Cuban Health Care. Don Fitz

rewards. Bound to secrecy, decades passed before they could share their stories.⁸¹ Yet the insights obtained by what they endured were essential for designing Cuban strategy, which is why Fidel grilled so many when they quietly arrived home.

      Before 1959, dedication to revolutionary medicine was expressed by students and doctors demanding full treatment for Cubans in poor urban and rural areas. This became the foundation for doctors volunteering for international missions during the 1960s. With the dawn of the 1970s, the question remained: Would sacrifices by the first doctors going to Africa lead to medical staff playing a key role in toppling a major racist government on that continent?

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      FROM POLICLÍNICOS COMUNITARIOS TO FAMILY MEDICINE

      The 1970s promised to be a difficult time for Cuba. Che Guevara, one of the one of the most inspiring leaders of the revolution, had been killed in October 1967. Furthermore, the decade began with the rabidly anti-communist Richard Nixon in the White House and with Cuba having somewhat chilly relations with both Moscow and Beijing. Finally, though Fidel Castro had hoped that the island would diversify its economy, Leonid Brezhnev made it clear that Cuba would continue to be a sugar monoproducer for the Eastern Bloc. Resigned to this fate, the revolutionary government announced that 1970 would be the year of the greatest sugar harvest in history. It set the production goal at ten million tons, which was almost double the 1968 harvest. Yet real production fell short of expectations, and workers taking time off from their jobs to work in the cane fields seriously damaged the economy. As a result, Cubans throughout the country participated in an intense discussion of the revolutionary process.

      Since redesign of the medical system occurred at the same time, I asked Dr. Julio López Benítez if that transformation had been part of the broad process of self-examination. He responded negatively:

      The failure of the sugar harvest and the change in polyclinics were completely different. We never sacrificed health care for other things. It was a moral mission. It was not compulsory for anyone to cut sugarcane. Doctors were not good at cutting cane, so, the ones who did it went back to practicing medicine to free others to cut cane.¹

      Yet even if the reorganization of medical clinics had little to do with Cuba’s self-critique in response to the sugar harvest failure, the changes in the health system were highly significant ones. López recalls:

      The change was patients going to clinics versus clinics going to the patient. The policlínico integral was a clinic of specialties, but they did not visit the community. The policlínico comunitario was based on visiting people in their communities.

       FROM POLICLÍNICOS INTEGRALES TO POLICLÍNICOS COMUNITARIOS

      Policlínicos integrales had begun in 1964, when Cuban medicine became strong enough to move beyond responding to the inadequacies of pre-revolutionary medicine and initiate a redesign of the system. Now, as medical planners became aware of problems with the first clinics, they laid the groundwork for the new policlínicos comunitarios. Though 1974 is given as the official date of the transformation, ideas for the new approach had appeared as early as 1969 and had existed in germinal form from the earliest days of medical revolution.²

      The original policlínicos integrales had made tremendous accomplishments. They pulled a disparate array of care providers together. For the first time, there was a single point of entry into a health system, that kept coherent records for every patient. They incorporated millions of Cubans into the health system who had never even seen a doctor before. They also developed a nationwide system of preventive and curative care while providing a systematic approach to confronting a range of diseases.

      Nevertheless, problems with policlínicos integrales emerged within five years of their creation. All basic care had fallen on their shoulders. Their duties had expanded so rapidly and become so complex that they found it difficult to provide all the services they were assigned.³ Adding to the complexity was the continued separation of specialists. Physicians rarely worked together as a team. This meant that patients were passed from one specialist to another, not knowing who they would see during a follow-up visit.