For the years 1959–1968, the number of doctors (A) and the number of doctors who left (B) is from Rojas Ochoa. For all years, the number of doctors who graduated is from Capote Mir. For the years 1969–1976, the number of doctors who left is estimated as 196 (average of doctors who left during 1963–1968) and the number of doctors in Cuba (A) is estimated as the number of doctors during the previous year minus the number of doctors who left (B) plus the number of doctors who graduated (C) minus a 2% attrition of doctors (from death, retirement, or change of profession).
SOURCE: Rojas Ochoa, “The Number of Physicians in Cuba, 1959–1968”; Navarro, “Health, Health Services, and Health Planning in Cuba”; Capote Mir, La Evolución de los Servicios de Salud y la Estructura Socioeconómica en Cuba; http://populstat.info.
Including data for the annual rate of population increase in the table provides a much better calculation of when Cuba recovered from the loss of physicians. The 6,239 doctors in Cuba by 1963 almost matched the 6,286 at the beginning of 1959. But the population increase meant that the doctor-to-patient ratio was still below the 1959 level. The 1959 ratio of .91 physicians per 1,000 people was probably attained early in 1970. This suggests that recovery of the pre-revolutionary doctor-to-patient ratio was most likely reached a couple of years earlier than Danielson’s estimate of 1972.67
Whichever date is used, Cuba’s medical coordinators were expecting a future decrease in the need for doctors. By the early 1970s, they were both preparing a quota to reduce the medical acceptance rate to 20 percent of all university applicants and encouraging medical students to transfer into other programs.68 This reflected the integration of divergent aspects of medicine as a system.
By the end of the revolution’s first decade, the policlínicos integrales had taken a qualitative leap from expanding access to medical attention to conceiving and implementing a novel approach to health care as a whole. Through their practice, the clinics showed that it was possible to overcome the deficiencies of capitalist medicine and develop the collective consciousness required for a new system to take root.
Many lessons of the first decade of Cuban medicine had been anticipated before the revolution confirmed them. It became clear that health care could only be improved if a country simultaneously addressed necessities such as food, housing, and education; medical campaigns must be based on mass participation; obstructive institutions such as mutualism could be overcome by creating a better method of care delivery before abolishing the old one; an institution could be improved by undertaking two contradictory processes simultaneously (such as centralizing and decentralizing medicine); and, despite the short-term damage of almost three thousand doctors leaving, the long-term renovation of medicine was enhanced by their absence.
These lessons laid the foundations for the unique Cuban network of clinics. Defined geographic areas offered single points of patient entry into a system that combined preventive care with treatment. Through decentralized control of their own functions, the Cuban clinics quickly gained an equal footing with hospitals.
Still, as the 1970s began, many unanswered questions remained. Could reallocation of resources continue to improve health even as Cuba remained poor and blockaded? Would the system of policlínicos integrales be able to reduce infant mortality? With the ratio of doctors to population approaching pre-1959 levels, would fewer students be admitted to medical school, or would unforeseen circumstances require a continued expansion of enrollment? Would policlínicos integrales continue as they existed during the period 1964 to 1969, or would other structures and services replace or alter them?
CUBA’S FIRST MILITARY DOCTORS
Cuba’s deployment of military doctors to Africa in the 1960s was a secret, known only at the highest level of government. In fact, accounts of these hidden efforts were not published until the beginning of the twenty-first century. Many forces during that decade pulled Cuba toward struggles in sub-Saharan Africa. First was the mushrooming of popular movements across the globe. The U.S. civil rights movement was joined by millions opposing the war in Vietnam. Zaire won independence from Belgium in June 1960, and the popular Patrice Lumumba became its first prime minister. After leading the National Liberation Front to victory over French domination in 1962, Ahmed Ben Bella was elected as the first president of Algeria. In August 1966, Mao Zedong launched the Great Proletarian Cultural Revolution to thwart the growth of capitalism in China. May 1968 saw a huge left upsurge in France that went beyond the Communist Party.
The second force pushing Cuba’s foreign policy was U.S. imperialism. Two decades earlier, the United States experimented with nuclear extermination in Hiroshima and Nagasaki. In the previous decade, the United States had slaughtered roughly 20 percent of the population of North Korea and the Central Intelligence Agency (CIA) engineered the overthrow of the progressive Jacobo Arbenz government in Guatemala. Fresh on the mind of Cubans was the connivance of John and Bobby Kennedy in the 1961 Bay of Pigs invasion and the 1962 missile crisis. At around the same time as the CIA was strategizing about how to poison Lumumba, it was also launching its efforts to kill Fidel Castro.1 Asserting dominion over Latin America, Lyndon Johnson invaded the Dominican Republic in 1965.
In the meantime, the Soviet Union was not acting like a reliable ally. The USSR had not sent troops to fight in Korea and did not do so in Vietnam, even after the massive U.S. buildup following the 1964 Gulf of Tonkin incident. Nikita Khrushchev had settled the missile crisis without bothering to consult Fidel, and Khrushchev’s successor, Leonid Brezhnev, made clear that Cuba should accept the subordinate status of being a sugar producer for the Soviet bloc.
Furthermore, Latin American communist parties did not take kindly to Cuba’s “foco theory” of revolution. Those parties centered on urban working-class movements while the Cuban leadership looked to a dedicated vanguard in the countryside, garnering support through armed struggle. As Che Guevara explained, “A small group of men who are determined, supported by the people, and not afraid of death … can overcome a regular army. This was the lesson of the Cuban Revolution.”2 Unlike countries in Latin America, those in Africa did not have established communist parties hostile to guerrilla efforts.3 With at least a third of Cubans being of African heritage, Cuban leaders felt beckoned from across the Atlantic.
HOPE MEETS REALITY IN AFRICA
Despite efforts by the United States to isolate Cuba, by 1964 the island had embassies in the African countries of Algeria, Egypt, Ghana, Guinea, Mali, Morocco, and Tanzania. In January 1961, Lumumba was murdered by allies of Moise Tshombe, and in 1964 followers of Lumumba, the Simbas (lions), began a guerrilla struggle that had strong revolutionary potential and routed government forces.4
In December 1964, Che began a three-month trek through Algeria, Ghana, the Congo, Guinea, Mali, Benin, Tanzania, and Egypt. Planning to lead an African revolutionary project himself, Che went to develop strategies and agreements with liberation movements. During his January 1965 meeting with leaders in Tanzania, Che emphasized the lessons from the Simba rebellion and proposed Zaire as the location for centralized training. African leaders disagreed with him, each wanting training camps in their own country.5
The more Che came to know the heads of several organizations, the more skeptical he became. He observed that they “live comfortably in hotels and have turned rebellion into a profession, at times lucrative.”6 Once on the battlefield, his doubts were confirmed:
Che had been told that he would find several thousand well-armed Simbas, eager to fight. There were, in fact, some 1,000 to 1,500 widely dispersed rebels who had no idea how to maintain their modern weapons…. They lacked a unified command.
The scouting teams … brought back grim reports from the fronts: idle rebels who … did not know how to use their firearms and showed no inclination to attack or to prepare to defend themselves. Everywhere chaos,