This work would never have been completed without the continued support of two people close to me. The decision of my daughter, Rebecca Vera Fitz, to go to medical school in Cuba altered the direction of my life. As I became intrigued with Cuban medicine, she encouraged me to make trips to the island and introduced me to several of her ELAM classmates. She also guided me to sites in Cuba that I never knew existed and sent many photos, all the while providing me with insights into Cuban culture and translating countless interviews, conversations, and correspondence.
As we learned about the Cuban revolution’s extraordinary accomplishments, my wife, Barbara Chicherio, and I discussed every observation either of us had. She aided me in conceptualizing how what happens in Cuba fits into a global environmental framework and encouraged me in my efforts to give voice to the island’s achievements. She also read and edited every article before publication and generously tolerated my neglect of social obligations.
THE THREE THOUSAND WHO STAYED
Stories of Cuban medical accomplishments often note that half of the country’s roughly six thousand doctors had left within a few years of the revolution. But just as professionals were forsaking their homeland en masse for the comforts of Miami, over three thousand doctors chose to stay. Why did they remain? More important, with the number of patients per doctor now almost doubled, how did they face the daunting task of transforming medicine? In addition to treating patients, their goals included expanding medical care to rural regions; increasing medical education to replace doctors who had left; making care preventive, community-oriented, and focused on tropical diseases; and redesigning a fractured and non-cohesive health system. Exploring changes during this transformative period in Cuban health care requires examining sources available in Cuba, as well as studying oral histories of Cuban physicians who lived during the revolution.
Before 1959, Cuba experienced three medical revolutions. Early “care” had been primitive. Despite the rhetoric of the Spanish invaders, there is no evidence that they brought techniques superior to that of the native Siboney and African folk healers.1 The first medical revolution (1790–1830) occurred amid brutality against slaves—an early “safety device” being overseers’ use of machetes to cut off the hands of slaves caught in rollers. Such events were not uncommon among those forced to work 20 hours per day. The revolution was led by Tomás Romay y Chacón (1764–1849), who introduced smallpox vaccination to Cuba, promoted public sanitation, and advocated medical treatment for slaves. Romay provided Cuban practitioners with an intellectual alternative to blind adherence to Spanish traditions.
The second medical revolution (1898–1922) followed a wave of Cuban doctors deserting their patients, as would happen again following the 1959 upheaval. At this earlier time, doctors fled the countryside to the safety of the cities, during the country’s two wars for independence (1868–1878 and 1895–1898). In their absence, disease, already rampant, ravaged the island. Of the 200,000 troops Spain sent to Cuba during the second war, 704 died in battle, 8,164 died of wounds, and 53,000 perished from disease, the most virulent killer being yellow fever, which claimed 13,000 lives. Though Carlos J. Finlay, a leader of the second medical revolution, had discovered the mechanism for the transmission of yellow fever as early as 1881, his research was ridiculed by medical professionals in Cuba, Spain, and the United States, and his findings were not implemented until 1900. A year later, Cuba was free of the disease. Along with the discovery of mosquitos as vectors for malaria and yellow fever, the second medical revolution was known for its emphasis on microbiology and immunology. As Ross Danielson summarizes in his history of Cuban medicine: “The second medical revolution was the completion of the first. Scientific method, gaining superiority as an intellectual device in the first period, yielded convincing practical technology only in the second.”2
The third medical revolution (1925–1945) was characterized less by new discoveries than heightened awareness. A split within the medical community widened as it became increasingly clear that any resolution of Cuba’s medical problems would require focusing on the needs of the rural population, preventive medicine through inexpensive services, and application of new knowledge of tropical medicine and parasitology.3 It was during this period, in 1925, that the country’s first national physicians’ organization appeared, the Cuban Medical Federation (FMC). That year also saw the founding of the Cuban Confederation of Workers and the Cuban Communist Party (CCP).4
Within four years, the FMC saw the formation of two internal political organizations: Renovación, which pushed for higher physician wages and better university training, and Unión Federativa (UF), which represented doctors in larger private medical organizations. In 1932 Renovación split into two further factions, Reformista and Ala Izquierda (Left Wing). By 1938, the FMC platform called for “pharmaceutical controls, workers’ accident protection, a minimum wage scale for physicians, prohibition of multiple positions, institutionalization of the sanitary career, improved hospitals, school health, sanitary provisions for the poor … [and] a physicians’ retirement plan.”5 Though its program reflected the views of Ala Izquierda, the FMC’s leadership remained under the control of the more conservative UF. Increased factionalism produced another, more leftist party, Acción Inmediata (AcIn), and a right-wing party, Ortodoxos, which called for dropping the demand that doctors not hold multiple positions (which made some rich and others under- or unemployed).6
Divisions among doctors intensified. AcIn won leadership of the Havana Medical College in 1941, but this leftist victory was reversed when a thousand doctors came to vote in 1942. That same year, however, AcIn won national leadership in the FMC, and in 1943 won again in the Havana Medical College. CCP members held leadership positions in the FMC from 1943 until the 1959 revolution. In 1951, doctors repeated calls for better organization of hospitals, minimum salaries, regulation of specialties, and modern medical standards. Above all, a deep concern for the lack of adequate rural health care defined the third medical revolution.
The three medical revolutions saw “mutualism” grow from a minor footnote to a major chapter in Cuban health care. Cuban historians describe mutualism as “a form of self-financed assistance” whereby a monthly payment covered treatment, hospitalization, and medications.7 The first mutualist plan was offered four hundred years before the revolution when, in 1559, a Spanish physician proposed a plan for medical care in exchange for a regular fee. Over the centuries, mutualism grew into contradictory subgroupings catering to Spanish immigrants, commercial associations, or unionized workers. Private fee-for-service care existed at the same time. A common complaint was that mutualist doctors would recommend private doctors for services not covered by the mutualist plan; then the two physicians would split the fees. Nevertheless, mutualist clinics fostered a collective attitude toward medical work, which would become critical after the 1959 revolution. Alongside mutualism and fee-for-service care was the state medical system, which provided limited care to the poor. On the eve of the 1959 revolution there were abundant, overlapping medical systems in the cities but rife negligence in rural Cuba. Of 456 health institutions during 1956, 42.8 percent were private or mutualist. Of these, 52 percent were in Havana.
MEDICAL CARE TRANSFORMED
Ten years after the revolution, Fidel Castro described the enormity of the health care problems that confronted Cuba in January 1959:
The absence of a national public health plan; semi-official and private services that were better than those provided by the government; an orientation toward curative medicine; abandonment of rural and some urban areas; individual medicine; mercantilism; competition between private services; administrative centralization with a public unaware of treatments that could benefit them.8
In addition, there was no reliable data on health indicators, an insufficient number of doctors and dentists being trained, and severe underfunding for the few existing research facilities. The pharmacy industry was 70 percent foreign-controlled and created many products lacking treatment value. Only 10 percent of children were covered by specialized