1791. Cuba’s Public Health Policy: Past Present and Future

By Graham Sowa, Havana Times, March 30, 2015

Patients waiting to see the doctor in a polyclinic  in Cuba

“Public health in Cuba is not a priority…,” my public health class teacher had finally said something that brought me back from daydreaming “…it is an obsession”.

After two years of clinical work in a Cuban hospital being back in a classroom learning public health theory is somewhere between mind numbing and infuriating.

I often wonder how I put up with this nonsense beforehand. Maybe because my Spanish was worse and I didn’t understand how empty theory sounds while outside the classroom door a very different reality is taking place.

Aside from the looming self-inflicted disconnect between theory and reality in Cuba my professor is absolutely correct, in Cuba public health is an obsession.

Getting to the status quo of a singular, state funded public health system is a journey marked four key periods and a contemporary fifth that is still being defined.

At the onset of the Revolutionary government control in 1959 the Cuban public health landscape looked much like the current United States: various levels of public, private, religious and mutual aid services.

The Revolutionary public health system began with a significant human resources shortage as tens of thousands of professionals left the island.

The government reacted by training new doctors in new medical schools. The first class held their graduation ceremony on the Pico Turquino, the highest point on the island. The invited guests were the peasants from the surrounding area, soon to be benefiting from these new graduates via the Rural Medical Corps. This symbolic act set the tone for the future of public health on the island.

Along with training thousands of new doctors nationalization of health centers began in earnest. Health insurance or “mutual aid” hospitals numbered 226 in 1961. By 1968 all but 27 had been placed under government control. The Salvador Allende Hospital where I work, once part of the Asturian Society, is legacy of this period. The last center nationalized (in 1970) was the “Centro Benéfico Jurídico de Trabajadores de Cuba”, now a pulmonary hospital that does our bronchoscopies and inpatient treatment of tuberculosis.

The second step was the Health Plan of 1970-1980. Focus was shifted from disease treatment to disease prevention in the cities and rural areas. Malaria, polio and diphtheria were eradicated. Dengue was said to be eradicated as well but now it can be argued to be an endemic disease once again, perhaps the same with cholera.

Medical service did not become universally free of charge until during the second decade of the revolution.

The internationalist mission of Cuban public health also began to expand to 3 continents during this time; a continuation of those national brigades of doctors that made up the Rural Health Corps mountainous eastern Cuba.

Part three of public health development came in the 70´s and 80´s with new health technology arriving from the Soviet Union. Investigative institutes were created, and Cuba remains one of the few countries in South America and the Caribbean with such an extensive offering of medical specialties and research fields.

The famous Polyclinic and Family Doctor were introduced as an experimental concept in 1984 to create a highly structured three tier prevention and treatment system that would cover every citizen of the island. This model was expanded to the whole nation within 10 years and largely governs public health policy today. This is also what bores the hell out of me in my public health class.

The fourth part of public health development in Revolutionary Cuba was surviving a hard right hook and uppercut combo. The first came in the form of the collapse of the Eastern European socialist projects and the second came as the form of the Torricelli and Helms-Burton act. The Soviet collapse erased foreign public health subsidies and technological support while the strengthened United States blockade made getting that money and support from other sources unlikely to impossible.

These crises in Cuban public health have constructed the reality of the system we live in today.

Doctors and patients are used to working and being cared for with a scarcity of materials, everyone knows hospital food will be terrible, and having good relationships with people in the health field is the most important part of navigating the bureaucracy of care.

The previous massive government expenditure toward public health grew even more when the Latin American School of Medicine opened in 1999 benefiting students from other countries (such as myself). This probably marks the last great public health change instigated by Fidel Castro.

Since Raul Castro became president the public health system has faced the same problem many tech startups in Silicon Valley face: how do we monetize a free service without sacrificing quality or creating barriers?

The answer to this question is what I propose to be the fifth step of the Cuban Public health system: creating an internationally profitable public health system based off of the previous egalitarian internationalist model.

Cuban doctors working in Venezuela and Brazil making money for the Cuban government have resulted in good health outcomes for millions of people and plenty of criticism about state coercion of public employees. Yet tens of thousands of Cuban doctors continue to go on mission. While some do leave these projects and immigrate to other countries many more are more or less satisfied with the experience. At least that is my impression from talking to those that return.

Medical school, residency, research and the biotechnology sector has been internationally commodified as a source of income for the Cuban state.

Now what was converted to a free public health system in the 1970´s is one of the biggest sources of income for the Cuban state. This incredible paradox should, at the very least, leave United States assumptions about static Communism ruling Cuba by the wayside. What is emerging in the public health system is a capital generating mechanism with the ends of paying for continued free health care for the Cuban people.

Next week one of our internal medicine wards at the Salvador Allende hospital will be closed to the Cuban population for use by medical tourism. Once again paying patients will walk through its doors after 50-odd years of free health care.

Obsession over public health in Cuba has pushed it to the point to accept that entering the globalized health market might be the best way to save socialism.