Cuban Health Care: The Ongoing Revolution
By Don Fitz
New York: Monthly Review Press, 2020
Despite a 60-year-long economic embargo and the collapse of the Soviet Union, the Cuban Revolution has not only survived but continues to produce impressive outcomes for its people and the world.
The revolution’s achievements include free universal public education; the eradication of functional illiteracy; free universal primary and preventative health care with its associated medical and scientific research institutes and facilities; and international solidarity aid, including exporting adult literacy programs to more than 30 countries, including Australia.
Cuban Health Care: The Ongoing Revolution, by Don Fitz, documents Cuba’s revolution in health care and its initiatives in medical internationalism post-1959. It is a must-read for anyone interested in Cuba’s revolutionary path, universal health care and building socialism in action.
Fitz has taught psychology at various colleges and universities in the United States and is on the editorial board of Green Social Thought.
His daughter Rebecca went to medical school in Cuba, attending the Escuela Latinoamericana de Medicina (Latin American School of Medicine, or ELAM), Cuba’s international publicly-run medical school established in 1999, which brings students from across the world to study medicine.
Fitz writes that Cuba had three medical revolutions before 1959: the first (from 1790–1830) focused on smallpox vaccination and sanitation; the second (from 1898–1922) on immunisation against yellow fever; and the third (from 1925–1945) on the relationship between poverty and disease.
“The goals of the third revolution,” writes Fitz, “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”.
A revolution in progress
Fitz writes that there are no blueprints for the outcome of a socialist revolution. The most one can do is, to “sketch the broad outlines of a new society, because those building it will complete the details”.
Cuba’s system of health care is universal, grounded in community-oriented primary care with an emphasis on preventative medicine, intersectoral collaboration with patients and communities, and a commitment to overseas service.
Before the 1959 revolution, Cuba spent almost 60 years as a de facto protectorate of the US. The quality of life in Cuba under US domination was truly abysmal: 14% of Cubans had tuberculosis; 13% had typhoid; and rural areas in Cuba were inundated with cholera, malaria, parasites, and other diseases. Infant mortality was 60 per 1000; 91% of Cubans were malnourished; and the average life expectancy was just 59 years. Vaccination programs were unavailable and only 10% of children were covered by specialised paediatric care. The pharmaceutical industry was 70% foreign-controlled, creating many products lacking treatment value.
Millions of ordinary Cubans, disproportionately Afro-Cubans and those in rural areas, had no access to health care at all.
1959 onwards
When the revolutionary forces led by Fidel Castro came to power on January 1, 1959, they faced the challenges of addressing widespread poverty and disease. There was no national health care plan and health care services provided by charitable organisations were generally better than those provided by the government. There was no orientation toward preventative medicine. Rural areas and some urban centres were woefully lacking in proper health care services.
No reliable data on health indicators existed, not enough doctors and dentists were being trained and there was severe underfunding of the country’s few research facilities.
Fitz notes that half of the country’s roughly 6000 doctors left the country within a few years of the revolution. Many settled in Florida. Those who chose to remain were ethically driven and for the part were committed to the ideals of the Cuban revolution or at least prepared to do what was needed at the time.
One of the first things the Castro-led government set about fixing was the disparity between the availability and quality of health care in urban and rural areas.
Further, it established a comprehensive medical model that was universal, community-based and free. The Committees for Defence of the Revolution (CDRs) — first organised in 1960 to defend the country from a possible US invasion — became a key part of the country’s health care initiatives.
Fitz writes that in 1959, priority went to hospital construction. By 1963 the government had established 122 rural medical centres and 42 rural hospitals, with 1155 beds, 322 doctors, and 49 dentists.
In the early years of the revolution numerous policlínicos (clinics) were established throughout the country. Beginning in 1964, the comprehensive and decentralised outpatient policlínicos integrales (comprehensive clinics), each serving a defined geographic area and independent of hospitals, were integrated into a nationwide medical system to “unify preventive and curative medicine” in communities.
Fitz documents how, despite the success of the policlínicos integrales, internal contradictions meant they were redesigned and re-emerged as policlínicos comunitarios (community clinics).
These clinics were further revolutionised, resulting in the appearance of the family doctor/nurse consultorio (consulting room) program in 1984, where doctor-nurse teams live in the neighbourhoods they serve, and work in small neighbourhood consulting rooms, each of which is tied to a policlínico. It continues to this day.
Each consultorio doctor/nurse team is responsible for up to 1500 patients. The family doctors in Cuba (one per 127 inhabitants) typically know their patients by name.
Each of the 451 policlínicos comunitarios directs the work of up to 30 consultorios, providing services for 20,000 to 60,000 patients. Services include diagnostic procedures, laboratory testing, dentistry, optometry, physical therapy, podiatry, natural and traditional medicine consultations and primary care specialties such as internal medicine, paediatrics, psychiatry, obstetrics and gynaecology.
These services are provided professionally notwithstanding the impact of the US embargo means many premises are substandard and it is difficult and costly for the clinics to purchase medicines, medical and surgical equipment.
Health care successes
Cuba eradicated polio in 1962, malaria in 1967, neonatal tetanus in 1972, diphtheria in 1979, congenital rubella syndrome in 1989, post-mumps meningitis in 1989, measles in 1993, rubella in 1995, and tuberculosis meningitis in 1997.
These positive health indicators are conveniently ignored in mainstream commentaries on Cuba.
Cuba is also renowned for its vaccine development, with 80% of all its vaccines being produced at home. Five COVID-19 vaccines have been developed by Cuba’s advanced medical research sector.
Cubans now have a slightly higher life expectancy and a lower infant mortality rate than the US population.
Fitz relates the Cuban medical system’s long struggle with HIV/AIDS. Despite some initial homophobia, Cuba ultimately made good progress on HIV/AIDS, such that medical journal The Lancet declared Cuba’s AIDS program “among the most effective in the world”.
Fitz documents how Cuba’s commitment to health care extends well beyond its borders. Cuba is renowned for its medical diplomacy, with thousands of specialist staff — members of Cuba’s Henry Reeve Brigade — regularly being sent abroad (to more than 154 countries to date) to help other nations tackle natural disasters, medical emergencies and other crises.
When Hurricane Katrina hit Louisiana in the US in 2005, the Cuban government offered to send medics, field hospitals and more than 75 tonnes of medical supplies to ease the humanitarian disaster. The White House scorned the offer.
Fitz refers to Cuba's military and medical internationalism in Angola. From 1975‒91 Cuba sent more than 43,000 aid workers to Angola and the book contains personal stories of Cuban doctors who worked in Angola.
Cuba didn’t escape the COVID-19 virus but its response has been among the fastest and most effective in the world, due in large part to its advanced medical and scientific research sector and the government’s ability to mobilise resources quickly.
Fitz provides first-hand accounts of medical students from around the world who trained at ELAM and in-depth accounts of ELAM students participating in community projects and international crisis relief.
Fitz presents the case for why the US medical system is so broken. Private profit (including profit-based health insurance) is at the top, but overdiagnosis, overtreatment, overpricing and over-prescription of overpriced drugs all combine to produce worse health outcomes in the US.
By comparison, Cuba’s highly effective health care system costs 5% as much as the US’ and produces superior health indicators and results.
Cuba’s successes are an inspiration to other countries seeking to improve their own health care systems. Fitz discusses collaborative efforts between Cuba and Venezuela, noting Venezuela’s unique effort to reproduce the entire Cuban health system via the Barrio Adentro (community clinics) programs.
Cuban Health Care: The Ongoing Revolution is an excellent book on a subject that is generally neglected or downplayed by mainstream Western academic writing.
It provides dimension and depth and adds new lustre to one of the greatest successes of the Cuban Revolution, a revolution that is truly ongoing.
Fitz writes in a scholarly but readable fashion. The book is fast moving and never dull. It is written by someone familiar with Cuba and its people, but his critical analysis of the Cuban health care system is never naively enthusiastic or overly idealistic.
I commend the book to all who are seeking a viable, humane, ethical and sustainable alternative to capitalism with all its inherent contradictions and shortcomings.
¡Hasta la victoria siempre!