During the 1960s, Cuban medicine experienced changes as tumultuous as the civil rights and anti-war protests in the US. While those in western Europe and the US confronted the institutions of capitalism, Cuba faced the challenge of building a new society.
The tasks of Cuban medicine differed sharply between the first and the second five years of the revolution. The years 1959-1964 aimed at overcoming the crisis of care delivery as half of the island's physicians fled. It was during the second half of the decade (1964-1969) that Cuba began redesigning medicine as an integrated system. A re-conceptualizations of health care which put the area polyclinic at the center of medical care created a model for poor countries that forever changed medicine.
The Policlínico Integral
When the revolutionary government took the reins in 1959, millions of Cubans were without medical care. It put enormous energy into building new facilities and expanding services. Nowhere was the crisis more severe than among the rural and black population of the island. [1]
The revolution inherited unintegrated, overlapping medical structures, including private fee-for-service practice, public assistance for the poor, a small number of large medical plans, and a large number of small medical plans. [2] These rarely offered preventive medicine and never a complete range of treatment, requiring patients to go from one provider to another (if the second was available). Though the second five years of the revolution continued to expand care, it focused on coordinating the disjointed medical system it inherited.
Accounts of Cuban medicine during the 1960s can be confusing. Some emphasize the increase in the number of polyclinics without noting their metamorphosis in the middle of the decade. [3]. The term “polyclinic” (or “policlínico” in Spanish) generally refers to a medical facility offering outpatient services. José Ruíz Hernández clarifies what happened in the Cuban system of policlínicos. In August, 1961, the Ministry of Public Health (MINSAP) began a study in Marianao (a town of 45,000) that sought to unify preventive and curative medicine. In May of 1964, it became the first policlínico integral in Cuba. [4] The next year, MINSAP began to spread the policlínico integral model throughout Cuba, making it “the point of departure for all health planning.” [5]
How did the policlínico integral differ from earlier policlínicos and why was it so central to creating the new medicine? MINSAP's plan addressed existing shortcomings by coalescing services. Staff at the new polyclinics would include at least a general practice physician, nurse, pediatrician, OB/GYN and social worker. [6] Dentistry was pulled under the umbrella. Nurses and social workers made house calls. [7] Staff extended services to workplaces, schools and communities. Community outreach included health campaigns such as mass vaccination programs and efforts to control malaria and dengue.
Vaccination began shortly after the revolution; but the policlínico integral structure vastly increased its effectiveness. In 1962, 80% of all children under 15 were vaccinated against polio in 11 days. In 1970, it took one day for the same national effort. [8] Malaria was eradicated in 1967, as was diphtheria by1971. [9]
Clinic staff coordinated primary care programs (maternal and child care, adult medical care, and dentistry) as well as public health (control of infectious diseases, environmental services, food control, school health services, and occupational and labor medicine.) [10] The policlínicos integrales were designed to integrate medical services in multiple ways. In addition to combining preventive and curative medicine they provided a full range of services at a single location, coordinated community campaigns and offered social as well as medical services. Most important, they provided a single point of entry into the system, allowing for a complete record of patients' medical histories and making them key to the transformation of health care.
It cannot be overstated that these advances in medical care could not have succeeded without massive changes throughout Cuban society that began immediately after the revolution and continued during the decade. The best best know was the literacy campaign of 1961. Programs also addressed racial discrimination, land reform, agricultural salaries, agricultural methods, improved diet, pensions, new roads, new classrooms, new homes, piped water, and urban/rural differences. The redesign of medical services was hardly a “stand alone” process – it was an essential component of remaking Cuba.
Structural Transformation as Mutualism Withers Away
The second half of the decade continued efforts to build up the number of medical staff and distribute them to rural and poor urban areas. Post-1965 efforts to increase nursing schools resulted in 20 existing on the island by 1969. [11] The number of nurses climbed from 2500 in 1958 to 4373 in 1968. [12] Similar pushes happened for auxiliary nurses, x-ray technicians, laboratory technicians, sanitarians and dental assistants. Always attentive to alternative medicine, Cubans integrated healers (curanderos) into the health system and MINSAP provided them with training as auxiliary personnel and gave them salaries. [13] As dentists were absorbed by the polyclinics, their numbers quadrupled from 250 in 1958 to 1081 in 1967. [14]
Though the first plan for a comprehensive national health service was developed in 1961 and implemented the next year, the plan was significantly revised in 1965. [15] The new plan altered the structure of the medical system itself. MINSAP addressed the unbalanced number, proportion and location of medical facilities. Only 22% of Cubans lived in Havana, which had most of the country's hospital beds (54.7%). The Oriente, or eastern part of the island, with a larger black population, was home to 35% of all Cubans but had only 15.5% of hospital beds. [16] The emphasis on new beds and doctors was in the east.
Also problematic was the existence of many rural hospitals with fewer than a hundred beds which could not provide a full range of services. Greater efficiency required an increase in rural polyclinics and concentration of hospitals in cities. The number of hospitals went down from 339 in 1958 to 219 in 1969. During the same time, the number of beds per hospital went up from 83 to 181. The total number of hospital beds increased from 25,170 to 41,027 (or, from 3.8 to 5.1 beds per 1000 Cubans). [17]
The role of the polyclinic became more central – more patients were initially seen at polyclinics where a physician could refer them to a hospital. The number of health visits doubled between 1965 and 1969, but visits to hospitals dropped from 28% to 19% of the total. At the same time, visits to polyclinics went up from 32% to 63% of the total.
Clinics changed not only in number but in type. “Mutualism” had existed in Cuba for 400 years. It was a pre-revolutionary holdover unable to resolve health issues because of its disheveled array of unconnected services. At the same time it was immensely popular. A task of the revolutionary government was to resolve these contradictory aspects.
Mutualism was similar to insurance, with subscribers paying a monthly fee for hospitalization and medical services. The type of services covered varied widely from plan to plan and always left something out. Of 456 Cuban health institutions in 1956, 42.8% were private or mutualist. [18] They were often owned by rich doctors and were a major barrier to an integrated medical system with facilities that offered a complete range of services. Unlike the new policlínicos integrales, mutualist clinics did not offer preventive medicine, were not adequately linked to hospitals, and did not have a specific geographical area where they provided services.
Given their popularity, the revolutionary government was wise to not nationalize mutualist clinics as it did many large, foreign-owned businesses in the early 1960s. [19] Instead, MINSAP created a task force in 1963 “to consolidate and rationalize mutualism.” [20] In Havana, mutualist clinics were required to provide comprehensive services. After 1967, the mutualism budget was included in the MINSAP budget. [21]
As mutualist clinics were required to be more and more similar to government clinics and ceased to have their separate financing, their reason for existence was withering away. In 1970, mutualism ended new memberships and monthly dues as it equalized services for members and non-members. It thereby ceased to exist.
At the same time, private medical practice, while not prohibited, faded into the sunset. Some authors suggest dates of 1968 and 1969, while Danielson says there were still 80 full-time private physicians as late at 1970. [22] By the early 1970s, Cuba had a unified medical system, with a focus on the polyclinic for care delivery and all services guided by MINSAP.
Centralization/Decentralization
Cuban planners carefully studied health systems of the Soviet Bloc (especially that of Czechoslovakia). These systems were typically overly centralized, leaving little opportunity for creative thought by practitioners or local administrators. Cubans developed the concept of “centralization/decentralization” which aimed to resolve the problem, making the policlínico integral a unique institution of Cuban medicine.
Shortly after the revolution, in August 1959, the government adopted the approach of “normative centralization and executive decentralization.” The central administration would set norms or guidelines for health care but local executives would specify how those guidelines would be put into practice. [23]
Centralization increased when the year-old revolution established MINSAP with Law 717 on January 22, 1960. Centralization also increased with a 1966 statute creating 10 new research institutes. [24] MINSAP was overseeing virtually all professional services by 1967. In addition to drafting norms and overseeing research, this included budgetary control, supervision of three medical schools and training programs for a variety of health care staff. [25]
What may be difficult for non-Cubans to grasp is that decentralization increased conjointly with centralization. As mutualist clinics were drawn into the medical system, MINSAP increased the number of base clinics and their decision-making power. While there was vertical control of programs for tuberculosis, leprosy and venereal disease, their efficiency was improved by the polyclinics' deciding how to implement them. [26] In general, the period was characterized by unifying and standardizing the rapidly expanding system of clinics while decentralizing clinic management, or increasing clinic autonomy.
This made a lasting impression on physicians who lived through those times. Dr. María Luísa Lima remembered that “MINSAP centralized the norms and research. Hospitals and polyclinics decided how to document use of drugs and which antibiotics to use for diseases. Hospitals and polyclinics decided how to do things such as managing their equipment.” [27]
Dr. Julio López felt the same. “There are norms regarding medical tasks. There is not a straightjacket about how to do things. Hospitals and polyclinics have to decide how to do many things. There must be a balance between working within rules while having a lot of freedom to make decisions.” [28]
At the very beginning of the polyclinic era, the Cuban government charted a course which would ensure their role as the cornerstone of decentralization: The policlínicos integrales would be independent of hospital control. The clinics would be distinct entities answering to MINSAP in each region. Instead of being administrative branches of regional hospitals, they would have a position equal to hospitals within the regional administration of MINSAP. [29]
Clinic independence was a key factor in distinguishing Cuba's approach from those in the Soviet Bloc. At that time, there were also regionalized medical systems outside of the Soviet Bloc in Puerto Rico and Chile. Clinic independence similarly differentiated Cuba's approach from theirs. [30]
Cuban doctors were well aware of this distinction. Dr. Oscar Mena emphasized to me: “The hospital does not give orders to the polyclinic. Polyclinics get orders from the regional administration and MINSAP.” [31]
As mentioned, the proportion of health care visits was shifting sharply from hospitals towards polyclinics. This meant that “the polyclinic — predominantly an outpatient facility independent of hospital control — was regarded as the core of the health services system as a whole.” [32]
Though polyclinics were independent from hospitals, their daily functioning was highly interconnected. Hospital performed and analyzed lab work for nearby polyclinics. Hospital doctors worked part-time in polyclinics both as consultants and by providing care. Similarly, polyclinic doctors worked for brief times in hospitals. [33]
By the end of the decade, 268 polyclinics each provided care to 25,000 to 30,000 Cubans. Each of 38 regional hospital “centers,” was affiliated with an average of seven polyclinics. A larger number of provincial hospital centers provided specialty care. [34]
A subtle but important component of elevating the status of the policlínico integral was creation of primary care as a specialty, which addressed everyday medical problem in clinics. Offering this as an option for post-graduate training put primary care physicians on par with other medical specialties as they became part of the core staff of policlínicos integrales.
Other forces further decentralized control into the hands of doctors. Instead of developing an ossified bureaucracy, MINSAP was relying on physicians for many aspects of its redesign. [35] Physicians were also working closely with the military due to sustained threats of invasion and nuclear war. [36]
Mobilization for a Health Revolution
In summary, policlínicos integrales became the link that united the structure and services of the new national medical system by making them independent of hospital control, authorizing them to determine how guidelines would be carried out, creating their own specialists, and, very importantly, assigning each a specific geographic service area so they became the entry point for all patients in the area. Yet nothing enhanced their stature more in the eyes of the average Cuban or better consolidated their position in the decentralization of health services than their role in coordinating health campaigns.
No one knew better than Fidel Castro that a government cannot merely decree that a campaign will occur – the literacy campaign showed that there must be massive involvement and enthusiasm for it to be successful. Policlínicos integrales walked the same path.
Fidel took a front and center position in mobilization. He motivated physicians, graduating medical students, and the entire country by reminding them that “Public health occupies a prioritized and sacred place in the revolution.” [37] Fidel pushed for changes that would accelerate production of medical personnel and rotate professors, instructors and residents from Havana to new medical schools in Santiago (begun in 1962) and Las Villas (begun in 1966). By 1969 doctors were teaching at 40 hospitals in Havana. [38].
One of Fidel's most important contributions was explaining that Cuba could improve upon eastern Europe's concept of community clinics. He believed that Cuba needed to create an example of public medicine that could be used by poor and undeveloped countries. The USSR donated equipment and 850 beds to the recently built Lenin Hospital in Holguín in 1965. Cuba's “repayment” was to provide medical care for countries even more poor, including Guinea, the Congo, Mali, and Viet Nam. International solidarity in public health was an indelible stamp left by Fidel. [39]
In eastern Europe, the Red Cross was often central in coordinating public health efforts. But the importance of the Cuban Red Cross was tiny vis-à-vis its voluntary mass organizations.” [40] These mass organizations included: the National Association of Small Farmers, which helped establish the first rural health centers and control tuberculosis; the Federation of Cuban Women, which addressed health education, family nutrition, and maternal and child health; and, the Confederation of Cuban Workers, which focused on safety committees in workplaces and state farms, as well as food safety. [41]
By far, the most important of the mass organizations were the Committees for Defense of the Revolution (CDRs), which were organized in 1960 to guard against sabotage and attacks from the US. They provided social networks for neighborhoods and soon became intricately linked to public health coordination. [42] By 1962 the CDRs had almost total responsibility for coordinating polio immunization, shortening the time for completing national vaccination from 11 days to 1 day after the establishment of policlínicos integrales. By 1968, the CDRs had enrolled over a third of the Cuban population. [43]
CDRs also took on the task of registering the entire population at policlínicos integrales. [44] Since each policlínico integral had a defined geographical area, 100% enrollment was not an unreasonable goal. [45] Working in conjunction with policlínicos integrales, the CDRs were heavily involved in social/preventive medicine by educating the population and involving them in combating flies and mosquitoes, controlling infectious diseases, blood donation, building schools and parks, and cleaning and repairing streets. [46] The connection of some of these activities to health care is not a far fetched as it may first seem. Patching enormous potholes is a good way to avoid injury by walking, bicycling or driving over them – it is good preventive medicine.
The director of the polyclinic was also the chair of the Area Health Commission, which included the CDRs and other mass organizations. Thus, the polyclinic was simultaneously linked to hospitals by sharing physicians and linked to the community by its central role in coordinating health campaigns [47]
Navarro observes that Latin American scholars often believe that lack of resources is the overarching cause of insufficient medical care in poor countries. But the first decade of the Cuban revolution shows that if limited resources are distributed in an egalitarian fashion medical miracles can happen. Similarly, it seems “unlikely that a redistribution of resources would have occurred without substantial redistribution of the decision-making power…” [48] The key to Cuba's medical revolution was (a) dedication and work by all health care professionals under (b) a well-guided structure set forth by MINSAP with (c) decentralized implementation of health campaigns by policlínicos integrales in coordination with mass organizations.
Lingering Issues
Despite Cuba's having forged a unified medical system with a single point of patient entry into a decentralized policlínico integral, significant issues persisted 10 years after the revolution. Most disturbing was that infant mortality continued to climb, just as had been the case in 1964. This could have been due to improved recording of deaths. Yet, an official Cuban source accepts the data as correct, attributing it to early neonatal death rates. [49] In agreement, Whiteford and Branch note that, “Since infant mortality reflects prenatal care and nutrition as well as conditions during and immediately following birth, it is not unusual to see such a pattern as a reflection of social upheaval.” [50] Whatever the reason, infant deaths per 1000 live births grew from 37 in 1965 to 40 in 1969. [51]
Another concern was that the fusion of centralization and decentralization was often not as smooth as hoped. Even though many revolutionary doctors took positions in MINSAP or as administrators of medical facilities, conflicts still surfaced between those whose primary jobs were re-creating the medical system and those whose daily work focused on care delivery. [52]
Sometimes contention was based on policy. Physician Julio López recalls that “…many doctors and administrators felt like polyclinics were for inferior doctors. This changed during 1965–1967. There had to be an overall change because many worked at the polyclinic because they were required to and not because they wanted to.” [53]
While the new ideology proclaimed the importance of preventive medicine, doctors and other clinicians frequently perceived health to merely be the absence of disease. [54] The changeover in attitudes did occur, largely through the education of the next generation of practitioners.
Discord arose regarding the role of health care professionals in determining policy. Doctors tend to be very autonomous and confident that their method is the best. What happens when their approach diverges from policy, the community and/or colleagues?
There was widespread disagreement over a parent wanting to “live-in” with a hospitalized child. Dr. Felipe Cárdenas described a father who had to walk three hours every day to see his son with gastroenetritis who was hospitalized in Guantánamo province. [55]
Most doctors and nurses were very opposed to initiating a policy of letting a parent sleep in a child's hospital room, fearing that s/he would be a nuisance. Dr. Ezno Dueñas recalled his experience at Lenin Hospital in Holguín when there was a shortage of nurses: “So we had to have mothers taking care of their children. Now, the mother is with the child in the hospital and is not upset.” [56]
Dr. Cárdenas agreed that “the mother is the person who knows the child best, such as when he last used the bathroom or vomited. She needs to be involved in the care.” [57] When the government decided to implement the policy of live-in parents it became very popular and resulted in shorter hospital stays for children. In general, the government sided with parents and the community during such disputes.
The effort to recruit more doctors continued through the decade. Women, who had traditionally been limited to career choices of teachers and nurses, now flowed into medical school and became 50% of students by 1970. [58] Government encouragement to attend medical school included personal appeals by Fidel – by 1970 applications to medical school comprised 30% of all university applications. [59].
Nevertheless, the stress of going to medical school in Cuba during the 1960s was enough to cause almost half of students to drop out. [60] One program to keep them enrolled was to create alumnos ayudantes (student assistants or peer tutors). Dr. María Luísa Lima, who currently teaches at ELAM (Latin American School of Medicine), began medical school in 1965 when she was 17 years old. She explained to me that ayudantes were those who had done well in basic sciences and were closely tutored by doctors so they could help others through those courses. The ayudantes both expanded the reach of professors and were themselves potential new faculty. [61]
Despite all efforts, there was still a shortfall of doctors in 1969. Bourne [62] states what is generally recognized: “The departure of thousands of doctors severely hurt the ability in the short term to provide health care for all, a major commitment of the regime.” But, could their absence simultaneously have enhanced the ability to Cuba to design its new medicine?
I asked Cuban historian Hedelberto López how difficult it would have been to implement the changes of the 1960s, including the development of polyclinics, if the counterrevolutionaries had stayed. He replied that “Of course, the revolution in medicine would have been impossible if doctors had not fled the country. They would have disrupted everything.” [63]
Julia Sweig agrees that concern over potential interference existed at the time: “Despite worries about losses of skilled professionals, Cuban authorities preferred that those who wanted no part of the revolution leave the island.” [64]
So, by the last half of the 1960s, the departure of half of Cuba's doctors to Miami proved to be a double-edged sword. One edge slashed into the health care of Cubans, depriving millions of desperately needed health care as the other edge cut off the ability of nay-sayers to hamper the building of a new medical world.
Perhaps those close to Fidel gazed into a crystal ball and envisioned that the damage of 3000 profit-oriented physicians unwilling to go to rural Cuba, complaining at instructions to work in poor urban areas, and constantly obstructing efforts to redesign medicine would cause more damage to health than would their absence.
Navarro notes that by the end of the decade the number of graduating physicians was greater than the number who had left the country. [65] While true, this overlooks Cuban population growth during the 1960s. [66] The issue is not merely the absolute number of doctors, but the ratio of doctors to patients. Table 1 combines Navarro's figures for the number of doctors at the beginning and end of the decades, Capote Mir's data for the number of medical students graduating annually, and information regarding Cuba's annual population. [67]
In order to reconcile Navarro's figures of 6300 doctors in 1959, 3000 departures (estimated for each of five years), and 7000 doctors in 1970, it is necessary to use an annual attrition rate of 1.98% (doctors who no longer practiced medicine due to death, retirement or change of profession). This 1.98% attrition rate was assigned to each year. From this, it appears that the 1959 ratio of .91 physicians per 1000 people was probably not attained until a few months into 1973.
This differs a bit from Danielson's estimate that the pre-revolutionary doctor/patient ratio was reached in 1972. [68] Whichever date is used, Cuba's medical coordinators were expecting a future decrease in the need for doctors. By the early 1970s, they were both (a) preparing a quota to reduce the medical acceptance rate to 20% of all university applicants, and (b) encouraging medical students to transfer into other programs. [69] This reflected the integration of divergent aspects of medicine as a system.
By the end of its first decade the polyclínicos integrales had taken a qualitative leap from addressing the quantity of medical attention to conceptualizing and implementing a novel approach to health care. They manifested a realization through practice that it was possible to transcend (address while going beyond) the deficiencies of capitalism and develop the consciousness required for a new medicine to take root.
Many lessons of the first decade of Cuban medicine had been assumed or suspected before the revolution confirmed them. It became clear that medical care could only be improved if a country simultaneously addressed necessities such as food, housing and education; medical campaigns must be based on mass participation; it may be possible to cope with an obstructive institution such as mutualism by creating a better method of delivering care before abolishing the old one; an institution could be improved by undertaking two contradictory processes simultaneously (such as centralizing and decentralizing medicine); despite the short term damage of 3000 doctors leaving, the long term ability to renovate medicine was blessed by their absence.
These lessons laid the foundations for originating the unique Cuban network of clinics with defined geographic areas which offered single points of patient entry into a system combining preventive care with treatment. Having control of their own functioning, the Cuban clinics had an equal footing with hospitals.
As the 1970s approached, unanswered questions remained. Could reallocation of resources continue to improve health even if Cuba remained poor and blockaded? Would the system of policlínicos integrales be able to reduce infant mortality? With the number of doctors per 1000 Cubans approaching the pre-1959 ratio, would the quantity of students admitted to medical school go down, or would unforseen circumstances require a continued expansion of physicians? Would policlínicos integrales continue as they existed during 1964-69 or would there be reasons for replacing or altering them?
Don Fitz is on the Editorial Board of Green Social Thought, which is sent to members of The Greens/Green Party USA. He is newsletter editor for the Green Party of St. Louis and was the 2016 candidate of the Missouri Green Party for Governor. A version of this appeared in the June 2018 print and online issue of Monthly Review.
The author thanks Candace Wolf for making her interview with Dr. José Gilberto Fleites Batista available, Hedelberto López Blanch for arranging interviews with Dr. Julio López Benítez, Dr. Felipe Cárdenas Gonzáles and Dr. Ezno Dueñas Gómez, and Rebecca Fitz for interview translation. He also thanks John Kirk, Linda M. Whiteford and Steve Brouwer for their helpful comments on an earlier draft of the article.
Notes
1. Don Fitz, “Cuban Doctors: The 3000 Who Stayed,” Monthly Review 68, no. 1 (May 2016), 43-56.
2. Ross Danielson, Cuban medicine. (New Brunswick: Transaction Books, 1979).
3. John M. Kirk and Michael H. Erisman, Cuban Medical Internationalism: Origins, Evolution and Goals (New York: Palgrave Macmillan, 2009); Linda M. Whiteford & Lawrence G. Branch, Primary Health Care in Cuba: The Other Revolution (Lanham MD: Rowman & Littlefield Publishers, Inc., 2008); Candace Wolf, “The Zen of Healing: Two Surgeons Speak, Spoken Histories of Dr. José Gilberto Fleites Batista and Dr. Gilberto Fleites Gonzalez,” Havana, Cuba, January 2013. (unpublished manuscript).
4. José R. Ruíz Hernández, Cuba, Revolución Social y Salud Pública (1959–1984). (Editorial Ciencias Médicas: La Habana, Cuba, 2008)
5. Danielson, Cuban medicine, 163, 180.
6. Whiteford & Branch, Primary Health Care in Cuba, 20.
7. Vicente Navarro, “Health, Health Services, and Health Planning in Cuba,” International Journal of Health Services 2, no. 3 (August, 1972), 410.
8. Navarro, “Health Planning in Cuba,” 426.
9. Ruíz, Cuba, Revolución Social y Salud Pública, 88.
10. Danielson, Cuban medicine, 170.
11. Ruíz, Cuba, Revolución Social y Salud Pública, 61.
12. Navarro, “Health Planning in Cuba,” 414.
13. Ibid, 415.
14. Ibid, 414.
15. Danielson, Cuban medicine, 143.
16. Navarro, “Health Planning in Cuba,” 412.
17. Navarro, “Health Planning in Cuba,” 411; Danielson, Cuban medicine, 164.
18. Ruíz, Cuba, Revolución Social y Salud Pública, 11.
19. Julia E. Sweig, Cuba: What Everyone Needs to Know (New York: Oxford University Press, 2009), 45.
20. Danielson, Cuban medicine,153.
21. Ibid, 178.
22. Roberto E. Capote Mir, “La evolución de los servicios de salud y la estructura socioeconómica en Cuba. 2a Parte: Periódo posrevolucionario” Instituto de Desarollo de la Salud: (La Habana, 1979), 41; Ruíz, Cuba, Revolución Social y Salud Pública, 48; Danielson, Cuban medicine, 164.
23. Ruíz, Cuba, Revolución Social y Salud Pública, 29.
24. Ibid, 62.
25. Danielson, Cuban medicine, 166-7.
26. Ruíz, Cuba, Revolución Social y Salud Pública, 43,56-7.
27. Author's interview with Dr. María Luísa Lima Beltrán, Havana, Cuba, December 23, 2013.
28. Author's interview with Dr. Julio López Benítez, Havana, Cuba, December 26, 2013.
29. Danielson, Cuban medicine, 169.
30. Navarro, “Health Planning in Cuba,” 424.
31. Author's interview with Dr. Oscar Mena Hector, Havana, Cuba, December 21, 2013 and January 1, 2014.
32. Danielson, Cuban medicine, 165.
33. Navarro, “Health Planning in Cuba,” 409.
34. Ibid, 408.
35. Ibid, 428.
36. Danielson, Cuban medicine, 147.
37. Ruíz, Cuba, Revolución Social y Salud Pública, 40.
38. Ibid, 59-60.
39. Ibid, 52-53.
40. Danielson, Cuban medicine, 171.
41. Navarro, “Health Planning in Cuba,” 424; Danielson, Cuban medicine, 173.
42. Danielson, Cuban medicine, 172-3.
43. Ibid, 173.
44. Ibid, 175.
45. Navarro, “Health Planning in Cuba,” 408.
46. Ibid, 420, 424.
47. Danielson, Cuban medicine, 171
48. Navarro, “Health Planning in Cuba,” 431.
49.Berta L. Castro Pacheco, Rosabel Cuéllar Álvarez, Longina Ibargollen Negrín, Mercedes Esquivel Lauzurique, Ma. del Carmen Machado Lubián, and Valter Martínez Corredera, Cuban Experience in Child Health Care: 1959–2006. (La Habana, Cuba: Ministry of Public Health, MINSAP, 2010),
50. Whiteford & Branch, Primary Health Care in Cuba, 54.
52. Danielson, Cuban medicine, 144.
53. Hedelberto López Blanch, Historias Secretas de Médicos Cubanos. (Centro Cultural de la Torriente Brau: La Habana, Cuba, 2005), 4.
54. Navarro, “Health Planning in Cuba,” 429.
55. Author's interview with Dr. Felipe Cárdenas Gonzáles, Havana, Cuba, December 26, 2013.
56. Author's interview with Dr. Enzo Dueñas Gómez, Havana, Cuba, December 26, 2013.
57. Author's interview with Dr. Felipe Cárdenas Gonzáles.
58. Navarro, “Health Planning in Cuba,” 414.
59. Ibid, 413.
60. Ibid, 419.
61. Author's interview with Dr. María Luísa Lima Beltrán.
62. Peter G. Bourne, Fidel: A Biography of Fidel Castro (New York: Dodd, Mead & Company, 1986), 196.
63. Author's interview with Hedelberto López Blanch, Havana, Cuba, January 10, 2017.
64. Sweig, Cuba: What Everyone Needs to Know, 48.
65. Navarro, “Health Planning in Cuba,” 414.
66. Ruíz, Cuba, Revolución Social y Salud Pública, 88.
67.Cuba: Historical demographical data of the whole country, Retrieved June 15, 2017 from http://www.populstat.info/Americas/cubac.htm
68. Danielson, Cuban medicine, 232.
69. Navarro, “Health Planning in Cuba,” 414,419.