THE DEVELOPMENT OF THE CUBAN HEALTH CARE

AND VALUE SYSTEM: TWO SYSTEMS, ONE IDEOLOGY

The fundamentals of how a government system provides for its citizen's rests on the morals and ideologies that underlie the system itself. A socialist government possess the essential aspect, "conception of liberty is the positive provision for the entire population" (Strachez, 1936:214). Liberty for the entire population, in other words: equality. Socialism’s foundation is based on egalitarian ideals for the benefit of its people, steering away from establishing an economic profit that would conflict with the liberty of well being. Health service is to be regarded as a social or human right, evenly available to all, versus a substantial determination by the commercial market depending on purchasing power. (Roemer, 1976). In the Cuban Socialist Constitution, health care is considered a right, guaranteed to every citizen. Medical care, along with food, clothing, housing and education, is "of the highest priority" (Schwab, 1997:18). By treating health care from a holistic perspective and implementing it as a constitutional right, Cuba has become a "powerhouse;" their health care a "jewel of the revolution" (Schwab1997:18). The purpose of this paper is to show how Cuba’s medical care system has been fiercely adhered to by its political leaders and citizens because of an ideology focused on human well being versus profits; how it has been installed into the national value system and adhered to throughout its growths. Cuba’s health care system is revolutionary because rather than focusing on profit, it has made its focus the health of individuals, which capitalist countries have de-prioritized. Establishing their ideology as the basis, Cuba has formed their health care system into a free service, just one of the aspects in their socialist philosophy. Health is a constitutional right. In their Constitution, these basic four principles form the foundation of their philosophy:

1. Health care is a human right rather than a product for economic profit. Therefore, all Cubans have equal access to health services, and all services are free.

2. Health care delivery is the responsibility of the state.

    1. Prevention and curative services are integrated with national social and economic development.
    2. The population participates in developing and maintaining the health care system. (Iatridis, 1990:30).

In addition to integrating the health care system into the ideology that formed the basis of the new socialist government, it has approached health care from a systems perspective. This entails recognizing that an individual’s well being is comprised of several components, and an efficient health care system must be designed to meet all the needs if it is aimed at complete well being. After WWI, a scientific discipline called systems analysis developed, where national leaders looked for the solution to problems from the perspective of "seeing the situation as a whole" (Roemer, 1976:3). Out of this new systems perspective, a new model of health was developed. Overall, there are three main determinants that influence an individual’s well-being (See chart on page 12 for details):

1. Physical environment: includes the geography and climate they live in, and basic necessities such as housing, food, and water.

2. Social environment: includes education, occupation, relationships, urbanization, etc.

3. Personal traits: attributes such as age, sex, immunity, genetic background, habits, etc. (Roemer, 1991:21).

Together, these three components influence an individual’s overall health. Health services have the responsibility to provide a means to meet these requirements of its citizens in order to establish a healthy population. According to the World Health Organization (WHO), in order to be effective, health services must consider both medical effectiveness; "quantitative health indicators like infant mortality rate, nutritional status, and life expectancy," and social impact; "not only social justice and the mobilization of community resources but the process through which people gain greater control over the social, political, economic, and environmental factors that affect their health" (Iatridis, 1990:29). These standards set by the WHO effectively fulfill the three determinants of the systems health model.

The Cuban health care system meets all these standards set by the WHO, therefore also

fulfilling the fundamental needs an individual requires in order to be in complete health.

Cuba’s socialist government approached health care and designed their delivery system, using the systems analysis approach. This is exemplified in their program called "Medicine in the Community" established in 1976.

It was argued that health and illness are conditioned by the interaction of bio-social human beings and their environment. Health was therefore a function of the biological, environmental, and social well-being of individuals. The fundamental objectives were promotion, maintenance, and improvement of individual and community health through their participation in the functioning, organization, and use of the system, with patient satisfaction as the primary goal (Nayeri, 1995:324).

This program, among others, not only is successful by applying the systems analysis approach, it is an example of the comprehensive, humanitarian ideology underlying the Cuban health care system. In 1985, during the American Public Health Association meeting, the Cuban Minister of Health was awarded the Edward Barsky Award for Cuba’s achievement of the WHO goal: "Health for All by the Year 2000" (Iatridis, 1990).

In order to clarify the importance of the health care system and at the same time explain the pride and will of its citizens who partake in it, I will describe the history of its development.

The Cuban health care system was not always designed as such, so comprehensively and equally. The emergence of their health care system is just one of the aspects that came from the birth of its socialist government, in the Revolution of 1959. Prior to the revolution, the majority of the Cuban population was under the oppression of the Batista military dictatorship. There was no free government-funded health program, and the health services were essentially conformed according to social class. The population of Cuba consisted of a proportionately small wealthy class who owned and controlled the bulk of Cuban wealth, the largest class of those who lived in or near poverty standards, and a small middle class. The very rich, top social class went to privately owned hospitals run by independent physicians, the middle class (about 10% of the population), went to Mutualistas, and the remaining large class of peasants and other poor citizens went to the remaining facilities: 46 overcrowded and understaffed government hospitals, some first aid stations in the main cities, and eight maternal and child health stations, built for the total population at the time of 8.5 million people. (Roemer,1976). The distribution of doctors was extremely uneven: high proportions were in the main cities with few, if any at all, in the rural areas.

There were several privately-owned healthcare facilities that were run under profit-oriented managements. The most commonly used services were the Mutualistas. These were family owned and operated insurance schemes. They were started by Spanish immigrants and colonists, originally run for their families and friends. They eventually expanded, sold memberships for monthly premiums, and charged on a fee-for-service procedure. In addition to these, there were military medical services that served the armed forces and their families. There were also industrial medical services, which were company-owned hospitals and clinics, run by the employers for their employees. Half of the fees were paid by the employer, the other half by employee wage deductions. Lastly, there were religious and voluntary facilities. These were few and small, sponsored by churches and donations, run by physicians who were often not compensated for their services. (Roemer, 1991).

The revolutionary movement came from within, first initiated among students and then spread through the large population of peasants. (This is significant because it is from these common people who held personal values that would eventually form the new national ideology.) The Batista government was overthrown by Fidel Castro and his guerillas in January, 1959. This new government, which was mostly formed by the poor population, had not developed a value for extreme luxuries of profit and power and simply desired a more healthy and equal Cuban nation. The pre-revolutionary health statistics of the Cuban population were poor. The poor population who live in conditions with poor hygiene, sanitation, and nutrition, contributed to the infant mortality rate of 60 per 1000 live births, a maternal mortality rate of 125.3 per 1000 live births, a general mortality rate of 6.4 per 1000 person, and a life expectancy of 65.1 years (Nayeri, 1995). They "inherited a for-profit health care system that was plagued by political corruption, poverty, illiteracy, economic inequality, and social injustice" (Iatridis, 1990:29).

The new government promised to provide Cuba, despite their limited resources and agricultural economy, a free quality health care system, establishing it as a national priority (Iatridis, 1990). Yet, transforming and rebuilding the nation around the new "human right philosophy" (Roemer, 1976:84) was a step-by-step process that has been revolutionized over three decades. The first major obstacle that the new government faced was finance. Up until the revolution, 75% of Cuba’s trade was with its powerful neighbor to the north, the U.S. (Nayeri, 1995). After the invasion of the U.S. in 1961 known as the Bay of Pigs, and after the placement of the U.S. Embargo in 1962, "total hostility of the U.S. government towards Cuba" was obvious (Nayeri,1995:327). Cuba looked towards the nations in the East for both assistance and advice. In an interview with a Cuban revolutionist, Roemer reported his statement, "We received helpful ideas from many countries, some capitalist and from all socialist countries. We blended these with creative initiative of our own" (1991:455).

Cuba’s most ample economic supporter was the Soviet bloc, which was a relationship that introduced both positive and negative effects to their development. First, financially they proved to be a beneficial aid:

The Cuban relationship with the Soviet bloc has been a complex one. On the one hand, Cuban economic development benefited from trade, technology, finance, and credit relations in the face of U.S. hostility. These proved essential for the rapid rate of growth which supported social programs in Cuba, including health care achievements. (Nayeri, 1995:327).

The Soviet’s generous assistance helped rebuild their struggling economy. On the other hand, the Soviet’s bureaucratic castes had social and political influences that conflicted with and hindered the absorption of the Cuban socialist philosophy. Probably the strongest influence in the revolution was Ernesto Che Guevara. He strongly disapproved of the relationship with the Soviet bloc because of the conflicts of philosophy and incentives. He criticized their "bureaucratic and technocratic nature and for it’s reliance on the market mechanist," versus the strategy that he helped develop, one of "economic, social, and political development to deepen and expand the leading role of working people and gradually replace moral motives for material incentives in all spheres of social life" (Nayeri, 1995:327). Basically, the Soviet influence threatened the new ideology focused on the intrinsic human worth versus the benefits of profit. Sadly, Che Guevara died and the influence he feared from the Soviet model lingered in the vulnerable society. "The Soviet model fostered bureaucracy and a self-seeking attitude in the Cuban population...health care workers began to respond more to personal gains than to social needs" (Roemer, 1991:451).

What originally seemed to be an economic blessing now turned to be a force that threatened the socialist moral foundation. The leaders of Cuba held a conference, and a rectification process was put into effect aimed at a return to Guevara’s ideology in 1986 (Roemer, 1991). This relationship with the Soviet Union, although rocky, did not tip Cuba. The determination to adhere to their basic ideology that benefited all was both the light they worked toward, and the foundation that kept them stable on their feet.

With the assistance that they were initially receiving form the Soviet bloc and other Eastern European countries, the Cuban people (for they worked together as a community, another glue that helped them succeed in their common goal) needed to rebuild three major deficiencies: their facilities, their resources, and their medical team.

MINSAP (Ministry of Public Health) was put in control of all resources for health care. They collected and integrated all the existing facilities from the former private organizations, compensating the owners (if they were still present, many were among the citizens that left) and renovated them. By 1970, the last Mutualista hospital and clinic were collected into the MINSAP network, therefore establishing all facilities under government control. That process made up much of the most intense transition period between 1962-1968 (Roemer, 1991). This process took the profit out of health care. Health care was now a government funded institution.

Cuba was now in the process of developing its new medical facilities; innovative, extraordinary, and unique. The Cuban health care system is so incomparable, on a theoretical level, because it brings together the medical community and residential community, creating a sense of belonging and unity which improves a person’s sense of security, improving their mental health. "By mediating between individuals and the social structure, the networks strengthen individuals and families and promote self-governance...In the industrial nations, urbanization and technological development have diffused, altered, and weakened mutual support groups; mobility has disrupted traditional primary groups" (Iatridis, 1990:32). Here stands a difference between a capitalistic health care system and a socialist health care system, and the success that complements the perspective of systems analysis.

The structure of Cuba’s health care delivery system is organized into six hierarchical levels that all interlock with one another and correspond to the country’s administrative and political departments (Iatridis, 1990). (See chart on page 13 for details). The uniqueness of the Cuban system begins at the local, personal level and ultimately made all its citizens "difficult to be forgotten or lost" (Iatridis, 1990:30). The medicine-in-the-community programs created in the 1970s brought the emphasis away from the hospitals and into the communities, changing the emphasis from illness to wellness, from treatment to prevention. It was a program described as a "stress prevention and outreach to families, not just responding to patient complaints" (Roemer, 1991:462).

The polyclinics, which provided primary health care to the residents in small areas called "sectors", were further divided into mini-polyclinics, which were even smaller local units. A family doctor team established in each unit would assume total responsibility for the health care of their assigned neighborhood (Iatridis, 32). Trust was therefore installed into the doctor-patient relationship, along with personal recognition - no one is just a case or a number, each individual is a part of the whole that makes up the community. The government also made it a health care equally accessible to every citizen, even those who lived in rural parts, so no Cuban lives more than 600 yards away from a physician (Hemmes, 1994).

Emphasis on the community is extended into education, which is also a free service to all Cuban citizens. As a result, they have achieved a 100% literacy rate, extraordinary for their economic status, and much higher than that of several industrial nations, including the U.S. (Schwab, 1997). Also an emphasis of health is applied to education. The physician teams work together with mass organizations to monitor routine community health functions, such as classes about sanitation, alcohol abuse, etc. (Hemmes, 1994). Special emphasis concerning prevention is ensured to maternity patients and vaccinations, aiming at early health intervention to create healthy young people. There are maternity homes established throughout communities, which not only offer residence to high-risk mothers, but also provides meals and vitamin supplements to outpatients in order to increase birth weights (Schwab,1997). This has contributed to a high rate of mothers giving birth in hospitals, 99% (Hemmes, 1994), and a Cuban infant mortality rate of 7.5 per 1000 births, lower than even some areas in the U.S. (Schmechner, 1994). Vaccinations are routine, "98% of all children have been vaccinated against 12 major diseases" (Schwab, 1997:18).

For a third world country especially, they have achieved high standards. Their three leading causes of death are the same as in most other industrial countries: heart disease, cancer and stroke (Iatridis,1990). Therefore, this ideology that has focused on early prevention starting in the communities, and oriented towards a full socioeconomic concept of wellness has proved successful.

The method that the Cuban government has used to maintain this ideology in the medical field is built into the education program that is designed in their medical schools. When the new socialist revolution took over, there was only one medical school and a great deficiency of physicians, since an estimated 40% of their medical staff left the country after the revolution, most of them leaving for the U.S., desiring to live in a for-profit oriented economy. Now, there are 15 medical schools in Cuba, and some 60,000 doctors (Schwab, 1997).

All physicians must complete a nine year medical program: five years of basic medical training, one year of in-hospital internship, followed by a mandatory three year placement at a rural post. Emphasis is put on family medicine, but those who wish to specialize in a certain field of medicine are required to fulfill a further three-year medical program. Education shifted from training only individual health workers to training teams and teaching team intervention and community-centered approaches. The basic training is designed to take emphasis away from competition in profit and prestige and replacing it with community and cooperation. Upon graduation, each graduate must abide the special Cuban oath which declares his or her intention to serve the people, to renounce private practice, to cooperate with government policies, to emphasize prevention and human welfare, and so forth. This inserts a common goal to work towards, with the intrinsic reward of achieving national wellness.

The Cuban medical system has definitely advanced. They now have 60,000 trained physicians to serve a population of less then twelve million. They have expanded to 284 hospitals, 440 clinics, 11 research institutes, and 15 medical colleges (Roemer, 1991). Some of their aspects have been criticized, though. For example: the doctor to person ratio (1:190) is considered too extravagant, and the annual expenditure of 10-15% of their GDP (Gross Domestic Product) for research and free medical care is also considered too much (Schechner, 1994). Yet, Cuba’s impressive growth cannot be denied, and is still predominantly admired by many nations in the world. The Cuban socialist philosophy has been further emphasized through the treatment to other countries. Many physicians volunteer to third world countries and they have participated in many relief efforts (Schwab, 1997). Their research contributions that their 5000 current researcher have developed are outstanding: Cuba …

Cuba’s hard work has paid of, literally. Their medical research and innovative medical technology has been exported abroad. Cuban exports of diagnostic equipment and pharmaceuticals earned Cuba $120 million in 1995 (Schwab, 1997). A second way that Cuba has used their technology for economic finance is through what has become known as "health tourism." This is a medical system they have developed for foreigners only in order to help finance the free service to their own citizens, the expenses of medical research, and so forth. Health tourism is a chain of private hospitals that provide paid services to foreigners only - in 1995 this brought in over $25 million dollars. Services performed include treatments for eye and skin diseases, open heart surgeries, Parkinson’s disease, kidney transplants, neurological disorders, and countless others (Schwab, 1997). The North American Congress on Latin America recorded that 7,000 foreigners from 60 different countries have visited Cuba to receive medical services (1997). Cuban medics have also been hired to go out to other countries at very profitable rates. These profits are redistributed into the health economy, one source reported 60% into the health tourism hospitals and 40% into health care for the citizens (Schechner, 1994). This system has also received some criticism for the dual-system it creates in Cuba. Some of the services that physicians perform for the foreigners they can not perform on the citizens, for the reason that they cannot afford it. The same country that criticizes health tourism is the same country that has contributed to the cause of their economic crisis: the United States.

The U.S. Embargo has caused the Cubans and their economy to suffer terribly. I will briefly touch upon the impacts of the U.S. policies simply to emphasize the power behind a nation’s ideology. This blockade has not only been a blockade of U.S. products, (mainly medical supplies that the Cubans were dependent on because of the cheaper import costs), but it came to be a "virtual world-wide blockade" (Nayeri, 1995:332) because all other nations were prohibited by the U.S. to trade any import with Cuba that was comprised of any U.S. part. For example, most antibiotics are produced under American patents, so these are included in the embargo. Any third country or foreign enterprise exporting these to Cuba will be threatened by U.S. sanctions (Schwab, 1997). This explains why one reported described it as a "virtual economic blockade" (Chelala, 1996:559). It has deprived the Cubans of, ultimately, an aspect of everything. From essential necessities such as some basic food groups, to intellectual trade items such as journals, to commodities we take for advantage such as gasoline. (That, actually, was ironically beneficial in the long run. Cubans have resorted to bicycles which has improved their physical health and the environment) (Flavin, 1997). The U.S. has not gained any respect or admiration for their embargo or any of the other policies they have enforced, (such as the Cuban Democracy Act, Trading with the Enemy Act, or the Helms-Burton Act just to name a few). In fact, at a United Nations General Assembly, nations voted overwhelmingly that the U.S. was in violation of Article 25 of the Universal Declaration of Human Rights that maintains that everyone has the right to the "health and well being of himself and his family, including...medical care and necessary social services" (Schwab, 199107:21).

The Cuban health care system has developed immensely. At the time of the revolution, the socialists started with run-down hospitals, poverty and disease stricken citizens, a severe shortage of physicians, and a nation and its people recovering from a long struggle with oppression. From creative ideas rose a new nation. Step-by-step the communities picked up the broken pieces and with collaborative effort, they have successfully put them together. The new Cubans developed their own Constitution with their own ideals. They transformed demolished facilities into the innovative hospitals that people from around the world come to receive treatment. They have built themselves research facilities that make worldwide medical contributions. The Cuban’s have replaced the profit-oriented physicians with bright new doctors, both male and female, that do not let the distraction of wealth interfere with the delivery of service to their patients. There is no competition among them, they work cooperatively to achieve the same purpose. The Cubans have transformed a nation that benefited only the wealthy few into a country that reaches out to all: young or old, rural or urban, leader or peasant. They have reinvented the concept of health care, and have stood as an example to many countries, even to some that are wealthier than Cuba. The Cubans have ultimately brought "first world care to a third world country" (Hemmes, 1994:53).

This transformation would never have been completed without the ideology the new socialist people created for the benefits of all its citizens. The Cubans have recognized the intrinsic value of every individual, and have made it their priority over the pleasures of wealth. Cubans do not pay for their health care, they help each other achieve it because health is everyone’s human and constitutional right. Human health has no affiliation in Cuba with the concept of riches. Significance is put instead on the person regardless of their status. By taking money out of health care, they have put health care back to where it should have initially stayed: the person. Cuba has the potential for advancing further than any capitalist community. A nation of healthy people united for the same effort will leave the greedy individuals fighting amongst themselves in the dust.  

REFERENCES

Chelala, Cesar. 1996. "Relations between the U.S. and Cuba; a Proposal for Action." The Journal of the American Medical Association 275:559-560.

Flavin, Christopher. 1997. "Cuba’s Dilemma, Self-Reliance or Global Exchange." World Watch 10:37-39

Hemmes, Michael. 1994. "Cuba: Its Health Care System May Offer Lessons for U.S. Policy-makers." Hospitals and Health Networks 9:52-55.

Iatridis, Demetrious S. 1990. "Cuba’s Health Care Policy: Prevention and Active Community Participation." Social Work. 95:29-34.

NACLA, North American Congress on Latin America, Inc. 1997. "Health Tourism Booms in Cuba.." NACLA Report on the Americas 30:46-48.

Nayeri, Kamran. 1995. "The Cuban health Care System and Factors Currently Undermining It." Journal of Community Health 20:321-333.

Roemer, Milton I. 1976. Health Care Systems in World Perspective. Health Administration Press. Ann Arbor.

Roemer, Milton I. 1991. National Health Systems of the World, Vo. 1: The Countries. Oxford University Press. New York.

Schechner, Richard. 1994. "Cuba: Lift the American Embargo Now." TDR (Cambridge, Mass.) 38:7-10.

Schwab, Peter. 1997. "Cuban Health Care and the U.S. Embargo." Monthly Review 49:15-25.

Strachey, John. 1936. The Theory and Justice and Practice of Socialism. Random House. New York.