S,,r SC, d hfrd.. Vol. IX. ,,p 87 10 96 Prrpamon Press Lid 1979. Prmted m Great Brnam

CHANGES IN CUBAN HEALTH CARE: AN ARGUMENT AGAINST TECHNOLOGICAL PESSIMISM* SALLY

GUTTMACHER

Columbia University, School of Public Health

and Ross DANIELSON Kaiser Foundation

Health Services Research Center. Portland, Oregon

Abstract-Since the popular revolution in 1959, alterations in the organization and delivery of health care in Cuba have paralleled the country’s broader political. economic and social changes. This paper discusses the evolution of the Cuban health care system during the past seventeen years within the wider context of societal development. The authors compare three “snapshots” of Cuba, the first in 1959. the second in 1970 and the last in 1976, and touch upon such issues as the organization of health care delivery, the recruitment and socialization of health workers and aspects of the process of receiving health care. They point out that the Cuban experience should be of particular interest to the underdeveiopwi world. For though it is true that a larger portion of national resources has been directed to the health and sociat services, nonetheless, it was largely through the reorgan~ati5n and equaiization of the pre-revolutionary health care system that improvement in the health stat& of the population was achieved. It appears that Cuba could well serve as an example for those who are skeptical about the possibihty of combining technical development with improvement in the humane quality-of care.

tion of its task by the organization a free enterprise System 16-j.

lNTRODUCFiON Aguimr ceeh~o~og~cufpeSSimiS??I

in

The Cuban councer-exumple

delivery has everywhere become a major focus for social commentary. Most agree that it is too expensive, and some are beginning to question whether an emphasis on institutionalization and technological innovation is essentialiy humane. Reflecting a growing critique of the once prevailing naive faith in technology, one of the most articulate of contempora~ social critics [I J has even suggested that technologically advanced societies are fundamentally incapable of developing institutions which can deliver humane medica care. What is new-and most dangerous-in the recent fascination with technological progress is its pessimistic extremism which, like the optimistic extremism which preceded it, inadequately examines the way in which the pathogenic potential and other inadequacies of medicine are moderated by the larger society. It is our expectation that the weight of evidence and practical experience will drive the contrary expressions of technological extremism toward a middle ground of constructive skepticism proper to the conditions and corresponding social critique of each society. But this middle ground is not intended as a justification for an escap ist mode of relativism, for a useful technological skepticism must embody a recognition that in much of the world a large part of the pathogenesis and inhumanity of medicine is a consequence of the deformaHealth

of production

care

We are going to examine the dehvery of health care in Cuba, a developing society which embodies a hopeful and basically opposing point of view to the new technological pessimism. The Cubans believe that by changing the pattern of control of the economic and political system one can humanize and dignify the delivery of health we without accepting the notion, f~hionable in some circles, that society (and especially developing societies) should eschew major aspects of technological development. In this paper we will discuss the evolution of the Cuban health care system since the popular revolution in 1959. The delivery of care has changed dramatically since pre-revolutionary days, paralleling the society’s broader social, pofiticaf and economic changes. We will present and compare three snapshots of Cuba, which we hope will iilustrate the evofution of the health care system. The first picture will give us a glimpse of Cuba in 1959, the start of the revolution; the second about 1970, a period of some economic setbacks and concomitant hardship for the population; and the third picture of Cuba in 1976. a period of greater strength and economic progress. In our discussion we will touch upon areas which are of interest to medical sociology, namely critical parameters in the relation between the medical system and other social institutions. Within each of our snapshots we will focus on the organization of health care delivery, the recruitment and socialization of health workers and aspects of the process of receiving and delivering health care. The purpose is to demonstrate in one sweeping view how one country’s social

* This paper was originally published in the Inc. J. Hlth Sera 7, No. 3. 1977. It is reprinted here by kind permission of Dr Vincente Navarro, because of its central importance to the theme of this Special Issue. 87

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SALLY GUITMACHER and

and medical revolution has embraced many elements of both technological development and humanist critique. Given the breadth of our focus, it will be helpful to first provide a brief synopsis of the Cuban revolution and the organization of health care. Cuba is neither Utopia nor a finished product, but its experience is of substantial interest to the underdeveloped world and to those in the developed countries who are concerned with experiments in genuine social reform. Synopsis: the Cuban recolution The Cuban revolution differs from those of the other socialist countries in that at the start it was strongly reformist, and neither communist nor social democratic. Unlike China and the Soviet Union, both of which had huge peasant populations, Cuba had a large rural proletariat with a history of political struggle [7,8]. After a revolutionary government was installed in January 1959, the leadership put through a series of liberal social reforms, such as the agrarian reforms which broadened land ownership and the urban reform, which halved or abolished rents on most housing. These reforms led to popular support and quick success in the early years, and a good deal of popular enthusiasm developed based upon them. But as development progresses-as quick pay-off measures and short-run planning gave way to longrun strategies, as budgetary resources moved from superficial abundance to real scarcity, as problematic outcomes of early solutions thrust themselves increasingly on the political agenda, and as the United States intensified its hostility toward Cuba-traditional reforms proved inadequate or inappropriate from the evolving perspective of the leadership. We might summarize Cuba’s development toward socialism by pointing out that Cuba was initially eclectic and experimental in her developmental policies, and that the leadership was genuinely committed to the wellbeing of the population and also willing to learn from its mistakes and current history. Finally, Cuba evolved into a socialist state, with some unintended help from the United States in terms of its punitive foreign policy and with some very intentional support from the world socialist community. This development toward socialism has been neither smooth nor without dissension. While half a million Cubans left the country, the 1960’s were years of effusive debate about the directions to be taken by the revolution. Che Guevara, whose views were strongly felt during the early period, championed a development program strongly emphasizing moral incentives, mass political mobilization and the central planning-an approach which broadly prevailed in the 1960’s and continues, with significant revision in the 1970’s. Groups espousing opposing views were chastized in particular for excessive emphasis upon technical expertise and bureaucratic attitudes and practices. It appears, however, that accumulated experience has modified the extremes of opposing viewpoints, and many who had early fallen into disgrace around technical issues have regained a measure of respectability in recent years [9]. But while the current level of stability and institutional maturity of the revolution contrasts sharply with the early years, a

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DANIELSON

strong measure of experimentation. innovation, eclecticism appears to be an enduring quality.

and

Cuban health orgntiization The primary processes and conflicts of the larger revolution found parallel expression in the organization of health services, their conceptualization, style of administration, and lay involvement, with conflicts occurring, for example, between those who engineered and participated in the expansion of rural and peripheral services and those who were engaged in the restructuring, partly from the top down, of the Ministry of Public Health. Still, it would be a serious error-albeit a very common one-to view the contemporary health system as a direct and simple byproduct of the central social, economic, and political arenas. The health system evolved also in accord with its own conditions, dynamics, and conflicts, while changes in the larger society implied causally powerful shifts in basic parameters and constraints on the workings of the system. A detailed analysts, however. of the conditions which led those at the periphery of the system to hold views about development which were in some aspects unique from those of the central planners, is inconsistent with the limitations and purpose of our paper. The central outcome of the revolutionary process. whatever its intricacies. was the establishment of a national health services organization which effectively mobilized available resources for health promotion. All of the formal components of health promotion are either included in or oriented by the rMinistry of Public Health. These components are rationalized within a logic of regionalization and functional hierarchahzation of service levels. Seven provincial service administrations are subdivided into regions and the regions in turn are composed of areas. For most purposes, the provincial institutions form the practical apex of services, with a decreasing number of services and activities continuing to depend on the historical legacy of institutional concentration in Havana. Provincial hospitals and clinics provide a third level of specialties and services. Regional institutions provide personnel and services for common hospitalizations, specialty and laboratory referrals, and back-up consultation for the primary range of services which are concentrated at the area or community level in the area polyclinic (or health center), and its affiliated organizations. Structures and programs have been designed with repeated reference to three goals: (1) centraiization of planning and decentralization of administration. (2) involvement of other social organizations and of the people in general in the concrete activities of health promotion, and (3) integration of service dimensions-preventive and curative, social and individual. environmental and personal. The strongest and most visible locus of lay involvement and service integration is the area polyclinic, which is at once a clinictype service center and also the organizational headquarters for the health affairs of the surrounding community. The Cuban area polyclinic has been widely acclaimed as highly successful and it is therefore especially interesting to find. as we will explain, that the area polyclinic is today targeted for a major structural and philosophical overhauling.

Changes

in Cuban

SNAPSHOT: CUBA 1959

Social con&ions In 1959, Cuba was a poor but moderately capitalized agricultural country which relied on sugar as its major export. There were insufficient energy resources; all petroleum crucial for development, had to be imported. Cuba had a history of colonization by Spain and neo-colonization by the United States, which determined the conditions of her economic and cultural stagnation and technological dependence. Given such conditions, Cuba suffered high rates of unemployment and rural workers were affected by “dead time,” a four to six month period of seasonal unemployment in the sugar industry. Health and educational services were correspondingly rudimentary or nonexistent in rural Cuba. While the single university in Havana was in theory open to everyone, its benefits were almost wholly reaped by those who could first afford private secondary education. Moreover, the chosen university careers and the consequent mode of professional work were inconsistent with the real needs of the country. Partly as a consequence, many people with advanced education were crowded into a marginal. unstable, and urbanbound middle class which was variously influenced on the one hand by the extravagant interests of the wealthy (there were more Cadillacs in Havana than in ony other city of the world) [lo] and by the petit bourgeois proper, and also, on the other hand, by the various movements and organizations which emerged to represent the interests of working people. Racial disparities-rooted in African slavery and related to class, European immigration, and urbanization-also were notable. Blacks constituted at least 209; of the population, and an extremely important and powerful interracial Afro-Cuban culture existed in Cuba. The active elements of this culture were based among the poor, which in Havana meant the lower one half of the population. Oriente Province, the least developed rural area in the country, housed a large part of the Black population. Following upon the base that was laid for racial disparities by years of slavery (which also ironically produced certain modes of racial and cultural integration) [ll], Cuban society was racially encrusted by successive layers of Spanish immigration. predominant until the 1930’s. and by prolonged contact with North American culture, business, and tourists. Sexual inequality was obvious. When the census was carried out in 1953, six out of seven women were found in the home and one fifth of all women were illiterate. Those women who did work, tended to work either as domestics or in the low paying tobacco and textile industries. Still another indicator of the woman’s situation was the prevalence of prostitution. Few women or Blacks were to be found in the university professions; in 1933 only 25 of some 1000 Havana physicians were women. The health status of the rural and poor typified that of a people whose government was essentially unconcerned with its welfare. Most people of rural Cuba were illiterate or semiilliterate, undernourished, and unable to purchase medical care of any reasonable quality [12]. Unequally available medical services and their focus on treatment rather than preven-

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tion were naturally accompanied by a high rate of infectious and parasitic disease which took a large toll. especially among the very young. Diarrhea1 diseases, including gastro-enteritis, were the leading cause of death in 1957, and the number one cause of infant mortality until 1962. The health profile of the Cuban population reflected its underdevelopment, with infectious diseases overshadowing the chronic diseases whose predominance is commonly considered an indication of socio-economic and medical development. Health

organization

The first health policy initiative of the new government was to accept the challenge of rural health needs. This objective derived from the government’s decision to regard as primary the contradiction between rural and urban Cuba, a decision which reflected the support that had been given to the Rebel Army by the rural population during the armed insurgence. The rural thrust of the burgeoning revolution addressed a clear constituency and provided the primary ingredients of a popular and morally persuasive ideology. The rural health strategy was from the beginning designed to establish health centers in every rural area, an experiment which anticipated and influenced the development of the area polyclinic in the contemporary national model [13]. The experience, for example, with lay participation in health promotion was especially influential. The rural services which were thus established, largely with the enthusiasm of young physicians and nurses who offered themselves for this idealistic purpose, soon demanded for their stable operation and expansion a program of compulsory rural service by graduating physicians. In 1960 one year was required; today compulsory service is set at three years. In the context of a highly politicized effort, the stint of rural service strongly influenced the subsequent development of many young health workers. This experience included an exposure to the political and developmental doctrines which predominated and direct contact with the moral justification of the revolution, and confirmation of the lack of concern by previous governments that was evidenced in the visits of peasants who had never received physician services before the revolution. The rural effort had consequences for other sectors of the Cuban health enterprise as it existed in 1959: support was demanded of professional associations, the medical school was called upon to orient its training to the needs of rural service, and the scarcity of personnel and other resources for existing urban services was aggravated. The situation was further exacerbated by the hostility of the United States and the flight in 1960-1963 of many physicians. In the crisis situation that then existed, the net effect of such developments was to force maximum utilization of health resources. This could only be done through a major overhaul of the organization of medical care. This, in turn, confirmed the conclusions of earlier analyses [14, 15, 161 which called for major planning efforts and revamping of medical care delivery. The road was opened for this revamping by a 1959 decree which placed all health activities under the direct administration or under the ultimate authority of the

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Ministry of Public Health. Meanwhile, accompanied by intense conflict, the consolidation of revolutionary influence within the university began to bring education into line with social needs. Medical education was reformed and streamlined in terms of prevailing concepts (e.g. internships were guaranteed; norms and residency programs for specialization were established). In addition, many working class students, Blacks, and women were recruited and supported for medical studies. Structurally, two kinds of institutions had dominated pre-revolutionary medical care: public institutions and mutuahst institutions. Public institutions (many should be called semi-public because of the indirect manner of public control and accountability and their subsidization of private practice), included hospitals, dispensaries, and traditional public health programs. These were centrally administered from the national level through a variety of parallel hierarchies, although some services in Havana (the principal exception) were directed by municipal administration. Mutual& services were of several kinds, but their common characteristic was their use of a direct prepayment mechanism. At least 30 such institutions of some consequence existed in Havana alone, and some of them had delegations in interior cities. Historically, the hugest programs were created and controlled by Spanish ethnic or regional associations whose importance increased throughout the period of massive emigration from Spain. Other mutualist programs were physician cooperatives and some were straightforward business ventures of one or two physician directors. It is essential to point out that almost all of the 100,000 people in Havana who received the services of mutualism were White and received care in institutions which, excepting the Centro Benefice, usually excluded and otherwise segregated the Black population [17J The development of the rural health service then, was the first medical innovation in revolutionary Cuba. The second was to improve primary public services. This was accomplished by increasing their budgets and by consolidating their administration. The third important policy direction was to place public constraints on the institutions of mutuahsm. These constraints immediately served to reduce the notorious inefficiencies and uneven quality within mutuahsm which stemmed from uncontrolled growth, lack of professional regulation, bald entrepreneurialism, and sometimes bitter competition. Despite the influence of mutuahsm, traditional fee-for-service practice was everywhere present in prerevolutionary Cuba as enclaves in both public and mutuahst institutions; additionally, there were exclusive private clinics and elite private hospitals in the wealthy suburbs. In general, there were few full-time salaried positions and physicians frequently combined one or more part-time positions with some type of private practice. As in all capitalist medical systems, the aristocratic areas of every sizeable city were marked by the elegant private office practices of the most prestigious physicians. In Cuba, these physicians stood in sharp contrast to the marginal, underemployed physicians who offered their services in the hole-in-the-wall offices of other districts. In contrast to most other non-socialist societies,

and Ross DANIELSON

elite practitioners were unable to successfully dominate the medical profession; indeed, after 1945 the Cuban Medical Federation was controlled by progressive, leftist, and communist leadership until the Federation disbanded in 1963 when its functions were superseded by the medical workers’ union and scientific associations. The strong presence of the left in pre-revolutionary Cuban medicine was a consequence of many factors, including the institution of mutualism, public physician employment, large numbers of marginal practitioners (partly explained by the power of the left within the University), and highly politicized professional culture which reflected the political currents of the larger society that had briefly coalesced in the frustrated revolution of 1930 [183. These remarks should not be taken to suggest that all physicians who remained in Cuba were revolutionaries or that those who were carried with t.hem the exact blueprints and necessary consciousness for the new society or for a wholly new medicine. But in the polarization of the early years, physicians who remained in Cuba included highly committed seasoned veterans of political struggle within the profession and others who were ideologically prepared for the principal elements of the new medical orientation, with its stress on prevention over cure and on periphery extension over core technology. By contrast, the abandonment of the country by non-revolutionary physicians served as a dramatic symbol to new medical generations of the social irresponsibility of pre-revolutionary medicine. Quite logically, then, the New Physician would serve where the need was greatest and would consider the entrepreneurial practice of the profession unethical. SNAPSHOT:

CUBA

1970

Social conditions The year 1970 marked the close of a period, begun in 1968, that was known as the *revolutionary offensive”. The objective of the offensive, to use the combative terms which had come to express the Cuban situation, was to mobilize the resources of the country in order to achieve a dramatic new level of economic and social. development, a superior base for the construction of communist society. The plan represented at once the evolving goals of the revolution and a critical evaluation of the strengths, weaknesses, and problems of the eclectic first years. Revolutionary from the beginning in confronting the real problems of the society, the revolution came to be called sociaffsr in 1961 and communist in 1965 when the previous Integrated Revolutionary Organizations disbanded to form the Cuban Communist Party. The early years had proven effective in mobihzing citizens for the tasks of defense, rural development, hurrican disaster relief, public health programs, and the famous literacy campaign [20]. As land reform, industrialization, and agricultural diversihcation efforts disrupted the previous organization of sugar production, mobilization of urban labormostly from service and bureaucratic occupationsbecame a useful means of meeting labor requirements of the harvest. Meanwhile, the initial goals of full employment, rural development and increased real income for working people--especially for the pre-revolutionary poor-led to a sift under the crush of scar-

Changes in Cuban health care city conditions to a regulated consumer economy which guaranteed equal distribution of goods and services by rationing consumer items and decreasing salary stratification [213. Unwilling to compromise the initial goals of economic investment and income transfer. Cuba’s consequent inability to produce or import other than strictly essentially consumer goods in the barest amounts argued in favor ol an economic strategy to abandon most free merket pricing systems, and to utilize methods of mobilization and moral incentives to secure effective labor utilization. The program of moral incentives was additionally intended to produce positive changes in social values and to elevate the meaning of work [22]. Elsewhere within the economic sphere, the first years after 1959 had revealed the pitfalls. if not the outright impossibility, of attempting to swiftly implement the watchwords of agricultural diversification and domestic industrialization in a neo-colonial single cash crop island society, which was faced with an imperialist blockade and covert economic sabotage. Without abandoning available international capitalist market relations, the Cuban economy had to secure a position within the socialist world community. In particular, it was realized that industrialization had to adjust itself to agricultural goals and that agricultural planning had to begin with the stabilization and technical perfection of sugar production rather than its abandonment. Intital. planning estimated the optimum level of annual sugar production to be some ten million tons, a target which was set-overoptimistically-for 1970, the conclusion of the revolutionary offensive. The year 1970, then, was a difficult one not only because it ended three years of sacrifice but because in important respects the revolutionary offensive was unsuccessful. The offensive ended with the conclusion of the sugar harvest in late sprimg of 1970, ‘and the remainder of the year was marked by retrospective analysis and development of corrective strategies. Cuba had not failed to mobilize resources, human or material, and workers had not failed to respond to moral incentives. Rather, it appears that the scale of mobilization was simply beyond the capacity of the administrative and political structures of the society. Production techniques and mechanization were unequal to the 1970 target, and the negative effects of minor technical difficulties were multiplied in an effort to meet that target. As a result of this stress, other economic sectors were disrupted and set back. Faced with this experience in 1970, Cuba, now highly socialized after ten years of revolution (the last small businesses were closed to preempt black marketeering) was turned toward new courses [23]. On the one hand she sought strategies that would more securely guarantee economic stability and labor productivity and would ease the sacrifices demanded of the Cuban people. On the other hand she sought to gradually move away from reliance on large campaigns of voluntary mass mobilization and toward political reforms that would eventually broaden the democratic participation of the population in decisionmaking and thus enhance the effectiveness of decentralized administration. Mobilization and other characteristics of the period before 1970 had other consequences, of course, which

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were not always summarized in the analysis of production figures. One indicator that racial and sexual inequalities were decreasing was that counter-revolutionaries and disgusrados (those who are displeased with the revolution but do not act against it) increasingly complained that Blacks were getting everything. morals were declining and women were losing the “enchantment of feminity”. Income levelling and equalization of opportunity began to undermine the infrastructures of racism and sexism [24,25]. Mobilization in the first ten years also contributed to a heightened social conscience and understanding. Public visibility and popular participation in the process of developing, implementing, and criticizing major social policies led large numbers of ordinary people to acquire an understanding of socio-economic matters that is unknown in many societies. Nealfh organization The foregoing discussion is relevant to health organization in many respects. Most importantly, the mobilization context provided the social context for the formation of many medical personnel, and by 1970 the majority of Cuban physicians had been trained by the revolution. The mobilization environment, direct participation by students in manual labor and Marxist studies caused the new health workers and students to be highly conscious of the social meaning of their work. Owing to the clarity and popular acceptance of revolutionary objectives, the cynicism and alienation common in many countries were virtually unknown to Cuban youth [26]. Medical students were noteworthy in this regard, and in 1968, for example, a higher percentage of young communists were found among medical students than among other student categories except political science.. The importance attributed to health matters was not only evidenced in the full financial support for medical studies, but also in the continuously growing budget of the health and social service sector as a whole. Compared with the turbulent history of economic development efforts, the health arena gives the impression (only partly misleading) of having developed with greater continuity. This impression derives from the stability of the general model of regionalization which was early implemented in 1961-63. Continuity also derives from the uniformly effective leadership and the stabilizing contribution of the significant number of progressive physicians who had had considerable pre-revolutionary experience in radical politics, health administration, leadership of the medical federation, and participation in the armed struggle against Batista. It is also probable that in comparison to the economic sector, the components of health administration were better understood (or perhaps more understandable), less seriously disrupted by setbacks (such as massive medical emigration and the blockade), and more amenable to centralized planning and decentralized administration. Nonetheless, a more complete view, too complicated for adequate presentation here, would identify a series of shifts in policy which derive from the process of confronting the concrete health problems of the society and from the contradictions and critical evaluations which evolved from this confrontation.

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The building of rural primary services was followed by the national decentralization into provincial administrations. The rationalization of provincial and regional hospital organization was followed, almost out of necessity, by the improved organization of outpatient services at the area or community level. The latter concept came to be embodied in the integrated polyclinic (“integrated” because it combined all health affairs) which took clear conceptual form in 1965 and was almost fully-implemented in 1970. In 1968, the development and organization of separate sectors within each area (the average area included 25,000 inhabitants) became yet another goal, primarily in order to facilitate the work of sanitarians, community health nurses and lay participants, whose activities were coordinated by the polyclinic and by the area’s “public health commission”. The latter was a very effective body chaired by the polyclinic director which was composed of representatives of organizations which were involved in health related matters. Notable among these were the Women’s Federation and the Committees for the Defense of the Revolution, along with the Association of Small Farmers, the Cuban Labor Confederation and representatives of school, factories, and government bodies. The area polyclinic deserves special attention here, for by 1970 it was regarded as the central focus of the entire health system [273. Interestingly, as a predominantly outpatient health center, the area polyclinic was rather unique in comparison to health center development in other countries, especially with respect to the polyclinic’s administrative independence from the associated regional hospital. Coordination was achieved by means of a regional administration and through a plan of work which employed primary specialists (internist, pediatrician, obstetrician-gynecologist, and dentist) rather than general practitioners. The polyclinic’s primary specialists were strongly encouraged to also work in nearby hospitals and hospital-based specialists were required to provide regular services in the polyclinic. The purpose of these measures was to secure coordination of service between polyclinic and hospital and also to insure a focus on the former by the hospital system itself. By 1970 Cuba had accomplished a redistribution of resources into rural areas which was clearly evidenced in a proportionate decrease of hospital beds and personnel in Havana [28]. Physicians were encouraged to .remain in less developed areas after they had completed their rural service, and a successful effort had been made to recruit medical students from the rural proletariat. The change in the recruitment base of physicians has served to decrease the social distance between physicians and patients as has the fact that post-revolutionary doctors tend to be young, educated by the revolution and experienced in work-study programs and voluntary labor. Half of medical students in 1970 were female; another half-not the “other” half-were of working class background; and many were Black. Medical education had been reformed principally along the lines of existing critiques of the pre-revolutionary university (which had not measured up to its own standards) and thus has continued to resemble the standard North American and European models. Although the

Ross DANIELSON

basic experience of a medical education was not dissimilar to that in non-Socialist countries, there were. however, a number of significant innovations in both the organization of medical education and the delivery of care. The curriculum strongly emphasized preventive and epidemiological concerns; team teaching was organized around body systems rather than around academic departments; and medical students associated with other health workers in work-study programs. Clinical services which served as teaching settings had developed a very strong community orientation, and the entrepreneurial sector was practically eliminated from the delivery of health services. Medical and dental pre-clinical studies were combined, and all physicians and dentists (dentists are considered physicians with specialization in “estomatology”) have practically identical pay and career structures. Finally, drug and medical equipment industries and pharmacies were nationalized and their rationalization eliminated redundant products and reduced the dangerous practices of excessive selfmedication [29]. The major facets of health care are provided at no direct cost with nominal pharmacy prices and special provision of medicines when they are required for chronic conditions. The results of these changes were striking. With little technical innovation besides conventional modernization, regionalization, and socialization and with moderate increases in total expenditures and resources, the health profile of the Cuban people underwent a dramatic change. Major causes of death shifted from infectious diseases to chronic illness, cancer, stroke and heart disease. This change, especially the decline in early childhood mortality, cannot be attributed simply to preventive and sanitary measures. Infectious and parasitic diseases were not immediately reduced, but their seriousness was rapidly diminished as new health care programs provided effective access to care. In addition, through community-based health education campaigns, people have become more knowledgeable about aspects of prevention and also more highly motivated to seek health care rapidly for themselves and their children. It is no surprise, then, that there was a large increase in the use of services from 1959 to 1970 .[30]. This increase occurred even though nearly one half of prerevolutionary physicians left the country before 1964. It appeared that by 1970 Cuba had nearly accomplished its major objectives in health promotion. During this period, it might be said that, aside from the organization of the community health centers, Cuba had not yet deployed many health workers in a particularly innovative fashion, partly because she chose and was able to train enough new physicians to more than make up for those who abandoned the country. A remarkable exception to the lack of innovation in the training and use of health workers was in the field of dentistry, where personnel and resources were very scarce-partly, it seems, because the pre-revolutionary dental profession had been less progressive than medicine and had sharply restricted the number of students. Given these restrictions (and also the advent of the high speed drill), Cuba embarked on a plan of regionalized dental clinics which efficiently utIE%iI scarce resources by employing dental assistants to clean, open, and fill teeth. Similarly, in other

Changes

in Cuban

areas or health care. Cuba trained large numbers of technicians for laboratory. hospital and community work and their systematic training was a new and important achievement in Cuba.

SNAPSHOT: CUBA 1976

Social ~ondit ions The marks of the years after 1970 are economic consolidation and movement towards new political rorms. The new Cuban strength is internationally reflected in the near collapse of the United States sponsored economic blockade of Cuba: within Cuba, the ingredients of the new stability include the beginnings of political decentralization and elected representational government, utilization of flexibie price mechanisms for non-essential consumer goods, improvement of transportation, increasing mechanization of agriculture, revision and reduction of mobilization techniques and moral incentives. and greater encouragement of production by means of an emphasis on administrative responsibility and moderate material incentives. Institutional maturity is reflected in an increasingly standardized legal process. adoption of a new family code after a year of heated public discussion, celebration of the first national congress of the Cuban Communist Party, a newly constituted National Assembly, and the ratification by national referendum of a new constitution for socialist Cuba. The new constitution affirms the rights and duties of the Cuban citizen and the irrevocable nature of the socialist transformation, and it specifies a structure of representational government to be known as “people’s power” [31]. In an allied institutional development, change is occurring in the role or labor unions. In keeping with the drive for greater administrative accountability, it appears appropriate that unions should be less involved with enterprise management (as was the tendency under mobilization) than with the presentation and defense of the immediate interests of workers. Technical expertise for management is now prized equally with, ir not more than, ideological sophistication. Of the two consumer markets rationed and “free”. the former includes most essential products and the latter, with some duplication of the former, includes an expanding variety of goods. The prices of rationed items continue to be deflated to assure uniform availability, and the prices of free market items-depending partly on their distance from necessity-vary greatly and can be quite high. To some extent the free market items. serve as material incentives, and prices reflect the desire to mobilize the large amounts of savings that many individuals accumulated during the period of more acute scarcity. In contrast to 1970, there are hardly any long lines at the shops and few interruptions in the supply of essentials. Also contrasting with 1970 are the increasing number and attendant problems of automobiles, most of which are destined for use by state enterprises and some, under specified criteria, for individual use. A super highway is near completion between Cienfuegos and Havana, and track is being laid for a modern railway that will run the length of the island.

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But to those who visit Havana. the most visible change between 1970 and 1976 is that-for the first time within the revolutionary years-buildings of all kinds are being painted and renovated. This change does not indicate the end of the efforts to restrict the growth of Havana (considered overgrown during the pre-revolutionary years) but rather the beginning ol’a period which will improve some of the less essential amenities of life. Clubs, small restaurants and. entertainment are highly visible and patronized, even though in the case of clubs and restaurants the prices are somewhat high. Domestic recreation facilities are being constructed along with tourist accommodations for the increased flow of visitors from Canada, the Caribbean and Europe. Cubans speak proudly of their elaborate system of schools and of the facilities and attention provided to the students who attend the rapidly expanding system or boarding schools in the countryside (and comparable institutions in cities), where secondary students combine study with manual work and outdoor sports. Given the new economic and political vitality and the visible improvement in the living conditions of the vast majority of the population, there is a feeling in the country that Cuban socialism is coming of age. Health

organization

The 1970-1976 changes just described are rooted in the constructive critique of 1970 conditions; this is also true of the health system. However, in the case of the health system the changes that are occurring are more surprising to the outside observer because the system already appeared highly successful and rather consolidated, although not without problems, in 1970. The appearance of success in 1970 is further supported by epidemiological data which indicates a marked improvement in the health status of the population by 1970 [32]. One of the much discussed aspects of the success was the high degree of lay involvement in health-related work and the multiple channels for effective critique of the system by the community and by patients [333. It is primarily from such sources, we believe, that the recognition of problems and ameliorative innovations have been derived. The most dramatic changes are taking place in the organization and philosophy of work by primary-care specialists in the area polyclinics. Here it had become clear that somewhat idealist& staffing methods (in particular the exchange of personnel between hospital and polyclinic which in theory gave primacy to the community focus) made it difficult for a patient to always or even frequently be seen by the same clinic worker. The opposite was true as well; physicians had trouble following a single patient through the various stages of treatment. Due to rapid movement of personnel, and a somewhat diffuse concept of teamwork, exactly who had responsibility for a given patient at a given time was sometimes unclear or easily overlooked. The tug of war between hospital and polyclinic had not gone easily, as had been hoped, and the requirements of part-time work by polyclinic physicians in the hospitals (and oice versa) had negative consequences for the patient. Focussing sharp attention at the problem of personal accountability.

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an analysis in 1970 of pediatric hospital readmissions led to a program of discharging high-risk children not to the parents but to the area health facility, designating a specific health worker as personally responsible for the subsequent recuperation of the child. A variety of experiments were aimed at remedying problems of primary care, and in 1972-1974 the concept and prototype of the new model polyclinic began to take form as part of a larger program known as “medicine in the community” [34]. This program is an extension in many respects of the previous goal of producing a “new physician” dedicated to the objectives of community medicine. These physicians would choose to do their advanced clinical training at the community level rather than requesting the more “glamorous” hospital-based assignments. The new polyclinic differs from the previous model chiefly by its method of work. The polyclinic’s responsibility for the health of the people in its area is entrusted to physician-nurse teams and the work of these teams is “sectorized” in the fashion of a capitation system. That is, just like the community work of the sanitarian whose work was already sectorized in the 1968 model polyclinic, the work of each team is directed almost exclusively toward a specified geographical segment of the polyclinic’s area. A pediatrician-nurse team, for example, is thus responsible for the health promotion and maintenance of all children in a specified area. Two kinds of activities replace the former requirement of hospital work. On the one hand, the physician-nurse teams are expected to spend a relatively large part of the time (about 12 hr per week) in making home visits or in related community work, such as health education or liaison with community groups. On the other hand, the physician dedicates time to “intraconsultation”. That is, instead of referring patients away to specialists, the primary care physician participates directly in meetings between the patient and specialists. Although the patient may consequently follow a course of treatment with the specialist or in the hospital, the primary physician follows the case and continues to schedule appropriate intra-consultations. Following the case does not include, except in special circumstances, the actual supervision of hospital care. A number of consequences follow from the new case-work approach to care. The patient no longer has to wait for a centralized clinic record room to draw his chart. Instead she or he goes directly to the team ofIice where all records of the catchment area are located. Although the internist may not be specifically trained in family medicine, the new organization of health care delivery is expected to promote a family and social approach, since the internist (who makes home visits) will deal with all the adult members in a dwelling and neighborhood. Health activities of lay organizations are also expected to be improved by the direct involvement of the physician-nurse teams. The staff of the polyclinic holds regular meetings with the citizens of each sector in order to insure continuing community participation in the protection and promotion of health. Finally, an important consequence of the clinical team having a specified case load is that preferential and aggressive attention is given to persons of high

and Ross

DANIELSON

risk. (For example, the team will request to see the mother of a high birth-weight newborn to be certain the the mother is not diabetic.) Presently there are four or five prototypical new polyclinics and at least twenty-two are expected to be thus classified by 1980. Meanwhile, all area polyclinics are being instructed to develop plans to implement, in accord with their conditions, the principles of the new polyclinic. The transformation of old polyclinics is being expedited by the use of the new polyclinics as teaching settings. The clinics are also innovative in terms of the content of the curriculum; the new polyclinics now have social psychologists as regular members of the teaching staff who stress the psycho-social aspects of health care and are involved in research projects aimed at improving the quality of care. Other aspects of the health system development, as of 1976, bear mention. Medical education is increasingly decentralized and students are placed in hospitals and clinics throughout the seven provincial areas after their first two years of pre-clinical studies at one of the three Cuban universities. (There was only one university and medical school before 1960; by 1965 two others were fully operative in Santa Clara and Santiago de Cuba). Hospital development continues, and the first major hospital facility to have been built in Havana by the revolutionary government is about to receive some of the scientific institutes which had been located in antiquated facilities. Another new institute, the Institute for Health Development, will soon move into quarters which are being renovated by voluntary workers recruited from the national offices of the Ministry of Health. This institute will be primarily concerned with issues of health administration, statistics and epidemiology. Attempts are being made to educate the consumer about health matters and to demystify aspects of medicine through radio and television programs and other means. CONCLUSIONS This brief exposition of social and health care development in Cuba’s seventeen years of revolution demonstrates that modernization, organization, and technical development have improved and humanized the delivery of health care. Our survey has shown that the dehumanizing side effects of bureaucratic institutional care are subject to significant correction in a social context which is free to respond to such concern. Institutional racism in health care, racist and sexist divisions of labor and other forms of stratification by status in the professions, grossly unequal distribution of productive medical resources, bureaucratic impersonality, mystification of medical knowledge, and even (although it has not been elaborated above) excessive self-medication in the population, are all being addressed. Taking health care out of the market place while guiding its development by socialist perspectives has provided a context for an innovative self-corrective medical care system. We hardly feel it necessary to point out what the reader might have already concluded: namely, that the health status of the Cuban population and the chance for the individual to anticipate enjoying a long, productive life have greatly improved.

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Changes in Cuban health care Judging from what has happened in Cuba in the last seventeen years. we argue that cynicism concerning the humane possibilities of modern technology must give way to a chastened optimism. A constructive skepticism toward technology may well emerge out of the concrete process of confronting real health problems in specific social conditions. To be sure, technology and organization cannot by themselves overcome problems rooted in deep economic inequalities or repressive social relations. But it is certainly premature to argue that modern societies have adequately explored the creative use of a highly technological medical care system and should now abandon it. For those who promote the new technological pessimism from comfortable retreats. we recall a debate that took place some hundred years ago, in the Havana Academy of Sciences. In the wake of cholera, Dr Carlos J. Finlay presented data which associated the spread of the disease with the course of the Zanja Real (the supply ditch which served the poor sections of the city). The Academy, however, was determined to proclaim the waters healthy and thus, Finlay was forced to quip, if the water of the Zanja were so good, why had they built the Aqueduct (which served the best sections of the city)? [35]. Acknowledgcmenrs-We would like to thank Eric Holtzman and Kim Hopper for their thoughtful comments on previous drafts and Gail Garbowski for her care and patience in preparing the manuscript. REFERENCES 1. Much of what Ivan Illich says in Medicul Nemesis [Z] has been said before; the error of his argument is largely one of overstatement; the harm in his view lies in its facile acceptance. indeed its popularity, even among the medically sophisticated. See also his critics. e.g. Navarro V. [3]. Thomas L. [4] and lngman S. and Danielson R. [S]. 2. lllich I. Medical Nemesis. Calder & Boyars, Ltd. London, 1975. 3. Navarro V. The industrialization of fetishism or the fetishism of industrialization: a critique of Ivan Illich. Inc. J. Hlrh Sew. 5(3), 351-371. 1975. 4. Thomas L. Rx for Illich. N. Y. Rec. Books 23(14), 3-4, September 16. 1976. 5. Ingman S. and Danielson R. Toward redesigning 175-187, national health systems. Rer. Anthroa. March-April. 1976.6. The obfuscating convergence hypothesis (that socialist and capitalist societies under the axe of technological development are essentially the same) which is always implicit and sometimes explicit in Illich’s position, should be thoroughly discredited at this juncture. Much of Illich’s discussion simply does not apply except by exaggeration to socialist societies; there is little similarity between the wealthy surgeons of the United States and the modest stature of their colleagues in Bulgaria or between the ponderous figure of the (scarce) small town dot in the United States and China’s barefoot doctor or the U.S.S.R.‘s feldsher. 7 Zeitlin 2. Cuba: Revolution without a blueprint. In Cuban Communism (Edited by. Horowitz I. L.), pp, 81-92. Transaction Books. New Brunswick. New Jersey, 1970. Century. 8 Wolf E. R. Peasant Wars of the Twentieth pp. 251-173. Harper & Row, New York. 1969.

9. Ritter A. R. M. tionary

Cuba:

The Economic Developmenr of RevoluSrraregy and Performance. .Praeger, New

York, 1974. IO. Ruiz R. Cuba, The Making of a Reoolution. p. 9. University of Massachusetts Press. Amherst. Massachusetts, 1968. 11. Thomas H. Cuba: The Pursuit of Freedom. Random House, New York, 1971. 12. Agrupacion Catolica Univenitaria. Encuesta de trabajadores rurales 1956-1957. Economia _V Desarrollo, No: 12, 1972. 13. Danielson R. Cuban health care in process: models and morality in the early revolution. In Topius und Utopias in health (Edited by lngman S. and-Thomas A.). no. 307-333. Mouton. The Hague. 1975. 14. D& C. and Poblete Troncoio M. El problemo midico J la asisrencia murualista en Cuba. Report of the International Labor Office, Havana, 1934. 15. Foreign Policy Association, Commission on Cuban Affairs. Problems q/ the New Cuba. Foreign Policy Association, New York, 1935. 16. Torras J. Los factores economicos en la crisis medica (Report Prepared for the Cuban Medical Federation, 1957). Economia y Desorrolfo. No.’ 13, 7-34, 1972. 17. One of the most interesting and politically deviant mutualist programs was the Centro Benifico y Jerudice de 10s Trabajadores de Cuba. This program was inaugurated in 1946 by the Havana Transport Workers Union, with inspiration from communist leaders. Remarkably successful, it was expanded to offer services to all Cuban Workers who wished to enrol. Albeit against significant resistance, the center even established delegations in some interior cities. Thus, by 1959. the Centro Be&co enrolled some 25,000 subscribers and could reasonably boast a history of service innovations, including a preventive emphasis and a team approach to care. Finally unlike almost all other mutualist associations, the Centro Be&co admitted Blacks and served them without discrimination. 18. The history of Cuban mutualism and radicalism in the prerevolutionary medical profession deserve extensive study. These topics, along with others relevant to the present paper, will be analyzed in a forthcoming, comprehensive book. Cuban Medicine by Ross Danielson c191. 19. Danielson R. Cuban Medicine. Foreword by Eliot Friedson. Transaction Books, New Brunswick, New Jersey, 1978. 20. Early in the 1960’s Cuba had elaborated a system of mass-based organizations that involved the population directly in a variety of social, political and economic activities. These block, community, and work-based organizations (Committee for the Defense of the Revolution. Federation of Cuban Women, Association of small Farmers, the reformed Cuban Labor Confederation) provided a central means for education and political development of the population, and also the means for carrying out mobilizations. These activities were a hallmark of the first decade of the revolution, helping to sustain broad enthusiasm, a sense of cohesion, and the accomplishment of specific social and economic tasks. 21 Rationing of scarce commodities, such as milk or poultry, was designed to guarantee adequate supplies especially to the very young, the aged and the ill. This program, coupled with the rural focus (where nutrition was notoriously inadequate), the intensification of production of commodities (including the creation of a fishing industry), and the provision of low cost or free meals at workplaces and schools, clearly improved the nutritional status of much of’the population while it’ sharply curtailed the consumption of luxury items.

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22. Kahl J. The Moral Economy of the Cuban Revolution. In Cuban Communism (Edited by Horowitz 1. L.), pp. 95-115. Transaction Books, New Brunswick, New Jersey, 1970. 23. Castro F. Speech of July 26. 1970. Gramma Weekly Review, August 2 1970. 24. Booth D. Cuba, Color and the Revolution. Science and Society 40, 129-172 1976. 25. Hagerman A. Women. In Cuba: People and Questions (Edited by Ward K.) Friendship Press, New York, 1975. 26. Hochschild A. Student Power in Action. In Cuban Communism (Edited by Horowitz I. L.). pp. 53-71. Transaction Books, New Brunswick, New Jersey, 1970. 27. Danielson R. The Cuban polyclinic: organizational focus in an emerging system. Inquiry (Special issue on comparative analysis of health systems, Edited by Elling R. H.), 12 (Supplement). 86-102. 28. Rojas Ochoa F. La real hospitalaria de1 Ministerio de Sallid Pirblica en el period0 1958-1969. Reoista Cubana 29.

de Medicina

IO, 3-42,

and Ross DANIELSON 30. Rojas Ochoa F. El policlinica y la asistencia a pacientes ambulatories en Cuba. Rerisrtr Cubanu de Medicina 10, 214-225, 1971. 31. This activity is part of the microbrigade program, a scaled down continuation of previous mobilization methods. The work of microbrigades, as the name implies. is performed in smaller teams and usually directed toward tasks which are close to the workers’ immediate interests, such as in housing that will be occupied by co-workers. 32. Cuba, Ministerio de Sallid Pdblica, Direccibn de Estadistica. Anuario esradistico. Instituto Cubano del Libro, Havana, 1975. 33. Orris P. The Role of the Consumer in the Cuban Health Sysfem (unpublished M. P. H. dissertation, Yale University School of Public Health). Yale University, New Haven, Connecticut, 1970. 34. Fernindez Sacasas J. A. er al. Programa integral de sallid para el adult0 seglin el modelo de medicina en la comunidad. Rev&u Cubana de Administracidn de Sahid

1971.

Cuba, Ministerio de Sallid Priblica, Diez a&x ptiblica. Institute de1 Libro, Havana. 1969.

de sallid

35.

1, 155-174,

1975.

Finlay Carlos J. Obras Complefas, Vol. 3, p. 410. Cuban Academy of Sciences, Havana, Cuba, 1967.

Changes in Cuban health care: an argument against technological pessimism.

S,,r SC, d hfrd.. Vol. IX. ,,p 87 10 96 Prrpamon Press Lid 1979. Prmted m Great Brnam CHANGES IN CUBAN HEALTH CARE: AN ARGUMENT AGAINST TECHNOLOGICAL...
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