Cuban Health Care. Don Fitz

      PREFACE

      CUBA SHOWS THAT CHANGE IS CONSTANT

      When I first read Karl Marx as a teenager I questioned what socialism would look like and wondered why he did not spell it out as did so many utopians of his time. I knew socialists who explained that Marx avoided doing so because the process of struggle would lead to new social formations, which would then become the building blocks of post-capitalist societies. In the words of Ian Angus, “Fighting to limit the danger caused by capitalism today will help lay the basis for socialism tomorrow.”¹ However, hearing such explanations in my late teens still left me dubious. I wondered if “dialectical materialism” were nothing more than a way for socialists to camouflage their lack of clarity about the type of social organization to come. As I read more about the Paris Commune and especially the soviets of the Russian Revolution, I was able to grasp why no one can seriously make blueprints for a revolution’s outcome. Instead, one can only sketch the broad outlines of a new society, because those building it will complete the details.

      My role changed as years went by and I began explaining to others that, as a revolution copes with unforeseen problems, it must develop new solutions and incorporate them into social relationships in ways that could barely be imagined in the old society. One day my daughter Rebecca phoned after visiting Cuba to tell me that she’d heard of a medical school there that attracted students from all over the world. Soon she decided that she wanted to attend, and I gave her my encouragement. I became increasingly fascinated with Cuba’s medical system, which I discovered was at least as remarkable as the country’s agricultural innovations that I had heard so much about. Delving into Cuban medicine led me to realize that it beautifully demonstrates how fulfilling the goals of the 1959 revolution brought forth novel institutions which, interacting with forces both inside and outside Cuban society, led to innovations that could not have been conceived prior to the revolution.

      Cuba had three medical revolutions before 1959: the first (from 1790 to 1830) focused on smallpox vaccination and sanitation; the second (from 1898 to 1922) centered on immunization against yellow fever; the third (from 1925 to 1945) brought a heightened awareness of the relationship between poverty and disease. The goals of the third revolution were fulfilled only after 1959, as the new government realized that providing preventive medicine to rural as well as urban areas required reorganizing the delivery of care.² Chapter 1 of this book, “The Three Thousand Who Stayed,” describes the tasks of those Cuban doctors who did not emigrate to Florida or elsewhere but remained to expand medical services, build a unified health system, and redesign medical education as they learned the role of mass mobilization in effecting changes.

      At the time of the Cuban revolution, much of the world was well aware that the “actually existing socialism” in the USSR was no longer an inspirational force. As Michael Lebowitz writes, “Real socialism had not produced the new human beings who could build a better world.”³ The physician Ernesto “Che” Guevara was key in inspiring the Cuban revolution to recognize that socialism required the creation of the “new man,” for whom ethical motives prevailed over material ones. In the early 1960s, revolutionary doctors challenged the ideology and practice of the former neocolonial regime by extending medical care beyond the western urban center of Havana, which was predominantly white, to areas that were mainly rural, more black, and closer to Haiti in the eastern part of the island. They also planted the seeds of internationalism with the first medical mission to Algeria in 1963. The initial stage of medical transformation in Cuba, then, involved the expansion not just of care but of medical consciousness, which became a material force shaping the country’s health system.

      Overcoming the former system’s racist and classist discrimination required confronting the contradiction that egalitarian health care could not be attained within systems that were inherited from capitalism. The way that Cuba addressed the contradiction between the revolution’s anti-capitalist goals and the residual capitalist structures in the island is the topic of chapter 2, “The Birth of the Cuban Polyclinic.” Numerous clinics, or policlínicos, as they are called in Latin America, existed in Cuba alongside other caregiving