When he was eighty-seven years old, Dr. José Gilberto Fleites Batista recalled the revolutionary epoch to Candace Wolf: “Before the Revolution, there were big hospitals only in the capital, in big cities, but not in rural areas, in the countryside and in the Sierra.”10 The physician-to-inhabitant ratio was 1 to 248 in Havana and 1 to 2,608 in the eastern provinces. Medical education was largely theoretical, offering little hands-on experience. There were not enough teaching hospitals, and education was oriented to making money. Dr. Julio López Benítez completed his specialty in pediatric nephrology in 1960, shortly after Havana’s medical school reopened following the revolution. He remembers that “some were in medicine as a business. In Calixto-García Hospital, three hundred professors charged their patients.”11
The principal health care task during the first five years of the revolution was creating services. In 1959, priority went to hospital construction. By 1963, the revolutionary government had established 122 rural centers and forty-two rural hospitals, with 1,155 beds, 322 doctors, and 49 dentists. In order to accomplish the primary task, it was necessary to bring cohesion to the disjointed medical system. On January 22, 1960, Law 717 created the Ministerio de Salud Pública (Ministry of Public Health, or MINSAP) and Law 723 established Rural Health Services.12 As MINSAP consolidated and extended state services, it had an ambivalent attitude toward mutualism, which was based on privately owned services. Nevertheless, it would have been a serious blunder to attempt to abolish mutualist clinics during the upheavals following the revolution. Widespread mutualist services provided a cushion for the effects of doctors’ abandoning private practice as they left the island. This lessened the pressure on public services as they expanded and reorganized. As time went by, contradictions within mutualism intensified as its members realized that its services were inconsistent and health care could be obtained at no cost through state clinics. Instead of attacking the system, MINSAP developed a 1963 report describing how to consolidate and rationalize mutualism.
Revolutionary changes cannot be made by legislative decree alone. They require the type of mobilization campaigns that swept Cuba. There were efforts to end unemployment, increase the salary of 350,000 sugarcane workers, implement a pension system, end discrimination in access to beaches, build 10,000 new classrooms, and send 3,000 teachers to rural areas. A new rationing system ensured equitable distribution of food and consumer goods. Pointing to the need for preventive care, it focused on pregnant women, undernourished infants, and children with chronic illnesses.
The literacy campaign was the best known of these mobilization efforts. In 1953, 23.6 percent of the Cuban population was illiterate (41.7 percent in rural areas). In a single year, more than 707,000 people were taught to read and write. Within a few years, the campaign brought illiteracy down to zero. These early campaigns were launched at a time when Batista supporters still roamed the countryside. Fleites recalls: “Thousands of students went into the countryside to teach the people how to read and write. It was a beautiful campaign, but it came with a harsh price. The counterrevolutionaries assassinated some of these idealistic students.”
Medical and education campaigns were thus essential components of a much broader social transformation. In 1960, Law 723 required medical graduates to spend a year in rural service. By 1963, 1,500 doctors and fifty dentists had served in rural Cuba. In February 1960, the first group of 357 doctors went to areas where there had previously been no doctors. Many had to stay in the homes of campesinos, peasant farmers. They found people so much in need that initially they could provide only curative, rather than preventive, medicine. Efforts to implement preventive medicine went forward, however, and by the end of 1960 doctors had given twice as many DPT vaccines (for diphtheria, pertussis, and tetanus) as had been provided during the five years previous to the revolution.
The anti-malaria campaign began in 1961. The next year saw the first national campaign to vaccinate against polio, a clean water campaign, gastroenteritis control, and a major program to improve medical staff training. There was even an anti-rabies campaign for street dogs. MINSAP developed fifteen goals for the years 1962 to 1965 that focused on “infant mortality, vaccinations, pregnant women, transmissible diseases, infectious diseases, preventive medicine, worker health, and goals for administering these and recording statistics systematically.”13 Simultaneously, it improved plans for hurricane disaster relief and cut the price of eyeglasses and medications by 50 percent.
NEW DOCTORS, NEW EDUCATION
The wave of revolutionary fervor sweeping through the island took a distinctive form in medical school education. Batista had responded to protests by closing the University of Havana, including its medical school, from 1957 to 1958. When the school reopened in 1959, there was a new approach to education. Dr. Enzo Dueñas Gómez had a specialty in pediatric neonatology and was in the first class to graduate after the revolution. He told me how, following the revolution, “the culture of teaching changed. In the classical medical education before 1959, students could go to class if they felt like it and they received little practical experience. This is why they could skip class. After the revolution, students had to get to class for practical experience and go to rural areas.”14
Dr. Felipe Cárdenas Gonzáles graduated in 1962 with a specialty in pediatric cardiac surgery. He observed a new way of recruiting students: “We created a new culture of revolutionary medicine. The professors of medicine who stayed went out looking for good students who could become doctors.”15 Inspired by free tuition, many of the new students came from working-class backgrounds. Once enrolled, they found a plethora of revolutionary organizations. Incoming students were required to take classes focusing on rural and tropical medicine as well as preclinical sciences. For the first time, the medical school taught biochemistry. Hospital internships were made a prerequisite for graduation. Before 1959, a short course on social medicine was offered in the last year, after students had already formed their clinical perspectives. After 1959, social medicine was included in each year’s curriculum.
Student and government involvement was reforming old systems of faculty control over education. On July 29, 1960, the medical faculty was evenly divided when it met to discuss a proposed Superior Governing Board for the university. A month later, in August 1960, only nineteen professors remained in the medical school—the only one in Cuba. They formed a nucleus of young, competent doctors who took on monumental responsibilities to sustain the medical training system.
To accommodate more students, the number of teaching hospitals increased from four to seven, and new medical schools opened in Las Villas and Santiago de Cuba. Students and doctors adjusted to the strenuous demands of the revolution. “No one rested during those years,” Cárdenas remembers. “We worked as hard as we needed to. I did guardia for 24 hours and then I did surgery and then I had to study and write a work-up for new students.” MINSAP contracted medical instructors from twenty-six countries: 120 arrived in 1964 and 92 in 1965. Most came from Argentina, Mexico, and Ecuador. Others were from Bulgaria, the Soviet Union, Czechoslovakia, and Hungary.
Ross Danielson writes: “Other responses by the university to the flight of physicians included a reduction of the pre-internship period from 6 to 4 years, and from 4 to 3 years in dentistry.”16 I asked four physicians—Dueñas, López Benítez, Cárdenas, and Mena—how the shortened period affected teaching, and all denied that such a process had happened. López Benítez was emphatic: “I participated in developing the curriculum for fourteen educational plans, beginning in 1963, and we never had fewer than six years of study.”17 Though shortening the required period of medical study might seem like an efficient crash course to train more doctors, it appears unlikely that it was ever done. The first five years of revolution had transformed the culture of medicine and provided care to those who had never received it, but doctor-to-patient ratios had not improved.
“WHEREVER THE REVOLUTION NEEDS ME”
The new government, and particularly Fidel, received a tremendous response to calls for revolutionary commitments. Fleites’s enthusiasm was born from dislike of the Batista regime:
I sympathized with the revolutionaries, but I lived outside of that. My world consisted of operating on my patients and taking care of my family. The only time that the revolution and