State of Health: Pleasure and Politics in Venezuelan Health Care under Chavez by Amy Cooper (review)

In State of Health, anthropologist Amy Cooper takes readers back to a time in the not-so-distant past, when the government of Hugo Chávez enacted a series of public sector reforms aimed at improving the lives of Venezuela's urban poor. Perhaps most notable among these is Barrio Adentro (Inside the Barrio). Adapted from a pillar of Cuba's revolutionary health system, Barrio Adentro moved physicians (many of them Cuban) and clinics into the neighborhoods where people lived. Cooper argues that the program not only parleyed Venezuela's oil wealth into free, accessible primary care available for the first time in many residents' lives but also became a source of "pleasure" for poor urban Venezuelans

By exploring the many forms such pleasure took in a Caracas neighborhood, Cooper aims to highlight the "extramedical meanings of government medicine" (p. 22). In chapters on clinical encounters, medical pluralism, community health work, and elder care, Cooper amasses evidence to show that at its zenith in the late 2000s, Barrio Adentro's clients reported improved physical well being as well as feelings of empowerment, inclusion, and even joy. Importantly, Cooper claims, pleasure was not a fleeting phenomenon. The sense of inclusion and affection created by, for example, the warmth of a doctor's touch, deepened and sustained the impact of medical services. In many ways, it seems that pleasures, rather than measurable health outcomes, were the major results of the program.

Consider the example of Magdalena, a community member profiled in Chapter 5. After her first encounter with a doctor in her new local clinic, she experienced what she called an "awakening" (p. 106). The pleasure she derived from that clinical visit inspired her to begin volunteering in her local Health Committee (Health Committees were another manifestation of the Chávez regime's version of participatory democracy). Magdalena is not alone. Cooper meets many residents—most of them avowed Chávez supporters—whose experiences of being treated with dignity in clinics caused them to look for ways uplift the dignity of their neighbors.

Of course, infectious pleasure does have its limits. In a later chapter, Cooper documents the rise and fall of Misión Negra Hipólita, a program designed to aid at-risk groups including the homeless and drug addicts. The mission was not successful, in part because these at-risk individuals, known as indigentes, failed to show up, to participate, to actively seek out care. It is here that Cooper does a particularly effective job of using ethnography to unsettle familiar narratives. In critical studies of public health (and of development more broadly), "participation" has long been viewed with suspicion, partly because it has frequently been tethered to the idea that those who refuse to volunteer, or to self-motivate, can be dismissed as unworthy of the privileges of citizenship. The urban poor are increasingly called upon to prove their deservingness of services, from food aid to medical care. Participation, in other words, has been rightly seen in some places as an outgrowth of neoliberal austerity. In Venezuela, participation had a different valence. Chávez and those who supported his programs viewed it as a tool for un-doing austerity, not entrenching it.

Readers will be aware that in the years since Chávez's death, pleasure has been in short supply in Venezuela. In her conclusion, however, Cooper forcefully argues that the excitement and energy she documented a decade ago were no anomaly. While she is clear-eyed about the failings of Chávez's successor, Nicolas Maduro, to deal with the collapse of the petroleum economy—as well as the ongoing efforts of embittered elites to undermine the Bolivarian project)—she suggests that even relatively short periods of collective pleasure have much to teach the rest of the world. Readers who have watched Venezuela descend into violence, starvation, and desperation might be pessimistic about the...