NO LONGER A FAVOR BUT A RIGHT: STATE MEDICINE IN REVOLUTIONARY

CUBA, 1959-1970

An Honors Thesis

Presented by

Michael Moreshead

Completion Date:

April 2015

Approved By:

Dr. Julio Capó, Department Of History

Dr. Sigrid Schmalzer, Department Of History

ABSTRACT

Title: No Longer a Favor but a Right: State Medicine in Revolutionary Cuba, 1959-1970

Author: Michael Moreshead

Thesis/Project Type: Independent Honors Thesis

Approved By: Dr. Julio Capó, Department Of History

Approved By: Dr. Sigrid Schmalzer, Department Of History

This paper investigates the formation of a public health system in modern Cuban during the

years from 1959 to 1970. The goal is to identify some of the specific programs and methods that

constituted the state’s public health system and to understand how those policies were related to

the revolutionary ideology that inspired and defined Fidel Castro’s government. This was done

by studying state discourse, including state newspapers, speeches by government officials,

Ministry of Public Health publications, and doctors’ memoirs. This study showed that

construction of hospitals and clinics, effective distribution of medical personnel, targetted

programs against specific disease, and widespread sanitary education brought about significant

gains in health outcomes for many Cubans. The study further showed that a consistent and

pervasive state ideology both shaped these programs and employed them to legitimize the new

revolutionary state. This case shows that public health in revolutionary Cuba is a result of both

effective and innovative policies and of an ideological system that brought health entirely into

the realm of state power.

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Acknowledgements

I want to first thank my mentors. Dr. Sigrid Schmalzer for believing in this project from

the beginning and giving me all the support I needed to make it a reality. For guiding me through

the research process, directing my thinking, and generally being an insightful, supportive, and

inspiring mentor. And most of all for the encouragement she gave every week that made me feel

like I could press on regardless of how research was going. This project would not have

happened without her. Likewise, Dr. Julio Capó for his guidance, support and endless

encouragement. My writing would not be anything without his notes and endless insight. I am

forever greatful to both of you for making this a reality.

I want to recognize in addition all of my history professors at UMass who taught me

everything I know about researching, writing, and learning about history. A special thank you to

Dr. Joel Wolfe for teaching that Latin America 121 class that first got me interested in the

immense, rich world of the history of Latin America.

Thank you to my parents, Harold and Mary Moreshead whose endless support gives me

the strength to do everything I do. For supporting me all the way through my undergraduate

career and making me feel like all my goals were possible at every single turn. I would not be

anywhere at all today without them.

To Cheryl Speare, for teaching me so many years ago what studying history could really

be. You continue to be an inspiration to me.

And to Cassie. For listening with patience and love for an entire year about the ups and

downs of my research. For all her love and every little thing she does, it means everything to me.

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Introduction

The Cuban Revolution of 1959 is now 56 years old. Discussion of the revolution is

weighted with divisive politics and ideological conflict. However, even harsh critics of Fidel

Castro and his revolution cannot deny its success in the fields of health care and education. Cuba

today has a life expectancy on par with the United States and Canada. The same can be said for

infant mortality and rates of certain infectious disease. Furthermore, these metrics are roughly

equal in Cuba across race and class, while in the United States African Americans have a lower

life expectancy than the national average by about five years.1 Health care is free and accessible

to all Cubans and even during the economic turmoil of the Special Period the government

maintained high levels of care for the Cuban people. The achievements of the Cuban Revolution

in health care, all the more impressive for having been done with a budget many times smaller

than that of more developed countries and under the shadow of the U.S. embargo, are looked to

today as an example for third world nations trying to improve domestic health standards. Indeed

the Cuban government regularly sends doctors abroad to serve in developing countries training

local doctors, establishing health infrastructure, and administering to local patients in an effort to

spread the accomplishments of the revolution. However, one is hard pressed to find examples of

other nations that have adopted the Cuban model or had similar success. What then, were the

unique factors that characterized the government’s approach to public health in Cuba? How did

those factors inform the development of a public health program, and how did they contribute to

its success or impede it? How did the government measure success in public health and what

strategies did they employ to achieve it? What can the government’s approach to public health

1 World Health Organization, “Life Expectancy Data by Country,” Last modified 2014. http://apps.who.int/gho/data/node.main.688

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tell us about the Cuban revolutionary state more generally? This project attempts to answer some

of these questions, or at least begin to unravel them in the context of the first decade of

revolutionary Cuba. I chose the period from 1959-1970 because these were the formative years

for a public health program which has persisted now for over five decades. Although many

changes have taken place since the early years of the 1960’s, many of the basic structures and

ideas that informed revolutionary public health 50 years ago are still in place today. This project

looks at how those structures and ideas emerged from a political ideology, were shaped by the

political and economic realities of the day, and ultimately became the unique and in many ways

successful public health system so characteristic of revolutionary Cuba today.

The subject of this project is state medicine. For that reason, I try to explain public health

as a state project, theorized, presented, and implemented by the state. Public health is a broad

term and covers the systematic prevention of disease and promotion of health not just through

state programs but through community and individual efforts as well. My project does not speak

to the latter, nor does it attempt to explain how individuals interacted with, adopted, rejected,

benefited, suffered, or otherwise encountered the state’s public health program. The reasons for

this are two-fold. First is a simple problem of space. To explain both the government program

and the individual experience in the same paper goes beyond the scope of a forty-page

undergraduate thesis. The second is related to sources. While publications by the Cuban

government are relatively easy to come by, written material by individuals who experienced the

program are exceedingly rare, especially for someone doing research exclusively from the

United States. Studies in Cuba, such as P. Shawn Brotherton’s On Revolutionary Medicine and

others have shed some light on the experience of individuals. However, finding such information

has proven difficult even for researchers working in Cuba. This is because government control

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over the narrative on public health is so pervasive and restrictive that even with years of research

on the island it is difficult to come to an understanding of the experience of the people that is

separate from that government rhetoric.

Having neither the time nor the resources to attempt to extricate government rhetoric

from personal experience, I chose instead to study Cuban revolutionary public health on the

government level. For this reason my sources are almost exclusively government produced or

government sponsored, and my conclusions are limited to the programs, successes, and failures

of the state. These conclusions hopefully reveal the state’s vision for public health and how that

vision became a reality through specific programs and broader political and social structures.

Understanding that proces is interesting from the public health perspective because it suggests

ways in which a committed government or other organization could apply resources to improve

health standards the way that Cuba did. This study is valuable from the historical perspective

because the Cuban state’s approach to public health helps us understand the importance of social

programs to the revolutionary government, the role of ideology in shaping those social programs

and the government more generally, and the political and social structures that supported and

broadened the power of the early revolutionary state. To study the government’s perspective I

used a variety of state produced or sponsored publications. I worked in archives of the Granma

Weekly Review, an internationally published weekly review of the Cuban state newspaper. I also

read speeches by government officials and publications by the Ministry of Public Health and its

various journals. To supplement these documents I looked at World Health Organization

publications, correspondence among the international medical community, and secondary

writing on public health in revolutionary Cuba. These sources are limited to the perspective of

the state and for that reason my project omits objective measurements or value judgements on

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the public health program and instead attempts only to explain public health as it was understood

and implemented by the revolutionary state.

This project is divided into three sections, each taking a distinct perspective on the first

ten years of the Cuban public health program. These are rhetoric, programs and policies, and

broader political and social structures. The intention is to explore the public health program first

as an ideological vision, then as concrete practice informed by that vision, and finally as made

possible by the social, political, and geo-political context in which it was implemented. The first

chapter is focused on state rhetoric. This is because ideology was as much a part of Cuban public

health as doctors or medicine. Marxist and revolutionary ideology formed the backbone of the

public health system in Castro’s Cuba, so much so that it is at times nearly impossible to separate

it from practice. It is essential then to articulate exactly what that ideology was before attempting

to explain how it was implemented. To do that I looked to state rhetoric, in the form of

newspapers and speeches by top party officials to try to identify a clear and consistent

framework for how health was talked about and thought about by the revolutionary Cuban state.

In Chapter 1 I identify the salient characteristics that appeared consistently in state rhetoric

across years and mediums. Taken together, these characteristics formed an ideologically

coherent state narrative that understood health and healthcare as the natural right of every Cuban

citizen. This core ideology and the rhetoric that supported it essentially informed the actual

programs that the government put into place to improve health among the Cuban people.

Rhetoric was an essential part of the Cuban public health program. However, the question

for many policy makers and lay people alike is how did the Cuban government reach their public

health goals, not just how did they talk about it. So in chapter two, I explore some of the key

programs that raised health standards to the levels we see today. I focus on rural parts of the

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country, where care was most lacking before the revolution and where the government most

focused their efforts. To this end, I worked with memoirs of rural service doctors and

government publications. No program was more important to health in rural Cuba than the Rural

Medical Social Service, which compelled graduating medical students to serve as general

practitioners in the remote rural hospitals and clinics. These doctors carried out state policies that

targeted infant mortality, infectious disease, and personal hygiene. Together these programs had

the impact on health indicators that the government so proudly touts today.2 These policies were

not, however, separate from state ideology, nor were the doctors that implemented them.

Tempting as it may be to look at programs and their success or failure in a vacuum, to ignore the

role of rhetoric in these programs is to miss a key element of the public health system. The

system we see came about as vision transitioned into practice. It is in that point of transition that

we can begin to understand Cuban health care. These programs did not, however, succeed

exclusively because of ideology or their inherent brilliance. In the final chapter I look at the

social and political structures in revolutionary Cuba that allowed for the public health program to

exist in the way that it did.

The final factor in the success of revolutionary public health in Cuba was the political

and social organizations that supported the government’s system. While government policies

were important, they would not have been successful without political organization, support

among common people through social organizations, and extensive foreign aid. These structures

are difficult to identify through government publications alone, since the state narrative is not

explicit about the systems that underlaid government programs, only the programs themselves.

For this reason, in Chapter 3 I look at the 1962 campaign to vaccinate against polio as an

2 Dr. Gregorio Delgado Garcia. “Prologo.” Cuadernos de la Historia de la Salud Pública, 116 (2014) http://bvs.sld.cu/revistas/his/his_116/hist01116.htm

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example of how the political, social, and geo-political structures that surrounded Cuba’s public

health program made its success possible. The polio case is a useful example for several reasons.

First is the availability of documents. The Cuban government published a twelve page report on

the campaign that detailed the process used to carry it out in 1962, just months after the

campaign finished. I also benefited from the Albert Sabin archives, a collection of

correspondence and documents related to the American inventor of the oral polio vaccine used in

the Cuban campaign. These letters shed light on the international context of the campaign and

place Cuba firmly in a global system of socialist countries all working towards similar health

goals. Beyond sources, the polio campaign is a useful case because of the important role of mass

organizations. These social organizations were made up of everyday Cubans and supported by

the government. They were tasked with carrying out volunteer projects for the revolution, as well

as maintaining ‘revolutionary vigilance’ in their community, which meant reporting on counter-

revolutionary thoughts or activities.3 These organizations constituted the social structures that

supported public health in revolutionary Cuba and in the instance of the polio campaign provided

the ground support needed for the massive and simultaneous distribution of the vaccine. Finally,

the administration of the polio campaign reflected the highly centralized nature of the public

health program. Looking at the campaign in this context helps show how a powerful central

government was important to the public health program in general.

First and foremost, public health in Cuba was ideological. It was presented as a reason for

being for the revolutionary state. That ideology came from a Marxist and humanitarian

understanding of the role of the state in the lives of individuals and was presented in a conscious,

consistent rhetoric that characterized it as such. Ideology is an essential facet of the program and

3 “Vacunación Antipoliomielitica en Cuba” Tribuna Medica de Cuba 24 (470–5) (1962): 16–27.

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a starting place for understanding it. It does not, however, explain its success. In strict terms of

policy, rapid construction of hospitals and clinics combined with effective distribution of doctors

to rural areas constituted the greatest factors in improving health standards for rural populations.

Along with hospital construction and staffing came extensive hygiene and sanitary education,

targeted programs to support expectant and new mothers and campaigns against infectious

disease. Taken together, these programs constituted the original public health system (at least in

rural Cuba). However, these programs would not have been possible outside of the political

context of revolutionary Cuba. Extensive state control over political and social life characterized

Fidel Castro’s government and was essential to the success of public health. All doctors were

employed by the government, and rural service (or service in another sector) was a mandatory

condition of medical education. Hygiene and sanitary education was carried out through the

state’s propaganda machine, which dominated radio, television, and the press.4 Mass

organizations were employed to both educate the population on the community level and carry

out projects such as polio vaccination that otherwise would have required a prohibitive amount

of planning and labor. Finally, support from the Eastern bloc in the form of supplies, medicines,

doctors, and advisors made the government’s ambitious programs possible in the face of the U.S.

embargo. Vision, ideology, and concentrated, progressive programs were therefore important to

the Cuban health program, but do not explain its success alone.

Cuba is a case where a comprehensive vision for public health started as nothing more

than that, a vision, and developed into one of the most successful alternative models for health

care in the developing world. The revolutinary government accomplished this using immense

and pervasive state power over the medical profession, national discourse, and individual lives.

4 “Vacunación Antipoliomielitica en Cuba”

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Medicine in Cuba was, in fact, both a manifestation of and a reason for state power. One’s own

health was to be understood as the result of that state power and promoting one’s health meant

participating in it. For this reason, the Cuban system as it was implemented in the 1960’s could

not be replicated in today’s political climate. However, this does not mean that there are not

lessons to gain from it. The successes of the Cuban program were real, and understanding the

institutional supports and rhetorical presentation of that program could help us begin to see how

those programs can be extracted from those institutions and applied in modern settings.

Replicating that success without becoming entrenched in the ideological conflict that weighs on

discussion of the Cuban revolution is in the best interest of public health advocates in the

developing world and right here at home. Furthermore, understanding how state power was

exerted through health in Cuba can challenge us to consider how our own health and health

practices are guided, supported, or otherwise defined by the structures of power in our own

society. Doing so begins with a study of the Cuban program within its ideological and political

context. This paper begins to undertake that study, with the hopes of understanding Cuban state

medicine as it developed.

Review of Existing Scholarship

The Cuban public health system is not a new subject for scholars of Latin America or

public health in general. However, there are few studies looking closely at the first ten years of

the revolutionary health system and the programs and processes that created an effective and

highly politicized public health. Studies to date examine the current state of public health in

Cuba and the people’s relationship to it. They also examine health as it related to the

modernization and state building process in Latin America.

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Public health as a historical and political subject is well explored in scholarship on Latin

American. Public health history in general today focuses on ideas of power, the state, the politics

of health, and the impact of state policy on health outcomes. Diego Armus, in Disease in the

History of Modern Latin America, outlines the existing trends in Latin American health

historiography. He argues that “the emphasis of this history of public health is not so much on

the health problems of individuals as on those of social groups, and on the study of political

interventions to preserve or restore collective health.”5 The book itself is a collection of essays

that focus on new historiographical approaches to health and disease. Public health is part of that

new historiography but it also includes approaching epidemics as a historical question, looking at

disease as a historical and social phenomenon, and writing health history in the context of

external influences and the state building process.6 The social and political aspects of disease are

studied more closely in the collection Patología de la Patria (Pathologies of the Fatherland),

edited by Gilberto Hochman, Stephen Palmer, and Maria Silvia Di Liscia. In the introduction to

that collection Hochman argues that “the organization of diverse legal and institutional

instruments (hospitals, sanitary centers, campaigns, specific sanitary agencies, among many

others) for the above all rural populations of the hinterland of Latin America imprinted a distinct

dynamic on the process of medicalization.”7 This idea of the medicalization of the rural

population is central to public health programs in the Cuban Revolution. Hochman and Armus’s

collections each explore similar themes to my work in other Latin American contexts, making

them useful models for my own study on Cuba.

5 Diego Armus, “Disease in the Historiography of Latin America,” in Disease in the History of Modern Latin America, ed. Diego Armus, (Duke University Press: 2003) 4. 6 Diego Armus, “Disease in the Historiography of Latin America,” 6-16. 7 Gilberto Hochman, Patología de La Patria: Enfermedades, Enfermos, y Nación en América Latín (Buenos Aires: Lugar Editorial: 2012) 13-14.

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Studies dealing specifically with the Cuban context address a wide variety of issues and

take numerous approaches. There are several broad views of Cuban medicine that consider its

development in the context of the entire century. Sergio Diaz-Briquet’s Cuban Health

Revolution, Katherine Hirschfield’s Health Politics and Revolution in Cuba Since 1898, and

Cuban Medicine by Ross Danielson all fall roughly into this category. Diaz-Briquet asserts that a

health revolution in Cuba started almost sixty years before the Castro regime. In his study, he

takes mortality rate as a benchmark statistic and traces the evolution of health care in Cuba

starting at the turn of the century. Hirschfield’s work on the other hand is a direct critique of the

revolutionary state’s reporting on health statistics, especially information on conditions during

the Batista regime. Both works are carefully detailed in their statistical research and provide a

comprehensive view of morbidity and mortality along with other health metrics in both

revolutionary and pre-revolutionary Cuba. Hirschfield’s work, however explicitly sets out to

challenge the state narrative on conditions on before the revolution. Diaz-Briquets, on the other

hand, is more interested in identifying trends and changes in health care through the century and

is more inclined to take certain government numbers at face value, without losing his critical,

scholarly view of the system as a whole. Both works are essential to my study because they take

a comprehensive and critical view of the concrete achievements and shortfalls of the

revolutionary government’s health program. Much of this project takes for granted the statistical

information comprised and analyzed by Diaz-Briquets and Hirschfield. However, neither work

takes a close view of the characteristics or development of a state vision for health in the first ten

years of the revolution. It is in this context that I hope to expand upon their research.

There is another set of scholarship that looks at health as part of the social and political

culture in Cuba. “Health as Culture and Nationalism in Cuba” by Candace Johnson, and “Update

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Cuba: On the Road to a Family Medicine Nation” by Margaret Gilpin both deal with Cuba’s

modern day health culture. They each assert that state programs have built a unique culture

around health and health care among the Cuban people. Johnson asks, “How have the

development of health systems and health ‘rights’ contributed to a country’s national identity?”8

She concludes that “it is clear that Cuba’s public health goals and achievements contribute to its

sense of nationalism.”9 Gilpin, on the other hand, is more concerned with the development of the

Cuban health system in the context of the development of a broader socialist society. She has a

laudatory view of the regime in general and is mainly concerned with how “by providing

universal health care and differentiated access to programs for vulnerable populations, the Cuban

state secures for its citizens a level of health status unmatched in other developing countries.”10

The two studies are important to this work because they look at the public health program’s

results and try to explain them in terms of social and political influence. One studies the culture

surrounding health and the other the more concrete ways health care has developed in Cuba.

Both, however, are interested in health as a part of the culture and nationalism of Cuba. This is

important to my own work because it demonstrates the effect that the state’s approach to

medicine had not just on public health itself but on the political and social state of the nation.

One study that was essential to my understanding of medicine in revolutionary Cuba

approached the politics of Cuban health through the experiences of individuals. P. Sean

Brotherton’s Revolutionary Medicine focuses on health and body among Cubans in the Special

Period, which began in 1989 with the collapse of the Soviet Union and continued throughout the

8 Candace Johnson, “Health as Culture and Nationalism in Cuba,” Canadian Journal of Latin American and Caribbean Studies 31 (2006): 61. 9 Candace Johnson, “Health as Culture and Nationalism in Cuba,” 110. 10 Margaret Gilpin, “Update-Cuba: On the Road to a Family Medicine Nation,” Journal of Public Health Policy 12 (1991): 83-103.

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1990s. Brotherton’s goal is to “explore the Cuban government’s changing policies and objectives

in the primary health care sector.”11 He does so through field research in Havana from 1998 to

2010 in which he conducted interviews with a wide range of participants and recipients of the

Cuban healthcare system. Brotherton’s central theme is “how state policy, enacted through the

government’s public health campaigns, has affected individual lives and changed the relationship

among citizens, government institutions, public associations and the state.”12 Brotherton’s work

is especially relevant to this project because it is concerned with the development of a state

narrative. He examines how the state uses narratives about health to legitimize itself and how

those narratives change in the context of crisis. While Brotherton examines how that narrative is

reflected back in the attitudes of Cuban people, my project is concerned with the development of

that narrative on a state level and how actual public health policies interacted with that narrative.

In this piece I intend to expand upon his ideas by looking at the formation of the institutions that

established the role for public health that he so clearly articulates.

Other articles dealing include a comparative study of Cuba and Chile by Harold

Watizikin. Harold Watizikin’s study, from 1983, uses a comparison between Chile and Cuba’s

socialist health programs to demonstrate how “consolidation of state power, mass mobilization,

and resolution of the contradiction between public and private sectors were key elements in

Cuba’s success.”13 His evidence comes from working in the Chilean health system between 1971

and 1973 and observing the system in Cuba during 1979. Waitzkin argues that despite serious

setbacks in the years immediately following the revolution (nearly half of Cuban doctors

11 Sean P. Brotherton, Revolutionary Medicine: Health and the Body in Post-Soviet Cuba, (Duke University Press: 2012) 2. 12 Sean P. Brotherton, Revolutionary Medicine: Health and the Body in Post-Soviet Cuba, 4.. 13 Howard Waitzkin, “Health Policy and Social Change: A Comparative History of Cuba and Chile,” Social Problems 31 (1983) 235.

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emigrated), the consolidation of state power allowed for the construction of an entirely new

health system.14 Mass organizations provided the other key element of the new public health

system, with Committees for the Defense of the Revolution and the Federation of Cuban Women

playing integral roles in popular participation in the new health system.15 My own project

explores many of the same factors that Waitzkin did in explaining the early successes of the

Cuban health program but does so in the context of the state’s vision and its development rather

than in a comparative light as Waitzkin does with Chile and Cuba.

One study that is frequently cited in recent scholarship is “Looking at Health in a Healthy

Way” by Margaret Gilpin and Helen Rodriguez-Trias from 1978. The study was published in the

Cuban government-sponsored journal Cuba Review and is a detailed look at how health policies

were working in Cuba in 1978. The study describes in detail all aspects of the Cuban health

system. It outlines its origins, the principles that underlie it, and the process of constructing it.

Changes from the early days of the revolution to 1978 are described and the authors give

statistics on outcomes.16 For these reasons the study is a reference point for scholars looking for

specific facts about revolutionary medicine and appears as a source in many of the scholarship

discussed above. In terms of explaining concrete policies pursued in the first twenty years of the

Cuban revolution it would be challenging to find a more comprehensive or better-sourced study.

However, the study was sponsored by the Cuban government and the analysis presented reads as

though it was drawn from the pages of the Cuban state newspaper. While the study is detailed

and extremely useful for describing the specific programs that made up the Cuban health system

and their origins, it must be understood as scholarship that falls in line with Cuban state-

14 Howard Waitzkin, “Health Policy and Social Change: A Comparative History of Cuba and Chile,” 240. 15 Ibid. 16 Margaret Gilpin and Helen Rodriguez-Trias, “Looking at Health in a Healthy Way,” Cuba Review 7 (1978): 3–15.

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sponsored historiography. Although the study is a reference point for many scholars interested in

the early years of Cuban revolutionary public health policy I have made a conscious effort to

avoid relying on it for details about the program. I did this with the hope of exploring the early

years of the Cuban revolutionary health program through a fresh lens, perhaps avoiding some of

the biases that may have informed Gilpin and Rodriguez-Trias’s groundbreaking work.

There is a rich historiography on revolutionary medicine from within Cuba as well. The

publication Cuadernos de la Historia de Salud Pública (Journal of the History of Public Health)

publishes a variety of studies on public health in Cuba and Latin America throughout its history.

The publication is directly sponsored by the Cuban Ministry of Public Health (MINSAP) and its

articles therefore tend to repeat state lines on medicine. However, the journal includes close

studies of the development of polyclinics, changes in ambulatory medicine, the impact of

Ernesto “Che” Guevara’s thinking on public health, the development of health education,

antecedents to the present health care system, and a variety of other topics. The studies all fall

into the revolutionary narrative of socialist development into an idealized public health system.

However, by virtue of working in Cuba with the blessing of the government, the scholars writing

for the journal have extensive access to primary sources including interviews with doctors and

policy makers and archives from early clinics, government publications, and medical schools.

While the Cuadernos need to be understood as Marxist histories that fall into an explicit state

narrative they provide important summary and interpretation of primary sources from the

revolutionary period.

Chapter 1: The State Vision

Public health in Fidel Castro’s Cuba was not a product of the revolution but an aspect of

it. Improved access and quality of health care for all Cubans was a key goal of the revolutionary

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government from the very beginning. This idea was both implemented in policies and expressed

in rhetoric that painted expanded care as an obligation of the state. As policies were rolled out

their speed and success were folded into the state’s narrative about public health. Understanding

the public health campaign in Cuba in the 1960’s starts with understanding that narrative. The

rhetoric used to talk about public health was characterized by strong emphasis on expanded care

for rural communities, frequent references to the state of health before the revolution, the use of

statistics to support the point that health care had been expanded, emphasis on the obligation of

doctors and patients to be revolutionary, emphasis on preventative care, and framing public

health as an ongoing project. The entire system was underscored by Marxist ideology. It was not

uncommon to see all of these points come up in a public speech or state-sanctioned article on

public health. The particularities of the state’s rhetoric all contributed to the idea of a

revolutionary health program that was an inherent part of the state, thus making the public health

program not just a humanitarian project, but a conscious effort to legitimize and strengthen the

revolution. These particularities also help us to see how the programs that the state implemented

fell into and at times shaped an official revolutionary narrative. That narrative rested on an

ideology that took Marxism as its starting point, and from there presented medicine as

revolutionary, as an inherent duty of the state, and as necessarily different from the kind of

medicine practiced in western, capitalist nations.

Fidel Castro said in 1966 while speaking to a gathering of the Committees for the

Defense of the Revolution that “we shall pass through socialism and reach communism, and we

will arrive there following Marxist-Leninist paths.”17 Marxism was the foundational philosophy

for the Cuban state and public health was not excepted. Marxist thinking provided the

17 Fidel Castro, “Fidel Closes CDR 6th Anniversary Rally,” Granma Weekly Review, October 2, 1966, 2.

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philosophical framework for the idea that health care was a right of all people and that it was the

obligation of the government to provide it, which the Cuban government took as its starting point

for its public health program. Fidel Castro said in a speech closing out the XII Medical and VII

Dental Conference in Havana in 1966 that, “with the triumph of the revolution, all public health

activities have in the main become the responsibility of the Revolutionary State.”18 An editorial

in the Cuban state newspaper Granma written in 1966 said “medical care, food, and medicine

needed to save lives are given to those who need them regardless of the sacrifices or effort

required of the nation to provide them.”19 That idea, of the right to health care, was the

fundamental motive for the Cuban public health program in state rhetoric.

The call to the humanitarian purpose of medicine was not limited to the role of the

government. Doctors too were expected to treat medicine not as a commodity but instead as a

tool for the promotion of the wellbeing of the whole. Castro in 1962 called for “doctors free of

any spirit of selfishness and mercantilism.”20 For the Cuban revolutionary government, health

care was a right of all people and it was the duty of the government to provide for that right.

Beyond that, it was the duty of doctors to selflessly promote that right as servants of the people

and by extension the state. This state line could, however, have been informed more by

circumstances than by philosophy. Roughly half of the 6,000 doctors in Cuba fled the island

following the 1959 revolution. As a result, the Castro government needed doctors who would not

just accept the revolution but be fervent participants in it, lest they continue to abandon the

country. The doctor as a fervent revolutionary will be explored more in the next chapter when we

18 Fidel Castro, “Medicine is no Longer a Favor but a Right,” Granma Weekly Review, March 6 1966, 3. 19 Castro, “Medicine is no Longer a Favor but a Right,” 2. 20 Fidel Castro, “Inauguration of the Basic Science & Pre-Clinic Institute,” (speech given at inauguration of the Basic Science & Pre-Clinic Institute, Cubacana, Cuba, 1962) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1962/19621018.html

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look at revolutionary changes in medical education. Regardless of the inspiration for it though,

the idea that doctors would be servants of the greater good was the ideological basis for the fact

that all doctors were made employees of the state and could be compelled to go into rural

service, factory work, or even serve abroad after medical school. The role of doctors and the

state in providing health care was not, however, the only way that Marxism impacted the

government’s approach to medicine.

Marxist materialism, the idea that human experience is rooted in material conditions and

that those conditions are shaped by social forces, informed the Cuban revolutionary

government’s understanding of the very nature of health and health care. Fidel Castro argued in

1962 that health must be viewed not only on the level of the individual but also with regard to

“the medium where the individual is developed, the home, the school, the factory, the farm, and

the country.”21 In other words, Castro was saying that the material conditions of life have a

significant impact on health and illness. This was the basic idea behind what the government

called preventative medicine. Preventative medicine for the revolutionary government meant

understanding health on the community and society level, educating the population on sanitation

and hygiene, and providing readily available screening, in order to prevent rather than simply

treat disease. In this way they would promote health rather than manage sickness once it

happened. Government officials promoted preventative medicine from early on as the guiding

idea for the way care would be implemented in the new public health system. In 1963, speaking

at the close of a medical conference Castro said “I am talking of direct attention, direct medical

care, and preventative medicine,”22 and in 1965 at the commemoration of Lenin Hospital he said

21 Ibid. 22 Fidel Castro, “Speech Given at Medical Congress,” (speech given at medical congress, Havana, Cuba, February, 1963) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1963/19630225.html

19

“our medicine must become more and more preventative.”23 These ideas developed over time

and were repeated by other party leadership. In 1970, Dr. Heliodoro Martinez Junco, the Minister

of Public Health, gave a speech in which he laid out his vision of what preventative medicine

should be, saying that rather than focusing on disease and its treatment “health, adequate

anatomical and physiological forms, and their care are the elements that truly, from the scientific

point of view, constitute the basic principle of medical work.”24 Dr. Junco went on to rail against

what he called “traditional” medicine and even the western scientific establishment, saying that

traditional forms of diagnostics and treatment come from “a bourgeoisie imperialism that

deforms to such an extent that the world is harmed, despite the best instruments that it builds.”25

Preventative medicine then was meant to be the Cuban government’s answer to the capitalist

medicine that the government presented as lacking in both equality of access and best practices.

The distinction betweeen traditional and preventive medicine strengthened the connection

between public health programs and the new government, suggesting that not only was medicine

a part of the revolution, but that the revolution would be a part of the practice of medicine.

Government rhetoric presented an ideological outline for the public health program that it

promoted. Beyond this ideology, certain characteristics of state rhetoric promoted that program

in specific, revolutionary ways. The most basic aspect of the state’s narrative on public health

had to do with success. Articles and speeches emphasized above all the successful expansion of

care to rural populations. They did so first and foremost with statistics, citing the number of new

hospitals and beds constructed in recent years. Such numbers were repeated in articles regarding

23 Fidel Castro, “Dedication of Lenin Hospital,” (speech given at the dedication of Lenin Hospital, Holguin, Cuba. November, 1965) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1965/19651108.html 24 Dr. Heliodoro Martinez Junco, “Speech by Dr. Heliodoro Martinez Junco,” Granma Weekly Review, April 12, 1970 4. 25 Ibid.

20

mountain hospitals, a medical conference, and expanded dental care. Even as late as 1967,

Granma ran an article exclaiming that the public health budget for that year would be the biggest

in history. The article cited the construction of new hospitals with specific reference to the

number of beds now available, touted the number of new doctors being trained, and gave

statistics on cases of certain infectious diseases, namely malaria and diarrheic diseases, from

1961 to 1966.26 This reference to specific numbers was not limited to Granma articles, but also

appeared in party officials’ speeches. Addressing a graduating class of medical students, then

President Osvaldo Dórticos Torrado expressed pride in the specific number of graduating

medical students each year since 1960.27 In a speech to graduating students from a new

pedagogic institute in 1964, Fidel Castro discussed the rates of parasitism and cases treated at

various hospitals in the past year to emphasize the current state of public health.28 In each case,

numbers regarding specific programs demonstrated concrete successes of the public health

program and downplayed problems that may have existed with quality of care, availability of

materials, or other factors not easily represented with numbers. Statistics reflecting success

allowed the Cuban government to present consistent improvements in public health as part of the

revolutionary process.

Revolutionary rhetoric on public health was not limited to success in the present, but

instead framed the program as an ongoing one, with emphasis on goals for the future. Dr.

Heliodoro Martinez Junco gave a speech in 1970, in which he laid out a plan not only for

improving public health in general, but also talked at length about steps to reduce infant

26 Luis Baez. “1967 Public Health Budget – Biggest in History,” Granma Weekly Review, February 12, 1967, 9. 27 Osvaldo Dorticos Torrada, “Speech at Havana University School of Medicine Graduation Ceremony,” Granma Weekly Review, January 19, 1970. 28 Fidel Castro, “Graduation ceremonies for the Macarenco Pedagogic Institute and the Ana Betancourt School for Peasant Girls,” (speech given at Pedro Marrero Stadium, Havana, Cuba, December, 1964) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1964/19641206.html

21

mortality and complications at childbirth in the future. While praising the work that had been

done so far, Junco was most clear about his goals going forward, calling for a “new concept of

sterility, antisepsis, and asepsis,” as well as a “new concept of the obstetrician and the

gynecologist” to combat infant mortality from sepsis. The idea of pushing forward in light of

success appears throughout the state narrative on public health. Fidel Castro was succinct in his

1965 speech at the graduation of stomatologists from the University of Havana. After bringing

up the importance of stomatologists and mentioning the state of the practice before the

Revolution in the first paragraph of his speech, Castro noted “this does not mean we have

reached the goals for satisfying our needs; not at all.”29 Likewise, at a speech closing out a

medical conference in 1965, José Ramón Machado Ventura, Minister of Health from 1960 to

1967, drew attention to the need for better and more expansive pre-natal and neo-natal care while

still discussing the successes of the revolution.30 This focus on a continuing process, with

concrete, purportedly obtainable goals for the future, conveyed the idea that the revolution, both

in public health and at large, was ongoing. It implied that the revolution would continue to bring

advances of the kind already ascribed to it and, more broadly, that it was in the nature of the

revolution to constantly move forward and produce more results for the people as long as the

people continue to participate in it.

The state further defined its objectives and successes in public health not just by

discussing programs for the future but also by emphasizing a profound break with health

conditions and practices from before the revolution. Speeches and articles almost always made

29 Fidel Castro, “Stomatologists’ Graduation,” (speech given at graduation ceremony of school of stomatology, Havana, Cuba, June, 1965) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1965/19650619.html 30 Santiago Cardoza Arias, “We Shall Graduate 800 Physicians a Year from ’68 On – Machado,” Granma Weekly Review, September 11, 1966, 3.

22

reference to the severe lack of infrastructure and care that existed in the country, especially rural

areas, before the Cuban Revolution. Articles featuring mountain hospitals made special note of

such conditions. One said “when faced with an emergency they [rural people] had to resign

themselves to the worst.”31 Another took an equally dark tone, saying “our mountain people died

and their deaths didn’t even reach the statistical record.”32 Top party officials repeated this tone.

Fidel frequently referenced conditions before the revolution when talking about public health

achievements. He claimed that “up until 1958 the peasants completely lacked any medical

assistance,” and that institutions that did exist operated “often with a view towards profit.”33

Other party officials echoed these ideas. Dórticos, in 1970, described a situation where “doctors

concentrated themselves in the capital in search of more money, leaving public health in the rest

of the country abandoned.”34 In a speech closing a medical and dental conference at Baracoa, Dr.

Machado Ventura referenced “the almost total neglect of pre-natal care for women in the years

preceding the revolution.”35 The consistent reference to severe conditions prior to the revolution

is one of the clearest examples of the revolutionary government legitimizing the state through

rhetoric on public health. By asserting how poor conditions were before the revolution, the

government provided an argument for its own existence. Without us, these statements imply,

there would be little to no health care at all in the rural areas and the care that did exist would be

expensive and of poor quality. Therefore, the state must exist so that it can continue to provide

and improve health care for everyone. In fact, all discussion of the state’s achievements in health

31 Santiago Cardoza Arias, “A Mountain Hospital,” Granma Weekly Review, January 22, 1967, 10. 32 Mirta Rodriguez Calderon, “Mountain Hospital,” Granma Weekly Review, February 20, 1966, 5. 33 Fidel Castro, “Close of the XI Medical and VII Dental Conference,” (speech given at the XI Medical and VII Dental Conference, Havana, Cuba, February, 1966) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1966/19660227.html 34 Osvaldo Dorticos Torrada, “Speech at Havana University School of Medicine Graduation Ceremony” 35 Santiago Cardoza Arias, “We Shall Graduate 800 Physicians a Year from 1968 – Machado,” 3.

23

care have to be measured by conditions before the revolution, so it is natural for the state to

emphasize and even exaggerate those prior conditions.

The state of health before the 1959 revolution was a key talking point for the

revolutionary government and was generally depicted as being utterly deficient. Although health

care in Cuba before 1959 was lacking for much of the population, research by anthropologist

Katherine Hirschfield complicates the narrative that the state presented. Based on research

conducted in historical archives in both the U.S. and Havana, Hirschfield challenges the

assumptions that poor health conditions before 1959 were due primarily to U.S. intervention and

imperialism, and that the 1959 Revolution represented a radical departure from earlier models,

leading to “an immediate, dramatic improvement in health conditions for the majority of the

Cuban population.”36 Hirschfield’s research is thorough and significantly complicates and even

challenges the state’s narrative about health care before the revolution. It is important to note

such research because it is a reminder that what we see from the state is rhetoric, not reporting.

Their interest was in building a narrative that served a particular purpose and in that pursuit

history can and was at times adjusted or even re-written.

The state philosophy on public health was multi-faceted, encompassing the role of the

state, individual doctors, and the people at large in improving both access and quality of health

care. The role of doctors in the state’s vision was as professionals in service of the revolution and

their fellow man. Che Guevara defined a revolutionary doctor in 1960 in a speech to the Cuban

militia, saying that a doctor should be “a man who utilizes the technical knowledge of his

profession in the service of the revolution and the people.”37 Other sources elaborated on what it

36 Katherine Hirschfield, Health, Politics, and Revolution in Cuba since 1898 (New Brunswick: Transaction Publishers, 2007) 8. 37 Che Guevara, “On Revolutionary Medicine,” trans. Beth Kurti, (speech given to the Cuban milita, August, 1960) Che Guevara Internet Archive. https://www.marxists.org/archive/guevara/1960/08/19.htm

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meant to be a revolutionary doctor. In 1966, Dr. Raul Dórticos Torrada, Dean of Medical

Sciences at the University of Havana, gave a report to the XI Medical and VII Dental Congress

that explained the state of doctors’ training and asserted that “doctors must have a materialist

concept of life, a dialectic approach, and Marxist-Leninist philosophy.” The report went on to

say that the country must have “doctors who profoundly classify the practice of medicine as a

social function.”38 In 1962 Fidel Castro spoke of “a new concept of the function of doctor,” and

“doctors free of any spirit of selfishness and mercantilism.”39 The government had a clear vision

of a new kind of doctor in the public health system who would have Marxist thinking and would

carry out the state’s vision for revolutionary medicine on the ground. Doctors trained in the new

system were expected to believe in a Marxist concept of medicine and the state’s role in it. They

were also expected to carry out their profession in service of their fellow man and the revolution,

not themselves. Doctors thus had a significant role to play as committed vanguards and

practitioners of revolutionary public health.

Along with the call for doctors to be revolutionary came the call for mass participation in

the new public health program. In 1967, Dr. Machado Ventura, speaking to a meeting of

leadership of mass organizations, highlighted an individual who gave blood consistently every

three months as an exemple of a devoted participant in revolutionary health.40 Revolutionary

citizens were encouraged to participate actively in health campaigns. However, caring for ones

own health was also presented as participation in the revolutionary program. In an article about a

rural hospital, two and a half paragraphs were dedicated to an individual who was treated for an

injured hand but had not received his tetanus vaccine. The article said the nurse “could not

38 Osvaldo Dorticos Torrada, “Speech at Havana University School of Medicine Graduation Ceremony.” 39 Fidel Castro, “Speech at the Inauguration of the Basic Science and Pre-Clinical Institute.” 40 Oscar F. Rego, “Machado Ventura Concludes National CDR Conference on Public Health in Cuba,” Granma Weekly Review, January 29, 1967, 4.

25

understand how a worker could neglect getting something as simple and fundamental as a tetanus

shot.”41 Good sanitary practices were also presented as political participation. In an article on a

rural hospital, the author noted how “in this struggle [against ignorance] there is the help of the

increasing number of patients who have learned to trust their doctor.” The author also notes a

woman of some esteem in the community who was taught new hygiene techniques and then

asked to spread them to the people.42 Individuals therefore had a role to play in the state’s vision

for a new public health system. Regular citizens were expected to educate their neighbors,

organize themselves into public health enterprises, and help monitor each other’s health, all

under the guidance of the government. The new public health system was meant to be a personal

concern for individuals who were expected not only to benefit from it but to facilitate its

implementation.

Marxism was a formative principle for the Cuban public health system. However, Cuba

was not the first country to apply Marxist philosophy to public health. Eastern bloc countries had

been working on the idea for many years before the Cuban Revolution and had, in fact, already

developed a working system for how Marxist health care might be implemented. There was

significant collaboration between those countries and Cuba, in the form of exchange of

equipment and personnel. Lenin Hospital, completed in 1965 with the help of the Soviet Union,

had “an important part of its medical equipment donated by the Soviet Union, and even had part

of its staff comprised of Soviet doctors.”43 It is likely that with that exchange came significant

collaboration on policy as well. A 1962 publication by the Czech government titled

“Czechoslovak Health Services” gives a brief but detailed overview of the Czech health system.

41 Santiago Cardosa Arias, “A Mountain Hospital.” 42 Ibid. 43 Jose Vazquez, “Lenin Hospital: Modern Medical Center,” Granma Weekly Review, October 23, 1966, 7.

26

The similarities between the two programs are striking, and suggest if not collaboration between

the two countries, at least the following of an established model. Like the Cuban system, the

Czechs organized their public health under one Ministry of Public Health that coordinated all

care in the country and carried out its administration through regional offices. The Czech system,

like the Cuban one, had preventative medicine as a central tenent. Furthermore, the Czech

system considered hygiene and saintary education as “an integral part of the work of everyone

employed in public health service.” Such education was carried out not only by health workers

but by popular organizations and state-run media outlets, just as in Cuba. Popular organizations

such as the Czechoslovak Red Cross Society, the Trade Union Work Safety Commissions, and

other citizens’ groups were involved in blood drives, education, and other grass-roots health

campaigns, analogous to the role of the Committees for the Defense of the Revolution and the

national Red Cross in Cuba. Special emphasis was also given in Czechoslovakia to caring for

pregnant women and infants in an effort to reduce child mortality. There was even an emphasis

on hospital construction and an inclination to back up claims with statistics involving the

increased number of hospital beds and improving health metrics.44 These similarities likely go

beyond a mere convergent evolution of Marxist medicine and instead suggest that Cuba was at

least to some degree influnced by the Czech model. Given that there was already collaboration

on projects such as the polio campaign and Lenin Hospital between Cuba and the Eastern Bloc it

would not be a great leap to say that there was at least some collaboration between Czech,

Soviet, and Cuban officials in developing a public health system.

Cuban state rhetoric presented public health as a fundamental aspect of the revolution.

Specific rhetorical techniques, including the use of statistics, a narrative of ongoing success,

44 Zdenek Stich, “Czechoslovak Health Services,” (Prague: Ministry of Health, Czechoslovak Socialist Republic, 1962)

27

critique of the prior administration, emphasis on preventative medicine, encouraging mass

participation, and promoting doctors with revolutionary attitudes, worked to present public

health as a successful revolutionary endeavor. This idea gave legitimacy to the new government

and its ideology, since health care was now inextricably bound up in that ideology. Furthermore,

state rhetoric provided a framework and a justification for the programs and policies that the

government implemented to improve public health. Those programs should therefore be

understood in the context of rhetoric and ideology. However, the real needs and challenges of the

Cuban people also shaped those programs, and at times modified or challenged the state

narrative.

Chapter 2: Public Health in Practice

After walking for two hours, across unfamiliar paths, Dr. Gabriel José Toledo Curbelo,

Maquila his escort and head of the local militia, and the peasant that had summoned them in the

night, arrived at a shack, surrounded by twenty or so troubled and animated people. Crying

children were scattered among the crowd. The shack was small, with just one room and dirt

floors. In one corner of the room was an old bed, and on it was a thirty five to forty year old

woman in labor. Attending her was a short, black woman who identified herself as the midwife

for the area. She had been attending the birth since six that afternoon. It was close to one in the

morning. Dr. Curbelo examined the woman by lantern, the only light source in the house. The

baby was coming feet-first, and the midwife had overseen just five births before this, all without

complication. The doctor himself was fresh out of medical school and had, by his estimate, only

participated in 60 births, none of which had been similar to this one. In just half an hour, the

doctor completed the most challenging delivery of his life, with no instruments, electric light, or

basic medications. He sanitized a pair of rusty scissors in boiling water and used them to cut the

28

umbilical cord. He sutured the end of the cord with a candle wick, likewise sanitized in boiling

water. Both the mother and child were healthy and the doctor made the long journey back to his

home at La Isabel clinic in a rural part of Matanzas province, Cuba. 45

For the Cuban government, supporting the physical wellbeing of all citizens through

public health was a part of the very nature of the revolutionary state. To this point, this paper has

looked at how government rhetoric understood (or at least wanted its people to understand)

public health and the state’s role in it. The purpose of this chapter is to look beyond that rhetoric

at the actual steps taken by the government and individuals on the ground to realize the

government’s vision of a public health program in the early years of revolutionary Cuba.

Although public health was overhauled throughout Cuba, the focus here is on the rural parts of

the country and the Rural Medical Social Service. Rural Cuba is a useful case because in many

ways it was the lynchpin of the revolutionary program. Care was most lacking in the rural parts

of the country before the revolution and it was the expansion of care to these populations that the

government emphasized most when promoting a narrative of success about public health. Rural

Medical Social Service was a program in which recent medical school graduates were compelled

to work in the countryside as primary care physicians for the rural population. The program was,

in essence, the freely available medical care promised by the revolutionary government. Using a

collection of memoirs, written by rural service doctors and compiled by the Ministry of Public

Health, this chapter examines some of the strategies that these doctors used to improve public

health, and how those strategies were guided not only by government rhetoric but also by the

challenges inherent in improving health standards in rural Cuba. First, however, it is important to

45 Dr. Gabriel José Toledo Curbelo. “Recuerdos de Médico Social Rural” Cuadernos de la Historia de la Salud Pública 116 (2014). Web. http://bvs.sld.cu/revistas/his/his_109/his02109.htm

29

understand the revolutionary context in which rural service doctors were educated and how that

context may have informed their thinking and practice.

I. Medical Education

To form a new kind of medicine, a new kind of doctor needed to exist in Castro’s Cuba.

To that end, the plan of study for medical students underwent frequent changes from 1959 to

1969 in order to integrate state ideas on revolutionary doctors and medicine. The plan of study

was first adjusted in 1959 and again in 1960. The plans of study for 1959 and 1960 were roughly

the same and strayed little from traditional medical subjects, the notable exception being the

inclusion of preventative medicine as a course for 6th year students. The major shift towards

revolutionary education came in 1962 and 63 when reforms were implemented across higher

education that included a new course of study for the medical school. The new program included

three semesters of dialectical materialism, two semesters of political economy, and one semester

of organization of public health and the history of medicine. Another noteworthy change from

this period was the shift from a seven year program to a six year one, with the sixth year being

devoted entirely to internship in a hospital. The program was adjusted again in 1966, now

including one semester each of historical and dialectical materialism, two semesters of

organization of public health, and one semester with ten hours per week of preventative

medicine. Interestingly, the program also included three semesters of English, so that newly

graduated doctors could read international medical journals.46 These courses indicated a clear

intent to include Marxism and the state line in medical education. Courses such as dialectical

materialism and preventative medicine would have encouraged medical students to think about

46 Gregorio Delgado Garcia, “Planes de estudios de la carrera de medicina de 1959 a 1966 y cambios en el profesorado,” Cuadernos de la Historia de la Salud Pública, 107 (2010) http://bvs.sld.cu/revistas/his/his_107/his06107.htm

30

themselves and their work as being in service of the revolutionary process and their fellow

Cubans. Whether or not such lessons took hold in the hearts of the students is hard to say and

certainly varied from doctor to doctor. However, it is clear that the state implanted its vision for

revolutionary doctors into the medical school program and it is likely that this education had at

least some impact on how newly graduated doctors approached their work. It was especially

important for the government to develop doctors who would be loyal to revolutionary ideas

because of the massive flight of doctors that took place in Cuba following the 1959 revolution.

In first few years following the 1959 revolution nearly half of the roughly 6,000 doctors

in Cuba fled the island. The one medical school in the country, the University of Havana, was

not spared. By 1962 only 23 of the over 100 professors that held positions in 1959 remained in

their jobs. Of the professors who left the school, 61 were directly or indirectly forced out by

government action, some on the grounds that they “constituted an obstacle in the application of

reform.”47 Almost 30 professors renounced their positions voluntarily and 44 retired ostensibly

due to age. Of the remaining 23, six more fled the country within the next few years, leaving just

17 professors from before 1959. 53 new professors were hired in 1960 and another 73 came in in

1962.48 The almost complete turnover of the professorship at the University of Havana was a

significant factor in the formation of the doctors that carried out the revolutionary health plan.

Professors who were hired to replace the fleeing doctors were young and believed in the

government’s vision. In interviews conducted in 2002 as part of a day of celebration for health

workers, professors who were hired around the time of the revolution recounted their reasons for

47 Roberto Guerra Valdés, qtd in “Planes de estudios de la carrera de medicina de 1959 a 1966 y cambios en el profesorado” Cuadernos de la Historia de la Salud Pública 107 (2010) http://bvs.sld.cu/revistas/his/his_107/his06107.htm 48 Gregorio Delgado Garcia, “Planes de estudios de la carrera de medicina de 1959 a 1966 y cambios en el profesorado.”

31

becoming professors and staying in Cuba. Dr. Raimundo Llanio Navarro said that once the

Revolution triumphed he “decided to contribute my knowledge and unconditional support to

make the dreams of those valiant fighters a reality.”49 Dr. Gloria Varela Puente said she was

filled with Revolutionary fervor after January 1st, 1959 and applied for a professorship after the

massive flight of professors in 1959 and 1960. Dr. José López-Sánchez, who graduated medical

school in 1938, said he always had the ambition to be a professor but his militant communism

prevented it.50 The effect of this almost complete shift to professors favorable to the revolution

was profound. The medical professorship became a pillar of support for the government’s

revolutionary vision. Doctors who filled the new public health system were educated by these

revolutionaries according to a revolutionary program. Thus, beginning in 1960, the medical

profession, which at the start of Castro’s regime abandoned the country en masse, was developed

into a vanguard class for the new public health system and by extension the revolution itself, just

as described by the revolutionary rhetoric.

II. Rural Medicine

Doctors that graduated from the new medical school program were compelled to go into

service for the revolutionary government for a period of roughly (it varied as the program was

being developed) two years following graduation. This could mean working as doctors in

factories, on collective farms, or (a few years later) in international service. A great number of

recent graduates served their time in the Rural Medical Social Service. The Rural Medical Social

Service was put into place by Fidel Castro’s government in 1960. The program placed recent

medical school graduates into remote rural zones to work as primary caregivers for the residents

49 Infomed, “Jornada de Homenaje al Trabajador de la Salud del 27 de Noviembre al 3 de Diciembre 2002, Personalidades,” Ministerio de la Salud Pública, Last modified May 12, 2002. http://www.jornada.sld.cu/reportajes.html 6 Ibid.

32

there. Some rural doctors were stationed at hospitals, while others had only small clinics. These

doctors provided free medical care to the rural communities and were often the only trained

doctors in wide reaching areas. Rural service doctors staffed the clinics and rural hospitals that

were being constructed all across Cuba. Along with their counterparts in neighborhood

polyclinics in the cities and suburbs they were the front lines of free and available medical care

in Cuba; the reality behind the rhetoric. These doctors were educated in the new, Marxist system

by professors who remained loyal to the Castro government after the revolution. For this reason,

many of them thought about their own work in a revolutionary way and attempted to bring

revolutionary principles to the way they practiced. These attitudes led to an essential intersect

between the state narrative on public health and the way it was practiced on the ground. The

details of the rural service doctors’ experiences shed light on what the state’s vision for public

health meant in real terms, on the ground among the rural peoples of Cuba.

In 2014, the Cuadernos de la Historia de la Salud Pública, (Journals of the History of

Public Health) a publication of the Cuban Ministry of Public Health, collected the recollections

of five doctors who served in the Rural Medical Social Service in the early 1960’s. The five

doctors had a variety of experiences from working alone in a clinic to working in a 100+ bed

hospital. All, however, entered the program immediately after medical school and were stationed

in a rural zone for periods ranging from six months to two years. The recollections were recorded

in or around 2014. A few subjects, themes, and characteristics were common to each narrative.

Taken together they build a picture of what free and available health care actuallly meant in the

rural parts of revolutionary Cuba. The doctors’ work reflected the most prioritized goals of the

revolutionary government’s health program. These included hygiene and sanitary education,

prevention of infectious disease, and care for expecting and recent mothers. Each doctor talked

33

specifically about what they did to work towards those goals and how their work fit into a

broader national plan. Some of the key obstacles to public health in early revolutionary Cuba

also come through in the doctors’ memoirs. These included a persistent lack of basic supplies

and staff, inexperience among young rural service doctors, and well as poor infrastructure that

inhibited movement of doctors and patients alike. Understanding the details of this service lets us

understand how the government’s rheotric on public health presesented itself in practice and how

that narrative shaped and was shaped by the experiences of doctors on the ground.

The doctors chosen to give recollections for the Journal of the History of Public Health

had lifelong careers in the Cuban medical system and strong favor with the communist party. For

this reason their recollections line up with the state idea that doctors should practice their

profession in service to their fellow Cubans and the revolution. Dr. Humberto Cabrera was

explicit about his ideas about service, saying “the compassion for all those people forgotten for

centuries gave us the strength and courage to make bold decisions.”51 Other doctors were no less

explicit in how they saw their role. Dr. Curbelo described “the doctors that were incorporated in

the process of revolution, that represented the forces of progress, the revolutionary forces in that

forgotten village.”52 All of the memoirs to some degree or another contain revolutionary

thinking. The fact that they fall along socialist lines is important because it means that the

memoirs themselves are a part of an ideological narrative. They are unique from other state

narratives in that they are written about personal experience, rather than general goals or

programs the way newspapers or official speeches were. The memoirs therefore provide a useful

51 Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa. Oriente Sur,” Cuadernos de la Historia de la Salud Pública. 116 (2014) http://bvs.sld.cu/revistas/his/his_109/his06109.htm 52 Gabriel Jose Toledo Curbelo “Recuredos de Médico Social Rural.”

34

halfway point, showing both how the state narrative interpreted certain specifics of medical

practice and how that practice helped build the state narrative.

III. Targetted Practice

Rural service helped explain the specific public health goals that constituted the government’s

program. Decreasing the rates of certain infectious diseases was a key goal of the new public

health system and was mentioned frequently in public discourse. The term ‘infectious disease’

referred to a wide range of targetted diseases, including polio, tetanus, diphtheria, malaria,

diarrheic disease, and parasitic diseases. It was not uncommon to see successes with these

diseases folded into the government’s broader narrative on health. It is likely that this was a case

of conditions on the ground informing narrative, since infectious disease is a common cause of

death in developing countries.53 Diarrheic diseases and parasites were targeted first and foremost

through sanitary education. Dr. José Toledo Curbelo talked about a lack of basic hygiene

education among the rural population he worked with in 1960, saying they “did not know the

dangers of going without shoes … the necessity of boiling drinking water, or to carefully wash

food that is consumed raw.” To combat the problem, Dr. Curbelo started a bi-weekly seminar in

a local schoolhouse where he would talk to locals about hygiene and good health practices.54

Work like this, combined with state media constituted the hygiene education that was talked

about on the national level and helped bring about improvements in rates of infectious disease.

Dr. Curbelo combatted parasitic and diarrheic disease in another way as well. He ordered

new latrines for the community. In his memoir the process was presented as seamless and

collaborative. He asked the informal head of the community to take a survey of all of the homes

53 “The Ten Leading Causes of Death by Broad Income Group,” World Health Organization Fact Sheet. February, 2007. http://www.who.int/mediacentre/factsheets/fs310.pdf 54 Gabriel José Toledo Curbelo. “Recuerdos de Médico Social Rural.”

35

and determine how many latrines were needed. The latrines were ordered from the government,

delivered by the army, and constructed by the community all within about fifteen days.55 On one

level we see here a concrete way in which the rural service doctor worked towards achieving the

revolutionary government’s stated goals in public health. Latrines were needed because they

helped reduce the rates of parasitic diseases, so they were installed. However, we can also see a

convenient narrative come up around that practice that that reflects the government’s vision of a

revolutionary society that could go to work for rural people. The rural service doctor, sent from

Havana in service of the rural community, learned of a need by working closely with the people.

He then collaborated with the local community leader and communicated the need to the central

government. The Revolutionary Army delivered on the need, and the community worked

together to construct their new latrines. The lines between rhetoric and practice are thus blurred,

leaving us with a narrative that describes practice just as much as that practice served to support

a revolutionary narrative of success.

Another key goal of the revolutionary government was improving maternal and neo-natal

care. Rural service doctors’ recollections reflected this goal. Many of the writers described

delivering babies, especially in adverse conditions. One doctor described a woman who had

unexpected twins because she had not been for a consultation before going into labor. The same

doctor described a girl who he referred to a larger hospital in Barracoa, but who came back a

month later without having gone and who had stopped coming for consultations in her last month

of pregnancy.56 Dr. Curbelo’s story of delivering a baby in a shack in the night is also

representative of the some of the problems pregnant women faced at the time and the way the

55 Ibid. 56 Hector Vera I. Acosta, “Donde Los Hombres se Crecen,” Cuadernos de la Historia de la Salud Pública 116 (2014) http://bvs.sld.cu/revistas/his/his_109/his03109.htm

36

state understood them. Rural service doctors followed the state’s goal on problems with births of

improving care for expectant mothers and increasing hospital births almost to the letter. In doing

so they achieved some improvement in infant mortality. Other government programs also

targetted infant mortality and maternal health to some success.

Maternity homes were a government program that was established in the early 1960’s.

These were government-run homes that provided a place for expectant mothers who lived far

from a hospital to stay in the last few weeks of pregnancy. The homes meant that the mothers

could be observed and cared for and could get to the hospital quickly once they went into labor.

This was a real government program that did work towards the stated goal of improving maternal

safety and care. However, the program was still placed in a revolutionary narrative. A

revolutionary publication described the houses as a case of “from the necessity arose the

institution,”57 a popular rhetorical device for explaining the ability of socialism to meet the needs

of the people. In this way, the maternity home program was represented in terms of the

revolutionary narrative. They also were a case of the application of preventative medicine, since

they provided a safe community space to promote health rather than simply treat sickness.

Maternity homes thus lent power to state narratives about improving the health and wellbeing of

rural people. However, this rhetorical process did not necessarily detract from the fact that the

program existed and made real improvements in some peoples’ lives. Although rhetoric was at

times almost impossible to separate because of the nature of the Cuban government’s reporting

on public health, we can still appreciate how the two together constituted a program that did real

work in the direction of improving infant mortality and care for expectant mothers. This does

57 José Gil de Lamadrid, “Hogar de Maternidad. ‘La Bonita.’ Centro Piloto para Atención Pre-Materna en Camagüey,” in Cuadernos de la Historia de la Salud Pública, ed. José A. Gutiérrez Muñiz and Gregorio Delgado García. 101 (2007), originally published in Revista Bohemia. 56 (21). May 22, 1964. http://bvs.sld.cu/revistas/his/his_%20101/his11101.htm

37

not, however, mean that government rhetoric did not at times under-represent or outright conceal

real challenges or shortcomings in the public health program.

IV. Challenges

Rural service doctors were enlisted in the program immediately after medical school.

This meant that although they received some practical training in teaching clinics, none had

experience practicing on their own. One doctor wrote that he had studied hard and had a good

academic record for a class of 600 that had begun studying in 1950 (the University of Havana

was closed by Batista from 1956 to 1959 to suppress revolutionary activity58). However, he

admitted “the reality was that, in practice, I had never given consults, at least not alone, and I had

never been confronted with many patients at once.”59 Although not every doctor was as explicit

in addressing their inexperience, they were all recent graduates. One began his memoirs by

recalling his graduation ceremony.60 Another described being the first group to graduate from the

new six-year plan of studies.61 Regardless of their exact descriptions, the doctors make no effort

to hide the fact that they are recent medical school graduates with little clinical experience. This

made their time in Rural Service a learning experience for them, but made care-giving

challenging, causing episodes where inexperience could have put patients at risk.

Almost every recollection of rural service has a moment where the doctor was faced with

a situation they were not qualified to treat. Dr. Doris Rodriguez Bello described treating a young

man who came in with a dislocated shoulder from a soccer game. She had to look up the

58 Universidad de la Habana, “Historia de la Universidad de Habana,” last modified March 18, 2013. http://www.uh.cu/node/13 59 Gabriel Jose Toledo Curbelo “Recuredos de Médico Social Rural.” 60 Hector Vera I. Acosta, “Donde Los Hombres se Crecen.” 61 Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa. Oriente Sur,” Cuadernos de la Historia de la Salud Pública, 116 (2014) http://bvs.sld.cu/revistas/his/his_109/his06109.htm

38

procedure in a book. The patient told her after that it seemed like an easy treatment, but Dr. Bello

wrote “this surprised me too, I had no prior experience, and so I breathed a sigh of relief that

time. I was very happy I had brought my books.”62 Dr. Humberto Sainz Cabrera spoke more

generally of the broad range of medicine he had to practice, often with little experience to guide

him. Speaking of his medical group from 1963 to 1965 he wrote “we sutured wounds of every

type, attended birthing complications … performed, between everything, operations from head to

foot … with very good results taking into account our level of knowledge.” He went on to say,

though, that “the love of the profession and compassion for that population forgotten for

centuries gave us strength and courage to make bold decisions and to learn treatments that we

never would have realized staying in the city hospitals.”63 In both cases the doctors provided a

narrative of overcoming their inexperience through dedication to the work and revolution. Dr.

Acosta even says that he had no training in births in his internship and had to learn them while in

rural service.64 Dr. Cabrera says explicitly that rural service is where “we were formed as men,

as doctors, and as revolutionaries.”65 These narratives thus reflect a state ideal, in which rural

service doctors, though inexperienced, learned from practice and became better revolutionaries

and doctors. Although the doctors involved can point to instances of this happening, one should

look critically at the idea that the inexperience of these recent medical school graduates was

overcome in all cases. In fact, these graduates were often placed in charge of rural service areas,

or left with only one or two other doctors. Almost all of them had limited resources and

62 Doris M. Rodriguez Bello, “Vivencias de mi participación en la primera misión médica rural del primer grupo de graduados en el año 1960,” Cuadernos de la Historia de la Salud Pública, 116 (2014) http://bvs.sld.cu/revistas/his/his_109/his04109.htm 63 Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa. Oriente Sur.” 64 Hector Vera I. Acosta, “Donde Los Hombres se Crecen.” 65 Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa. Oriente Sur.”

39

assistance, and none had clinical experience beyond internships in medical school. Their

memoirs (which were produced for a MINSAP publication) don’t discuss this inexperience

outside of a narrative about learning and growth. However, in 1970 a major shift in public health

was carried out and one of the cited reasons for it was inexperience and high turnover among

rural doctors.66 Therefore, although the state encouraged a narrative of learning from experience

among the people, in practice the idea had serious shortcomings that ultimately led to an

overhaul in rural medicine. Other shortcomings in the early years of the program were dealt with

by rhetoric in different ways.

Staffing and equipment at rural medical stations were often limited. Dr. Curbelo had only

two assistants in his small consultorio (clinic) and neither were medically trained. He also had

almost no medical equipment when he first arrived and had to be stocked a few weeks later. His

clinic did not even have consistent electricity for the first four months, until a small plant was

constructed to power the town and clinic.67 Dr. Hector Acosta likewise worked with intermittent

power outages in his rural hospital in 1964.68 Other doctors who served later and in bigger

settings had access to more resources, but never enough to completely cover the needs of the

community. Dr. Pedro Rodríguez Hernandez was assigned to a rural hospital with twelve beds

and worked with just one other doctor in 1962.69 Dr. Humberto Sainz Cabrera was assigned to a

rural hospital with 120 beds in 1963 that was meant to serve over 80,000 potential patients. He

worked with seven other doctors, and a set of nurses. Each doctor had a specialty and oversaw

66 Shawn P. Brotherton, “Health and Healthcare: Revolutionary Period (Cuba)” Cuba 1 (2009). 67 Dr. Gabriel José Toledo Curbelo, “Recuerdos de Médico Social Rural.” https://www.academia.edu/1129995/Health_and_Health_Care_Revolutionary_Period_Cuba_ 68 Dr. Héctor I. Vera Acosta. “Donde Los Hombres se Crecen” Cuadernos de la Historia de la Salud Pública V. 116: 2014. Web. 69 Dr. Pedro Rodríguez Hernández. “El Médico en Imias: Pinceladas del Servicio Médico Rural.” Cuadernos de la Historia de la Salud Pública. V. 94: 2003. Web.

40

their corresponding departments.70 Regardless of scale staffs were limited by available

personnel. A national shortage in trained staff limited the quantity and quality of care that rural

clinics could provide. To address this, government officials emphasized the training not just of

doctors but of technicians. Castro said in 1962 “and our country will, very soon, have ore

technicians than any country in Latin America.”71 Although government rhetoric was quick to

present overwhelming progress in training new technicians, there was virtually no discussion of

the shortages that caused this need. A succes narrative was promoted, but real problems facing

the clinics in the moment were ignored. This can explain why equipment shoratges, which

proved more challenging for the government to overcome, were discussed very little in both

official rhetoric and rural service memoirs. The case of staffing and equipment shortages thus

serves as a useful reminder that while the government’s narrative was often informed by real

successes, it was ultimately a tool of the revolution and could be edited to suit this end at the

expense of a complete and accurate picture of the health program.

Rural Service was, by definition rural. The program stretched across Cuba and many areas where

doctors were sent were extremely remote. Almost every rural service memoir contains some

description of the journey the doctor took from Havana to their destination. Dr. Hector Acosta

wrote about going by bus from Havana to Santiago and then by jeep to Guantanamo, finally

resting after a 24 hour journey.72 Dr. Cabrera wrote of“an incredible journey over a path covered

in ravines and precipices that lasted more than seven hours.”73 Other doctors had similar

70Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa. Oriente Sur.” 71 Fidel Castro “Inauguration of the Basic Science & Pre-Clinic Institute,” (speech Given at the Inauguration of the Basic Science & Pre-Clinic Institute, Cubanacan, Cuba, October 1962) Castro Speech Database. University of Texas. http://lanic.utexas.edu/project/castro/db/1962/19621018.html 72 Hector Vera I. Acosta, “Donde Los Hombres se Crecen.” 73 Dr. Humberto Sainz Cabrera, “Memorias del Servicio Médico Social Rural. Período 1963-1965. Municipio de Baracoa, Oriente Sur.”

41

accounts of a long and perilous journey. Regardless of the details, the journey was usually

twenty four hours or more and crossed difficult terrain. The emphasis on the remoteness of rural

medical posts gave the sense that the doctors were bringing medicine to a distant and untouched

society. This falls in with the government’s idea that the rural regions were devoid of any proper

standard of care. It also suggests the very real challenges faced by the government in bringing

care to the most remote parts of Cuba. Furthermore, the actual distance of these populations from

the metropolis meant that rural service doctors were in some ways envoys of the revolutionary

government. They were bringing free medical service of a kind that had not been seen before in

these distant parts of the country, making them important representatives of what the revolution

could do for populations that had little connection to politics in Havana. It was not only doctors

though that had trouble reaching their destination, patients too often faced long journeys, despite

the fact that the clinics were established specifically to bring medicine closer to them.

While some patients lived relatively close to the new clinics, many would have to come a

long way by foot or by horse if they could spare one. One doctor covered patients in an area of

40 kilometers and many did not have means to reach the clinic.74 If patients were seriously ill,

they could be carried by hammock by as many as ten men for as far as 2 ½ miles.75 The clinics

often had a jeep that acted as an ambulance, but it was frequently in spotty condition. A doctor

recalled “patients that had some illness that prevented them from walking would be brought to

the hospital by any vehicle they could find.” If a vehicle was unavailable, a stretcher was

constructed and the patient would be carried.76 Doctors would also to travel to reach patients who

74 Doris M. Rodriguez Bello, “Vivencias de mi participación en la primera misión médica rural del primer grupo de graduados en el año 1960.” 75 Pedro Rodríguez Hernández, “El Médico en Imias: Pinceladas del Servicio Médico Rural,” Cuadernos de la Historia de la Salud Pública, 94 (2003) http://bvs.sld.cu/revistas/his/cua_94/his0994.htm 76 Hector Vera I. Acosta, “Donde Los Hombres se Crecen.”

42

lived in more distant parts of their area. One doctor would make monthly trips to a cooperative

about two hours away to check up on workers there.77 Regardless of the specifics, the unifying

theme was remoteness. This remoteness lends some credence to the government claim that

before the revolution there was little care available to these hard-to-reach rural peoples and

presented a real challenge to bringing medicine too them.

Although staffing, supplies, and even electricity were often short, rural service doctors in their

memoirs frequently point out that they never lacked basic medicine. Dr. Pedro Hernandez noted

that in 1962, due to the American embargo “in Cuba there was a lack of many medicines that

traditionally came from capitalist areas and that we were quickly substituting for others, or

importing primary materials and developing our pharmaceutical industry. In Imias in 1962,

innovations were arising like in the rest of the country and there was never a lack of a basic

medicine.”78 Dr. Hector I. Vera Acosta said that medicine was ordered monthly from a medical-

dental cooperative and “there were neither quantitative nor qualitative limits, and we never

lacked any medication.”79 Even Dr. Curbelo, who lacked some basic equipment said the

medicine cabinet was well-stocked with basic medicines.80 It’s difficult to evaluate these claims

objectively, since they fall in line with claims made by the Cuban government. However, it is

likely that support from the Soviet Union and other Eastern Bloc countries was important to the

continued presence of necessary medicine. Vaccines for the anti-polio campaign that began in

1962 were manufactured in Russia and sent via Czechoslovakia.81 While this is only one case, it

indicates a policy of importing medicine and supplies and suggests the beginning of reliance on

77 Dr. Gabriel José Toledo Curbelo, “Recuerdos de Médico Social Rural.” 78 Pedro Rodriguez Hernandez, “El Médico en Imías: Pinceledas del Servicio Social Rural.” 79 Dr. Hector I. Vera Acosta, “Donde los Hombres se Crecen.” 80 Ibid. 81 “Vacunación Antipoliometica en Cuba.” Tribuna Médica de Cuba. 24(470-5) (1962) 16–27.

43

eastern bloc allies for such medicine. Therefore, although the government and doctors were

reporting a state of plenty, this may have been heavily predicated on support from the U.S.S.R.

The state narrative however was often more interested in emphasizing success through

commitment, revolutionary practice, and local development and therefore the role of Eastern

European support was often downplayed or omitted from public discourse. This pattern is

studied more closely in the next chapter, which looks specifically at the campaign to eradicate

polio.

Rural medical service in Cuba was the point of intersection between the government’s

rhetoric on public health and its application on the ground. Rural Service doctors were the free

medical care that the Cuban government promised in rural Cuba and were therefore a

cornerstone of the revolutionary health program. They carried out key programs such as hygiene

education, maternity care, and preventative policies targetted at infectious disease that brought

about real gains in public health in Cuba. Their experiences also revealed some of the challenges

faced by that same program, including inexperience among rural doctors, the remoteness of

many populations of rural Cubans, and limited availability of well trained staff and medical

supplies. By looking at these experiences in the context of government rhetoric we can see the

essential details that brought success to the Cuban health program. We can also see how practice

at times informed rhetoric while rhetoric guided how doctors and even patients thought about

medical care and the way they carried it out. While widely distributed doctors and targeted

programs were the basic instruments for the success of public health in early revolutionary Cuba,

these programs would not have been possible without broader political and social structures to

support them. The next chapter looks at these structures through the lense of the vaccination

campaign against polio which began in 1962 and continues to this day.

44

Chapter 3: Polio Eradication in Revolutionary Cuba

In 1962 the Cuban Ministry of Public Health (MINSAP) began an ambitious vaccination

campaign against polio. Eighty percent of Cuban children were to be vaccinated in two separate

doses, each over a two week period. Children lined up at schools and mothers brought their

infant children to the nearest infirmary. Children two and over took the vaccine in the form of a

candy. Infants under the age of two received drops of vaccine suspended in sugar solution

administered by a doctor or nurse. During the first two-week campaign almost ninety percent of

Cuban children from Havana to the Sierra Maestra lined up at schools, community centers,

policlinics, and hospitals to receive the first dose of vaccine.82 The second dose was administered

four weeks later with similar success. The program continues to this day. Studies conducted by

the Cuban government and reviewed by the American inventor of the vaccine suggest that polio

virus transmission ceased by 1967. No studies by any organization have detected wild polio virus

in Cuba since 1970 and the World Health Organization declared Cuba the first country in the

western hemisphere to completely eradicate the disease in 1994.83

The campaign to eradicate polio is noteworthy because it sheds light on some of the key

political and social structures that made the revolutionary government’s health program unique.

It is particularly useful to look at the polio campaign because the strategies used to implement it

were well documented at the time. The two central pillars of the program were the national

Ministry of Public Health which monopolized planning and administration of the vaccination

program, and mass organizations made up of volunteer civilians which worked under the

direction of the federal government and carried out education and distribution on the community

82 “Vacunación Antipoliomielitica en Cuba,” Tribuna Medica de Cuba, 24 (470-5) (1962) 16–27. 83 Enrique Beldarraín, “Poliomyelitis and its elimination in Cuba: An Historical Overview,” MEDICC Review, 15 (2) (2013) 30.

45

level. The system was supported by intense collaboration with the U.S.S.R. and the rest of the

Eastern bloc. Starting with the administration of the campaign we can break down its key

characteristics and use them to see how each of these organizations allowed the Cuban

revolutionary government successfully built a new public health system from the ground up.

The Cuban Ministry of Public Health organized and oversaw the vaccination campaign

against polio in 1962. Several high-ranking MINSAP officials were part of this committee. This

included the sub-secretary of hygiene and epidemiology, the president of the national medical

school, and the president of the national red cross, and representatives from mass organizations

such as the Committees for the Defense of the Revolution and the Federation of Cuban Women.

They planned and oversaw the campaign on the national level.

Similar committees concurrently existed at both the regional and municipal levels.

Committees at each level consisted of the director of public health for the region, other high

ranking public health officials, representatives from mass organizations, and a representative

from the department of education. Regional committees were responsible for the storage and

distribution of the vaccine while municipal committees coordinated the work groups that

administered it. These problems were regional in nature and effectively handled by regional

planners. However, all work regarding policy or planning remained in the hands of the central,

national committee.84 This division of responsibilities supported a powerful central public health

authority with regional subsidiaries performing various specialized functions. Rather than

autonomously planning or administering the campaign, regional committees were responsible for

local storage and distribution networks. This suggests that management of the public health

system was more or less consolidated in the national Ministry of Public Health in Havana.

84 “Vacunación Antipoliomielitica en Cuba.”

46

Regional and municipal organizations performed auxiliary functions and dealt with conditions

specific to their region but had very little autonomy in terms of actual policy making. The

distribution of responsibility in the polio campaign was a manifestation of the idea that the

revolutionary government would take responsibility for the health of the population. What that

meant in practice was the consolidation of power over health in the hands of the national

government. There was no autonomous unit of care beyond the Cuban revolutionary state in

administering the campaign and in the health system in general. Powerful, centralized control

over all aspects of health and health policy allowed for the tight coordination of a large-scale and

complex system and helps explain its success. This powerful government institution was

complemented by mass organizations made up of civilian volunteers that brought community

level health care under government control.

Mass organizations, including Committees for the Defense of the Revolution (CDRs), the

Federation of Cuban Women (FMC), and the National Association of Small Farmers (ANAP)

were an important organizing tool for the Cuban revolutionary state. They were made up of

volunteers from every part of society and were tasked with supporting the revolution through

neighborhood projects and surveillance of political activity on the community level. Mass

organizations were represented in the polio campaign on the national, regional and local

coordinating committees. The organizations were responsible for registering every child in their

respective region from one month to fourteen years of age on vaccination cards. These cards

were given to every family in the area on a one per child basis to be brought to the site of

vaccination. When the child received the first and second dose, it was marked on the card. At the

end of the campaign, the mass organizations collected the cards and compiled final statistics on

the distribution of the vaccine. Mass organizations were also responsible for spreading

47

information about the vaccine and the “creation of a popular conscience about the benefits of the

campaign.”85 Mass organizations were thus the point of contact between Cuban families and the

national campaign against polio. These organizations were made up of average Cubans that

participated on a volunteer basis. They were community members, generally trusted by their

friends and neighbors. This made them effective mediums for spreading the government’s

message about the importance of the polio vaccione and meant that they could assemble reliable

information on the families that lived in their communities. This intimate contact with the

population allowed the government to reach 93.5% of Cuban children under 15 in the first year

of the campaign.86

The ability of mass organizations to reach the population in the case of the polio

campaign reflects their place as an intermediary between the government and the people. Mass

organizations provided a way for public health to be promoted and at times enacted on the

ground by trusted members of the community. They gave the government enormous reach into

areas where officials may have been sparse and saved money by limiting the number of

professionals required for such campaigns. Mass organizations, being political in nature, also

brought a revolutionary attitude to the campaigns they were promoting. Mass organizations were

therefore a way for the Cuban government to give the masses a participatory role in their own

public health while still directing the program from one administrative center.

While work on the ground was carried out by and large by Cuban civilians, the

vaccination campaign would not have been possible without support from the Soviet Union and

collaboration with Eastern Bloc scientists. Before Cuba began its anti-polio campaign in 1962,

Eastern Bloc countries were already working on mass immunization against polio. In 1956 a

85 “Vacunación Antipoliomielitica en Cuba” 86 Ibid.

48

Soviet medical mission comprised of leading virologists visited the United States to study the

production of the Salk polio vaccine. While there they visited the lab of Dr. Albert Sabin, who

was also producing a polio vaccine at the time. Dr. Sabin kept up scientific exchange with the

Soviet virologists after their visit and by 1958 the Soviet Union was able to domestically produce

the Sabin polio vaccine. In 1958 and 1959 virologists in the Soviet Union, Czechoslovakia, and

Hungary conducted large-scale field trials of the Sabin vaccine, involving over 16 million

individuals between them.87 Dr. Karel Zacek, who would later head the virological survey of

polio in Cuba, conducted the trials across four regions in Czechoslovakia and remained in

contact with Dr. Albert Sabin throughout the process. Dr. Zacek sent Dr. Sabin information

about the trial both before and after it was conducted, including detailed statistics and

methodological information. In 1959 the two met in Prague (not for the first time) to discuss the

results of Dr. Zacek’s trials.88 Because of his profound involvement in anti-polio campaigns in

Eastern Europe and his personal connection to Dr. Sabin, Dr. Zacek’s appearance in Cuba in

1962 as overseer of the polio vaccination campaign puts that campaign firmly in an expansive

international context that included the Soviet Union, several Eastern European countries, and

scientists in the United States.

The international context of the Cuba campaign was deepened by the fact that Dr. Albert

Sabin was himself in contact with top officials in the Cuban program. In July 1962 Dr. Sabin

sent a letter requesting information on the Cuban vaccination program to Dr. Heliodoro Martinez

Junco, sub-secretary of hygiene and epidemiology, director of the polio campaign, and future

87 Dora Vargha, “Between East and West: Polio Vaccination Across the Iron Curtain in Cold War Hungary,” Bulletin of the History of Medicine, 88 (2) (2014) 319-342. 88 Albert B. Sabin to Karel Zacek. April 8, 1959. Albert B. Sabin Collection. University of Cincinnati Archives.

49

minister of public health.89 Dr. Junco happily complied and Dr. Sabin was sufficiently

impressed. He responded with warm words and advice on maintaining immunization following

the mass campaign. Dr. Junco himself invited Dr. Sabin to attend Cuba’s X National Medical

Congress to participate as a member of the congress and to speak on the polio campaign.90 While

a prior commitment prevented him from visiting in 1962, Dr. Sabin did come to the island in

1967 and said in an interview there that “one can rest assured that there has actually been a

complete elimination of poliomyelitis in Cuba.”91

The correspondence between MINSAP officials and Dr. Albert Sabin, along with his

involvement in anti-polio campaigns in Eastern Europe, suggests an interconnected international

community of public health workers and doctors at top levels of government working almost

simultaneously on the problem of polio elimination. As a direct result of cooperation between

Soviet scientist and Dr. Sabin, Sabin oral vaccines were produced in the Soviet Union and

distributed in various campaigns in socialist Eastern European countries. In 1962, Cuba joined

those countries with a massive and successful vaccination campaign. Dr. Sabin was in direct

contact with health officials and researchers from many of those socialist countries, including

Cuba, throughout the late 1950s and early 1960s. In that capacity, he observed, assisted, and

commented on the various vaccination campaigns. Given the extent of research on the Sabin

vaccine in Eastern Europe in the late 1950s, it is almost certain that the campaign in Cuba was an

extension of ongoing work throughout the Soviet sphere of influence and international medical

community. Such collaboration on the polio campaign suggests the depth of the relationship

89 Albert B. Sabin to José Ramón Balaguer. July 12, 1962. Albert B. Sabin Collection. University of Cincinnati Archives. 90 Albert B. Sabin to Heliodoro Martinez Junco. September 24, 1962. Albert B. Sabin Archives. University of Cincinatti Archives. 91 “Sabin Impressed by Cuba’s Gains in Education and Health,” Granma Weekly Review, December 24, 1967.

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between Cuba and the Eastern bloc on public health and health care. However, publications

associated with the Cuban government both from the time make almost no mention of this

international influence. A 1967 Granma article describing the public health budget listed polio

eradication as a major accomplishment of the revolution. The article contained a brief description

of the campaign, but credited only “the Ministry of Public Health’s excellent work in the field of

preventative medicine” and made no mention of support from Eastern Europe.92 A 1967 Granma

article about Lenin Hospital did acknowledge that the Soviet Union donated the bulk of the

hospital’s medical equipment. However, it also described how visiting Soviet specialists

“immediately adapted their methods to the situation, working day and night with the Cubans.”93

In this case, the state was willing to recognize collaboration with the Soviet Union but

highlighted Cuban agency, carefuly avoiding any appearance of paternalism or dependence.

Cuban publications on polio vaccination likewise downplayed the international

community’s role in laying essential groundwork for the campaign’s success. The original 1962

Cuban government report detailing the campaign mentions that the vaccine was produced in the

Soviet Union and that Dr. Karel Zacek was the leading virologist behind the Cuban campaign.

However, the document makes no explicit mention of the widespread use of the vaccine in

Eastern Europe just a few years before or its implications for Cuba. Instead, the document stated,

“The Ministry of Public Health of the Revolutionary Government of Cuba conscious of the

possibility of eradicating this disease, ordered the immediate use of a vaccine of proven

effectiveness, safety, and easy administration.”94 The proven effectiveness to which they refer

came from the studies conducted in Eastern Europe. Although the Sabin vaccine had been used

92 Luis Baez, “1967 Public Health Budget – Biggest in History,” Granma Weekly Review, February 12, 1967, 9. 93 Luis Baez, “1967 Public Health Budget – Biggest in History.” 94 “Vacunación Antipoliomieletica en Cuba”

51

in capitalist countries, the most detailed studies to date were, in fact, from Czechoslovakia,

Hungary, and the U.S.S.R.95 Later, the document says that the government “coordinated with the

Ministry of Public health of the U.S.S.R. for the procurement and shipment via cable, where they

specified the type, number of doses, dates of shipment, and other details regarding the same.”96

From this description, it sounds like the Cuban government simply placed an order for the

vaccines. There is no mention of cooperation or even really communication about the campaign

itself. A MEDICC article on the history of the polio campaign in Cuba written in 2013 likewise

describes how vaccines were produced in the Soviet Union, but mentions nothing of the role of

Eastern bloc research and planning in the campaign.97

The absence of virtually any mention of the precedent set by Eastern European nations in

mass polio vaccination indicates that the Cuban government had an ideological stake in its

presentation of the polio campaign. The Cuban government wanted to present polio eradication

as a product of the revolutionary approach to health care and an act in service to the people of

Cuba. While official organs of the Cuban government had no problem discussing cooperation

with the Soviet Union, they did not want to give the impression of reliance on them, or indeed of

any sort of subservience to Soviet influence. Therefore, although in all likelihood there was

significant communication between public health officials in the Eastern Bloc and Cuba before

the 1962 campaign was carried out, the Cuban government had a vested interest in presenting it

as an almost entirely domestic success. The disparity in what was presented and what happened

in this case is telling because it shows how the government used a consciously skewed narrative

about health to a political end. While rhetoric and reality often coincided, this case helps

95 Dora Vargha, “Between East and West: Polio Vaccination Across the Iron Curtain in Cold War Hungary,” 96 Ibid. 97 Enrique Beldarraín, “Poliomyelitis and its elimination in Cuba: An Historical Overview.”

52

demonstrate that the government’s rhetoric on health practice was a distinct entity with its own

purpose that was at times separate from the stated goals of the national public health program.

The polio vaccination campaign of 1962 is a useful example for understanding the

political, social, and geo-political systems that supported the Cuban government’s approach to

public health. First of all, it reflected the way that administrators in Havana were responsible for

the planning and administration of almost all aspects of the public health program. Regional

ministries were responsible for the particularly regional issues of storage and distribution, but

had no say in the planning or execution of the campaign. This centralization helped establish the

national government as the only autonomous actor in the application of public health, thus

consolidating power around one of the most important endeavors of the revolutionary state. The

polio campaign also reflected the importance of mass organizations in carrying out the Cuban

government’s vision for public health. These organizations gave the government a broad base of

support on the ground that could be used to administer their programs, generate enthusiasm

among the people, and bring the government’s vision for health to the level of the individual and

the community. Mass organizations played a key role in the application of state power more

generally in revolutionary Cuba. Those who are interested in knowing more about mass

organizations specifically should look to Lillian Guerra’s book Visions of Power in Cuba:

Revolution, Redemption and Resistance, 1959-1971 which explores (in part) the role of popular

organizations in the establishment of state power in Castro’s Cuba. Finally, the network of

international researchers and policy makers involved in eradicating polio in socialist countries in

the 1950s and 1960s reveals the depth of cooperation between the Soviet Union and Cuba in

building a public health system. The Cuban government’s disinclination to highlight such

collaboration indicates how the government wanted public health achievements to be a part of a

53

domestic, revolutionary success narrative, free from dependence on a foreign superpower. More

broadly it suggests that developing a revolutionary narrative on public health was a conscious

goal of the revolutionary government distinct from developing a public health system.

Centralized control of the health system, support from mass organizations, collaboration with the

eastern bloc and targeted, ideological rhetoric were all key factors in the Cuban revolutionary

government’s rapid establishment of a new, ideological, and ultimately successful public health

system.

Epilogue

What can we take away from the formation of a public health system in Cuba? Are there lessons

that we could apply to our own world, our health policy, or to developing nations? Almost

certainly. The Cuban system as it was formed in the 1960’s and continually developed over the

following four decades is a monumental achievement. While flaws existed and exist today it

achieved its goal of health indicators on par with what we would call the most advanced western

nations, and health equality greater than many of them. Indeed, medical tourism has become

popular in Cuba, with foreigners coming to the island to receive discounted treatment and

recover on a sunny beach in Havana. Cuba has undoubtedly achieved something, but what does

it mean in the modern world, and what does it mean in a world where capitalism is popularly

regarded as the only path to development?

Public health in the developing world can be seen as a monumental, almost

insurmountable task. When Ebola struck West Africa in 2014 the situation quickly escalated as

relief workers bemoaned the lack of good infrastructure, materials, transportation, and education.

Aide became directed at building up temporary clinics and spreading lifesaving information. A

lack of infrastructure such as this is common, indeed almost expected in the developing world.

54

Those very deficiencies, however, were the first targets of the Cuban health program. Hospital

construction and staffing, combined with sanitary education and preventative infrastructure that

would stop the spread of infectious disease was prioritized and achieved. It is not impossible then

for a small, poor, developing nation to have the tools necessary to protect and promote the health

of its people. That is not to say that Ebola could have been prevented or a crisis averted if other

nations had adopted Cuba’s system. The crisis merely highlights the deficiencies that are all too

common today. In Cuban health metrics today we see the difference that addressing these

deficiencies has made.

The Cuban system could not, however, be replicated exactly as it was in a capitalist

society. Cuba’s revolutionary public health was driven by Marxism and depended on massive

state power. The program required the immense commitment of state resources, including

building materials and an impressive workforce. It also required complete control over the

salaries and distribution of doctors. As state employees doctors went where they were told and

received compensation far below western standards. Public health in Cuba also made use of

social organizations, directed by the state, which put personal and communal health on the

doorstep of every man woman and child in the nation. The national media was likewise

completely controlled by the state and could distribute information constantly and at the will of

the Ministry of Public Health. Cuban officials would also argue that their system is defined by pa

complete re-thinking of the very nature of health and sickness, with the prevention of disease and

promotion of the healthy man in his community and society at the forefront of medical thinking.

State power was therefore fundamental to the workings of the Cuban public health system. This

does not mean, however, that its successes or even some of its programs could not be replicated.

55

Cuba’s hallmark programs could conceivably exist in a capitalist nation, outside of the

all-encompassing power of the revolutionary state. Many nations have the resources to construct

hospitals and improve their public health infrastructure. There are even wealthy states and wide-

reaching charitable organizations that would support such projects such as the Soviet Union did

in Cuba. One also doesn’t have to look far to find doctors dedicated to a humanitarian purpose,

who see their work as part of the common good and commit themselves to it for that reason. A

program that would recruit such individuals for a term of service out of medical school is far

from inconceivable. We are also not incapable of organizing into volunteer groups for the

promotion of our community’s health. This is already done for blood drives and across the world

against cancer, AIDS, and other devastating diseases. It is not even such a stretch to think that we

could begin to see our health as part of our whole lifestyle, and dependent on preventing disease

rather than treating it. What we lack in the capitalist world that Cuba had was ideology. The

Cuban revolutionary state had a fundamental, uniting idea that public health was the right of all

people and that it was their duty to provide for that right. This idea defined everything else they

did and said with regards to public health. What developing nations lack that Cuba had then was

not wide-reaching state power, but the political will to undertake such a massive and ambitious

project. In Cuba that will came from a relentless ideology. The revolutionary state believed

fundamentally in the idea that health was the right of all people and that it was their duty to

provide for that right. The application of that idea expanded their power, but it also brought

immense gains to the health of the Cuban people. How to replicate that success under other

conditions of power is the subject of future studies. However, it is clear that any attempt to

replicate that success in today’s world must start with some person or body having that visionary

political will.

56

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