Cuban Health Care. Don Fitz
own record-keeping system. Beginning in 1964, policlínicos integrales, or comprehensive polyclinics, all with similar structures, were integrated into a nationwide medical system. Each serving a defined geographic area, the policlínicos integrales provided distinct points of entry into the medical system and vastly reduced the previous chaos of multiple independent providers. Although the policlinics had borrowed many ideas from Soviet bloc countries, they were more decentralized. In great measure, this was due to their independence from hospitals. Average Cubans came to hold the policlinics in high esteem because of their role in coordinating mass health campaigns.
Though the policlínicos integrales addressed the most serious internal problems of Cuban medicine, the sharp contrast between the mass care provided on the island and the dire situation of the rest of the world’s poor countries loomed large. The Cuban military carried out secret missions that were accompanied by doctors to support African uprisings in the early 1960s. The role of Cuban medical staff during its early forays into Africa is the subject of this book’s third chapter, “Cuba’s First Military Doctors.” Those doctors, who were often unaccustomed to dangerous field conditions, now had to perform under the stress of enemy fire. They gained considerable knowledge about treating diseases they had not previously known. Racial differences that had tormented Cuba before the revolution saw a strange twist of roles between doctors and soldiers aboard ships to Africa. By the end of the 1960s, Cuban doctors had had four very different African experiences: in Algeria, they had treated only civilians; in Zaire,4 the doctors had been disappointed by rebels who showed little enthusiasm for victory; in the Congo, they heard government proclamations which proved to be empty rhetoric; in Guinea Bissau, however, they had felt the satisfaction of working with a successful insurrectional movement with a strong commander and dedicated troops.
Inside Cuba, the innovations of the 1970s and 1980s relied heavily on what doctors had learned in the 1960s. Oddly enough, placing polyclinics in communities gave rise to an understanding of their limitations in providing genuine community health care. Chapter 4, “From Policlínicos Comunitarios to Family Doctors,” describes how the internal inconsistencies of policlínicos integrales led to their complete redesign and their reemergence as policlínicos comunitarios. It also describes how contradictions within the latter resulted in the appearance of the Family Doctor/Nurse program. Though the policlínicos integrales had carried out a herculean task in bringing together disconnected services into a unified health care system, they were still insufficiently connected to the communities they were intended to serve. The shift to policlínicos comunitarios preserved the concept of the clinic being linked to a defined geographic area but added a critical element: in addition to people going to clinics, health professionals would now visit patients in their homes.
Polyclinics were reorganized so that specialists working together in teams would make home visits. As this system went into effect, practitioners discovered that despite its improvements, specialist teams of doctors and nurses were covering an area so large that they did not know patients well enough to anticipate impending problems. Then the revolutionary idea arose of creating doctor-and-nurse teams who would specialize in community medicine. These teams would live and work in areas small enough for them to walk to patient homes and monitor a variety of health-related problems simultaneously. The practice of doctor-and-nurse teams becoming a part of the community began in 1984. A novel residency training program played an important role in helping medical professionals combine coping with the most frequent daily problems and recognizing which symptoms required referral to a polyclinic or hospital.
As Cuba transformed its health system, the gap increased between the level of care of its citizens and the languishing medical situation of the newly independent African countries. Chapter 5, “Cuban Doctors in Angola,” details campaigns in southern Africa in the 1970s and 1980s where doctors applied the knowledge gained during the medical missions of the 1960s to an enormously higher level of armed struggle. As Angola’s independence from Portugal approached in 1974, three factions emerged: the Popular Movement for the Liberation of Angola (MPLA), which represented the country’s only hope for autonomy, and two groups closely aligned with imperial powers. The medical situation was dire, since most doctors had fled Angola, with only fourteen remaining. After initially hesitating, Cuba answered Angola’s call for military and medical aid. Then, following a major intervention by South Africa, Cuba rushed its soldiers and doctors to the Angolan front. As in the campaigns of the 1960s, Cuban doctors learned how to treat battle wounds and tropical diseases they had not seen at home. Now, however, their efforts were open rather than secret and the number returning home with these experiences would be much larger.
Though it appeared that the fighting might end by 1976, South Africa continued to send troops and pro-Western Angolans increased their attacks. There was, however, a lull, and Cuban doctors focused on helping civilians, treating injured combatants, and protecting themselves. During this time, tens of thousands of Cuban medical staff, teachers, and construction workers went to Angola and to dozens of other African countries, and to Asia, Latin America, and the Caribbean. In Angola, the lines were drawn between the MPLA, with Cuban and Soviet support, versus South Africa with its Angolan allies and U.S. support. The fighting reached a peak during the period 1985–88, with Fidel Castro conceiving military maneuvers that cleverly outwitted the supporters of apartheid. When Cuba’s military left Angola in June 1991, its aid workers, including doctors, were forced to leave too, because otherwise they would have been brutally attacked by pro-Western Angolans.
More than a third of a million Cubans returned at the end of the Angolan wars, and they were jolted by what confronted them. One was the global HIV/AIDS epidemic to which Cuba was particularly vulnerable. Could the island’s medical system cope with it? Then, just when the country had modified its quarantine policy and established novel treatment approaches, another huge trial came with the December 1991 collapse of the Soviet Union. Previous medical challenges had been ones over which Cuba had a large degree of control because they either originated internally or were external events they chose to participate in. Chapter 6, “A Time of the Unexpected,” focuses on how a health system developed during three decades of revolution confronted powers outside Cuba threatening to shatter its foundations.
With the fall of the Eastern bloc, the island lost its subsidies from the USSR, a large majority of its imports including oil, and most of its market for exports. This “Special Period in the Time of Peace,” as it was called, affected people’s health directly. At the same time, it hindered the state’s ability to provide medical care as well as educate future professionals. Would Cuba be able to survive decreasing food supplies and shortcomings in daily hygiene and emergency care? As the AIDS crisis intensified globally, especially in southern Africa and the Caribbean, Cuban care delivery confronted its own homophobia, once again confirming that consciousness can become a material force. Rather than the positive form of consciousness of its own power being a material force in the liberation of the working class, consciousness in the form of prejudice proved to be a negative force by interfering with the quality of medical care for those with HIV/AIDS.
The tightening of the U.S. embargo caused Cubans to profoundly alter their daily lives, while the government, with great trepidation, began its own version of Lenin’s New Economic Policy (NEP). That is, Cuba decided to allow tightly supervised mini-capitalism within a context of highly expanded tourism. Whereas some Bolsheviks had used the slogan “Get Rich!” during the NEP, the Cuban policies during the Special Period were more in line with a slogan like “Survive!” Health care services became a priority for revenue from other economic spheres. This, along with the egalitarian structure of Cuba’s medical system, allowed the country not only to recover during the Special Period but even to improve medical indicators by the turn of the millennium. Along with direct care, medical institutions and research expanded.
At the same time, Cuba resumed its international aid programs, though in a variation that prioritized medical aid. In 1998, Hurricane Mitch slammed Central America, prompting a response from Cuba. That event set the stage for the biggest transformation thus