S&S Quarterly, Inc.

Guilford Press

Health and Revolution in Cuba

Author(s): Nelson P. Valdés
Source: Science & Society, Vol. 35, No. 3 (Fall, 1971), pp. 311-335
Published by: Guilford Press
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 HEALTHAND REVOLUTIONIN CUBA
NELSON P. VALDÉS

ASSUMPTION of powerby the Cuban revolutionary

government on January1, 1959,founddramaticeconomic,
social,and culturaldifferences and inequalitiesbetweenthe
urbanandtheruralregions. The towns, despitetheirpocketsofpov-
erty,monopolized national income,consumption, nutrition, educa-
tion,comfort, and health.Meanwhile, theruralpopulation, under
a heavyburdenofmisery, remainedpowerless, forgotten, back-
and
wardin everyrespect.1 It was a classicalpatterncommonto the
ThirdWorld:internalcolonialism,2 theexploitation by theurban
areas,whichcontrolled theinstitutional framework of thecountry,
of the rural workersand peasants,who producedthe country's
wealth.
Ifjusticeandequalitywereto becomea reality, it wasabsolutely
to
necessary put an end to thedegradation and want ofa largeseg-
mentofthepeople.Thoroughsocialand economicchangeshad to
be instituted to assuretheprogress of thenationand thehealthof
its citizens.
This paperattempts to assessthewayin whichthehealthprob-
lemhas been handled by theCastroregime,comparing, wherever
possible,thesituation beforeand aftertherevolution. In examining
thedata,it will be foundthatthepresentCuban government has
made revolutionary advancesin manymajor areas. It has made
medicalserviceavailableto all thepeoplewithoutcharge.Facilities
and personnel in thehealthsectorhavebeengreatly expandedde-
a
spite catastrophic drain of pre-revolutionaryphysicians and pro-
1 Dudley Seers, ed., Cuba: The Economic and Social Revolution (Chapel Hill, 1964);
and LowryNelson, Rural Cuba (Minneapolis, 1950).
2 The phenomenon has been systematicallydiscussed by Pablo González Casanova,
"Internal Colonialism and National Development," in Irving L. Horowitz et ai,
Latin American Radicalism (New York, 1969), pp. 118-139.

311

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312 SCIENCE AND SOCIETY

fessors. Medical provision for the rural population has increased

markedly.Physicians and other medical workershave been made ac-
countable to the people, and the emphasis has been shifted from
treatmentto the prevention of disease. Despite these advances, there
are many areas in which little, if any, progress has been made-
notably, nutrition,housing and medical supplies.

The Sanitary Environment

The health of a people is not solely related to the availability ot

hospitals, physicians, or medicine. The frequency of sickness 01
death also depends on the extent to which the environment-in-
come, diet, housing conditions- permits the growth and develop-
ment of a healthy population.
Earnings and Diet. In Cuba, as a rule, the poor were sicker than
the rich. They sufferedfrom malnutrition and could not finance
their own health. The affluent,however, could pay to be healthy,
could eat more, and could see medical personnel often.
Concrete evidence demonstrates these assertions. In 1956 the
Catholic UniversityAssociation made a survey of agricultural work-
ers. The main purposes of the inquiry were

to make, forthe firsttime in Cuba, a detailed, accurate,statisticalstudy

of the living conditionsof agriculturalworkers,which may serve as a
firmbase for analyzingeconomic and social problemsand findingsolu-
tions to them; to give our membersin the cities an opportunityto be-
come aware of the realityof our countrysideand learn its difficulties.
with certainknowledgeand
And, last but not least, to be able to affirm,
in the no-
proofreadyat hand, that the Cuban peasantsfindthemselves
man's-landbetween abandonmentand helplessness, thanks to national
as as it
egoism,and that our nation cannot apire to true progress long
does not give proper attentionto our countryside.3

In 1956 there were 350,000 agricultural workers with 2,100,000

Their
dependents comprising about 40% of the nation's population.
=
total annual income, 190,000,000 pesos (1 peso $l), amounted to
10% of the national income.4 A familyof six had an annual income

3 Melchor W. Gaston, Oscar A. Echeverría,and René de la Huerta, Por que Reforma

Agraria (Havana, 1957),p. 6.
4 Ibid.

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 HEALTH AND REVOLUTION IN CUBA 313

of 548.75 pesos,5or 7.60 pesos a monthper capita. More than half

of the familieshad annual incomesof less than 500 pesos,and only
7.2% earned more than 1,000 pesos annually.
More than two-thirds of all earningswere spent on food, 10%
more than in 1934,because of a 194% increasein salariesbetween
1934 and 1956,comparedto a 228% rise in the price of food.Thus
in 1956 the rural familiesspentmore moneyon food while eating
less than 20 yearsearlier.6In 1956 a familyof six could spend only
17 centsper personon food.7It is not surprisingthatmalnutrition
was widespread (91% in the countryside)and that the average
weightof the agriculturalworkerwas 16 pounds below the theo-
reticalaverageand the heightwas farless than thatof the average
Cuban.8
The principalsource of energywas rice, constituting24% ot
the totaldiet,followedby beans (23%) and root crops (22%). Out
of every100 families,only 11 could have milkregularly,while corn
was available to 7, meat to 4, bread to fewerthan 4, eggs to about
2, and none had greenvegetables.9Most Cubans had a verystarchy
diet, with few proteins,minerals,or vitamins,and many carbohy-
drates.More than one-thirdof the Cuban people sufferedmalnu-
trition,including6 out of every10 rural residents.10 Such a defi-
ciencyin nutritionwas reflectedin generalphysicalweakness,small
bone structure,low resistanceto diseases,and a high incidenceof
anemia.
Once, when speakingat the Ministryof Public Health (MPH),
ErnestoGuevara told his audience of physicians:
You musthave seenchildrenin themountains whosebodiesappearto

5 In Seers,op. cit.,theerroneous figureof$590.75is given.

6 ForeignPolicyAssociation, Problemsof theNew Cuba (NewYork,1935),pp. 79-86.
7 Por que ReformaAgraria,op. cit.,p. 60.
8 Ibid., p. 16. A surveymade in 1959of the ruralpopulationof Las Villas by the
provincialuniversity disclosedthat the averagerural familystill consistedof six
members witha yearlyincomeof 657 pesos,an improvement of 20% overthestudy
madein 1956by theCatholicUniversity However,73% of the families
Association.
had an averageincomeof 715 pesosa year,while27% earnedless than496 pesos
annually.See SamuelFeijoó,"Abrumadoras razonesdel éxodo ruralcubano,"Revo-
lución(Havana),November 2, 1959,p. 22.
9 Ibid.,pp. 20-24.
10 WyattMacGaffey and CliffordR. Barnett,TwentiethCenturyCuba (New York,
1965),p. 196.

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314 SCIENCE AND SOCIETY
be eightor nineyearsold, yetmostof whomare thirteen or fourteen.
They are the authenticchildren of the SierraMaestra, the authentic
childrenof hungerand misery, creaturesof malnutrition.11
A surveyof the nutritionalstatusof Cuban childrenwas also
made in 1956.12The sample13comprisedchildrenfromthe sixth
graderangingin age from11 to 13. In termsof economicstatusthey
reprsentedthe so-calledmiddle class,since the surveyexcluded the
wealthiestand the poorestsectorsof the students.The data14dis-
closedthatricewas thegreatestsinglesourceof calories (almostone-
fourth);that sugar providedalmost as many calories,followedby
lardsand oils; thatmeat providedslightlymorethan 10%; and that
flourand beans accountedformore than 5% each. Childrenin pri-
vate schools were taller and heavier than those going to public
schools; yet 10.4% of the formerwere underweight.This leads to
the conclusionthatmalnutrition musthave been widespreadamong
the poorer sectors.The frequencyof underweightchildren,who
also had the largestdeficienciesin calcium, vitaminA, thiamine,
and riboflavin,occurredamong rural ratherthan urban children,
while theoppositewas truewithrespectto therateof obesity.Skele-
tal deformities were found in one of everynine children,and was
attributedto low consumptionof calcium.
Althoughincome has been more evenlydistributedsince 1958,
the citiesstillreceivea large proportionof the nationalwealth.On
September26, 1966, Castro acknowledgedon Havana radio that
"therestill remainsa by-product of capitalistexploitation:the ex-
ploitation of the countrysideby the city."Is therestill widespread
povertyin the rural areas?Severalrevolutionary authoritiessay yes,
althoughsome outsideobserversdisagree.In 1969 a formerofficial
of 'the UN Food and AgricultureOrganization (FAO) stated that
70% of the Cuban people since the revolution"live betterthan
theydid before."15Nonetheless,the extentof betterment, because
11 Rolando E. Bonachea and Nelson P. Valdés, ed., Che: Selected Works of Ernesto
Guevara (Cambridge,1969),p. 258.
12 "Nutritional Status of Cuban Children," Nutrition Reviews, Vol. 16, No. 9, Septem-
ber 1958,pp. 271-273.
13 The sample had 2,171 subjects out of a total sixth-gradepopulation of 41,883 stu-
dents from public and private schools; the urban population was representedb)
1,016students,the rural by 1,155.
14 Ibid., p. 272.
15 Erich H. Jacoby, "Cuba: The Real Winner Is the AgriculturalWorker," CERES:
FAO Review, Vol. II, No. 4, July-August1969,p. 32.

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 HEALTH AND REVOLUTION IN CUBA 315

of the extremeausteritysince 1962,remainsan open question.

No exact figureson food consumptionhave ever been given by
the regime,and a general idea can be gained only by considering
the rationingsystem16 begun in 1962. In principle,at least,ration-
ing assures of
equality consumption.17 The system, it mustbe added,
sets limitsto the amount anyone can purchase a given product,
of
but does not guaranteethe availabilityof supplies.In 1958, forex-
ample, 10.2 lb. of rice per capita were available each month; this
had declined to 6 lb. in 1962 and to 3 lb. in 1969. The 2.2 lb. of
meatavailable weeklyin 1958 fellto 0.75 lb. by 1962 and remained
at thatlevel; similarlythe 2.4 lb. of grainsmonthlyfell to 1.5 Ib.;
the 2.9 lb. of fatsto 2 Ib.; the 2.1 lb. of beans to 1.5 lb. Almosta
half-literof milk had been available daily in 1958; thisfell to one-
fifthliterin 1962 and 1963 and even thenwas allowed only to chil-
dren underseven,the aged, the sick,or miners;but by 1969 these
categorieswere allowed almosta full liter.The biweeklyfishavail-
abilityfellfrom1.1 lb. to 0.5 Ib., but was almostrestoredby 1969;
chickenfell from3.2 lb. a monthto 2 lb. No information for 1958
was available concerningthe amounts of bread, condensed milk,
vegetables,or sugar in supply; but by 1969 the amountsreported
were respectively 50 gramsa day, 3 cans a month,3.5 lb. a week,
and 6 lb. a month.18Thus a markeddecline in the availabilityof
manyfoodstuffs was experienced;but it is possible thatonly those

16 Rationing in Cuba differsfrom that of other underdeveloped countries. Rationing

in Cuba is the consequence not only of low agriculturalyields and a growingpopu-
lation, but also is a product of the fact that most Cubans have money to buy what
is on the market. In Cuba, goods are rationed; in other countries, income is ra-
tioned; hence a shortageof goods does not occur- the people simplycannot buy the
goods that are available.
17 Preferentialtreatmentin terms of food is accorded by the state to the military,
police, scholarshipstudents,and hospital personnel. High militaryofficialshave been
reported to get more groceries than their ration cards state. See The New York
Times, December 11, 1970,p. 6.
18 Rationing decrees of March 12, 1962, and October 8, 1963; FAO, AgriculturalCom-
modities Projections for 1975 and 1985 (Rome, 1967), 2 volumes; FAO, National
Rice Policies (Rome, 1966), p. 99; Jacques Chonchol et al, Proyecto de Plan Quin-
quenal para el Desarrollo de la Agricultura Cubana, 1961-1965 (Havana, 1961);
Informe sobre Cuba (Miami), November 30, 1963; U.S. Department of Commerce,
Investmentin Cuba (Washington,July 1959); Facts on File (New York), April 30-
May 6, 1970,p. 313; Keesing's ContemporaryArchives(London), June 7-14, 1969, p.
33395; Revolución (Havana), January 17, 1959; Instituto Nacional de Reforma
Agraria,Informe(Havana), May 17, 1959. :

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316 SCIENCE AND SOCIETY

in the upper levels of societyreally felt it, while the lower class,
despite the decrease,augmentedtheirconsumption.19
In additionto theirrations,a largeportionof thepopulationare
servedfreemeals.In 1965,626,300personsa day werefedbreakfast,
lunch,or dinnerwithoutcharge;202,200,000persons-one-fourth of
the population-were being fed in this way in 1970.21Also, there
are restaurantsand cafeteriasselling food at moderateprices and
manywork centershave a dining room where employeescan eat
lunch for 1 peso or less.22
Are Cubans betterfed today?Estimateson the averagedaily per
capita calorie intakeindicatethatthishas declinedfrom2,740 dur-
ing the period 1951-1957 to 2,320 in 1962-1963, and as low as
2,100 in 1965-1966 (out of a daily requirementof 2,460 calories).23
National averagesare oftenmisleading,since theyconceal dispari-
ties betweenregions;the rural people, whose food consumptionin
the 1950s was much below the national average,seem to have re-
ceived a fairershare of caloriesand nutrientssince 1959. On Sep-
tember 17, 1956, however,Castro recognizedthat therewere still
thousands of children not receiving all the nourishmentthey
needed.24It must be concluded that underconsumption still exists
in Cuba, despitethe improvement in someruralareas,and thatsince
1961 Cubans have been eatingless each year.25
Housing, In the 1950s Cuban dwellingsdid not meet minimal
19 Several nutritional studies of various rural communitieshave been made in Cuba,
but none, to our knowledge,ever was printed. See Granma (Havana), December 18,
1969,p. 5.
20 Mario Gerda Gutiérrez,"Cuba: alimentos para todos," Punto Final (Santiago, Chile),
April 8, 1965,pp. 10-11.
21 Fidel Castro,speech made on July26, 1970.
22 There are also many high-pricedrestaurants,quite out of reach of the budget of
the average Cuban workeror peasant, and this has angered many people.
23 For data on calorie intake, see MacGaffeyand Barnett, op. cit., p. 196; Lester R.
Brown, Man, Land, and Food (Washington,D.C., 1965), p. 142; FAO, Agricultural
Commodities . . . (op. cit.), Vol. I, p. 36, and Vol. II, p. 78; U.S. Department of
Agriculture, The Western Hemisphere Agricultural Situation (Washington, D.C.,
1966),p. 21.
24 Granma, September25, 1966,pp. 4-5.
25 Agriculturalproduction grows at the rate of 0.1% annually, while the population
grows 2.1% annually (since 1961); FAO, The State of Food and Agriculture(Rome,
1968),p. 15.

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 HEALTH AND REVOLUTION IN CUBA 317

requirementsof hygiene.Many poor people, particularlychildren,

were easypreyfora varietyof diseases.26
In 1953, 63% of all dwellingswere located in the urban areas
where57% of the population lived. Not only were rural families
relativelyovercrowded;of the homeslistedas in extremelybad con-
dition,the rate was 25.9% in the rural areas comparedwith 8.6%
in the cities.27
A studyin 1958 disclosedthat62.5% of all sheltershad thatched
roofsand dirtfloors,and 53% had no baths.28A littleover half the
urban homeswere built of masonry,but in the countrynot even
3% wereso built; palm and wood thatchprovidedthe buildingma-
terialforalmost70% of Cuban homes.Floorswere oftendirtyand
muddy;homeswere infestedwith insectsand rodents.
Electricpowerwas available to 58% of all homes,but not to the
poor in the countryand partsof the cities,whosemeagerwagesand
salariesdid not affordsuch luxuries.In the cities 87% of the fam-
ilies used electricpower,but in the interioronly9.1% did so. What-
everfood the poor managedto purchasecould not be preservedby
mechanicalrefrigeration, which existedin only 17% of all Cuban
homes; foreveryrefrigerator in the rural regionstherewere 13 in
the cities,and 96% of countrydwellingshad no refrigeration what-
ever,whereas37.5% in the citieshad some refrigeration.
The systemfor the disposal of human wastes was also inade-
quate. Only 28% of all homes had inside flushtoilets; 13.7% had
flushtoiletsoutside the house; more than 33% had latrines;and
23.2% (in the countryside54.1%) had no facilitieswhatsoever.
Good drinkingwater,indispensableto the protectionand im-
provementof health, was not an inexpensiveor easily available
item. More than three-fourths of all rural familiesobtained their
waterfromrivers,wells, or springs,manyof which were contami-
nated; 2% of themreceivedinside piped water,comparedwith a
35% nationalaverage.
Has the housingproblembeen solved by the revolutionary au-

26 Marcia N. Koth, et al., Housing in Latin America (Cambridge, 1965), p. 32; Unión
Panamericana, América en Cifras 1967 (Washington, 1969), Vol. I, p. 29.
27 For detailed statisticson housing conditionsin 1953, see República de Cuba, Censos
de Población, Viviendas y Electoral (Havana, 1953), pp. 209-215.
28 Pedro M. Baeza, "Educación médica en América," Universidad de La Habana (July
1962),p. 93.

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318 SCIENCE AND SOCIETY

thorities?Definitelynot. At firstthe Cubans discoveredtheirneeds,

but onlyafterwards did theycome to realize thatthe povertyof the
countryset tremendously high limitationsto what theycould do.
Cementand otherresourceswerelimited,and whatwas at hand had
to be used to build roads, port facilities,schools,dams, hospitals,
and other structures;housingwas relegatedto the bottomof the
prioritylist.
In 1964, 15% of the dwellings,housing18% of the population,
were in extremelypoor condition,and another31%, housing36%
of thepeople,werein poorcondition.In otherwords,655,000homes
were urgentlyneeded to provideadequate housingto 54% of the
Cuban population.In general,1,200,000homeshad to be improved
or replaced.29
At the closingsessionof the National BuildersCongressin Oc-
tober1964,Castronotedthata programof building2,000,000homes
by 1990 had to be introduced,to produce 80,000 homes yearly.30
In 1965 he proposedthe building of 100,000homes annually,but
then he added that the countrycould not accomplishthis forlack
of resources,and concludedwiththe pessimisticnote thatthe hous-
ing problemwas something"that the Revolutionhas not even be-
gun to seriouslydeal with."31On August29, 1966,Castroacknowl-
edged that governmentofficialswere constantlybesieged wherever
theywentby people in desperateneed of housing,but he observed
thata solutionin the immediatefuturewas absolutelyimpossible.32
And in late 1970 he reaffirmed thatthe housingshortagewas a "ter-
rible problem,"adding: "This is a problemof which we are only
too aware," since 90% of the people who approachedthe authori-
ties alwayspoint out theirtremendousneed fora new shelter;but,
accordingto Castro,"There is no way of solvingthat problem."33
In 1964 the state repaired 13,502 dwellingsand constructed
17,284,accordingto a reportgiven by the Cuban delegate to the
World Health Organization(WHO).34 However,in early1968,Cas-
29 Alberto Arrinda, "El problema de la vivienda en Cuba," Cuba Socialista (Havana),
December 1964,p. 14.
30 Speech on Radio Habana, October 26, 1964.
31 (Instituto del Libro), Discursos de Fidel en los aniversariosde los CDR, 1960-1967
(Havana, 1968),p. 159.
32 Politica (Mexico), September15, 1966,pp. x-xi.
33 Granma, December 20, 1970,p. 3.
34 WHO, EighteenthWorld Health Assembly,OfficialRecords (Geneva, 1965), p. 172.

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 HEALTH AND REVOLUTION IN CUBA 319

troreportedthatin the firstnine yearsof the Revolution"we have

not built more than 10,000dwellingsper year,whereaswe need to
build some 100,000dwellingsannually/'35 If that is reallythe case,
thenthe figuresgivento WHO are exaggeratedor else construction
from1965 to 1967 substantiallydeclined to a yearlyrate of 5,756.
Moreover,a yearlydeficitof 90,000 dwellingshas been accumulat-
ing,creatingan aggregateover the last 12 yearsof morethan 1,000,-
000 homesrequired.Dwellingconstruction per capitalseemsto have
declinedfrom1.5 per 1,000inhabitantsin 1958 to 1.2 in 1967.36
In the firstfiveyearsof the revolutionary regimean averageof
11,089homeswereconstructed annually,49% of themin the coun-
tryside.37Meanwhile a system prioritieshas been drawn up for
of
the construction and deliveryof new homes.The rural population
has precedence,followedby projectsto eradicateurban slums and,
eventually,run-downtenements.
The need forrural housingis pressing.In 1960 a housingcen-
sus in the countryside revealedthatalmost2,000,000Cubans lived
in "miserablehuts,with the poorestof sanitaryconditions,1'38 re-
quiringthe promptconstructionof 400,000 dwellings.Rural proj-
ects have been put into effectand have deliveredless than 10,000
new homesa year.The homes,whichare free,are simple,comfort-
able, somewhatsmall, but equipped with furnitureand sanitary
service.Most slums have disappeared,and the inhabitantsplaced
in new housingunits.39
Worthyof note is the thoroughchange in housingpropertyre-
lationsbroughtabout by therevolutionary regime,whichon March
10, 1959,enacteda law reducingby half the cost of all units with
a monthlyrentofunder100 pesos,by40% thosewithrentsof 100 to

35 Granma,January14, 1968,p. 2.
36 Carmelo Mesa Lago, "Availability and Reliability of Statisticsin Socialist Cuba/'
Latin American Research Review, Summer 1969, p. 72. One Cuban publication
states that from 1959 to 1969, 140,000 dwellings were built. If this is true, then
from 1967 to 1969 the yearlyaverage was 16,600.The author, however,could have
included the units built from 1959 to 1963 by the private sector,thus giving a false
impressionof the actual rate of growth.Bohemia (Havana), October 24, 1969, pp.
32-39.
37 Arrinda,op. cit,,p. 16.
38 Arturo Acevedo, "¿Bohios, para que?", INRA (Havana), December 1960, p. 46.
39 A fairlyuseful summaryof these programs can be found in Don Burke, "Urban
Renewal in Cuba," Guardian (New York), February 15, 1969, p. 18.

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320 SCIENCE AND SOCIETY

200 pesos,and all othersby 30%.40The Urban ReformLaw of Octo-

ber 14, 1960,expropriatedall urbanflatsand placed themunderthe
state.Rentswereto be paid to the government and wereconsidered
as amortizationtowardownershipby the occupants,who must pay
promptlyand regularlyand maintainthe premises.They can change
theirhomes forothersonly througha state institution.41
Those living in homes built in or prior to 1940 were to cease
paymentin 1965 if renthad been paid punctuallysince 1959. And
afterMay 1961 all new vacant units were distributedto families
who had to pay rentequal to 10% of the familyincome.Moreover,
in mid-1966,the rightto live rent-free forthe restof theirliveswas
granted to all occupantsof run-down tenements who had made at
least 60 monthlypaymentssince 1959.42A total 268,089families
of
no longerwere payingrentin 1969.
Are sanitaryconditionsin Cuban homes better?Informationis
sketchy.The mostrecentreporton the disposalof sewage,made in
1964 by the Cuban government, disclosedthatabout 77 of the 276
communitiesin the countrywith more than 1,000 inhabitantshad
organized arrangementsfor the disposal of human waste. About
1,200,000personsin thesecommunitieswere servedby sewagesys-
tems;2,800,000othershad onlyseptictanksor latrines.43 The water
supply, on the otherhand, has been markedlyimproved.44
More domesticelectricpower was available. In 1958, 732,000
homeshad electricity;45 by 1970,988,000families-a littlemorethan
halfof all homes-used electricpower.40
It is clear that few positiveachievementscan be demonstrated;
thereis stilla housingcrisis.More than 70% of the populationlive

40 Gaceta Oficial (Havana), May 3, 1959.

41 Boris Goldenberg, The Cuban Revolution and Latin America (New York, 1965),
p. 195.
42 Urban Reform Law (Havana, 1967), pp. 5-10. The Cubans announced in 1966 that
four years later all rent would be abolished, but on December 7, 1970, Castro re-
versed that position.
43 WHO, Third Report on the World Health Situation, 1961-1964 (Geneva), April
1967,p. 131.
44 1953 Cuban census and Ildeu Duarte Filho, "El financiamientode proyectosde in-
geniería sanitaria," Boletín de la Oficina Sanitaria Panamericana (Washington),
January-June1970,p. 65.
45 Grupo Cubano de InvestigacionesEconómicas, Un estudio sobre Cuba (Coral Ga-
bles, 1963),p. 169.
46 Bohemia, October 9, 1970,pp. 30-35.

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 HEALTH AND REVOLUTION IN CUBA 321

in inadequate houses, dwellingsthat do not provide the sanitary

environment indispensablefora healthypeople.

The Health Sector

Health appears to have been "reasonablygood"47in the pre-
revolutionary years.Various authorshave stressedthatin Cuba the
rate of mortalitywas low and the numberof physiciansand hospi-
tal beds per capita was high.48Argumentshave been put forthto
provethatthe country'shealthsystemwas efficient, progressive,and
needed littlereform.Such assessments, based on national averages,
presenta false impression;any usefulanalysishingeson the ques-
tion of how health facilitiesand personnelwere distributed.
Health Personneland Facilities Before the Revolution. In the
nearlysix decades from1899 to 1958 the Cuban people increased
theirnumbersfourfold,while the numberof physiciansmultiplied
by five.In 1957 the doctor-to-population ratio was 1:998, the sec-
ond highestin Latin America.49Medical serviceswere, however,
relativelyunavailable to the inhabitantsof the rural areas; medical
skillsand facilitieswere concentratedin the large cities.More than
60% of all physiciansin 1958 lived and workedin Havana. Need-
less to say,the regionswith the fewestphysiciansneeded them the
most.50Even when doctorspracticedoutside of Havana Province,
theydid so primarilyin the provincialcapitals.51Such a concentra-
tion in the cities resultedprimarilyfromthe desire of the physi-
cians to make a good living.In the citiesmore people could afford
to pay for treatment.52 In otherwords,medical personnelcongre-

47 José M. Illán, Cuba, datos sobre una economia en ruinas (Miami, 1964), p. 26.
48 FOROC, La seguridad social en Cuba (Miami, 1965),pp. 7-8.
49 Theodore Draper, Castroism,Theory and Practice (New York, 1965), p. 100. For the
number of physicians,consult the censuses; also Granma, February 12, 1967, p. 2.
50 Noteworthyis the fact that 70% of the medical students graduating in 1955-
1956 had to migrate because they could not find a job (in the capital). In 1956 the
Cuban Medical Association had a symposiumto discuss the problem.
51 For a provincial breakdown of the distributionof physiciansin 1958, see Bohemia,
January 5, 1968, pp. 25-26 and 28-31; Carlos Font Pupo, "La Salud del Pueblo,
preocupación basica de la Revolución," Cuba Socialista (Havana), April 1963, p. 53.
52 There are secondary causes, such as the facilities found in urban areas. For a
thorough consideration of the issue, see "The Urban and Rural Distribution of
Medical Manpower/' World Health Organization Chronicle (Geneva), March 1968,
pp. 100-105.

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322 SCIENCE AND SOCIETY

gatedin the urban areas because healthwas a commodityto be sold.

Medical services,their scope and extent of coverage were deter-
mined by a commitmentto profitsand not to serve the needs of
Cubans.53
The trendtowardconcentratingin the city of Havana is also
visibleamong dentists.In 1899,40% of the total were in the capi-
tal; in 1957 it was 62%.54 But the ratio of dentistsincreasedfrom
1:3,000 in 1899 to 1:2,224 in 1957. Nurses followeda similarpat-
tern.55
In 1958 therewere 88 hospitalsin Cuba, withone bed forevery
300 persons.But the distributionwas irregularand completelyin-
adequate when the densityand morbidityrates of the population
weretakenintoaccount.The urbanareasreceivedpreferential treat-
ment,with80% of all beds to be foundin the cityof Havana.56For
the entirerural populationtherewere only 10 beds in a singlehos-
pital. Moreover,witha fewexceptions,the hospitalslacked internal
organization.57
The needs of the people receivedlittleconsiderationin the pre-
revolutionary years.The construction of hospitalsand otherhealth
facilitieswas "mostoftenthe resultof politicalratherthan techni-
cal decisions."58The health sectorwas a channel to distributepo-
litical patronage,a usefulway to become rich. One studystated:
Often,accessto a clinicor a hospitalbed couldbe obtainedonlythrough
the politicalorganization of the town.Serviceswerechanneledto the
ruralpopulationthrough leadersofthepartyin power.. . . Publichealth
positions, like othergovernment jobs, also weresubjectto the patron-
age systems.59
Needless to say,public officials were concernedwith the health of
the people only everyfouryears,duringthe weeksbeforeelections.
53 Charitableand mutualaid associationsmade a contribution to the healthof the
peoplein the cities,
although a fee was ofteninvolved.
54 Censusfor1899;Granma,November19,1969,p. 4,
55 For statisticson dental and nursingpersonnel,censusesfor 1899 through1933;
WHO, SecondReporton the WorldHealth Situation, 1957-1960(Geneva),pp. 121-
123.
56 Carlos Font Pupo, "Hada la salud pública socialista,"Cuba Socialista(Havana),
July1965,p. 39.
57 Raúl de Velasco,"Cuba," WorldMedicalJournal,May 1959,p. 141.
58 MacGaffey and Barnett, op. cit.,p. 201.
59 Ibid.

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 HEALTH AND REVOLUTION IN CUBA 323
Radical Institutional Changes.The healthsystembeforethe
Revolution was plaguedbya lackof coordination of private,char-
itable,and publicinstitutions. In 1959 a seriesof administrative
measuresbroughtabout a completeoverturn of the institutional
structure and a morebroadlybasedand comprehensive systemof
medicalcare.The Ministry of PublicHealthacquiredbroadpow-
erswithwhichit introduced a unifiedhealthsystem underitscon-
trol.This centralauthority,it must be noted,exercises a supervi-
sory,coordinating, and financial ratherthanan executiverole.
In 1963the MPH established completecontroloverall health
as theresultof thenationalization
facilities of privateand charita-
ble concerns. Reorganization becamemorethorough and planning
morecentralized. Uniformplansweredrawnto assuremaximum
efficiencyand avoidduplication.
At present theexecution ofhealthplanstakesplaceat threelev-
els,all directlysupervisedby the MPH: provincial, regional,and
local.60Thereare healthdivisionsforeach of thesix provinces of
Cuba, each division the
representing authority of the MPH and re-
sponsibleforthe implementation of policy.The eightprovincial
hospitals(two in Havana, two in Oriente, and one in each of the
otherprovinces), eachwith600 beds,givespecializedserviceto the
inhabitants of theareas.61
Each provinceis dividedintoregions.There are 38 healthre-
gionswithurbanhospitalsdoinggeneralsurgery. Each establish-
menthas a capacityof about350 patients.The regionsare subdi-
videdintohealthareas,eachwithat leastone polyclinic.62 The poly-
foroutpatients
clinic,an institution withpreventive and socialfunc-
tions,has a gynecologist, dentists,pediatrician,epidemiologist,
nurses, and one internon duty.Thereare also healthworkers who
teachthe surrounding communities basic principlesand methods
ofhygiene. Each ruralpolyclinic has from20 to 30 beds,equipped

60 This model was taken fromthe Soviet Union and the Easetrn European countries.
UN Department of Economic and Social Affairs,Report on the World Social Situa-
tion (New York, 1963), p. 37; Gaceta Oficial (Havana), February 6, 1962, and No-
vember29, 1962.
61 Edward Rice, "Cuba: Services for All," World Health (Geneva), December 1968, p.
15; Granma,February12, 1967,p. 9.
62 WHO, Second Report on the World Health Situation, 1957-1960 (Geneva, 1963),
pp. 121-123; Third Report on the World Health Situation, 1961-1964 (Geneva,
1967), pp. 129-130; Cuba Internacional (Havana), September 1970, p. 7.

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324 SCIENCE AND SOCIETY

to deal with general medicine,obstetrics,and pediatrics.Surgical

casesare sentto regionalhospitals.Furthermore, in the mostremote
rural areas dispensarieshave been built to provide primarymedi-
cal assistance.Some have dentistsbut lack beds; when necessary,
patientsare sent to the rural hospitals.
More importantyetwas the conceptof healthand medicalcare
as a biologicalrightavailable to everyoneat no directcost.63From
the outsetthe revolutionary statehas recognizedthe responsibility
of assuringall its citizensa healthydevelopment-a radical break
withthe past.
Facilitiesand Personnelin theRevolution.The quantitativede-
velopmentof public medicine became a priorityin the firstfive
years of the revolutionarygovernment.The MPH increasedthe
capacityof the facilitiesat hand and built new unitsthroughoutthe
nation: 66 new hospitalsfrom1959 to 1964,6438 of them in the
countryside.This broughtthe number of state hospitalsto 120;
these,added to 25 othersnationalizedby 1963, provideda total of
145 hospitals.In 1968,accordingto one version,Cuba had 180 pub-
lic hospitals;if the mutual benefitclinics are added, 215 hospitals
could be counted.65
Health facilitiesincreasedfrom1959 to 1968 as follows:92 new
hospitals,260 polyclinics,56 rural dispensaries,20 public health
laboratories,40 stomatologicalclinics,8 dentalsurgeryservices,and
14 blood banks.66 Moreover,halfofall new hospitalswereestablished
in theruralregions,30 of themin OrienteProvince,whichsuffered
themostfrombackwardness The ruralhospi-
and lack of facilities.67
and simple. But theyhave broughthealth
tals are small, efficient,
to people who only dreamedof it. One observernotes:
These units,builtin themostremoteareas,are bringing healthcare to
thousandswho previously had to wait on the coastto signala passing
shipto takethemto thecitiesfortreatment. All alongthecoastof the

63 Health servicesare freefor all inpatients.Outpatients,on the other hand, must pay
for theirmedicine.
64 Pupo, "Hacia la salud . . .", loe. cit.
65 Bohemia, January2, 1969, p. 29; for statistics,1959 through 1968, see also Granma,
April 3, 1968; OCLEA (Havana), January 1969, p. 28.
66 "Salud Pública," Bohemia, loe. cit.; Francisco Rojas, "Revolución: Salud Pública,
logros y perspectivas,"OCLAE, loe. cit.
67 K. S. Karol, Guerrillas in Power (New York, 1970), p. 597.

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 HEALTH AND REVOLUTION IN CUBA 325
ruralprovinces are thegraveyards of thosewho could waitno longer.68
Howeverthe rural hospitalshave one major weakness:a scanty
supply of beds.69In 1968 these hospital comprised22% of the
totalnumberof hospitals,but had only3% of the beds.70Of course,
theseunitswere createdto delivergeneralmedical care,not forin-
tensivetreatment.
The availabilityof hospitalbeds, in itself,is not a reliable indi-
catorof the level of health.Nonetheless,from1959 to 1968 public
healthbeds almostquadrupled (from10,843to 38,760),71the major
increasetakingplace in the early 1960s because of the rapid con-
structionof hospitalsand the expropriationof the privatesector.72
Moreover,bed facilitiesat all levels almost doubled from1958 to
1968. In 1958 therewere 25,745 beds, 3.9 forevery1,000 persons;
in 1968 therewere 47,660,5.9 per l,000.73
The expansionof servicesdemanded increasedmedical person-
nel. But here the governmentconfronteda serious shortage,not
onlybecause of the growthof facilities,but also because of the mi-
grationof physicians.From 1959 to 1964 the medical ranks de-
clined by 1,445; if the rate of graduatingmedical studentsis con-
sidered,this means that more than 2,000 doctorsfled the island.74
68 Don Burke, "Cuba Makes Health Care Revolution," Guardian (New York), Feb-
ruary 1, 1969, p. 16.
69 The building of polyclinics started to receive preferenceafter 1965, which could
account for the low rate of beds in the countryside.
70 Carlos Rafael Rodriguez, "Análisis para el primer decenio y perspectivas para el
segundo," Panorama Económico Latinoamericano (Havana), September, 1969, pp.
22-23.
71 Granma, April 3, 1968; the statisticsrefer only to budgeted beds, not those in
mutual benefitclinics.
72 In 1959 estimateswere that Cuba needed 40,000 new beds. If the estimate was cor-
rect, a deficitof 19,000 beds still exists. See Raúl de Velasco, loe. cit.
73 The bed figurefor 1958 from Bohemia, January 5, 1964, pp. 25-31; that for 1968
from Bohemia, January 2, 1969, p. 29, and Granma, January 19, 1969; they in-
clude public and mutual benefit clinics. The ratio of beds to population from
WHO, Twenty-secondWorld Health Assembly, Official Records (Geneva, 1969),
pp. 68-69; ratios supplied by Cuban officialsfor similar years often show great
divergencies,as exemplifiedin the yearly reports presented by the Cuban delega-
tion to the World Health Assembly.
74 According to Willis P. Butler, "Cuba's Revolutionary Medicine," Ramparts, May
1969, more than 2,500 trained doctors left Cuba for the United States from 1959
to 1965. A lower figure,1,275, appears in Organización Panamericana de la Salud,
Migration of Health, Personnel, Scientists, and Engineers from Latin America
(Washington,1966).

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326 SCIENCE AND SOCIETY

It was imperativeto make up the lossesby introducinga crashpro-

gram.The timeof studywas shortenedand qualificationsreduced.
After1964 this extensiveand concentratedprogrambegan to pay
offnumericallyas the numberof doctorssoon passed the 1959 level
and in fiveyearsincreasedby 2,645,to a totalof 7,500in 1969.Even
with 1,200moredoctorsthan 10 yearsearlier,however,the ratioof
physiciansto populationremainedstable at about l:l,000.7B
Distributionof medical personneldid improve,albeit slowly.
In 1963, when the national average was one physicianfor every
1,180 persons,Havana Provincehad 3,253 physicians-that is, one
forevery320 persons-whilethe remainderof the countryclaimed
only one forevery2,150 inhabitants.76 In 1969,approximately half
of the nation'sdoctorswere still in the capital,77but in that year
one physicianout of everysevenwas practicingin the countryside.78
The Trainingof Medical Personnel.The Cubans believe thatto
merelyproduce qualifiedhealth personnelcannot solve the health
problemsof the country.The graduatesmustalso be trainedto face
adverseconditions.Hence, the teachingof medicine has changed.
Preventivemedicine is taughtas an integralpart of clinical sub-
jects,and fromthe outsetthestudentsare broughtinto contactwith
the socio-culturaland economic peculiaritiestheywill face while
practicing.79
The biological foundationsof medicine were combined with
social and politicalstudies,in the wordsof a government authority,
so thatthe studentswouldnot regardthe sickpersonsimplyas a hos-
pitalpatient,butseehimin histotality, as a socialbeing,sinceanyother
viewleads to thedehumanization of man.80
Years earlierthe MPH made the same point in a different
way:
75 The 1959numberof medicalpersonnel(6,300)is fromGranma,January19, 1969,
p. 2; the 1964number(4,855)fromWHO, WorldHealth Annual Statistics, 1964-
1970; the 1969numberfromGranma,loc. cit.The ratiois fromBoletínde la Ofi-
cina SanitariaPanamericana(Washington), June 1970,p. 33, and WHO,
January-
Twenty-second World Health Assembly, Records
Official (Geneva,1969),p. 382.
76 WHO, WorldHealth Statistics Annual (Geneva,1967),Vol. II.
77 Zdravookhraneniye RossiyskoyFederatsii(Moscow),February1970,pp. 38-41.
78 Radio Habana, January9, 1969.
79 Such measureshave not been takenin mostof Latin America."MedicalEducation
in Latin America,"WorldHealth OrganizationChronicle(Geneva),October1970,
pp. 467-470.
80 JuventudRebelde (Havana),July9, 1970,p. 2.

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 HEALTH AND REVOLUTION IN CUBA 327
Doctorsshouldfirst understand theproblemsthataffect our societyand
refrainfrombeingindividualsenclosedin ivorytowersundertheslogan
of scienceforitsown sake.Rather,thewatchword mustbe: sciencefor
thehealthof all our people.81
Those enrollingat the threemedical schools82must be at least
17 yearsof age and have a secondaryschoolcertificate. Afterpassing
competitiveentryexaminationsthe pupils studyforsix years.The
firstthreeyearsare devotedto the studyof premedicaisciences.In
the second year historicaland dialectical materialism,as well as
politicaleconomy,philosophy,and foreignlanguage courses,must
be taken. In the fourthand fifthyears the curriculumincludes
therapy,psychiatry, surgery,pediatrics,obstetrics,and severalothei
in
courses.Finally, the sixthyear, time is devoted entirelyto prac-
tice at hospitalsand clinics. There are 23 health establishments
where the internspracticetherapy,surgery,obstetrics,gynecology,
pediatrics,hygiene,and epidemiology.
The workof each sixth-year studentis gradedby his instructors
fora whole month.The ratingis based on the instructors' observa-
tions, not on tests.A Soviet observer noted that "in ratinga stu-
dent's internship, due consideration is given to his interest in the
science,his reportson theoreticalmatters,practicalor laboratory
work,as well as his ideologicallevel."83
Afterthe sixthyear an annual examinationis taken,and then
the studentbecomesa physicianand may practice.However,each
graduatemustworktwo or threeyearsin a rural area.84The num-
ber of graduatingphysicianssince 1961 has increasedfrom335 in
1961 and 355 in 1966 to 420 in 1968 (a numberattainedbrieflyin
1962) and to 923 in 1969.85
Upon graduating,Cuban physicianspledge to renounceprivate
practiceand workonly forthe state.86In 1959, 83% of all doctors
81 Granma, September 11, 1966.
82 Of the 158 senior professorsteaching medicine at the Universityof Havana, all
but 17 migrated after 1959. Leo Huberman and Paul Sweezy, Socialism in Cuba
(New York, 1969), pp. 56-57. In 1966 there were 207 professorsat the Havana
institution.
. ...
83 Zdravookhraneniye op. cit.,pp. 39-40.
84 Law No. 1141 of January 11, 1964; see Granma, June 21, 1968, p. 2.
85 Granma, January25, 1970, p. 2.
86 The pledge, begun in 1965, states: "We promise ... to renounce private practice
. . . and to make effectivewith our attitude the new proletarian philosophy of the

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328 SCIENCE AND SOCIETY

(5,297) were in privatepractice,while 17% (1,003) were employed

by the state; in 1969, 93% (7,291) workedfor the state,only 7%
(709) werein privatepractice.Some of theprivatepractitionerswere
also employeesof the MPH.87
To make up forthe shortageof doctors,stresshas been givento
oftenyoung,are
the trainingof medical assistants.These assistants,
trainedfromtwo to sevenmonthsin hygieneand given the respon-
sibilityof lookingafterthe health of 10 to 15 familiesin isolated
areas. The auxiliariesalso receivedadequate supervision.88
The ranksof medicalassistantshave grown.From 1959 to 1969,
over 20,000were trainedas nurses,nurses'aides, or laboratorytech-
nicians.89Dental personnelincreasedas well. About 80% of the
dentistsworkedfor the state in 1968, 70% more than in 1958. In
1967,Havana Provincehad 45% of the country'sdentists.90
Medical care has been carriedout with the directparticipation
of the people fromthe veryfirstyearsof the Revolution.This is an
exercisein social medicine.Citizensaid medical personnelin pre-
vention,care,aftercare, sanitation,and mobilization.This participa-
tion is nationwide,and the fightagainst disease is enthusiastic.91
Only such a break withtradition,despitecriticismto the contrary,
has filledthe vacuum of medical personnel.To have followedthe
old schemeswould have meantneglectin servinga portionof the
people. The Revolutionrefusedto do this;serviceto all tookprece-
dence,even if qualitysuffered.92
medical sciences and ... to maintain in ourselves the spirit of scientificand po-
litical improvementin order to reach the technical level necessary and to make
ourselves true communists.. . . We state our readiness to give our help, scien-
tific or otherwise, to the peoples that are fightingfor their national liberation
and their economic, political, and social independence. . . . We pledge to defend
with our lives this heroic socialist and communistrevolution.We make this pledge
before our people and our Maximum Leader, Fidel Castro, Commander-in-Chief,
whatever it may be, wherever it may be, whenever it may be, at your ordersl
Fatherland or Death. Venceremos." The pledge was read over Radio Habana on
November 14, 1965.
87 Granma, January 19, 1969, p. 2, and January 25, 1970, p. 2; Pupo, "Hacia la sa-
lud pública . . . , " op. cit., p. 4.
88 Gaceta Oficial (Havana), March 23, 1962, pp. 3592-3594.
89 WHO, Twenty-second World Health Assembly, Official Records (Geneva, 1969),
pp. 68-69.
90 Granma, February 26, 1967, p. 6.
91 Rice, op. cit., p. 15.
92 This position has been supported by international health authorities. See Dr.

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 HEALTH AND REVOLUTIONIN CUBA 329
Government expenditure on healthin 1968was 10 timeshigher
thanin 1958.Althoughthisfiguredoes not accountforwhatwas
spenton privatemedicine,or thechangein thevalueofmoney, thè
government increaseditspercapita in
investment thehealthofeach
Cubanfrom3 pesosin 1959to 23 pesosin 1968.In budgetaryterms,
thismeantthatthe totalspenton public healthincreasedfrom
22,000,000pesos to 236,000,000pesosin the period1958-1969.93
The HealthoftheCubanPeople
The principalobjectiveof expandingthe healthsectorunder
therevolutionary government has been to furnish medicalservices
toall thepeoplein orderto improve theirphysical and mentalwell-
and
being prevent disease.In evaluatingtheseefforts,and theextent
ofanyimprovement, arerequired.The mostuse-
suitableindicators
fulyardstick are generaland infantmortality, lifeexpectancy, and
thefrequency ofdiseases.
GeneralandInfantMortality. On January 2, 1967,Castrostated
that"therearecertainhighly indicative
figuresshowing whata revo-
lutioncan mean to a country,"adding thatone of them is thean-
nualdeathrate (thenumberofdeathsper1,000persons). According
to a Cubanofficial, "The annual death ratein our country was 13
in every1,000inhabitants" beforetheRevolution, and thatfigure
has been reducedto 6.8. Castrochallenged"any slandereror
smearer" of theRevolutionto denysuchprogress.94 The assertion
was,nevertheless,misleading.
The crudeannualdeathrateis a limitedindicatorof thelevel
ofhealthofa country, restrictedby differencesin thefrequency of
deathsin specific of
ages or sex the population.Moreover, Castro
may have been usingan estimate madeby theEconomicCommis-

Abraham Horwitz, "Agenda para la salud en las Americas," Boletín de la Oficina

Sanitaria Panamericana (Washington),October 1970, p. 333.
93 Figures divergent from those cited here appear in the various reports given by
the Cuban delegation to WHO; sometimesthey are higher, sometimeslower. For
the statisticsgiven here those for 1958 are from Juventud Rebelde (Havana), Jan-
For inter-
uary 8, 1969, p. 2; those for 1969, from Granma, August 2, 1970, p. 2.
mediate years,see Granma, April 3, 1968, p. 6, and Bohemia, January 2, 1969, p.
29. The budget totals include running expenses and investments.
94 Prensa Latina (Havana), January 6, 1967.

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330 SCIENCE AND SOCIETY

sion forLatin Americaforthe years1945 to 1954.95Yet it could be

shownthatthe annual mortalityrate in the decade beforeand the
decade after1959remainedat 6.5 per l,000.96The ratesbefore1959,
however,should be taken with some reservationbecause less than
90% of all deathswere registered,and infantsdyingbeforeregis-
trationof birthwere not recorded.Since 1959 these shortcomings
have been eliminatedto a large degree;all infantdeathsare noted,
althoughit is possible thatsome deathsin isolatedareas are unre-
corded. Hence it could be said that the death rate appears to have
declinedsomewhat;but to pinpointthe extentis impossible.
Cuba has one of the lowest mortalityrates in Latin America.
However,thenumberof totaldeathshas steadilyincreased,particu-
larlysince 1961. (The figurefor 1957 was 40,409; for 1961,45,945;
for 1962,51,579; for 1967, 50,442.)97The incrementmay reflectan
upwardtrendin populationgrowth.
A more acceptableindicatorof changesin the health of a peo-
ple is the rate of infantmortality(deathsof those under one year
of age per 1,000live births).Underdevelopednationsshow a high
infantdeath rate because of lack of services,low income, inade-
quate nutritionof parents,and poor hygiene;wheneverthesecon-
ditionsimprove,infantdeathsdecline.98
In compilinginformation on thisimportantfactorin Cuba, the
analyst soon encounters several First, as mentioned
difficulties.
earlier,before1959 the deathsof childrenwere not recordedif they
died beforetheywereregisteredas born.Secondly,underregistration
95 The same report pointed out that from 1945 to 1960 the estimated annual mor-
tality rate was 12 per 1,000 inhabitants,but Castro preferredto use the higher fig-
ure covering 1945-1954. See Comisión Económica para América Latina, Boletín
Estadístico de la América Latina, Voi. VII No. 1, October 1962 (Supplement),
Table IV.
96 The Population Index, which obtains its figures from the United Nations, also
rate foi
presents divergenciesfrom the Castro and CEPAL estimates. The death
1950-1954 given in the Index is 6.6 per 1,000 (July 1962, 1966, and 1969 issues).
But the rate of 12 per 1,000 is also supplied (July 1964, 1965 issues), and one ver-
sion (July 1960) offersa third figure,7 per 1,000. Similar contradictionsappear
: for the period 1955-1959, all of which are also based on UN estimates.
97 For the annual number of deaths, 1957 through 1967, see UN, Demographic
Yearbook 1957-1969; Cuba, Dirección Central de Estadística, Junta Central de
Planificación, Compendio Estadístico de Cuba (Havana, 1967); Lowry Nelson,
"Cuban Population Estimates, 1953-1970," Journal of Inter-AmericanStudies and
World Affairs,July 1970, pp. 392-400.
98 UN, Report on the World Social Situation (New York, 1969), pp. 23-24.

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 HEALTH AND REVOLUTION IN CUBA 331

in the rural areas was widespread,presentinga lower infantmor-

talityrate than actuallyexisted."
In the 1930sinfantdeathscomprised18% of all deaths,and the
rate per 1,000live birthswas 76.100By 1958 it was reportedthat 33
of every1,000childrendied beforereachingtheirfirstbirthday.In
1968 the rate had increasedto 37.4. But in 1969 the mortalityrate
of infantsnumbered44.7 per thousand,a significantincrement.101
How can thisdramaticupward change,at the verymomentwhen
medical care seems to have been more readily available, be ex-
plained? It is possible that registrationimproved,giving the ap-
pearanceof more cases. It has oftenbeen pointed out that better
alwaysfollowbetterhealthservices.102
statistics Yet such an explana-
tion would mean that everyyear the statisticalcollection of the
revolutionary regimehas been greatlyimproved.Such a generaliza-
tion, however,will not do. It appears that a deteriorationin the
health of children has taken place, primarilyas a result of the
and medicalproducts(because of the blockade
scarcityof foodstuffs
establishedby the United Statesand the inabilityof the Eastern
European nationsand the Soviet Union to supplyenough).103 The
qualityofthemedicalpersonnelmightalso be a factor.
The childrenin the rural areas are still more prone than urban
childrento chronicand debilitatingdiseases.In 1969 the mortality
rateof childrenunderthe age of one rangedfrom34.3 per 1,000in
Havana Provinceto 52.5 in Oriente.104 A programof sanatoriums,
with intensivecare and feedingunits,has begun to operate in the
latter province.There are also 9,000 hospital beds in pediatrie
wardsin the island.

99 OficinaSanitariaPanamericana,Informesobre el progresode la Investigación

Interamericanade Mortalidadde la Niñez (Washington, 1970),p. 2.
100 O. AndrewCollver,BirthRates in Latin America:New Estimatesof Historical
Trendsand Fluctuations(Berkeley, 1965),p. 108.
101 The rateof 125 deathsper 1,000live birthsis givenfor 1950-1955in MacGaffey
and Barnett,op. cit.,p. 198,but such an estimateis too high.The figuresgiven
hereare fromWHO, WorldHealth Statistics Annual (Geneva),1962-1970;WHO,
Third Reporton the WorldHealth Situation,1961-1964(Geneva,1967),p. 129;
UN, DemographicYearbook,1969;Granma,November23, 1969,p. 4.
tz,"RecentMortality
102 GeorgeJ. Stoini Trendsin Latin America,Asia and Africa,"
PopulationStudies,November1965.
103 The lack of medicaments has been acutesince 1961.Granma,November27, 1966,
p. 5.
104 Granma,October11, 1970,p. 11.

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332 SCIENCE AND SOCIETY

In the 1960s, 15% of Cuba's childrenwere under fiveyearsof

age, but the mortalityrate in the group was still high,accounting
for23% of all deathsin 1963. In 1965 thisfiguredeclined to 21%,
but by 1969 it had increasedagain to 24%.105The mortalityrate
of childrenbetweenthe ages of one and fourhas experiencedlittle
change.
To ascertainchangeby comparingthe distributionof deathsby
age in the 1950sand the 1960s is impossible.Accurateinformation
forthe yearspreceding1959 is lacking.However,infantmortality
accountedfor19% ofall deathsbetween1959and 1966.One-quarter
pf all deathsin Cuba takesplace among thosewho are less than 15
years old.
The distributionof deathsby age in the firstsevenyearsof revo-
lutionarypoweris shownin thistable:106
Age % of Population % of All Deaths*
To 1 1.4 19.0
1 to 4 15.4 2.9
5 to 14 21.9 2.8
15 to 24 17.8 2.8
25 to 34 14.3 2.6
35 to 44 11.1 4.1
45 to 54 8.9 7.3
55 to 64 6.2 13.1
65 to 74 3.0 15.1
After75 1.4 28.0
* (A difference does not appear.)
of 2% becauseof deathsforwhichno age is specified

In consideringthe main causes of death by disease in the 1950s,

heart disease represented19% of the total, followedby gastroin-
testinal diseases (9%), tuberculosis (5.4%), arterioscleroticdis-
eases (5.4%), bronchitis(4.5%), vascularlesions affecting the cen-

105 WHO, WorldHealth StatisticsAnnual (Geneva),1966-1969;WorldHealth Or-

ganizationChronicle(Geneva),January1969,p. 31; Boletín de la OficinaSani-
taria Panamericana(Washington),January-June rates
1970,p. 33. For mortality
of infants,1961 through1969,see WHO, Third Report on the WorldHealth
Situation,1961-1964(Geneva,1967),p. 129; Twenty-second World Health As-
sembly,OfficialRecords(Geneva,1969),p. 69; Granma,October11, 1970,p. 4.
106 Unión Panamericana, Américaen Cifras(Washington,1968);WHO, WorldHealth
Annual (Geneva),1966-1969.
Statistics

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 HEALTH AND REVOLUTION IN CUBA 333

trai nervoussystem (4%), and diseases peculiar to early infancy

(3%). Other illnessesaccountedfor fractionalpercentages.107
Infectiousand parasiticdiseaseswere the main illnessesaffecting
children.Deaths fromthesecauses were particularlytragicbecause
theywere preventable.(Gastroenteritis alone killed 65 per 100,000
in 1951.)108These diseasescaused 43 deathsper 100,000in 1959 and
51 in 1962.100Thereafterthe frequencydiminishedforall ages but,
whethercaused by bacteria,viruses,or parasitic infestations,in
1964 these diseaseswere still the principal causes of mortalityin
children,accountingfor80% of deathsunder one year of age. Be-
cause of the highdeathratea special programwas institutedwhere-
by the cases were taken,wheneverpossible,to special hospitalsfor
rehydration. As a resultof thisprogram,in 1968 deathsfromgastro-
intestinaldiseases were 28.1 per 100,000, or 16% of all infant
deaths.110Moreover,while 7,000 personsdied fromdiarrhea-related
illnessin 1958,by 1968 the toll was l,300,ni a decline of 64% The
rural areas, despite the improvement, are still the worsthit.112
Deaths fromparasitismin 1965 accountedfor4.3% of the total,
but the percentagewas 22.8 forthoseunder 15. Most of the deaths
were of infantsbetweenone and fouryearsold.113Similarly,while
deaths from respiratorydiseases (influenza, pneumonia, bron-
chitis)had a rate of 44 per 100,000,the rate among thosewho were
less thanone yearold was 546.3 deathsper 100,000children.114
It should be observedthat more people over 60 years of age
live todaythan ever before.In 1953 it was 6.9%. In 1961 the per-
centage was 7.2.115This slight improvementis attributedto two

107 Statisticsgiven here are for 1951 only.

108 Census for 1953.
109 Organización Panamericana de la Salud, Resumen de los Informes Quadrienales
sobre las Condiciones de Salud en las Americas, 1957-1960 (Washington, 1962),
p. 35.
110 WHO, Twenty-secondWorld Health Assembly, Official Records (Geneva, 1969),
pp. 68-69; Granma, January 19, 1969, p. 2.
Ill Granma, January 19, 1969, p. 2.
112 The infant mortalityin Las Villas, for instance, from gastroentiritisin 1965 was
71.3% of all deaths. Revista Cubana de Pediatria (Havana), February 28, 1967,
pp. 85-97.
113 WHO, World Health StatisticsAnnual (Geneva), 1969, Vol. I, p. 504.
114 Boletín de la Oficina Sanitaria Panamericana (Washington), November 1970, p.
402.
115 Radio Habana, March 13, 1968.

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334 SCIENCE AND SOCIETY
factors.Life expectancy,which had been 57 years (1945-1960),
jumped to 67 yearsby 1969. Moreover,the incrementin the people
over 60 was the directresult of a baby boom in the early 1900s
afterthe dramaticshrinkageof birthsbetween1894 and 1898,dur-
ing thewar of independenceagainstSpain.116
Preventionand Treatmentof Disease. The conceptof health in
the firstfiveyearsof the revolutionwas dominatedby an emphasis
on treatmentand the givingof medical servicesto as manypeople
as possible.In 1964 a shifttook place fromquantityand treatment
to quality and prevention.Preventionand promotionof the peo-
ple's health became the watchwords.It was a natural second step
afterthe material basis of health planning had been established
throughthe expansionof facilitiesand personnel.
One of the main communicablediseasesof Cuba has been in-
testinalparasitism.The InternationalBank forReconstruction and
Developmentreported in 1951 that between 80% and 90% of the
childrenin rural areas sufferedfromthe illness.117 In 1956 a survey
of rural familiesshowedthatat least 36% of themwere aware that
theyhad parasites.118In 1957 a studyof infantsforwhom medical
aid was sought public healthcentersrevealedthat55% of those
in
whowereexaminedhad parasites.119 And in 1959an exhaustivestudy
made by public healthauthoritiesthroughoutthe countrydisclosed
that 71.96% of all Cubans were afflicted with parasitism;in the
rural zones the percentage was 86.54.120
Effectivemeasures to curtail intestinalparasitismfrom 1959
to 1964 were fewand minor.Exact information on how manypeo-
ple have sufferedfrom parasitessince then is not available, but it
appears thatthe frequencyhas declineddramatically.121
Anotherpreventabledisease is tuberculosis,knownas the "dis-
ease of the workers/*Like parasitism,it originatesin miserableliv-
ing conditions, lack of hygiene,and insufficient medical care. In
1956, 14% of the rural population sufferedor had sufferedfrom

116 CarmenA. Miró,"The Populationof Latin America,"Demography, Vol. I, No.

1, 1964,p. 39.
117 IBRD, Reporton Cuba (Baltimore,1959),p. 441.
118 Por que ReformaAgraria,op. cit.,p. 28.
119 Boletín de la OficinaSanitariaPanamericana(Washington),
September1959,p.
259.
120 Baeza, op. cit.,p. 97.
121 Pupo, "Hacia la salud. . . ," op. cit.,p. 47.

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 HEALTH AND REVOLUTION IN CUBA 335

Yet from1954 to 1959 the averagerate of vaccina-

tuberculosis.122
tion was 43,245 per year. Only about 10,000childrenreceivedthe
BCG immunizationannually.123
With the revolutionthe reportedcases of tuberculosisclimbed,
reachingin 1964 more thandouble the figurefor 1958. That yeara
national tuberculosiscontrolprogramwas established.A massive
campaignof vaccinationand radiographywas launched. Under the
slogan"No truceagainsttuberculosis,"anti-tuberculosis
committees
were formedin all neighborhoods, and extensivehealth education
was propagated.Over 90% of all childrenborn in hospitals124 are
immunized,as well as all studentsin elementaryschools,and close
to 25% of the population over 15 years of age. The number of
deathsdiminishedfrom1,402in 1962 to 940 in 1967. Malaria and
poliomyelitishave been totallyeradicated.

Conclusion
The health sectorhas undergonea most profoundtransforma-
tion. The governmenthas taken the responsibility for promoting,
protecting,and recovering the health of the people, while treat-
menthas given way to the preventionof disease. The budget,fa-
cilities,and personnelof the healthsectorhave expanded at a rate
withoutprecedentin the historyof the island. Social inequityhas
been abolishedby the freeprovisionof medical care. Further,the
revolutionary government has been extremelysuccessfulin mobiliz-
ing the populationin order to eradicatedisease (suchas malariaand
polio). Rural medical services have improveddramaticallyand for
the firsttimein Cuba the providersof medical care are accountable
to the consumersof that care. Despite the problemsof nutrition,
housing,and medical supplies,it must be concluded that positive
progresshas been broughtabout by the Revolution.Still,much re-
mainsto be done,particularly withrespectto the healthof children,
and the infantmortalityrate mustbe reduced.

Bosque, New Mexico

122 Por que Reforma Agraria, loc. cit.
123 Baeza, loc. cit.
124 In 1969, 98% of all births took place in hospitals; it was 64% in 1962. Granma,
October 11, 1970, p. 11.

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