Reviewed Book
State of Health: Pleasure and Politics in Venezuelan Health Care under Chávez. Amy Cooper, Oakland: University of California Press, 2019, 216 pp.
State of Health: Pleasure and Politics in Venezuelan Health Care under Chávez is an accessible, eminently teachable book set in Venezuela at the height of the Bolivarian revolution. It was 2006–2009, a time of widespread hope and optimism. High prices for oil, Venezuela’s major export, allowed then-President Hugo Chávez to expand social programs and mitigate inequality. One such program, Barrio Adentro (Inside the Neighborhood), brought biomedical services and treatment to underserved communities. Barrio Adentro shared some of the philosophical tenets of Latin American social medicine. It aimed to rectify a system of privatized, curative medical services that failed to treat the poor, ignored the social determinants of disease, exacerbated inequality, and empowered a self-interested class of professional urban elites. It offered community-based primary care and participatory programs as a way to provide greater equity, coverage, and access. Unlike similar programs in Costa Rica, Chile, or Nicaragua, Barrio Adentro was staffed largely by thousands of Cuban doctors sent to Venezuela as part of a massive oil-for-doctors swap. They were assisted by a cadre of minimally trained but enthusiastic community volunteers and Chávez supporters.
Cooper worked alongside the community health worker chavistas who loved Barrio Adentro. Her opening chapters capture their enthusiasm as they danced, partied, and socialized in the name of therapy. Many had access to decent medical care for the first time in their lives. They enjoyed feeling worthy of the state’s attention. Participating in Barrio Adentro’s fun, healthy activities, such as bailoterapia (dance therapy), made them physically and politically stronger. When the state constructed its signature octagonal brick Barrio Adentro clinics in their neighborhoods, they felt included and proud. They appreciated the Cuban doctors’ intimate, egalitarian interactions with them, in contrast to the snobbish, discriminatory attitudes of other Venezuelan doctors. They credited Barrio Adentro with disrupting long-standing class hierarchies and acknowledging their human dignity.
State of Health is organized around the argument that government-sponsored medicine can be a source of pleasure and satisfaction. In contrast to many Latin American medical ethnographies that document the distrust and suffering wrought by state-sponsored medicine, Cooper proposes that “joy, excitement, and satisfaction were central to people’s experiences of Barrio Adentro” (p. 3). The idea that medical care can be pleasurable is powerful in its simplicity. Imagine if state-sponsored medical care were delivered with warmth, caring, and intimacy by a government committed to doing its best to guarantee health for millions of citizens? What if free, high-quality medical services were available in every neighborhood? The Barrio Adentro program allowed its beneficiaries to feel newly visible and valued. Cooper argues that such a program not only has the power to improve health outcomes (which are less her concern), but fundamentally to “transform people’s sense of themselves” (p. 22). This is, perhaps, the lesson Cooper most wishes to convey—that a better world is possible.
Barrio Adentro was good at offering local, compassionate medical care for people of modest means, but its successes were also attributable to what it did not do. Cooper explains that Barrio Adentro did not attempt to establish a monopoly on health care or authoritative medical knowledge. The state did not attempt to displace popular saints or religious healers, non-biomedical practitioners, or other forms of medical pluralism. Barrio Adentro managed to avoid some of the criticisms lodged against other socialized medical programs, in part because it took a hands-off approach to the heavy-handed public health measures enacted in Cuba, China, and elsewhere. Barrio Adentro workers did not engage in epidemiological surveillance, not did they undertake massive public sanitation or mass vaccination campaigns. The program did not collect population statistics or even keep patient charts (p. 96). Cooper mentions these facts but leaves the reader to ponder what they might mean. Was Barrio Adentro part of a long-term strategy to improve public health or merely a mechanism of political expediency? Did Barrio Adentro resonate only or primarily with Chávez’s supporters?
A sense of disillusionment creeps into later chapters, as Cooper accompanies the volunteer health workers on their outreach efforts. In one case, volunteers fan out across the neighborhood, going house to house to identify people with disabilities. One passerby dismisses them as chavistas. Cooper shows how the campaign challenged the volunteers’ “sense of moral and political certitude” (p. 116). This led me to wonder about the extent to which Barrio Adentro is perceived as a political or polarizing project, but Cooper travels with the chavistas and perhaps for this reason does not engage the arguments of Barrio Adentro’s detractors or those of the “right-wing opposition” (p. 151). Nonetheless the structure of the book steers us all—Barrio Adentro community health volunteers, author, and readers—toward gradual disappointment. In a later example, Cooper follows community health volunteers as they try to tackle the challenge of homelessness. The volunteers’ initial optimism begins to sour when some homeless people refuse their offers of help. Cooper explains that the volunteers were forced to confront the “limits of a model of citizenship that required people to demarginalize themselves” (p. 143). How, we all wonder, would the Bolivarian revolution deal with those who—for a variety of reasons—resisted its charms? The patina of pleasure begins to wear thin.
Cooper could not have known when she started her research that the Venezuelan state was headed for collapse. The country now faces a devastating economic and humanitarian crisis, with millions of refugees fleeing their homes to avoid starvation. As she finished writing the book in 2018, she addressed the situation, which was by then quite dire. Some clinics were still open, she said, and Barrio Adentro “remained a government priority” (p. 151). Yet Cooper does not allow the crisis to derail her fundamental argument that “particular forms of government medicine can produce pleasure and empowerment by making people feel recognized, cared for, and valued” (p. 153). Her point is well taken, at a time when many medical anthropologists may feel too jaded to embrace revolutionary postures. Revolutions can offer valuable lessons, Cooper insists, even when they fail. By putting pleasure at the center of her analysis, Cooper sets out to offer a corrective to the critics and pessimists in medical anthropology. Given the calamity now unfolding in Venezuela, however, the trope of “pleasure” feels like an uneasy fit with history.