The issue of healthcare reform is one that is consistently identified by opinion polls as being among the most important to Americans. The United States continues to be the only fully industrialized nation that lacks a public healthcare system, a feature of modern “democracy” that is taken for granted in most developed countries. Most American proponents of healthcare reform typically cite the models utilized by Canada, Western Europe, or Australia as the most appropriate guides for the implementation of universal healthcare in the United States. However, Don Fitz, a Green Party activist, provides a comprehensive overview of a model for reform that originates from what many would consider to be a surprising place. Cuba is widely regarded by Americans as an impoverished “Third World” nation. Yet, Fitz’s Cuban Health Care: The Ongoing Revolution describes how Cuba’s approach to healthcare during the six decades since the 1959 revolution has produced rather extraordinary results.
The overview of Cuban healthcare begins with an examination of the challenges that Cuba faced immediately following the revolution. Previously, healthcare in Cuba had been almost entirely private. After the revolution, Cuba lost approximately half of its physicians with most of these becoming émigrés to the United States in search of a more lucrative place to practice medicine. Only about three thousand Cuban physicians remained and those who stayed did so out of a commitment to their profession. The methods of funding healthcare before the revolution typically relied on either fee-for-service relationships between physicians and patients or “mutuals” that functioned as a kind of private insurance system operating on a semi-cooperative basis. The very limited healthcare that was available to the poor was mostly provided by the state.
An innovative reform that was implemented following the revolution involved the creation of “polyclinics” organized on the basis of a structural framework described as “centralization/decentralization.” Under this model, small teams of healthcare professionals were assigned to serve individual communities, with each healthcare team having a collection of families under their care, usually numbering in the range of 120 to 150 family groupings, with the families including 600 to 800 persons. Clinicians would often visit patients at home. The polyclinics functioned within a centralized meta-level framework that was based on a single system of healthcare provision. The individual teams providing healthcare to particular communities were the decentralized component of the system. It was not the provision of health care that indicate decentralization but rather the ability to decide how to do it locally.
Over time, Cuban healthcare practices experienced a series of innovations. The initial community-based polyclinics eventually evolved into a system of family doctors that were able to provide personalized care in a way that included the cultivation of physician-patient and physician-community relationships. The achievements of Cuba in the area of healthcare are particularly astounding when it is considered that Cuba is an island nation with approximately the same population size as New York City. Clearly, the Cubans have been highly capable of successfully managing their own affairs in spite of the hardships the country has faced in the post-revolutionary era. The obstacles faced by Cuba have largely been due to the hostility of the United States and the Americans’ persistent attempts to undermine the achievements of the Cuban revolution.
An important aspect of Cuban healthcare has been the role of Cuba’s military doctors in providing health services to insurgent movements in Africa, a process that began when Cuba began offering support to anti-colonial resistance forces on the African continent in the 1960s. Cuban physicians involved in Africa often traveled clandestinely in order to avoid detection by Western intelligence services or those of colonial and neo-colonial governments on the continent. African resistance leaders often preferred that Cuba send black doctors so that the Cuban physicians would more easily blend in with the local population. The role of Cuban doctors in establishing healthcare services in impoverished African nations such as Angola, which was involved in an intense anti-imperialist struggle in the 1970s and 1980s, attests to the quality of the Cuban healthcare system and its exportability to other nations. Cuba faced a predictable crisis after the fall of the Soviet Union, which occurred during a time when the AIDS crisis was also presenting challenges to Cuba’s healthcare system. Cuba responded to the economic crisis of the post-Cold War era through the implementation of changes reminiscent of those adopted by Lenin during the period of the New Economic Policy.
Aside from the interesting overview of the history of post-revolutionary Cuban healthcare provided by Fitz, the discussion of medical education in Cuba is also quite fascinating. Fitz’s examination of Cuban medical training is based in part on his daughter’s experience as a student at the ELAM, or Latin American School of Medicine. ELAM was established by the Cubans and provides opportunity for students from around the world to study medicine on the condition that ELAM graduates serve as healthcare workers in an underserved part of the world upon the completion of their studies. Such a concept could theoretically be transplanted to the US where the medical education of students could be publicly funded in return for medical service in underserved communities.
Fitz provides an interesting profile of 13 students attending ELAM and their activities, including the participation of ELAM students in disaster relief activities such as the Haitian earthquake of 2010. During the first two decades of the 21st century, Cuban healthcare has continued to face a range of challenges. For example, dengue fever and mosquito-borne illnesses are common to Cuba’s tropical environment. Fitz describes the efforts of Mariela Castro, daughter of Fidel’s brother Raul to challenge discrimination against women, gender, and sexual minorities in Cuba. He likewise describes his own participation in Cuba’s March Against Homophobia in 2012. Post-revolutionary Cuba has a regrettable history of discrimination and repression directed toward sexual preference which the nation has fortunately made bold efforts to overcome in more recent years. Cuba has continued to provide much needed assistance to African nations in response to challenges such as the Ebola crisis in West Africa in 2014.
Clearly, Cuba’s achievements in the development of its healthcare system in the decades since the revolution have been remarkable. Fitz’s discussion of these achievements is not only thorough but well-documented from appropriately cited source material. The analysis of Cuban healthcare that Fitz provides is based on a synthesis of both scholarly research drawing from the relevant literature, including both English language and Spanish language sources, and the experiential research of Fitz and members of his family. If nothing else, Cuban Health Care: The Ongoing Revolution is an excellent representation of mixed method scholarship which includes painstaking documentation of the claims being made concerning the accomplishments of Cuban healthcare. Perhaps the most compelling aspect of the book is the statistical data that Fitz provides for the purpose of supporting his claims.
Astonishingly, Cuba has in recent decades managed to outperform the United States in a range of critical areas pertaining to general public health. As of the early 2000s, 45% of Cuban physicians were family doctors living in the same neighborhoods as their patients. The typical patient wait time at a clinic was 15 minutes. In the year 2000, Cuba’s infant mortality rate was 6.3 per 100,000 births compared with 7.1 for the United States. By the year 2017, infant mortality in Cuba had dropped to 4.1 per 100,000 births as opposed to 5.7 for the United States. Cuba has made comparable progress regarding life expectancy. In 1960, shortly after the revolution, Cuba’s average life expectancy was 64.2 years compared to 69. 8 years in the United States. By 2016, Cuba had slightly passed the United States with an average life expectancy of 79 years compared to 78.5 years for the United States.
A reasonable standard with which a society’s healthcare system can be evaluated is the combination of infant mortality rates and life expectancy that is experienced. One of the great achievements of modern civilization is the dramatic increase in life expectancy. During the height of its empire, ancient Rome’s life expectancy was only 48 years. In many historic societies, life expectancy was only in the range of 30 years. Low life expectancy rates were partially rooted in high rates of infant mortality and deaths from childhood diseases. In many families, a third to a half of the children would not survive until adulthood. Indeed, it was during the era of rising living standards at the dawn of modernity that the status of children began to increase dramatically with practices such as infanticide, child slavery, and child labor experiencing a significant decline.
Within the context of American political discourse, American healthcare is often touted as being “the best in the world” as opposed to supposedly backward nations of the Global South or “socialist” countries supposedly hampered by the ills of bureaucratization and inefficiency. However, Don Fitz describes how Cuba has been able to provide higher quality healthcare to its citizens than the United States in spite of the fact that Cuba spends only 4 to 5 percent per individual on healthcare compared to the United States. Indeed, some of the voluminous facts that Fitz provides would be comical if they were not so tragic. For example, an average hospital stay in Cuba costs $5.49 per day as opposed to $1,944 in the United States. It has been widely documented that medical bankruptcy is the leading cause of bankruptcy in the US. Fitz manages to marshal a vast range of evidence in support of his thesis that US healthcare is largely an elaborate corporate-perpetrated scam that frequently pales in comparison to Cuban healthcare, which often produces superior results at a tiny fraction of the costs.
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