Cuban Health Care. Don Fitz

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      BIRTH OF THE CUBAN POLYCLINIC

      During the 1960s, Cuban medicine experienced changes as tumultuous as the civil rights and antiwar protests in the United States. While activists, workers, and students in Western Europe and the United States confronted existing institutions of capitalism and imperialism, Cuba faced the even greater challenge of building a new society.

      The tasks of Cuban medicine differed sharply between the first and the second halves of the revolution’s initial decade. The years 1959 to 1964 were dedicated to overcoming the crisis of care delivery, as half of the island’s physicians fled. It was during the second half of the decade (1964–69) that Cuba began redesigning medicine as an integrated system. The resulting reconceptualization of health care, which put the area polyclinic at the center of medical care, created a model for poor countries that changed medicine ever after.

       THE POLICLÍNICO INTEGRAL

      When the revolutionary government took power in 1959, millions of Cubans were without medical care. The revolution put enormous energy into building new facilities and expanding services. Nowhere was the crisis more severe than among the island’s rural and black population.¹

      The revolution had inherited a patchwork of unintegrated, overlapping medical structures, including private fee-for-service practices, public assistance for the poor, a few large medical plans, and many small plans.² These rarely offered preventive medicine and never a complete range of treatment, requiring patients to go from one provider to another (if another was even available). Though the second half-decade of the revolution continued to expand care, it focused on reorganizing the disjointed medical system it had inherited.

      Accounts of Cuban medicine during the 1960s can be confusing. Some emphasize the increase in the number of polyclinics without noting their metamorphosis in the middle of the decade.³ The term “polyclinic” (policlínico) generally refers to a medical facility offering outpatient services. José Ruíz Hernández clarifies what happened in the Cuban system of policlínicos: in August 1961, the Ministry of Public Health (MINSAP) began a study in Marianao (a town of 45,000) that sought to unify preventive and curative medicine. In May 1964 it became the first policlínico integral in Cuba.⁴ The next year, MINSAP began to spread the policlínico integral model throughout Cuba, making it “the point of departure for all health planning.”⁵

      How did the policlínico integral differ from earlier policlínicos, and why was it so central to creating the new medicine? MINSAP’s plan addressed existing shortcomings by consolidating services. Staff at the new polyclinics would include at least a general practice physician, nurse, pediatrician, OB/GYN, and social worker.⁶ Dentistry was also brought on board, and nurses and social workers made house calls.⁷ Staff extended services to workplaces, schools, and communities. Outreach included health campaigns such as mass vaccination programs and efforts to control malaria and dengue.

      Vaccination began shortly after the revolution, but the policlínico integral structure vastly increased its effectiveness. In 1962, 80 percent of all Cuban children under fifteen were vaccinated against polio in eleven days. In 1970, it took just one day for the same national effort.⁸ Malaria was eradicated in 1967, as was diphtheria by 1971.⁹

      Clinic staff coordinated primary care programs (maternal and child care, adult medical care, and dentistry) as well as public health, including control of infectious diseases, environmental services, food safety, school health, and occupational and labor medicine.¹⁰ The policlínicos integrales were designed to integrate medical services in multiple ways. In addition to combining preventive and curative medicine, they provided a full range of services at a single location, coordinated community campaigns, and offered social as well as medical services. Most important, they provided a single point of entry into the system, allowing for a complete record of patients’ medical histories and making them key to the transformation of health care.

      It cannot be overemphasized that these advances in medical care could only have succeeded through the massive changes in Cuban society that began immediately after the revolution and continued during the ensuing decade. The best known was the literacy campaign of 1961, but other programs addressed racial discrimination, land reform, agricultural salaries, farming methods, improved diet, pensions, new roads, new classrooms, housing, piped water, and urban–rural differences. The redesign of medical services was thus hardly an isolated process—it was an essential component of remaking Cuba.

       MUTUALISM WITHERS AWAY

      The second half of the decade saw continued efforts to build up the number of medical staff and assign them to rural and poor urban areas. By 1969, twenty nursing schools had been opened on the island.¹¹ The number of nurses climbed from 2,500 in 1958 to more than 4,300 in 1968.¹² Similar pushes were made to augment the number of auxiliary nurses, X-ray technicians, laboratory technicians, sanitarians, and dental assistants. Always attentive to alternative medicine, Cubans also integrated healers (curanderos) into the health system, and MINSAP provided them with salaries and training as auxiliary personnel.¹³ As dentists were absorbed by the polyclinics, their numbers more than quadrupled, from 250 in 1958 to 1,081 in 1967.¹⁴

      Though the first plan for a comprehensive national health service was developed in 1961 and implemented the next year, it was significantly revised in 1965.¹⁵ The new version sought to alter the structure of the medical system itself, as MINSAP turned its attention to the unbalanced number, proportion, and location of medical facilities. Only around a fifth of Cubans lived in Havana, but the city had more than half of the country’s hospital beds. By comparison, the rural Oriente, the eastern part of the island, with a larger black population, was home to 35 percent of all Cubans but had only 15.5 percent of hospital beds.¹⁶ Thus, plans for new beds and doctors were concentrated in the east.

      Also problematic were the many rural hospitals with fewer than a hundred beds that could not provide a full range of services. Greater efficiency required an increase in rural polyclinics and concentration of hospitals in cities. The number of hospitals accordingly decreased from 339 in 1958 to 219 in 1969. In the same period, the number of beds per hospital more than doubled, from 83 to 181. The total number of hospital beds increased from 25,170 to 41,027—or, from 3.8 to 5.1 beds per one thousand Cubans.¹⁷

      The polyclinic took on a more central role, as more patients were initially seen at polyclinics, where a physician could refer them to a hospital. The number of health visits doubled between 1965 and 1969, but visits to hospitals dropped from 28 to 19 percent of the total. At the same time, trips to polyclinics went up from 32 to 63 percent of total medical visits.

      Clinics changed not only in number but in type. Mutualism, the prevailing model in Cuba for four centuries, was a pre-revolutionary holdover unable to resolve health issues with its scattered array of unconnected services. Nevertheless, it remained immensely popular. A key task of the revolutionary government was to resolve these contradictions. Mutualism broadly resembled insurance, with subscribers paying a monthly fee for hospitalization and medical services. The types of services covered varied widely from plan to plan, and none covered everything. Of 456 Cuban health institutions in 1956, 42.8 percent were private or mutualist.¹⁸ Often owned by rich doctors, these entities were a major barrier to an integrated medical system with facilities that could provide a complete range of services. Unlike the new policlínicos integrales, mutualist clinics did not offer preventive medicine, were not adequately linked to hospitals, and did not serve specific geographical areas.

      Nevertheless, given the popularity of mutualist clinics, the revolutionary government was wise not to nationalize them outright, as it did with many large, foreign-owned businesses in the early 1960s.¹⁹ Instead,