Cuba’s medical doctors: the 3000 who stayed

By Don Fitz June 5, 2016 -- Links International Journal of Socialist Renewal reposted from Monthly Review with the author’s permission -- Stories of Cuban medical accomplishments often note that half of the country’s 6,000 doctors had left by 1963. But just as professionals were forsaking their homeland en masse for the comforts of Miami, 3,000 doctors chose to stay. Why did they remain? More important, the number of patients per doctor now doubled, how did they face the daunting task of transforming medicine? In addition to treating patients, their goals included expanding medical care to rural regions; increasing medical education to replace doctors who had left; making care preventive, community-oriented, and focused on tropical diseases; and redesigning a fractured and non-cohesive health system. Exploring changes during this transformative period in Cuban health care requires examining sources available in Cuba, as well as studying oral histories of Cuban physicians who lived during the revolution. Before 1959, Cuba experienced three medical revolutions. Early “care” had been primitive. Despite the rhetoric of the Spanish invaders, there is no evidence that they brought techniques superior to that of the native Siboney and African folk healers.[1] The first medical revolution (1790–1830) occurred amid brutality against slaves. An early “safety device” was overseers’ use of machetes to cut off the hands of slaves caught in rollers. Such events were not uncommon amongst those forced to work twenty hours per day. The revolution was led by Tomás Romay y Chacón (1764–1849) who introduced smallpox vaccination to Cuba, promoted public sanitation, and advocated medical treatment for slaves. Romay provided Cuban practitioners with an intellectual alternative to blind adherence to Spanish traditions. Like the 1959 upheaval, the second medical revolution (1898–1922) followed a wave of Cuban doctors deserting their patients. Doctors fled the countryside during the country’s two wars for independence (1868–1878 and 1895–1898). In their absence, disease, already rampant, ravaged the island. Of the 200,000 troops Spain sent to Cuba during the second war, 704 died in battle, 8,164 died of wounds, and 53,000 perished from disease, the most virulent killer being yellow fever, which claimed 13,000 lives. Though Carlos J. Finlay, a leader of the second medical revolution, had discovered the transmission of yellow fever as early as 1881, his research was ridiculed by medical professionals in Cuba, Spain, and the United States, and his findings were not implemented until 1900. A year later, Cuba was free of the disease. Along with the discovery of mosquitos as vectors for malaria and yellow fever, the second medical revolution was known for its emphasis on microbiology and immunology. As Ross Danielson summarizes in his history of Cuban medicine, “the second medical revolution was the completion of the first. Scientific method, gaining superiority as an intellectual device in the first period, yielded convincing practical technology only in the second.”[2] The third medical revolution (1925–1945) was characterized less by new discoveries than heightened awareness. A split within the medical community widened as it became increasingly clear that any resolution of Cuba’s medical problems would require focusing on the needs of the rural population, preventive medicine through cheap or free services, and application of new knowledge of tropical medicine and parasitology.3 It was during this period, in 1925, that the country’s first physicians’ organization appeared, the Cuban Medical Federation (FMC). That year also saw the founding of the Cuban Confederation of Workers and the Cuban Communist Party (CCP).[4] Within four years, the FMC saw the formation of two internal political parties: Renovación, which pushed for higher physician wages and better university training, and Unión Federativa (UF), which represented doctors in larger private medical organizations. In 1932 Renovación split into two further factions, Reformista and Ala Izquierda (Left Wing). By 1938, the FMC platform called for “pharmaceutical controls, workers’ accident protection, a minimum wage scale for physicians, prohibition of multiple positions, institutionalization of the sanitary career, improved hospitals, school health, sanitary provisions for the poor…[and] a physicians’ retirement plan.”[5] Though its program reflected the views of Ala Izquierda, the FMC’s leadership remained under control of the more conservative UF. Increased factionalism produced still another, more leftist party, Acción Inmediata (AcIn), and a right-wing party, Ortodoxos, who called for dropping the demand that doctors not hold multiple positions (which made some rich and others under- or unemployed).[6] Divisions among doctors intensified. AcIn won leadership of the Havana Medical College in 1941, but this leftist victory was reversed when 1,000 doctors came to vote in 1942. That same year, however, AcIn won national leadership in the FMC, and in 1943 won again in the Havana Medical College. CCP members held leadership positions in the FMC from 1943 until the 1959 revolution. In 1951, doctors repeated calls for better organization of hospitals, minimum salaries, regulation of specialties, and modern medical standards. Above all, a deep concern for the lack of adequate rural health care defined the third medical revolution. The three medical revolutions saw mutualism grow from a minor footnote to a major chapter in Cuban health care. Cuban historians describe mutualism as “a form of self-financed assistance,” whereby a monthly payment covered treatment, hospitalization and medications.[7] The first mutualist plan was offered 400 years before the revolution when, in 1559, a Spanish physician proposed a plan for medical care in exchange for a regular fee. Over the centuries, mutualism grew into contradictory subgroupings catering to Spanish immigrants, commercial associations, or unionized workers. Private fee-for-service care existed at the same time. A common complaint was that mutualist doctors would recommend private doctors for services not covered by the mutualist plan, then the two physicians would split the fees. Nevertheless, mutualist clinics provided a collective attitude toward medical work, which would become critical after the 1959 revolution. Alongside mutualism and fee-for-service care was the state medical system, which provided limited care to the poor. On the eve of the 1959 revolution, there were abundant, overlapping medical systems in the cities and negligence in rural Cuba. Of 456 health institutions during 1956, 42.8 percent were private or mutualist. Of these, 52 percent were in Havana. Medical care transformed Ten years after the revolution, Fidel Castro described the enormity of the health care problems that confronted Cuba in January 1959:
The absence of a national public health plan; semi-official and private services that were better than those provided by the government; an orientation toward curative medicine; abandonment of rural and some urban areas; individual medicine; mercantilism; competition between private services; administrative centralization with a public unaware of treatments that could benefit them.[8]
In addition, there was no reliable data on health indicators, an insufficient number of doctors and dentists being trained, and severe underfunding of what few research facilities existed. The pharmacy industry was 70 percent foreign-controlled, and created many products lacking treatment value. Only 10 percent of children were covered by specialized paediatric care. Vaccination programs were unavailable.[9] When he was eighty-seven years old, Dr. José Gilberto Fleites Batista recalled the revolutionary epoch to Candace Wolf: “Before the Revolution, there were big hospitals only in the capital, in big cities, but not in rural areas, in the countryside and in the Sierra.”[10] The physician-to-inhabitant ratio was 1 to 248 in Havana and 1 to 2,608 in the eastern provinces. Medical education was largely theoretical, offering little hands-on experience. There were insufficient teaching hospitals, and education was oriented to making money. Dr. Julio López Benítez completed his specialty in paediatric nephrology in 1960, shortly after Havana’s medical school reopened following the revolution. He remembers that “some were in medicine as a business. In Calixto-García Hospital, 300 professors charged their patients.”[11] The principal health care task during the first five years of the revolution was creating services. In 1959, priority went to hospital construction. By 1963 the revolutionary government had established 122 rural centers and 42 rural hospitals, with 1,155 beds, 322 doctors, and 49 dentists. In order to accomplish the primary task, it was necessary to bring cohesion to the disjointed medical system. On January 22, 1960, Law 717 created the Ministerio de Salud Pública (the Ministry of Public Health, or MINSAP) and Law 723 established Rural Health Services.[12] As MINSAP consolidated and extended state services it had an ambivalent attitude toward mutualism, which was based on privately owned services. Nevertheless, it would have been a serious blunder to attempt to abolish mutualist clinics during the upheavals following the revolution. Widespread mutualist services provided a cushion for the effects of doctors’ abandoning private practice as they left the island. This lessened the pressure on public services as they expanded and reorganized. As time went by, contradictions within mutualism intensified as its members realized that its services were inconsistent and free health care could be obtained by state clinics. Instead of attacking the system, MINSAP developed a 1963 report describing how to consolidate and rationalize mutualism. Revolutionary changes cannot be made by legislative decree. They require the type of mobilization campaigns that swept Cuba. There were efforts to end unemployment, increase the salary of 350,000 sugarcane workers, implement a pension system, end discrimination in access to beaches, build 10,000 new classrooms, and send 3,000 teachers to rural areas. A new rationing system ensured equitable distribution of food and consumer goods. Hinting at the need for preventive care, it focused on pregnant women, undernourished infants, and children with chronic illnesses. The literacy campaign was the best known of these mobilization efforts. In 1953, 23.6 percent of the Cuban population was illiterate (41.7 percent in rural areas). In a single year, more than 707,000 people were taught to read and write. Within a few years, illiteracy was brought down to zero. These early campaigns were launched when Batista supporters still roamed the countryside. Dr. José Fleites recalls: “Thousands of students went into the countryside to teach the people how to read and write. It was a beautiful campaign, but it came with a harsh price. The counterrevolutionaries assassinated some of these idealistic students.” Medical and education campaigns were thus essential components of a much broader social transformation. In 1960, Law 723 required medical graduates to spend a year in rural service. By 1963, 1,500 doctors and 50 dentists had done so. In February 1960, the first group of 357 doctors went to rural areas where there had previously been no doctors. Many had to stay in the homes of campesinos, peasant farmers. They found people so much in need that initially they could provide only curative, rather than preventive, medicine. Determination for preventive medicine prevailed, and, by the end of 1960, doctors had given twice as many DPT vaccines (for diphtheria, pertussis, and tetanus) as had been provided during all of 1954–59. The anti-malaria campaign began in 1961. The next year saw the first national campaign to vaccinate against polio, a clean water campaign, gastroenteritis control, and a major program to improve medical staff training. There was even an anti-rabies campaign for street dogs (perros callejeros). MINSAP developed 15 goals for 1962–65, which focused on “infant mortality, vaccinations, pregnant women, transmissible diseases, infectious diseases, preventive medicine, worker health, and goals for administering these and recording statistics systematically.”[13] Simultaneously, it improved plans for hurricane disaster relief and cut the price of eyeglasses and medications by 50 percent. New doctors, new education The wave of revolutionary fervour sweeping through the island took a distinctive form in medical school education. Batista had responded to protests by closing the University of Havana, including its medical school, in 1957–58. When it reopened in 1959, there was a new approach to education. Dr. Ezno Dueñas Gómez had a specialty in paediatric neonatology and was in the first class to graduate after the revolution. Following the revolution, he recalled to me at age eighty-four, “the culture of teaching changed. In the classical medical education before 1959, students could go to class if they felt like it and they received little practical experience. This is why they could skip class. After the revolution, students had to get to class for practical experience and go to rural areas.”[14] Dr. Felipe Cárdenas Gonzáles graduated in 1962 with a specialty in paediatric cardiac surgery. He observed a new way of recruiting students: “We created a new culture of revolutionary medicine. The professors of medicine who stayed went out looking for good students who could become doctors.”[15] Inspired by free tuition, many of the new students came from working-class backgrounds. Once enrolled, they found a plethora of revolutionary organizations. Incoming students were required to take classes focusing on rural and tropical medicine as well as preclinical sciences. For the first time, the medical school taught biochemistry. Hospital internships were made a prerequisite for graduation. Before 1959, a short course on social medicine was offered in the last year, after students had already formed their clinical perspectives. After 1959, social medicine was included in each year’s curriculum. It became clear that student and government involvement was reforming old systems of faculty control over education. On July 29, 1960, the medical faculty was evenly divided when it met to discuss a proposed Superior Governing Board for the university. A month later, in August 1960, only nineteen professors remained in the medical school—the only one in Cuba. They formed a nucleus of young, competent doctors who took on monumental responsibilities to sustain medical training. To accommodate more students, the number of teaching hospitals increased from four to seven, and new medical schools opened in Las Villas and Santiago de Cuba. Students and doctors adjusted to the strenuous demands of the revolution. “No one rested during those years,” Dr. Felipe Cárdenas remembers. “We worked as hard as we needed to. I did guardia for 24 hours and then I did surgery and then I had to study and write a work-up for new students.” MINSAP contracted for medical instructors from 26 countries: 120 arrived in 1964 and 92 in 1965. Most came from Argentina, Mexico, and Ecuador. Others were from Bulgaria, the Soviet Union, Czechoslovakia, and Hungary. Ross Danielson writes that “other responses by the university to the flight of physicians included a reduction of the pre-internship period from 6 to 4 years, and from 4 to 3 years in dentistry.”[16] I asked four physicians—Dueñas, López, Cárdenas, and Mena—how the shortened period affected teaching, and all denied that such a process happened. Dr. Julio López was emphatic: “I participated in developing the curriculum for fourteen educational plans, beginning in 1963, and we never had fewer than six years of study.”[17] Though shortening the required period of medical study might seem like an efficient crash course to train more doctors, it appears unlikely that it was ever done. From 1959 to 1962, Cuba graduated 1,497 doctors. From 1963 to 1969, it averaged 498 graduates per year. This meant that by the end of 1963, five years after the revolution, the country still had roughly 1,000 doctors fewer than the 6,000 who practiced medicine in January 1959. Though the first five years of revolution had transformed the culture of medicine and provided care to those who had never received it, doctor-to-patient ratios had not improved. “Wherever the revolution needs me” The new government, and particularly Fidel, received a tremendous response to calls for revolutionary commitments. Dr. José Fleites’ enthusiasm was born from dislike of the Batista regime:
I sympathized with the revolutionaries, but I lived outside of that. My world consisted of operating on my patients and taking care of my family. The only time that the revolution and the operating room came together for me was when I hid a young man—a wounded revolutionary fighter who was running from Batista’s police. He arrived in the emergency room while I was an intern at the Calixto García Hospital and I hid him there from the police who would have tortured or killed him. But I will tell you that the triumph of the Revolution was a great moment for all of us.[18]
Even before the government required rural medical service, on November 29, 1959, medical students assembled to pledge their willingness to go to provincial Cuba. Soon after Dr. Julio López graduated from medical school, “a friend asked me why doctors were being sent to Santiago when there were not enough in Havana and I said that there were even fewer in Santiago. We’re all Cubans.” As Cuban society polarized, students were entering medical school with the expectation that they would be trained not for personal gain, but according to the needs of society. Renouncing private practice, a popular comment by students was that they would go “wherever the revolution needs me.” By 1963 it was very clear to those entering medical school that they were different from previous beginning students. Eagerness to go to the countryside likewise caught fire with practicing physicians. Dr. José Fleites was profoundly affected by his chat with the new Minister of Health: “That minister knew me and he talked to me about going with them. They needed many physicians to go to various places in the Sierra Maestra, to provide care for the peasants. And I said ‘Yes, I will go!'” Dr. López observed that “Fidel had a huge influence after the literacy campaign. He asked for people to study medicine and many who answered the call were teenagers.” One of those teenagers was Dr. Oscar Mena Hector, who spoke to me when he was sixty-two. He heard Fidel’s call when he was in middle school. He took the science entrance exams for medical school when he was fourteen years old. He did not pass then; but he did in 1970, and became a doctor in 1976. Medical campaigns in rural Cuba deeply affected those who participated. Dr. Fleites “will always remember the particular case of a dehydrated little boy. We gave him intravenous infusions because he had diarrhoea. I remember that boy well because he would have died of dehydration if we hadn’t been there.” Medical internationalism Cuba’s medical system interacted with other countries in many ways. As early as April 1961, Cuba signed a cooperation agreement with Czechoslovakia. The next year it sent technicians to Bulgaria to study preventive medicine. East Germany made an agreement in 1964 to send orthopedic supplies. Cuba also sent doctors abroad. In March 1960, only fifteen months after the revolution, an earthquake hit Chile and Cuba sent a small number of doctors for a brief period. The next year Cuba sent arms to Algerians fighting for independence from France. The boat returned with seventy-six injured Algerians and twenty child refugees. A 1963 medical brigade to Algeria had fifty-five Cubans, including twenty-nine doctors. There were forty-three men and twelve women. Details of this mission were not widely known until Hedelberto López Blanch published Secret Stories of Cuban Doctors, a collection of oral histories of Cuban medical workers serving in Africa in the 1960s and 1970s.[19] One of the doctors going to Algeria was Sara Perelló, who was eighty-four years old when interviewed by López. She had just graduated with a specialty in pediatrics. Her mother heard Fidel saying that the flight of doctors to France left Algerians even worse off than Cubans: “There are 4 million more Algerians than Cubans but they have only a third of the doctors we do.”[20] After her mother came home and told her that she needed to help them, Dr. Perelló went to MINSAP to volunteer. She was worried about leaving because her elderly mother was suffering from Parkinson’s disease. Her mother responded that Sara’s sister and husband would help her as would the government. “Now the thing to do is go forward and don’t worry about your mother who will be well taken care of.”[21] When Dr. Pablo Resik Habib was seventy-six years old, he told López that he was chosen to head the Algerian mission largely because of his Arab heritage. He had worked as an anesthesiologist, first in a hospital and then in a mutualist clinic. He left his three month old daughter in the care of his wife, who supported international efforts. Brigade members were promised a small stipend, with their salaries going to their families. Dr. Resik described the precarious plunge into Cuba’s first international mission: “We found ourselves in an Arabic country, Muslim, with habits, customs and cultures very different from ours.”[22] Dr. Zoila Italia Suárez would have completed her pediatric specialty; but, due to Batista’s closure of the university, her graduation was delayed until 1960. She went immediately to Granma province for her rural services. Her recruitment to the Algerian brigade personified the transition from campaigns to end the rural/urban dichotomy within Cuba to medical internationalism. Willingness to leave Havana for rural Cuba easily transferred to a willingness to leave Cuba to help meet medical needs in Africa. Dr. Italia emphasized that language was her main problem. During treatment she would have one translator for Arabic to French and a second for French to Spanish. When one woman brought in a child but spoke a form of Arabic that the translator did not understand, the mother took her hand and placed it on her son’s abdomen. Upon feeling a tumor, she sent him to the hospital immediately. She learned to diagnose based on where the mother touched the child or if she sneezed or coughed. The mission taught staff valuable medical experiences. Dr. Italia witnessed “many sicknesses that were rare or non-existent in Cuba. I saw a lot of tuberculosis, malnutrition, malaria, parasitic diseases and bacterial infections…. In Constantina, a military hospital was completely empty because the French doctors had left.”[23] Ernesto “Che” Guevara left a deep mark on this formative mission. Dr. Italia recalled that “Che visited us when we had only been in Algeria a month. He asked if we were having any difficulties and how we were able to interact with patients without knowing their language. Che only spent a few hours with us; but, we were distributed in various provinces and he went throughout the country.”[24] “One afternoon we were told that Che would meet us the next morning at 7 am,” Dr. Perelló reminisced. “We didn’t think that would happen because no one travels at night in Algeria. But when we arrived at the government house on April 13, 1963, Che was waiting for us at the door.” Che impressed her as serious to the point of being ascetic: “Che told us to forget the greenery and palm trees of Cuba and dedicate ourselves to our work.”[25] Algerian experiences left Cubans with stories that would inspire medical students for decades. Dr. Resik emphasized, “I received much more from this mission than I gave to it…. I am proud to have been one of the pioneers of this enormous example that the small Island of the Caribbean has given to the world.”[26] The 3,000 who left Many Cuban doctors had no desire to go to the provinces, much less to the Algerian desert. Two large waves of doctors left Cuba. The first accompanied the huge changes in health care delivery during the first couple of years. Many were owners of private clinics, directors of mutualist centers, and doctors who enjoyed high incomes from private practice. The second wave was provoked by the April 1961 Bay of Pigs invasion and the October 1962 missile crisis. Dr. López pointed out that “in William Soler Hospital there were 59 doctors. In one day in February 1961, 26 left. This was a month or so before the Bay of Pigs. They must have known that it would happen and left before.” Many departed with the advent of rural service, which would take them to locations lacking in the comforts of Havana. Dr. Cárdenas thought that “It was similar to Brazil where many doctors do not want to go to areas where they are most needed.” He added, “Most of the doctors who left were not rich but identified with them.” The literacy, medical, and other campaigns that engulfed Cuba’s poor, working, and farming classes were an affront to middle-class lifestyles. It went beyond the disruption of medical school—when Batista closed the university during 1957–1958, there was no great exodus of medical faculty. Dr. Dueñas suggested, “They knew that doors were open to them in the United States. Many doctors went to Miami not because they were counterrevolutionaries but because they could have so many things in the United States.” I asked four doctors—López, Cárdenas, Dueñas, and Mena—if the difference between those who left and stayed was primarily a generation gap, and they all replied no, age had nothing to do with it. They also agreed that it was not possible to know how a doctor would react to the revolution by his wealth. “Roberto Guerra was a well-known rich surgeon,” Dr. Dueñas pointed out. “He was very charismatic, with no children but a movie star lover. He was the first to give up his private practice and donated his clinic to the revolution so that it could be used for teaching.” “Dr. José Resno Albara renounced his millions of dollars and helped found the new revolutionary medicine,” Dr. López added. “Some doctors supported the revolution after it happened, but some had been revolutionaries.” “Does this mean that you could not know before 1959 who would help and who would not?” I asked, and heard an emphatic “Yes!” While it would be an overstatement to imply that there was no relationship between pre- and post-revolution attitudes of doctors, it would likewise be an overstatement to suggest that actions before 1959 could always predict a doctor’s loyalties once Batista was out. There were certainly some who were enthralled by the July 26 Movement who became dismayed once they saw its ideas actually implemented, rather than abandoning them, as in so many other successful Latin American revolutions. Contrariwise, many remained aloof from the struggle, perhaps believing that Cuba could never undergo a genuine transformation, but threw themselves into the struggle once they saw it happening. The defining contrast between the doctors who stayed and those who left was their attitude toward revolution itself—whether they were enraptured or repulsed by the changes unfolding before them. Race and the medical revolution Cubans of African descent were concentrated in the rural eastern part of the island, which is closer to Haiti and where Santiago de Cuba is the largest city. It is hard to overstate the importance of the 1959 revolution, which ushered in the most significant changes in the lives of black Cubans since the abolition of slavery. Calls to serve in rural areas and eastern provinces were synonymous with appeals to fight structural racism. These shifts inspired Dr. López to volunteer for service: “I was doing genetic research as a pediatrician when they told me that children were dying in Santiago and that I needed to get there; so I went to Santiago in the early 60s for a three month rotation.” Pre-revolutionary racism had not been subtle or limited. It was often open and uncompromising. Dr. López described “one hospital that claimed that it was dedicated to religious goals; but it only accepted white patients and would not accept black patients.” Dr. Mena’s family knew racism well. His “cousin, José Villena, studied medicine but was poor and had to sell tomatoes to buy books. He passed all his courses, but after his last exam, learned that he would not become a doctor because he was black.” Studies culminated in a tribunal exam, and one examining physician refused to pass black students. “Two years later, in 1959, he passed his exams and became a doctor.” His cousin practiced internal medicine in Camaguey until his death. The pre-revolutionary period was not without anti-racist efforts in health care, however. In 1938 the communist-led Transport Workers Union began a mutualist health plan with a clinic for its workers, the Centro Benéfico. After five years, it offered the plan to other workers and enrolled 25,000 by 1959. “The Centro Benéfico,” notes Ross Danielson, “was the only mutualist clinic which served a substantial number of nonwhite Cubans and served them without discrimination or segregation” (italics in original).[27] The outpouring of medical teams to poor urban communities, rural areas, and the eastern part of the island with coordination by the revolutionary government occurred at the same time that U.S. civil rights demonstrators were being beaten by police and attacked by dogs for demanding the right to sit at “whites-only” lunch counters. This contrast was not lost on Cubans or government officials in the United States. A New Consciousness The central contradiction facing revolutionary medicine was how to do much more with much less while also thinking and planning deeper than ever before. Writing twenty years after the revolution, Roberto Capote Mir summarized the period’s early accomplishments: creating a unified health system; increasing hospital beds and health care facilities, especially in rural and eastern Cuba; increasing every category of health care worker; and, attaining “active participation by the masses in the solution of health care problems.”[28] Of the many organizations created at the time, by far the most important for medicine were the Committees for Defense of the Revolution (CDRs), organized in 1960 to guard against counterrevolution. CDRs participated in multiple health campaigns, and after 1962, were responsible for polio immunization. In a different political climate, doctors became different people. “When I started my medical career,” Dr. López told me, “I thought that if a child died of hunger it was not my problem as a doctor. But now I understand that it is my problem.” Dr. Cárdenas was no less affected:
At the beginning people were for or against the revolution in a very theoretical way, but I became married to the revolution. There was a vaccination campaign in Realengo 18 (in Guantánamo). Patients had to come by foot and a woman brought a child who had gastroenteritis. His father had to walk for three hours every day to see him and I told him he could stay home because his son could leave in two days. The father would not leave because he said four other sons had died. This changed my life forever.
As physicians began to act as a medical “cadre,” they perceived themselves as embedded in a broader political agenda. A medical school graduate “could not fail to see his own efforts as only one part of a set of health-related measures: land reform, new roads, improved agricultural methods, schools, literacy programs, improved diet, and an end to seasonal unemployment.”[29] The imperative to serve the underserved became the guiding idea of medicine in Cuba. As Karl Marx had realized, “theory becomes a material force when it grips the masses.”[30] The sheer desire of isolated physicians to provide free care to the multitudes of impoverished Cubans could not on its own change medicine, any more than could a government attempting to create a new medical system by decree, if isolated from the mood of the country. But in a country where thousands of doctors had struggled for decades to create equitable health care, a revolutionary government that reflected that awareness could unite those struggles and reshape medicine. The consciousness of the 3,000 who stayed became the “material force” in the production of Cuban health care, as much a material force as the manufacture of pharmaceuticals or the construction of hospitals. Medicine was affected by that consciousness at least as much as Cuban dentistry was affected by the newly developed high-speed drills that Fidel acquired as ransom from the United States for the return of mercenaries captured after the Bay of Pigs invasion. Still unanswered, however, was whether this new medical consciousness would be powerful enough to overcome new challenges. The need for basic services was so severe that meeting it meant building physical facilities and focusing on specific illnesses and health problems. The relationship of health care institutions to the communities they served remained much the same. Though the municipal polyclinic begun in 1962 offered a new orientation, the atmosphere of crisis interfered with expanding this paradigm shift.[31] The question remained: Once the delivery of services improved, would the medical field be able to plan and enact fundamental changes in the way health care was delivered? A further dark cloud hung over medicine: infant mortality increased during the first few years of the revolution.[32] It is likely that a portion of the increase was attributable to better statistics. Some infant deaths that would not have been tabulated before 1959 were recorded after the revolution. The revolution was doing everything humanly possible to provide vaccinations and other pediatric services, but the flight of doctors took its toll. Schools were working sleeplessly to expand every type of medical training, and doctors were much more evenly distributed throughout the island. Yet by the end of 1963 there was still a lower doctor-to-patient ratio than there had been in January 1959. The question remained: would new students be able to continue such an intense pace and increase their numbers through the coming years? Though medical accomplishments were felt throughout the island, the trip of fifty-five medical staff to Algeria was not well publicized. Five years after the revolution, no one knew what its impact would be. Would it later be viewed as a waste of desperately needed resources? Or would it be possible that experiences gained from the Algerian mission would combine with medical approaches that were still embryonic within Cuba, and that this marriage would transform revolutionary dreams into a material force in the production of a new global medicine? Don Fitz is the editor of Synthesis/Regeneration: A Magazine of Green Social Thought and co-coordinator of the Green Party of St. Louis. The author would like to thank 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 translation. Thanks also to Steve Brouwer, John Kirk, and Joan Roelofs for their helpful comments on an earlier draft of this article. Notes [1] Ross Danielson, Cuban Medicine (New Brunswick, NJ: Transaction, 1979), 22. [2] Danielson, Cuban Medicine, 221–22. [3] José R. Ruíz Hernández, Cuba, Revolución Social y Salud Pública (1959–1984) (Havana: Editorial Ciencias Médicas 2008), 13; Danielson, Cuban Medicine, 131–33, 222–24. [4] Julia E. Sweig, Cuba: What Everyone Needs to Know (Oxford: Oxford University Press, 2009), 37; Danielson, Cuban Medicine, 103–104. [5] Danielson, Cuban Medicine, 107. [6] There does not seem to be any connection with the national political party, Ortodoxos, which attracted a young Fidel Castro in 1947. See Peter G. Bourne, Fidel (New York: Dodd, Mead,1986), 39, 53. [7] Ruíz, Cuba, Revolución Social y Salud Pública, 10. [8] Ruíz, Cuba, Revolución Social y Salud Pública, 17. [9] Berta L. Castro Pacheco et al., Cuban Experience in Child Health Care: 1959–2006 (Havana: Ministry of Public Health, 2010), 5. [10] Candace Wolf, “The Zen of Healing: Spoken Histories of Dr. José Gilberto Fleites Batista and Dr. Gilberto Fleites Gonzalez,” Havana, Cuba, January 2013 (unpublished manuscript). Dr. José Gilberto Fleites Batista was born in 1925. [11] Author’s interview with Dr. Julio López Benítez (born 1933), Havana, Cuba, December 26, 2013. [12] Roberto E. Capote Mir, “La evolución de los servicios de salud y la estructura socioeconómica en Cuba, Segundo Parte: Periódo posrevolucionario,” (Havana: Instituto de Desarollo de la Salud, 1979), 53; Ruíz, Cuba, Revolución Social y Salud Pública, 29. [13] Ruíz, Cuba, Revolución Social y Salud Pública, 43–44, 64. [14] Author’s interview with Dr. Enzo Dueñas Gómez (born 1929), Havana, Cuba, December 26, 2013. [15] Author’s interview with Dr. Felipe Cárdenas Gonzáles (born 1935), Havana, Cuba, December 26, 2013. [16] Danielson, Cuban Medicine, 141. [17] Author’s interviews with Dr. Oscar Mena Hector (born 1951), December 21, 2013, and January 1, 2014. [18] Wolf, “The Zen of Healing.” [19] Hedelberto López Blanch, Historias Secretas de Médicos Cubanos (Havana: Centro Cultural de la Torriente Brau, 2005). Dr. Sara Perelló was born in 1920. Dr. Pablo Resik Habib in 1930, and Dr. Zoila Italia Suárez in 1927. [20] Blanch, Historias Secretas, 9, 216. [21] Blanch, Historias Secretas, 223. [22] Blanch, Historias Secretas, 217–18. [23] Blanch, Historias Secretas, 235. [24] Blanch, Historias Secretas, 236. [25] Blanch, Historias Secretas, 224. [26] Blanch, Historias Secretas, 221. [27] Danielson, Cuban Medicine, 120. [28] Capote, “La evolución de los servicios de salud,” 57. [29] Danielson, Cuban Medicine, 134. [30] Karl Marx, The Critique of Hegel’s Philosophy of Right, cited in Georg Lukács, History and Class Consciousness (Cambridge, MA: MIT Press, 1968), 2. [31] Linda M. Whiteford and Lawrence G. Branch, Primary Health Care in Cuba: The Other Revolution (Lanham, MD: Rowman and Littlefield, 2008), 20. [32] Whiteford and Branch, Primary Health Care in Cuba, 54; Pacheco et al., Cuban Experience, 42.