The director of the local polyclinic was also the chair of the Area Health Commission, which included the CDRs and other mass organizations. Thus the polyclinic was simultaneously linked to hospitals by sharing physicians and to the community through its central role in coordinating health campaigns.47 Vicente Navarro observes that Latin American scholars often attribute inadequate medical care in poor countries to a simple lack of resources. But the first decade of the Cuban Revolution shows that when limited resources are distributed equitably, medical miracles can happen. Similarly, it seems “unlikely that a redistribution of resources would have occurred without substantial redistribution of the decision-making power.”48 The keys to Cuba’s medical revolution were (a) dedication and work by all health care professionals; and (b) a well-guided structure, set forth by MINSAP; with (c) decentralized implementation of health campaigns by policlínicos integrals, in coordination with mass organizations.
LINGERING ISSUES
Despite the achievement of a unified medical system with a single point of patient entry via the decentralized policlínico integral, significant issues persisted after the revolution’s first decade. Most disturbing was that infant mortality continued to climb. This could have been due to improved recording of deaths, but an official Cuban source accepts the data as correct, attributing the rise to early neonatal death rates.49 Linda Whiteford and Lawrence Branch agree, noting that “since infant mortality reflects prenatal care and nutrition as well as conditions during and immediately following birth, it is not unusual to see such a pattern as a reflection of social upheaval.”50 Whatever the reason, infant deaths grew from thirty-seven (per thousand live births) in 1965 to forty in 1969.51
Another concern was that the fusion of centralization and decentralization was often more bumpy than hoped. Even though many revolutionary doctors took positions in MINSAP or as administrators of medical facilities, conflicts still surfaced between those charged with recreating the medical system and those whose daily work focused on care delivery.52 Sometimes contention was based on policy. Physician Julio López recalls: “Many doctors and administrators felt like polyclinics were for inferior doctors. This changed during 1965–67. There had to be an overall change since many worked at the polyclinics because they were required to and not because they wanted to.”53 Despite the new ideology proclaiming the importance of preventive medicine, doctors and other clinicians often continued to perceive health as the mere absence of disease.54 A change in attitudes did occur, largely through the education of the next generation of practitioners.
Discord also arose regarding the role of health care professionals in determining policy. Doctors tend to be autonomous, confident that their own method is the best. What happens when their approach diverges from official policy, the community, or their colleagues? There was widespread disagreement, for example, over parents who wished to “live-in” with a hospitalized child. Dr. Felipe Cárdenas described a father who had to walk three hours every day to see his son, who was hospitalized with gastroenteritis in Guantánamo province.55 Most doctors and nurses strongly opposed letting parents sleep in a child’s hospital room, fearing that they would be a nuisance. But Dr. Enzo Dueñas recalled his experience at Lenin Hospital in Holguín during a shortage of nurses: “We had to have mothers taking care of their children. Now, the mother is with the child in the hospital and is not upset.”56 Cárdenas agreed that “the mother is the person who knows the child best, such as when he last used the bathroom or vomited. She needs to be involved in the care.”57 When the government decided to implement the policy of live-in parents, it proved very popular and resulted in shorter hospital stays for children. In general, the government sided with parents and the community during such disputes.
The effort to recruit more doctors continued through the decade. Women, whose career choices had traditionally been limited to teaching and nursing, now flooded into Cuban medical schools, making up 50 percent of students by 1970.58 Government campaigns to boost medical school enrollment included personal appeals by Fidel, and by 1970 applications to medical school comprised 30 percent of all university applications.59
Nevertheless, the stress of medical school in Cuba during the 1960s was enough to cause almost half of students to drop out.60 One program to retain students created alumnos ayudantes (student helpers, or peer tutors). Dr. María Luísa Lima, who now teaches at the Latin American School of Medicine, began medical school in 1965, when she was seventeen. She explained that the ayudantes were those who had done well in basic sciences and were closely tutored by doctors, so they could help others through those courses. The ayudantes both expanded the reach of professors and were themselves potential new faculty.61
Despite these efforts, the country still faced a shortage of doctors in 1969. As Peter Bourne and others have acknowledged: “The departure of thousands of doctors severely hurt the ability in the short term to provide health care for all, a major commitment of the regime.”62 But could their absence simultaneously have enhanced Cuba’s ability to design its new medical system? I asked Cuban historian Hedelberto López how difficult it would have been to implement the changes of the 1960s, including the development of polyclinics, if the counterrevolutionary physicians had stayed. He replied, “Of course, the revolution in medicine would have been impossible if doctors had not fled the country. They would have disrupted everything.”63 Julia Sweig agrees that concerns over potential interference shaped revolutionary leaders’ outlook: “Despite worries about losses of skilled professionals, Cuban authorities preferred that those who wanted no part of the revolution leave the island.”64 In effect, the departure of half of Cuba’s doctors to Miami in the 1960s proved a double-edged sword: it cut into Cubans’ health care, depriving millions of desperately needed health services, as the other edge cut off the ability of obstructionists to disrupt the building of a new medical world.
Navarro notes that, by the end of the decade, the number of graduating physicians was greater than the number who had left the country.65 Although true, this overlooks Cuban population growth during the 1960s.66 The issue is not merely the absolute number of doctors, but the ratio of doctors to patients.
Another factor complicating estimation of changes in the doctor-to-patient ratio during the first decade of the revolution is that Cuban researchers retabulated the number of physicians leaving the island. In 2015 Dr. Francisco Rojas Ochoa documented that the claim that half the physicians left was “a mistake that has been very frequently repeated.”67 Historical records from MINSAP showed that 2772 of the 6,286 Cuban doctors who practiced medicine in January 1959 left during 1959–68. This means that 44.1 percent departed, a number that is a bit less than half.
Table 2.1 combines figures from Rojas Ochoa for total number of doctors and the number who left from 1959 to 1968, Capote Mir’s data for the number of medical students graduating annually, and information regarding Cuba’s annual population.68 It also projects the number departing Cuba during 1968–76 based on the average number of those who left during 1963–68 and an assumption of a 2 percent attrition rate of physicians (due to death, retirement or change of profession), which allows for an estimation of the number of physicians during 1969–76.
Table 2.1: Physicians and Population in Cuba, 1959–1976