between the two governments.Footnote 14 But the new organisation's more specific raison d’être was, according to founder Melitta del Villar, the ‘tragic shortage of medicines and medical supplies’ in Cuba.Footnote 15 In a letter to a prospective sponsor, onetime Nation editor Freda Kirchwey, del Villar painted an ostensibly apolitical picture of aiding Cuban ‘mothers and children’, the ‘innocent victims’ of pharmaceutical shortage.Footnote 16
Del Villar, whose real name was Emma López-Nussa Carrión Amster, was born in Cuba but had lived all of her adult life in the United States. In 1961, del Villar, the stage name she used in her professional life, had left behind a spotty singing career to dedicate herself fulltime to humanitarian activities, even as she continued to cast herself as an outsider in the political realm. Nonetheless, as she organised to gather financial and political support for her group, she drew on the artistic, intellectual and political networks that had already emerged around Cuba in New York. In addition to Freda Kirchwey, by early 1962 the group, renamed the ‘Medical Aid to Cuba Committee’, included members like Sidney J. Gluck, a Marxist political scientist and Asianist who had worked to promote good relations with China in the 1950s; anti-war activist David Dellinger, who would become famous as a member of the Chicago Seven; New Left and SNCC stalwart and journalist Elizabeth ‘Betita’ Sutherland Martínez; and civil rights leader Bayard Rustin. With many of those members in attendance, the group announced its first public meeting in March 1962.Footnote 17 Even in advance of its debut, the group had already received requests from the island for medications totalling US$ 25,000.Footnote 18
In its appeals to the public, the Medical Aid for Cuba Committee (MACC) aimed for the heartstrings rather than the head. One November 1962 New York Times ad bemoaned that ‘Juanita’, an 11-year-old girl, was ‘dying’, while her physician father sat at her bedside ‘helpless and despairing’, because he ‘[lacked] the one drug’ that could ‘save his beloved child’.Footnote 19 The ad beseeched the reader to ‘save her life’ by providing funds to the organisation, which would be used to purchase pharmaceuticals and medical equipment for island hospitals. By May 1962, the group had amassed between US$ 20,000 and US$ 30,000 in donations.Footnote 20 Additional outlets, apparently unaffiliated with del Villar's, would soon appear in Los Angeles, Detroit and Chicago.
But del Villar's efforts to ward off the appearance of politics would ultimately fail her, as she, along with the MACC's treasurer and medical director, were summoned to appear before the Committee on Un-American Activities in November 1962.Footnote 21 The hearings were inspired by Committee suspicions that several MACC members were members of, or had participated in, the Communist Party at some point in their pasts. That assumption guided many of the initial questions introduced by committee members. In her testimony, del Villar refused to discuss her political beliefs, insisting they were not a ‘question for debate’ in these matters, despite her participation in Fair Play for Cuba.Footnote 22 Far from a ‘propagandist for the Communist regime in Cuba’, del Villar clung throughout the hearings to the humanitarian mission she had outlined at the start. She continued to do so even when presented with a telegram that she had jokingly signed ‘Pat O'Morte’ – shorthand, investigators suspected, for the revolutionary slogan ‘patria o muerte’ (fatherland or death).Footnote 23
In fact, Committee members remained convinced that both del Villar and MACC served hidden, more sinister, purposes. As Congressman Edwin E. Willis (Democratic representative for Louisiana) had pointed out at the start of the hearings, investigators operated from the belief that ‘Communist regimes’ often ‘made political use of aid or assistance, medical or otherwise’. MACC, they argued, likely aimed to ‘use very fine, appealing language to disseminate Communist propaganda’.Footnote 24 If del Villar was unwilling to confess to that charge, then she was simply a stooge, a ‘dupe’, manipulated both by the crypto-Communists in her organisation and by the Cuban government itself.
As investigators failed to convince del Villar to out her collaborators, they turned increasingly to the mysterious workings of her Cuban networks. Her primary contact, it turned out, was Dr Martha Frayde of the Hospital Nacional, a close collaborator of Fidel Castro's who would, decades later, join the opposition to his government. Frayde's official stripes were branded ‘ominous’ by Congressman Donald C. Bruce (the Republican representative for Indiana).Footnote 25 Responding to that charge, del Villar thoughtfully surveyed the corrupt dealings that had characterised Cuban healthcare before the Revolution, only to face Bruce's continued attacks on the ‘officialist’ character of all doctors and hospitals in Cuba. Yet del Villar was also forced to recognise that she could not speak to the fate of the medications sent by her organisation, given that the Department of State had denied their medical representative a visa to travel to Cuba. Evidence was presented, however, of her communication with Dr Frayde as to the medications and equipment that would best serve Cuban needs, some of which (including several parts for an X-ray machine) would not be approved by the Department of Commerce's Office of Export Control.
Though their questioning of other MACC members remained targeted to unearthing Communist sympathies, the Committee could not resist engaging in a final and suggestive piece of political theatre, calling three Cuban doctors to testify about medical conditions on the island. Dr Emilio Soto, who had left Cuba in 1960, affirmed that Frayde was unequivocally a Communist but, most importantly, that the shortage of medications in Cuba was ‘created by Castro himself. It was not a real fact, and I don't believe it was a real fact, because still the American manufacturers were there, and they were supplying medicine to the medical profession.’Footnote 26 Soto claimed that Castro aimed to deliberately stoke the misperception of a shortage to pin the blame for it on the Americans, even after US pharmaceutical companies had been nationalised by the government. A second witness, Dr José Tremols, noted that in 1960 – before he, too, left the island – US firms like Squibb, Parke Davis, Merck Sharp & Dohme could still be found in Havana, though supplies had become increasingly scarce. Investigators found his testimony to be in conflict with Soto's, and they pushed him to admit that medications had not become scarce, but rather ‘misdirected’ by the Cuban government. Tremols also testified to the appearance of Soviet bloc gloves, injections and tablets in the same year.Footnote 27
Yet the pièce de résistance was the appearance of one Dr X, who had defected to the United States a few months before the hearings. Dr X had agreed to appear before the committee only if his participation were made anonymous through the use of a false name and a mask. Dr X's testimony proved the most tantalising of all. US-made pharmaceuticals had largely disappeared by the time of his departure in 1962, and he speculated that this was due less to withholding on the part of the Cuban government than its inability to pay for supplies. In contrast, he continued, the Soviet bloc was not ‘prepared to give all the medicines, not in quantity, but in quality, that we are used to, to work with’.Footnote 28 Yet Dr X also alleged that even the small stores of American drugs that continued to filter in had been deliberately mislabelled as Soviet:
I think they bought in the common market medical supplies from the United States companies and then put it into cases as made in Czechoslovakia or made in Poland, and all that, but when you get the tablets you can see really that there were the names of Lederle and Sharpe & Dohme and, you know, those classical laboratories we have here.Footnote 29
Committee members further coaxed Dr X to affirm the officialist character of all medical facilities in Cuba, but it was this perplexing revelation about the coexistence of discrepant pharmaceutical regimes (along with a harrowing story about being forced to perform surgery at gunpoint) that struck them as most damning.
Perhaps it was. But it would not matter for long. The activism of the MACC would be brought to an end, not by the Committee's persecution, but rather by macropolitical events of a broader scope. As negotiators on both sides sought to unravel the fate of American hostages taken during the 1961 Bay of Pigs invasion, pharmaceutical scarcity would become a vital point of negotiation. It was the resulting deliberations over a resolution to the hostage crisis that instead led to the final dissolution of the Medical Aid to Cuba Committee in January 1963.
Drug Negotiations: The Bay of Pigs, Big Pharma, and Fidel
In April 1961, a group of CIA-backed Cuban exiles landed on the beaches of Playa Girón as part of an ill-conceived and ultimately unsuccessful attempt to overthrow the Castro government. An island-wide mobilisation led to the speedy defeat of the invading forces, and many of them were taken prisoner, later to face public and politically charged interrogations over their participation in the invasion.Footnote 30 Yet, as their relatives pushed the US government to settle their fate, the imprisonment of Brigade 2506 participants dragged on. It was not until some 20 months later, and thanks to the expert behind-the-scenes negotiations undertaken by lawyer James Donovan, that the majority of the prisoners would be released in December 1962.
Donovan's efforts turned on a deliberate reorientation of negotiating tactics. Castro had insisted from the start that tractors be traded for the Bay of Pigs prisoners, yet that demand had worried US politicians, who viewed tractors as potential war material. Fidel had then begun to demand a hefty indemnity payment, with prices set for each prisoner based on his assumed means. This request also found little traction on the US side. When Donovan took over the negotiations, he was thus pressed by the US government – specifically, Robert Kennedy – to push for payment in the form of food and medication, though the offer of medication was to be made quietly.Footnote 31 Donovan's initial conversations with Castro accordingly made no reference to anything but food.
But the Cuban government moved to take advantage of its juicy bargaining chip to resolve a number of shortages stemming from nationalisations and the imposition of the embargo. Following a first meeting, Donovan was sent a list of specific demands, including a letter from Castro requesting medications. Donovan immediately contacted John H. McKeen, Chairman and President of the Pfizer Co. and, conveniently, his upstairs neighbour. McKeen expressed tentative willingness to send medication from ‘unused inventories’ but speculated that those quantities would not be sufficient.Footnote 32 Donovan apparently received a more negative reaction from another friend, John T. Connor, President of Merck, Sharpe, & Dohme. According to one account, Connor was very reluctant to do anything that might aid President Kennedy, given the President's ‘anti-trust attacks’ on his company.Footnote 33 In response, Donovan touted the public relations boost that would accrue to Merck as a result of its participation. Connor thus agreed to the deal only if the Justice Department would promise not to prosecute the drug companies for ‘trust activity’ as a result of their collaboration. He also requested a ‘substantial tax deduction’ for Merck.Footnote 34
Unbeknownst to the Cuban negotiators, however, the shift to drugs actually redounded to the financial benefit of those companies and the US government. In emptying its inventories, Pfizer, for example, planned to unload ‘outdated’ drugs on Cuba, many of them effective but also less ‘clinically advanced’.Footnote 35 In addition, the ‘wholesale’ price that was being set for such drugs was actually the same as the ‘sales’ price, since Pfizer maintained no networks of wholesale distribution. This amounted to substantial savings: ‘not…more than US$ 10 million, or only one-sixth of the figures demanded for the “indemnity”.’Footnote 36 Castro, meanwhile, continued to expect that the sum total of medications would reach US$ 60 million.Footnote 37
These disagreements over pricing would remain a sticking point for weeks to come, with some interesting twists and turns. At one point, Castro himself sought to explain high drug prices in the United States, due, he speculated, to the prevalence of pharmaceutical advertising.Footnote 38 On 12 October, Robert Kennedy wrote to Donovan that the US government wished to take advantage of the difference between wholesale and sale prices to provide no more than US$ 10 million worth of goods in the exchange.Footnote 39 Nonetheless, significant lobbying efforts by Kennedy would be required to convince the pharmaceutical companies to move forward as a united front without fear of an anti-trust suit. Castro's single-spaced, 237-page list of drugs in fact required such cooperation, as no company would have been able to meet the demands alone.Footnote 40
Debates over the donations continued until the very last minute, with a late Cuban demand that US medical experts be drafted into the negotiations. In these exchanges, the Red Cross played a vital mediating role, facilitating the trip of several (alleged) Cuban Red Cross officials to Miami to inspect the shipments, where they were greeted by former Surgeon General Dr Leonard A. Scheele, among others. The two groups reportedly spent an entire night sparring over the exact content of the medical cache.Footnote 41 Differences were finally overcome, however, and the first shipment, including drugs and food items, left for Cuba on 22 December. Ultimately, roughly 50 pharmaceutical companies would provide US$ 23,263,000 worth of medications.Footnote 42
As news of the talks surfaced over the next week, those same companies, often through anonymous interviews, began to reveal the wariness with which they had first responded to Kennedy's request. Though rumours of a prisoner-for-medication exchange had long circulated in political circles, most in the pharmaceutical industry had assumed they would be compensated for drugs provided. US officials, on the other hand, apparently felt that any attempt to purchase supplies would only embolden Castro to make more outrageous requests. Yet the terms remained unsatisfying to pharmaceutical companies, and they had held off, ostensibly until the Cuban Missile Crisis convinced them of the urgency of the request. Even then, they refused to donate medical supplies until they were promised a generous tax break for their donations.
Nonetheless, industry representatives had continued to blanche at the magnitude of Castro's demands. This included, in one case, a ‘17-year supply of a compound used for diagnosing blockage of arteries in the brain or circulatory tree’.Footnote 43 But negotiating chief Donovan had assured them they could make their own decisions about what to send: ‘Whatever is good medicine for Americans is also good medicine for Cubans’, he insisted.Footnote 44 Ultimately, the companies would send ‘aspirin, insulin, hormones, blood anti-coagulants, bandages, vitamins, antibiotics, sulfa drugs, anesthetic drugs of all kinds, anti-malarials, and anti-diarrhetics’.Footnote 45 Some of the largest pharmaceutical companies, including Merck, Eli Lilly, and others, donated well above US$ 1 million worth of drugs, with Merck alone sending more than US$ 2 million worth.Footnote 46 Though the political circumstances undoubtedly accounted in part for the companies’ generosity, recent scandals within the industry also played a role, as in the aforementioned Senate hearings over medication prices and controversy over the Thalidomide tranquilliser, blamed for deformities in new-born babies.Footnote 47 The industry had thus reluctantly seized the opportunity for a public relations boost, just as Donovan assured them their donations would amount to that.
The first medications appeared on Cuban shelves in late February 1963, where ‘once-familiar boxes of Alka-Seltzer’ sent to Havana pharmacies ‘sold out in a matter of minutes’.Footnote 48 Cuban officials also promised that more medications would soon be debuted.Footnote 49 On the island, the donations seem to have fomented genuine gratitude toward negotiators like Donovan, who deemed the medications the ‘greatest propaganda on behalf of the United States that you can imagine’.Footnote 50 Donovan reported having been ‘stopped by strangers in Cuba’ who ‘thanked him for the drugs’. Some of them shared personal stories, like a woman whose husband had been ‘afflicted with arthritis and … suffering severe pain until drugs became available through the American shipments’.Footnote 51 She, like many others, ‘wanted [Donovan to know]’ that she ‘was grateful’.Footnote 52
Yet the flush days of medical plenty would not last. During a weeklong trip to Cuba in April 1963, Representative John B. Anderson of Illinois learnt that medical supplies had suddenly become scarce again. He spoke to one man whose relative had been ‘obliged to travel all the way to Havana for a shot of penicillin for which she was charged the equivalent of $30’. He further insisted that the drugs had ‘not been made available to the average Cuban’, but rather sent ‘to Russia instead’.Footnote 53 These allegations of misappropriation would be further disseminated by onetime Castro friend-cum-exile-leader Dr Luis Conte Agüero, who publicised an ‘underground report’ of Bay of Pigs medications being loaded onto a Soviet submarine destined for ‘Communist guerrillas in Venezuela, Panama, Nicaragua and Honduras’.Footnote 54
It is hard to square these divergent representations of the pharmaceutical scene in Cuba following the ransom shipments. We might account for some of the discrepancy if we hypothesise that the bulk of the drugs landed in Havana and did not reach as many Cubans in the provinces. Alternatively, Castro may indeed have used part of the shipment to pay back a bill with the Soviets, as others speculated, or to back leftist rebels in Latin America. More likely, he stockpiled some part of the shipment to prepare for future hardship ahead.Footnote 55
In any case, the perception of pharmaceutical scarcity in Cuba would soon come to dominate the US imaginary again, following a new set of revelations in early 1964. In May of that year, State Department officials confirmed that they had been quietly investigating Cuban purchase requests sent to multiple US pharmaceutical companies. Those appeals had been secretly forwarded to Upjohn Co., Merck, Eli Lilly, Smith Kline & French, G. D. Searle & Co., Parke, Davis, & Co., and others, through a Canadian organisation known as the Cuban Foreign Trade Enterprises (acting on behalf of MediCuba).Footnote 56 The quantities of drugs requested – totalling several million dollars in some cases – were substantial enough to provoke suspicion at many of those companies, where the bids had quickly been turned over to US government officials.Footnote 57
State officials shared the companies’ misgivings, noting that Castro could have easily purchased the drugs for less money elsewhere. One authority speculated that Castro sought not to acquire medications but rather to ‘increase American-Cuban trade to undercut American efforts to maintain the economic boycott’.Footnote 58 Of course, in 1964, medications remained one of the few categories of commerce not restricted by embargo provisions. But that too would soon change, as the Department of Commerce moved to rein in sales of food and drugs to Cuba. A new measure required ‘specific licences’ for future sales of those items.Footnote 59 One such licence would soon be requested by and granted to Sidney J. Gluck, a former participant in the Medical Aid for Cuba Committee, in order to send US$ 11,000 worth of emergency antibiotics to Cuba.Footnote 60
And so the avenues of medical exchange and commerce between Cuba and the United States were curtailed for the time being. The Cuban government responded by seeking many of these medications from Soviet bloc partners, especially Czechoslovakia and Hungary, but also Canada.Footnote 61 By April 1965, a Ministry of Public Health (MINSAP) official would maintain in an interview with the Washington Post that the issue of pharmaceutical shortage had been largely resolved. The problem, he added, was that Cubans continued to cling to brand label health-seeking, promoting distrust of the generic medications sent by Soviet allies.Footnote 62 Yet another informant in the public health sector disputed this characterisation, insisting that Cubans shrank not from the absence of brand labels, but rather from evident ‘impurities’ in the medications.Footnote 63 Other Cubans claimed both that medications remained scarce and that Soviet drugs in particular were untrustworthy. A Cuban father vowed that he would not allow his son to be vaccinated against polio: ‘I hear it will make him a Communist. The vigilante committee [sic, presumably the CDR] says I must give him the medicine or I will be arrested. I will not do it.’Footnote 64 Meanwhile, another interviewee noted his ‘surprise’ that the government had not ‘[used] the medical shortage in a propaganda campaign against the US blockade’.Footnote 65 ‘Apparently’, he continued, ‘they simply don't want it known’.Footnote 66
Even at the end of the decade, these conflicting accounts of pharmaceutical shortage would persist. In 1970, one recent exile asserted that only ‘standard [prescriptions]’ were available in Cuban pharmacies, while another noted that a doctor would have to ‘call the pharmacy before prescribing any drugs or medicine because he was afraid of being accused of being a counterrevolutionary for ordering something that wasn't on the market anymore’.Footnote 67 Evidently, the politics of pharmaceutical scarcity remained conflictive well beyond the highpoint of shortage. We might even say that the experience of medical crisis was often personal, as much as institutional.
Drugs (Un)branded: Medical Petitioning in the Revolutionary Press
If we return to our hazy image of pharmacy shelves, it remains difficult to parse the degree and extension of drug scarcity in 1960s Cuba. There were certainly moments of severe crisis, particularly in 1961 and 1962. Nonetheless, shortage was never an absolute measure. Most Cubans retained an active memory of their pre-revolutionary pharmaceutical selves. In many cases, that knowledge provoked gratitude for opportunities to become part of the public health apparatus that had not existed before the Revolution. Sometimes, however, the historical touchstone was rather the pharmaceutically cosmopolitan, self-medicating Havana of the recent past. Drug access, then, was not a neutral realm of clinical engagement, but rather a highly individualised experience.
As anthropologists of pharmaceuticals have long argued, the effects of medications cannot be understood in universal or exclusively physiological terms. They have thus sought to situate drugs in their ‘social life’: the practices and beliefs that shape popular engagement and understandings of ‘efficacy’. In the words of several pioneering scholars in the field, the ‘cultural efficacy of pharmaceuticals lies primarily in their capacity to carry meanings’, channelling illness and wellness, ideology, politics, market logic, and even the ‘metaphysical’.Footnote 68 The signifying reach of drugs lies precisely in their capacious effects. In diverse and sometimes mysterious ways, pharmaceuticals connect soma to psyche, individual to community, need to want, commerce to state, and the material to the ineffable; hence, the particular urgency attached to perceptions of drug scarcity.
But pharmaceutical meanings are made – not born – in historical time and social context. One of the most tendentious such transitions in the twentieth century has been the introduction of generic drugs, a phenomenon that Cuba and the United States faced at roughly the same moment. In early revolutionary Cuba, we can witness the political effects of that shift, with the evolution from US brand names to Soviet generics. In both places, the perceived intrusion of generics threatened physical and affective investments in favoured medications, carefully cultivated through decades of marketing and medical outreach. Often, the language of scarcity was thus a contingent one, glossing not absence but difference. Popular attachment to brands and names promoted suspicion vis-à-vis their disappearance, as familiar labels in English and Spanish gave way to inscrutable ones in Russian.
In the 1960s, the United States had also begun to wrestle with the rise of generic drugs, vigorously promoted following the landmark achievement of Medicare and Medicaid. But American doctors, Jeremy Greene writes, actively resisted mandatory generic prescribing, propelling debates about ‘therapeutic equivalence’ that would resonate long after.Footnote 69 These discussions of scientific quality were not, however, merely an effect of capitalist marketing. Instead, Greene suggests, we should understand brand preference as an artefact of massive investments in post-World War II research and development at ‘innovator’ drug companies. Those companies, he points out, had consolidated their hegemony by casting their non-branded competitors as therapeutically inferior, and organised around these claims an entire apparatus of moralistic marketing. It was those very promotional practices that would inspire Senator Estes Kefauver's 1962 hearings, in which he advocated for legislation that would ‘ban all brand names for prescription drugs and force a return to the prior arrangement of ethical marketing’.Footnote 70 These battles also left a mark on the American consumer, who had been directly and indirectly implicated in the formation of therapeutic preferences.
But how did that branding travel, especially in imperial contexts? Consumer goods are not neutral material objects; they rather serve, both intentionally and incidentally, as vectors of broader sentiments and anxieties around race, class, gender, and the body. These effects are often heightened when politicised.Footnote 71 Citizens of pre-revolutionary Cuba had long learnt to channel their aspirations to material, technological and political progress through a highly embodied relationship with US consumer culture.Footnote 72 That affinity for US material objects was particularly pronounced among the middle-class habaneros who most strenuously denounced the new regime of pharmaceutical ‘scarcity’. Complaints about scarcity, however, were not just an effect of class privilege. Across social and racial lines, many Cubans had developed sensuous connections to US products, including seemingly mundane items like Alka-Seltzer, whose disappearance was thus keenly felt.
These concerns about the material landscape of early revolutionary Cuba featured most prominently, we can imagine, in hushed conversations among friends and family. On at least one occasion, however, the conversation played out in a public forum. At precisely the moment that Donovan and Castro were battling it out behind the scenes, ordinary Cubans opened up a brief, if subtextual, conversation about scarcity in the pages of the revolutionary press. The official response to their concerns points to a fundamental disagreement on the implications of shortages. For governing elites, the recognition of scarcity was politically problematic, potential evidence of medical underdevelopment even when it might have engendered goodwill among the island's international allies. The revolutionary approach, then, was to remain silent on this front. The populace, however, would briefly take advantage of an opportunity to draw attention to those challenges, privileging everyday experience over symbolic battles and their macropolitical implications.Footnote 73
For a point of comparison, we need only consider the front page of the 10 March 1961 issue of the official newspaper Revolución, where a large image of the Parke, Davis, & Co. polio vaccine label appeared, accompanied by the bold type ‘CYNICISM’. The vaccine, apparently donated by the American Red Cross at Guantánamo, was thereby repudiated in the pages of Revolución. This ‘unsolicited help’, the caption continued, ‘which Kennedy has bragged about, provided by unclean hands and even manifesting the intention to engage in inhumane politicking’, offered ‘proof of cynical imperialist audacity’. That cynicism, it concluded, was particularly evident in the fact that the donated vaccines had already expired.Footnote 74
Ordinary citizens, however, would soon offer a different vision from the margins of that paper. In the closing months of 1962, letters published in a segment known as ‘Descarga’ (or ‘Blowing Off Steam’) began to request medications from the Ministry of Public Health or fellow citizens, sometimes citing the ‘exemplary worker’ to whom the drug in question would be delivered.Footnote 75 The ‘peticiones de medicina’ quickly became a regular feature, alongside complaints and requests covering appropriate revolutionary behaviour, public works and much more. On occasion, Ministry of Public Health (MINSAP) representatives would even reply to these requests, noting places when the medicine sought was inappropriate for the indicated disease.Footnote 76
Yet the Ministry of Public Health would not long limit its intervention to matters of prescription. In November 1962, MINSAP Minister José Machado Ventura wrote a letter to the editors calling out Cubans’ attachment to brand-name medications. Their refusal to accommodate the new medical reality was a mere holdover from the capitalist past, he claimed, given that many of the drugs removed from the market had no ‘curative effect’ and responded only to the financial interests of the companies that produced them.Footnote 77 In the future, Machado Ventura added, any requests for medications should be forwarded directly to the Department of Pharmaceuticals at MINSAP, where they would be investigated and attended. The objective, he tactfully noted at the end, was to ‘avoid … an anguished perception of a grave shortage of medications’, a notion, he added, that could easily be exploited by the ‘enemies of the Revolution’.Footnote 78 Evidently, however, the peticiones did not immediately cease, and a second note by the editorial staff was required to nudge readers in a different direction.Footnote 79
With that, pharmaceutical need summarily disappeared from the pages of the revolutionary press. Yet Cubans continued to pursue extraordinary measures to locate desired drugs. A new and unexpected source would soon emerge on the other side of the Florida Straits, courtesy of the imagined Cuban community created around CIA radio programming.
Drug Reciprocity: High Politics and Body Politics
The timing of Antonio Maceo's 1963 radio debut could not have been better planned. He took to the airwaves at the very moment that a public conversation about drug scarcity on the island began to close, as US drugs again became more difficult to access, and the public health system in general strained under the weight of a physician exodus. That context virtually guaranteed that Maceo would also attach political significance to health and drug scarcity. In his shows, Maceo crafted a medical politics of the personal, inscribing his political vision onto the individual body and its various ailments. Many times, his listenership – especially outside of Cuba – accepted this interpellation and identified as belonging to a hemispheric anti-Castro public. Nevertheless, just as often, correspondents skirted his conflation of body politics and macropolitics. Unlike their Latin American counterparts, who framed their appeals to him in the language of ideology, Cuban listeners more often exhorted Maceo to make good on his promises by delivering sensitive information and inaccessible medications.
Against the Cold War logic of the CIA and its exile collaborators at Radio America, ‘El Médico y Usted’ thus achieved unexpected social effects. As ideological kinship faded to the background of Maceo's Cuban correspondence, a micropolitics of solidarity assumed its place. Island correspondents implicated the exile leader in an ethics of everyday reciprocity – the Cuban notion of the compromiso, or mutual obligation. Transnational radio ties thus buttressed a system that Cubans would ironically baptise sociolismo: getting ahead, not by exhibiting exemplary political behaviour, but rather by drawing on one's well-placed socios, or friends. Scarcity, then, was not only a political language to be exploited, but also a vehicle for forging new kinds of relationships, premised on a pragmatic commitment beyond political bombast.
In elaborating these relationships, Cubans inverted the terms set by Maceo's highly politicised broadcasts. Maceo's partisanship had in fact posed a challenge to his producers, who had sought to cultivate a more sterile tone. The show's opening credits thus proclaimed that Maceo did not intend to ‘penetrate political terrain’, but rather to cover ‘topics and ideologies of a scientific and sanitary character’.Footnote 80 Paging through transcripts of show episodes, one frequently comes across political tangents that were edited out from the final presentation. An early memo to the host advised him that the ‘presentation and sign-off of the program should be lightly modified, to give it a more professional tone’.Footnote 81 Yet Maceo found room to reintroduce political concerns where they explicitly met medical ones. The revolutionary government's missteps in the area of public health, for example, were explicitly glossed as failures of governance, as was the much-commented decline in sanitary conditions and food access.
Nevertheless, even Maceo seemed to recognise that the more proximate cause of healthcare decline was the departure of many Cuban physicians in the early 1960s. In the show's opening segment, he explicitly referenced this context, and specifically the ‘absence of sufficient personnel’ along with the ‘professionals of “recent vintage” who without having completed the necessary and indispensable amount of studies, internship, etc., cannot logically act with the experience, nor at the level that is required of them’.Footnote 82 The show, then, proposed to speak on behalf of the ‘many Cuban doctors in exile who receive[d] letters requesting medical advice for their personal and familial problems’, while also reviewing medical advances in the ‘Free World’ for those Cuban physicians who still resided behind enemy lines.Footnote 83 ‘For the Castro regime’, he proclaimed on another occasion, ‘it is more honourable for a doctor to cut so many pounds of sugar, than to carry out a successful and scientific operation. All to the detriment of public health…’.Footnote 84
A spectacular news item of late 1963 allowed Maceo to bring these medical and political concerns together.Footnote 85 A story carried on 30 September by the Agencia de Informaciones Periodísticas, a CIA-backed news outlet run out of Miami, announced a grave epidemic of gastroenteritis in Santiago and Havana.Footnote 86 ‘Gastroenteritis threatens Cuba’, one headline screamed; ‘illnesses devastate Cuban children’, announced another. Below two photos of emaciated children, the story continued along hyperbolic lines:
These are two Cuban children in Communist Cuba. No, they are not photos from the ‘concentration camps’ of Weyler's time during the period of Spanish dominion in Cuba, nor are they from a Nazi concentration camp, or from Siberia in Russia, nor are they the children who die daily in China from hunger. They are two Cuban children who are trying to escape the terrible epidemic of gastroenteritis in the Children's Hospitals of Santiago de Cuba and Havana. They are two spectral beings, who pull on the heartstrings of the most insensitive, as they muster their own forces against the illness…Footnote 87
The story provided fodder for several episodes of ‘El Médico y Usted’, in dialogue with letters received from Cuba. One writer, who claimed to be ‘nearly a relative’ of Maceo's, fearfully begged for information about gastroenteritis, ‘for here no one knows anything, but the situation is that the number of sick children and even adults, is truly terrifying’. ‘Is there no vaccine or way to prevent or cure this?’ he wondered.Footnote 88 Another correspondent from Santiago de Cuba echoed this concern, informing Maceo that in that province ‘something like 300’ children had died. ‘My wife and I are devastated’, he continued, ‘because beginning a week ago, our two children … began to get thinner every day, with many stools every day, sometimes vomiting often, and we're unable to feed them. We've tried to find medication, but those, like specialized physicians are very difficult to find in our current situation.’Footnote 89
In response to these letters (Maceo suggested on air that he had received ‘hundreds’), Maceo dedicated a full show to gastroenteritis. Casting blame at a ‘lack of attention, carelessness’, and even ‘ignorance’, he framed gastroenteritis as a fundamentally political rather than medical condition. Castro, he insisted, should be held responsible for poor sanitary conditions and impoverished medical services. But revolutionary sentiment, he continued, was itself sickening: ‘Marxist-Leninist hate’ had left the Cuban populace ‘weakened, sick, and febrile’.Footnote 90 In the background of these indictments were Castro's own allegations that the US was waging bacteriological warfare against Cuba.Footnote 91 Maceo appropriated that logic to redirect the debate, depicting Communism itself as an agent of medical warfare.
Along similar lines, in a follow-up show on gastroenteritis, he echoed charges that the medications and food sent to Cuba in exchange for prisoners in the aftermath of Bay of Pigs had been misappropriated, to fatal effect. That accusation followed the announcement of an ‘asthma epidemic’ in Cuba by Cuba's Minister of Public Health. ‘As doctors we know, and we want to share this information with the exile community and Latin American people who don't know the terms of our profession’, Maceo began, ‘that it's impossible to have an EPIDEMIC OF ASTHMA in Cuba, since that kind of epidemic doesn't exist anywhere in the world’. Rather, he countered, what could be considered epidemic in Cuba was the continued scarcity of medicine and food, as well as the ‘bungling and ignorance’ of the Ministry of Health.Footnote 92
In Maceo's broadcasts, then, the political and the medical went hand in hand, particularly in his vision of Communism as endangering health. In fulfilling his spiritual duty as a physician, Maceo proposed at a ‘minimum’ to ‘remain in touch over these radio waves and talk, offer advice, almost … as it was before’.Footnote 93 But the politics of pragmatism could also be complicated, particularly when it came to the listeners who sought more than advice. From all over Latin America, Maceo received requests for autographed photos,Footnote 94 flags, and even recordings of the Cuban national anthem.Footnote 95 Far more often, however, listeners sought the medications they were unable to acquire in their own contexts.
Unsurprisingly, many of those appeals came from Cuba itself, and often for mundane drugs that had suddenly become scarce in the early 1960s. One listener from Camagüey informed Maceo that cortisone was nowhere to be found, and so her eczema went untreated.Footnote 96 Often, in spite of the political dangers, the imperative to acquire such medications was pressing enough that Cuban letter writers provided their full names and addresses in the hopes that Maceo would send them what they requested. Another correspondent from Santiago informed the doctor that there ‘was no medicine’ that could be found there for her melasma.Footnote 97 This was not for lack of qualified professionals, and she went on to praise the physician who attended her. Nonetheless, he had no medications to offer her, and had advised her to call on ‘some family member in the North’. Absent such a contact, she had decided to write Maceo ‘with all her heart to see if [he] might perform the charitable act of sending her some’.Footnote 98 Indeed, medications for prosaic skin conditions, ranging from eczema to psoriasis, were sought most often by Cuban letter writers, so frequently that Maceo tended to label these letters with the terse shorthand ‘pide medicina’ – a striking parallel to the ‘peticiones de medicina’ that had earlier appeared in the pages of Revolución.
But Cuban listeners also approached Maceo about more serious issues, including a Camagueyan listener who had written him about a case of progressive syphilis. The required antibiotic was not available in Cuba, but she was certain that Maceo would send it to her:
We have faith in you and in God, that you will consider my case, to send me as quickly as possible the necessary amount of medication to save once more a LIFE, we are poor people, we hardly have economic resources, but we await the medical aid of that Organization that sponsors the program so widely listened to in Cuba, every single night.Footnote 99
Not all correspondents, however, so freely beseeched Maceo for his aid. One Cuban wrote to Maceo from Jacksonville, Florida, on behalf of his epileptic nephew on the island, reminding him of the need for quick action given that ‘nearly all of the transmissions of Radio America are blocked by Communist Radio in Cuba’.Footnote 100 Another faithful listener dared to write to Maceo directly from Havana to request information about colitis and appendicitis, but indicated that, ‘for obvious reasons’, Maceo should send it not to her but to a middleman.Footnote 101
In Maceo's correspondence, one thus finds a complicated alchemy of solidarity and reciprocity. His listeners from elsewhere in Latin America often led with baroque expressions of political solidarity as grounds for requesting medical solidarity and even charity. So common is this language of affective transaction that it assumes an almost generic quality in the letters, where one finds denunciations of ‘Muscovite tyranny’ transitioning almost seamlessly into entreaties for assistance. Only rarely does one find something rather more complex, such as the admission of one Mexican listener that he had found it necessary to balance his Radio America consumption with Radio Havana, ‘to be able to form a clearer idea of the Cuban situation’.Footnote 102
Far more prosaic, however, are the letters of Maceo's Cuban correspondents. There we see an assumed logic of everyday solidarity: a supposition of familiarity grounded in the new social codes of scarcity. ‘Even though you barely know me I'm practically a relative of yours’, began one 1963 letter from Santiago de Cuba. The author went on to remind Maceo of a social relationship that pivoted around his mother, on whom the doctor had apparently operated several years earlier. He also offered news of the gastroenteritis problem that plagued Cuba while wondering if there might be a ‘vaccine or something to prevent or cure this’. Finally, Maceo's correspondent closed by calling on God to deliver a ‘Cuba free of so many ills’, and asking the physician to write to him at the ‘house of Cheché’.Footnote 103 Information, presented and requested; degrees of separation, specified as grounds for reciprocity; and medications, openly and unabashedly sought: this was the social framework elaborated by Maceo's Cuban correspondents, in which he occupied a position of comparative privilege and, thus, obligation.
In order to parse the social codes of scarcity presented in Maceo's correspondence, it is perhaps useful to turn to the scholarly literature on solidarity and reciprocity in the Soviet Union, specifically as condensed in the untranslatable concept of blat. Alena Ledeneva defines blat as ‘a distinctive form of non-monetary exchange, a kind of barter based on personal relationships’.Footnote 104 She further points out that blat falls somewhere between a ‘commodity exchange’ and ‘gift giving’, premised not on the content of the trade but rather the fact of its occurrence: ‘Blat was thus not a relationship for the sake of exchange but an exchange for the sake of a relationship.’Footnote 105 In a context of general scarcity, access itself became an object of social value and, along with it, an abstracted quality, increasingly divorced from discrete items. Entangled, in turn, were the networks of giving and receiving, access and distribution that shaped daily life, often in a kind of alliance of citizens against the property invested in the state.Footnote 106 Not all blat relations, however, were born equal. Often, Ledeneva argues, ‘reciprocal exchange relationships’ could be ‘very asymmetrical, with one party being obliged to give much more than the other’.Footnote 107
Though comparatively undertheorised, solidarity and reciprocity have played an equally central role in revolutionary Cuban society, as embodied in the mutually compatible categories of ‘sociolismo’ (a word play replacing the ‘socia’ in ‘socialism’ with ‘socio’, a popular term for buddy or friend) and ‘compromiso’, or obligation. Per Lillian Guerra, official blowback against sociolismo seems to have intensified in the late 1960s, in the context of a crackdown against apparent vestiges of capitalist behaviour. In that moment, sociolismo drew particular concern as a vehicle of political corruption, namely in the ‘practice of providing black market goods or services to government employees in return for priority treatment or better rations’.Footnote 108 Anthropologist Mona Rosendahl, working on the period before the fall of the Soviet Union, found that the ‘social’ and ‘economic’ aspects of reciprocity continued to compose the fabric of social life in Cuba.Footnote 109 We know little, however, about the genesis and evolution of ‘sociolismo’ and ‘compromiso’ in the early years of the 1960s, when the evaporation of diplomatic relations with the United States first plunged Cuba into a full-fledged economy of scarcity. Yet we have a glimpse of that world in Maceo's Cuban correspondence, where his listeners collectively sketch a medical solidarity for revolutionary times.
In the Latin America Cold War, all minds were potential recruits in an ideological war of vast proportions. This was the assumption that drove massive investments, both in the US and in Cuba, in the machinery and programming of propaganda. Where CIA strategists and revolutionary officials proposed grand narratives of hemispheric (anti-)Communist collaboration, however, Maceo's audience presented something rather more mundane, even when dressed up in the trappings of political identification. In response to the health politics of ‘El Médico y Usted’, some Cubans offered up their bodies for Maceo's politicising consideration. Yet it was those same bodies, particularly on the island, that also articulated a new ethos of solidarity, averse to hyperbole and grounded in the terrain of everyday want.
The sudden disappearance of brand-name medications in early 1960s Cuba was far from a simple medical phenomenon. The alleged deterioration of public health, made vivid in widespread depictions of empty pharmacy shelves, quickly became fodder for political debates beyond Cuba's borders. In this arena, leftist solidarity activists squared off against the aging vestiges of McCarthyism; US pharmaceutical companies begrudgingly sought redemption in the Bay of Pigs negotiations; Cuban exile leaders decried the alleged misappropriation of the same; and MINSAP officials sought to bury the debate altogether.
Yet ordinary Cubans responded in more varied, often contradictory, ways to the same set of geopolitical circumstances. Some, particularly those accustomed to more extensive access before 1959, mourned the passing of an age of pharmaceutical plenty, while refusing to accept the Soviet substitutes imported in their place. Other Cubans, more invisible in the historical record than their indignant counterparts, undoubtedly welcomed the extension of public health into rural and previously underserved areas. Pharmaceutical scarcity helped to usher in a levelling effect of sorts, placing many Cubans on the same – increasingly impoverished, at least temporarily – playing field when it came to drug access. That in turn promoted new forms of revolutionary sociability, grounded in pragmatism and solidarity.
We can theorise about the same phenomenon from the vantage point of the 1990s, when economic catastrophe following the dissolution of the Soviet Union forced Cubans to resume health-seeking strategies of the desperate past, from an official repurposing of ‘alternative medicine’ to expanded black market traffic in drugs.Footnote 110 In the intervening decades, of course, many Cubans had learnt to live with generic drugs, and to use them enthusiastically and even prolifically, prompting more than a few complaints on the part of MINSAP officials. In fact, Cuban officials have become accustomed to blaming continued shortages, not only on the political impact of the US embargo, but also on the self-medication practices of ordinary Cubans.Footnote 111
This discursive framework – and the structural problems that sustain it – represent the direct inheritance of the therapeutic culture charted here, wherein politicisation has long been the norm. If public health continues to represent the shining achievement of the Cuban government, any shortcoming in this area necessarily raises questions about revolutionary rhetoric as a whole. Meanwhile, exile groups seize on news of drug shortage, not to mention the latest dengue or cholera epidemic, as telling evidence of political failure. In between, of course, remain the island Cubans forced to accommodate the ideological depictions of both groups, while scrambling to resolve their health needs, many in the diasporic tradition of Maceo's correspondents.Footnote 112 So what if we were to shift our gaze from the elite political squabbles waged in the language of health politics, and focus instead on the everyday practices of survival? There, we would inevitably find evidence of significant continuity – and ingenuity, too.