Cuban Health Care. Don Fitz
rich surgeon,” Dueñas pointed out. “He was very charismatic, with no children but a movie star lover. He was the first to give up his private practice and donated his clinic to the revolution so that it could be used for teaching.” “Dr. José Resno Albara renounced his millions of dollars and helped found the new revolutionary medicine,” López Benítez added. “Some doctors supported the revolution after it happened, but some had been revolutionaries.” I asked, “Does this mean that you could not know before 1959 who would help and who would not?”—and heard an emphatic “Yes!”
Although it would be an overstatement to imply that there was no relationship between pre- and post-revolution attitudes of doctors, it would likewise be an overstatement to suggest that actions before 1959 could always predict a doctor’s loyalties afterward. Certainly some who were enthralled by the July 26 Movement became dismayed once they saw that the revolution actually implemented its ideas (rather than abandoning them, as in so many other successful Latin American revolutions). Conversely, many who had initially remained aloof from the struggle—perhaps believing that Cuba could never undergo a genuine transformation—later threw themselves into the struggle once underway. The defining contrast between the doctors who stayed and those who left was their attitude toward revolution as it actually took shape: whether they were enraptured or repulsed by the changes unfolding before them.
RACE AND THE MEDICAL REVOLUTION
Cubans of African descent were concentrated in the rural eastern part of the island, which is closer to Haiti and where Santiago de Cuba is the largest city. It is hard to overstate the importance of the 1959 revolution, which ushered in the most significant changes in the lives of black Cubans since the abolition of slavery. Calls to serve in rural areas and eastern provinces were equivalent to appeals to fight structural racism. These shifts inspired López Benítez to volunteer for service: “I was doing genetic research as a pediatrician when they told me that children were dying in Santiago and that I needed to get there; so I went to Santiago in the early ’60s for a three-month rotation.”
Pre-revolutionary racism had not been subtle or limited, but rather open and uncompromising. López Benítez described one hospital that “claimed that it was dedicated to religious goals; but it only accepted white patients and would not accept black patients.” Mena’s family knew racism well. His cousin José Villena “studied medicine but was poor and had to sell tomatoes to buy books. He passed all his courses, but after his last exam learned that he would not become a doctor because he was black.” Studies culminated in a tribunal exam, and one examining physician refused to pass black students. “Two years later, in 1959, he passed his exams and became a doctor.” José Villena practiced internal medicine in Camaguey until his death.
The pre-revolutionary period was not without anti-racist efforts in health care, however. In 1938 the communist-led Transport Workers Union began a mutualist health plan with a clinic for its workers, the Centro Benéfico. After five years, it offered the plan to other workers and enrolled 25,000 by 1959. “The Centro Benéfico,” writes Ross Danielson, “was the only mutualist clinic which served a substantial number of nonwhite Cubans and served them without discrimination or segregation” (italics in original).27 The outpouring of medical teams to poor urban communities, rural areas, and the eastern part of the island with coordination by the revolutionary government occurred at the same time that U.S. civil rights demonstrators were being beaten by police and attacked by dogs for demanding the right to sit at “whites-only” lunch counters. This contrast was not lost on Cubans or many in the United States.
A NEW CONSCIOUSNESS
The central contradiction facing revolutionary medicine was how to do much more with much less while also thinking and planning deeper than ever before. Writing twenty years after the revolution, Roberto Capote Mir summarized the period’s early accomplishments: creating a unified health system; increasing hospital beds and health care facilities, especially in rural and eastern Cuba; increasing every category of health care worker; and attaining “active participation by the masses in the solution of health care problems.”28 Of the many organizations created at the time, by far the most important for medicine were the Committees for Defense of the Revolution (CDRs), organized in 1960 to guard against the counterrevolution. CDRs participated in multiple health campaigns, and, after 1962, were responsible for polio immunization.
In a different political climate doctors became different people. “When I started my medical career,” López Benítez told me, “I thought that if a child died of hunger it was not my problem as a doctor. But now I understand that it is my problem.” Dr. Cárdenas was no less affected:
At the beginning people were for or against the revolution in a very theoretical way, but I became married to the revolution. There was a vaccination campaign in Realengo 18 [in Guantánamo]. Patients had to come by foot and a woman brought a child who had gastroenteritis. His father had to walk for three hours every day to see him and I told him he could stay home because his son could leave in two days. The father would not leave because he said four other sons had died. This changed my life forever.
As physicians began to act as medical “cadres,” they perceived themselves as embedded in a broader political agenda. A medical school graduate “could not fail to see his own efforts as only one part of a set of health-related measures: land reform, new roads, improved agricultural methods, schools, literacy programs, improved diet, and an end to seasonal unemployment.”29
The imperative to serve the underserved became the guiding idea of medicine in Cuba. As Karl Marx wrote: “Theory becomes a material force when it grips the masses.”30 The sheer desire of isolated physicians to provide care at no cost to impoverished Cubans could not on its own change medicine, any more than could a government attempting to create a new medical system by decree, if isolated from the mood of the country. But in a country where thousands of doctors had struggled for decades to create equitable health care, a revolutionary government that reflected that awareness could unite those struggles and reshape medicine.
The consciousness of the three thousand who stayed became the “material force” in the production of Cuban health care, as much a material force as the manufacture of pharmaceuticals or the construction of hospitals. Medicine was affected by that consciousness at least as much as Cuban dentistry was affected by the newly developed high-speed drills that Fidel acquired as ransom from the United States for the return of mercenaries captured after the Bay of Pigs invasion.
Still unanswered, however, was whether this new medical consciousness would be powerful enough to overcome new challenges. The need for basic services was so severe that meeting it required building physical facilities and focusing on specific illnesses and health problems. The relationship of health care institutions to the communities they served remained much the same. Though the municipal polyclinic, begun in 1962, offered a new orientation, the atmosphere of crisis prevented this paradigm shift from expanding.31 The question remained: Once the delivery of services improved, would the medical field be able to plan and enact fundamental changes in the way health care was delivered?
Another dark cloud hung over medicine: infant mortality increased during the first few years of the revolution.32 It is likely that a portion of the increase was attributable to more accurate statistics. Some infant deaths that would not have been tabulated before 1959 were recorded after the revolution. The revolution was doing everything humanly possible to provide vaccinations and other pediatric services, but the flight of doctors took its toll. Schools were working sleeplessly to expand every type of medical training, and doctors were much more evenly distributed throughout the island. Yet by the end of 1963, there was still a lower doctor-to-patient ratio than there had been in January 1959. The question remained: Would new students be able to continue such an intense pace and increase their numbers through the coming years?
Though medical accomplishments were felt throughout the island, the trip of fifty-five medical staff to Algeria was not well publicized. Five years after the revolution, no one knew what their impact would be. Would the efforts in health care later be viewed as a waste of desperately needed resources? Or would the experiences gained from the Algerian mission combine with medical approaches that were