community medicine in cuba

Journal of Community Psychology Volume 13, April 1985

Community Medicine in Cuba Eliseo J . Ptrez-Stable

University of California, San Francisco

The 25 years of revolution in Cuba have brought about great changes in the health care system. The health status of the population has been transformed from that of a developing country to one approximating the developed countries. The delivery of primary care at the community level has evolved over the past 15 years as a result of critical evaluations of the new implemen- tations. The community polyclinic has been the basis for all health planning since 1975. This model has the health of the community as its main concern and the mechanism for involving the community in health care decisions has been established. The history of the community polyclinic and the evolution of the guidelines by which it functions are reviewed. In practice, many problems persist and the strategy for resolution of current conflicts will provide for interesting developments in the near future.

The Cuban Revolution has been a source of great debate throughout the Americas for the 25 years of its existence. The political and economic issues have been biased by opposing ideological positions, but the evaluation of Cuba’s social programs has been more objective, at least from an intellectual perspective. There has been a general con- sensus that in the fields of education and public health, Cuba’s ambitious programs have resulted in remarkable achievements. In 1970 an official, formerly with the United States Agency for International Development, reached the following conclusion:

Cuba has come closer to some of the Alliance objectives than most Alliance members. In education and public health, no country in Latin America has carried out such ambitious and nationally comprehensive programs. Cuba’s centrally planned economy has done more to integrate the rural and urban sectors (through a national income distribution policy) thap the market economies of other Latin American countries. (Levinson & de Onis, 1970)

The availability of health care in Cuba prior to 1959 was dependent on one’s socioeconomic background. The urban middle class and sectors of the white working class utilized private sources of health care or benefited from the mutualist system-health care institutions based on a direct prepayment mechanism. An estimated 6300 physicians were practicing in a country of approximately 6.9 million people (Ministerio de Salud Pdblica, 1976), but nearly 4000 of the physicians were located in the metropolitan area of La Habana (Navarro, 1972). The health status among the rural population, urban poor, and most working class people was not good. Morbidity and mortality from infectious diseases (e.g., diahrrea in children, parasites, tuberculosis) were high. Preventive measures and basic hygiene were of little concern to the pre-1959 governments.

The revolutionary government has made accessible health care a priority in its social program. Modest investments in basic resources and a dedicated group of men and women have demonstrated how an underdeveloped country is able to transform the health status of its people. The achievements are even more impressive in view of the

This research was supported in part by a grant from the Henry J . Kaiser Family Foundation. Reprint requests should be sent to the author, 400 Parnassus Ave., A-405, Division of General Internal

Medicine, Department of Medicine, University of California, San Francisco, CA 94143. 124

I25 COMMUNITY MEDICINE IN CUBA

emigration of nearly one-half of Cuba’s physicians by 1962 (Navarro, 1972), the continued state of hostility created by the United States, and the process of carrying out an economic and social revolution. The control of infectious diseases and the establishment of effective health services are two major health gains of the first decade of the Revolu- tion. In the 1970s, Cuba was able to turn to specific issues confronting medicine in the developing and the developed countries.

La Habana was the host city for the World Health Organization-sponsored health care conference, “Health for All,” in July 1983. The conference highlighted Cuba’s successful endeavors in health care and received enthusiastic responses from the Third World delegations. Cuba has reduced infant mortality to 17.3 per 1,000 live births, increased life expectancy to over 72 years, and increased the number of physicians to over 17,000 or one per 578 persons (Ubell, 1983). The polyclinic-based primary care health system has played a crucial role in the successful control of tuberculosis; Cuba had a case rate of 8.3 per 100,000 inhabitants in 1982, which is lower than the reported case rate in the United States (Perez-Stable & Pedraza, 1984).

The accomplishments of the Cuban Revolution in health care have been the result of a firm political commitment and a significant but modest economic investment. The Cuban government appropriated 7.8% of its budget to the Ministry of Health in 1982. This figure is similar to the proportion invested in health by the developed countries. Cuba now faces the chronic diseases as leading health problems and struggles with the advent of high tech medicine (Ubell, 1983).

This article reviews the basis for health planning in a community setting in Cuba. The development and functioning of the area polyclinic in its old or pre-1975 model is detailed with an analysis of its drawbacks. The change in strategy that partly evolved from consumer criticism led to a new model for the area polyclinic-medicine in the community. The essential elements of the community polyclinic and the current functioning of the system are examined. Finally several problem areas are identified, the im- plications for future planning are pointed out, and possible future directions of community medicine are reviewed. Some of the information contained in this article is a result of personal visits to the Plaza Polyclinic and interviews with staff physicians and the assistant director, Dr. Pedro Pons, during September 1980 and November 1981.

Principles of Health Care The health care system in revolutionary Cuba has been developed under the assump-

tion of health as a human right and not as an economic privilege. This basic principle has paved the way for the success of health care delivery in Cuba-a popular and important accomplishment. The systematic renouncing of fee for service by all graduating medical students after 1965 has placed a limited time on the lifespan of private practice medicine in Cuba (PCrez-Stable, 1975). The only health services that are not free to individuals are the cost of outpatient medications, and even in this situation there are special arrangements made for expensive but necessary drugs. In comparison to the developed and developing countries, Cuba has one of the most accessible and effective health care systems in the world and by all available parameters has the least economic barriers (Roemer, 1976).

The principle of central planning is the cornerstone of the structure of health care services organization in Cuba. The delivery of primary care services to the entire population has been an important element in the control of infectious diseases. The Ministerio de Salud Pdblica’s [Ministry of Public Health] (MINSAP) policy in structuring primary

126 ELISE0 J . PEREZ-STABLE

medical care has followed the suggestions of McKeown in Great Britain by delineating primary care specialists by patient age and sex (McKeown, 1965). The concept of general practice or family practice as defined by others (Titmuss, 1963) has not been widely im- plemented in Cuba. In the past two years, small numbers of family physicians have been trained with the goal of serving rural communities. However, internists, pediatricians, and obstetrician-gynecologists continue to staff the front lines of the health care system’s clinical services. One rationale for the specialization scheme has been that it allows the integration of primary care with hospital care (Navarro, 1972). The relative advantages inherent in this model at the service delivery level have further justified the establishment of three primary care specialists as opposed to the all encompassing general practitioners.

The Area Polyclinic The evolution of the public sector of medicine during the first six years of the

Revolution created a bottleneck of services at the outpatient level. The abandonment of private practice by most physicians and the marked reduction of private and mutualist clinics contributed to a demand for the ambulatory services of the reorganized large hospitals (Danielson, 1979). It is in this context that MINSAP decided in 1965 to es- tablish the area polyclinic as the point of departure for all health planning. The health area covered by the polyclinic would become the basic unit of health services delivery and administration. The polyclinic was conceived as a predominantly outpatient facility independent of hospital control. Hospital services have been centralized since 1959 and duplication of services have been avoided. The polyclinics’ independence from hospital control was a step towards the decentralization of ambulatory services. This decentralization has been fostered by the creation of a large number of area polyclinics (Navarro, 1972). The involvement of the community in the health system not only as consumers but also as participants has been facilitated by the Cuban model of the area polyclinic.

The polyclinic was designed to provide or be responsible for the provision of clinical services, environmental services, community health services, and related social services to a specifically defined area and population. The integration of curative and preventive services and of social and clinical aspects of health care is the ambitious goal set for the polyclinic by MINSAP planners. The average population covered by a polyclinic in an urban area is 25,000 with as few as 7500 in rural areas (Danielson, 1979). The model is intended to be accessible to the targeted population and efficient in providing a wide range of primary services. The administrative independence of the polyclinic is a key difference in the Cuban system when compared to similar institutions in other socialist countries. Independence has not meant isolation as the regional hospitals and other health facilities have obligations to meet with the area polyclinics. However, the direct participation of the population at the local neighborhood level has been stimulated by this independence. Public health nurses and Sanitary workers are required to go into the community in order to effectively carry out their work. The involvement of the neighborhood committees has been essential. Volunteers have been recruited from the general public including the folk practitioners or curunderos (Ministerio de Salud Pdblica, 1969). These auxiliary personnel have been called on to staff first aid stations, assist in vaccination campaigns, promote health education, and perform many other functions. In fact, the health accomplishments of the early years of the Revolution would

COMMUNITY MEDICINE IN CUBA 127

have been impossible without the support and participation of the masses at the local level.

Evolution of a Critique By 1970 there were 308 polyclinic health centers distributed throughout the island

functioning to deliver primary care services (Ministerio de Salud PGblica, 1975). Graduating physicians make the commitment to provide two years of community health service which is frequently assigned in the remote rural health centers. Thus, expansion of the ambulatory system was not hindered by inadequate staffing in the traditionally un- deserved areas. Following the failure of the 10 million ton sugar harvest in 1970, Cuban society underwent a wholesale reexamination from the top Communist Party leadership to the common citizen in the street. The heaith care system did not escape careful scrutiny in this period. The accomplishments of the Revolution in the area of health were indisputable; there were major reductions in morbidity and mortality from infectious diseases, effective immunization programs, reduced infant and maternal mortality, and accessible health care to the entire population (Pan American Health Organization, 1974). However, the hospitals had received greater priority in material support and the area polyclinics were relegated to an inferior role. Meanwhile, consumer complaints regarding the polyclinics were increasing and the revitalized trade unions were channel- ing the criticism to MINSAP health planners.

- - (48.2)

(1 7.3) 20 10 I 1 I I 1 I I I I I 1

1958 62 66 70 74 78 82

-

Years

Figure 1. Infant and maternal mortality, 1958-1982. (A Infant mortality rates per 1000 live births; 0 Maternal mortality rates per 100,000 live births.) Adapted from Ministerio de Salud Pliblica, 1981, 1983.

128

1 6 . 0 ~

12.0

0.0

4.0

ELISE0 J . PEREZ-STABLE

-

-

- deaths)

I l ' I ' l ' 1 ' 1 ' 1 ' ~ " ~ ~

1964 66 68 70 72 74 76 70 00 82

Year

Figure 2. Tuberculosis mortality in Cuba, 1964-1982. (Death rate per 100,OOO inhabitants.)

In 1972 the Plaza Polyclinic (located in a central Havana working class district) was the site of a very important and innovative experiment. A formulation of models based on the accumulated criticisms of existing services helped to mold the Plaza Experiment. The initial impetus came from the lack of community experience that medical students had in the teaching settings. The Plaza Polyclinic would now serve as a teaching center and as a model for health care in the community. The residents of the area were mostly new inhabitants of housing projects and thus they had not yet begun to relate to the polyclinic for their health care needs. This setting was ideal to initiate an active mode of care in the community (Danielson, 1979).

In 1974, MINSAP designated a commission to elaborate the concept of community medicine within the socialist ideology and character of Cuba's health care system. This assessment commission produced a document highly critical of the established polyclinic system as it was functioning and it subsequently made concrete suggestions for im- provements based in great part on the Plaza Experiment (Muiiiz, Montejo, Arzola, & Garcia, 1976). Five of the major problem areas identified by the commission are listed and examined below.

(1) Lack of continuity of care. A major complaint of patients had been that frequently a different physician would see them at each visit. The established priority for hospitals led to short or inconsistent staffing at the polyclinic with the noted results. An extension of this problem manifested itself when a polyclinic patient was hospitalized, as the patient's primary physician had a difficult time providing even minimal follow-up for his or her inpatients.

( 2 ) Impersonal care. A direct consequence of the lack of continuity of care is the undermining of the patient-provider relationship. In a cultural setting where per- sonalismo is of prime importance, the absence of more personal care led to great dissatisfaction among patients.

( 3 ) Passive attitude towards health promotion. Medical training continued to emphasize the hospital experience at both the student and postgraduate levels. Physicians


at the polyclinic were primarily concerned with curative and rehabilitative practices and health care maintenance concepts were mostly ignored. In addition, many physicians were poorly trained to handle the medical problems encountered at the polyclinic resulting in frustrations and feelings of ineptness.

(4) Insuficient teamwork. As a consequence of the biomedical orientation of physicians, the potential role for the sanitary workers, social workers, psychologi,sts, and even nurses in the health care of the community was not realized. The pivotal role that physicians could play as health team coordinators for a defined population had essentially been ignored.

( 5 ) Inappropriate use of consultations. The poorly developed patient-provider relationship and the inadequate training of physicians in outpatient medicine led to frequent and inappropriate referrals to specialty services outside of the polyclinic. The results were dissatisfied patients and frustrated primary care and specialty physicians (Muiiiz et al., 1976).

Cuban society in the 1970s was developing mechanisms to integrate citizen criticisms. The importance of maintaining patient satisfaction in a proper perspective had been partly forgotten in the struggle to meet basic health care needs. The assessment commission successfully brought forth the main concerns regarding the polyclinic and it provided the groundwork for increased lay participation in the health care of the community.

Medicine in the Community Medicina comunitaria (Medicine in the community) is defined as all of the planned

activities of integrated medical care with the objective of reaching an improved health status of both the individual and the community (Mutiiz et al., 1976). This concept was promoted as a response to the problems outlined above and, although somewhat similar to the concept of primary care in the United States, some differences are notable. Primary health care services in the United States rarely have any effect beyond the individual or the family unit while Cuba’s model of medicine in the community has a set goal of improved community health. The organization of society in the United States along the free enterprise principles limits the potential interventions of a health care provider; Cuba’s socialist organization encourages the implementation of necessary measures. The fundamental elements of the newly conceptualized policlhico com- unitario (community polyclinic) and the results of these at the practical level during the past eight years are examined below.

There are seven guiding principles that provide the basis for the new community polyclinics. These were proposed by the assessment commission and they had been tested to some degree during the Plaza Experiment. The model community polyclinics incor- porated these principles a priori, and all area polyclinics have been mandated to incor- porate these elements as much as local conditions permit (Muiiiz et al., 1976).

(1) Integrated health care. This emphasizes the previously stated principle of con- sidering all facets of an individual’s care, i.e., to include curative, preventive, rehabilitative, biological, psychological, and social aspects.

( 2 ) Sectorization of full-time polyclinic work. This defines a new method of work for the polyclinic staff. The primary care physician-nurse clinical team now are responsible for .a certain number of inhabitants within the polyclinic’s catchment area, a geographically bound system. For example, a pediatrician-nurse team will be responsible

130 ELISE0 J. PEREZ-STABLE

for the health of 2000 children (under age 15 years) within a specified community, independent of health status.

(3) Regionalization of health care. This refers to the established levels of primary, secondary, and tertiary care, thus placing the polyclinic at the starting point of the health care system.

(4) Continuity ofcare. The clinical team will continue to follow the same population as long as they are working in the polyclinic. The patient’s medical records are now filed in the corresponding team’s office, thus facilitating the retrieval of information.

Dispensarizacibn. This is a term borrowed from the Soviet model which has been interpreted by one author as “active medicine” (Danielson, 1979) and essentially prioritizes health needs according to the diagnosis. In an internist’s assigned population, for example, each adult carries a diagnosis or is designated as healthy. Different diagnoses will trigger specific protocols for case reviews as will be detailed later. This provides guidelines for the frequency and the means by which categories of problems should be followed.

Teamwork. This was considered very deficient in the old model and has become an important issue in the community polyclinic. The internist, pediatrician, and gynecologist each work in conjunction with a nurse and together compose the primary team for a particular population. In turn, an internist-nurse team must cooperate with the pediatrician-nurse team in the delivery of health care to a single family and inevitably the gynecologist-nurse team becomes involved. Public health nurses, sanitary workers, and lay volunteers all participate in a coordinated fashion with the clinical teams. The polyclinics are also staffed by a health psychologist and sociologist who provide ongoing analysis of the polyclinic’s functioning as well as much needed services.

(7) Active citizen participation. The institutionalizing of the Poder Popular after 1975 sets the framework for increased nonphysician participation in deciding the health care needs of the community. The local municipal assemblies have a delegated authority over the health care arena and the local health commissions are responsive to the Poder Popular. This is an added dimension to the existing citizen participation through the mass organizations-Committees for the Defense of the Revolution (CDR), the Federa- tion of Cuban Women (FMC), the trade unions (CTC), and the Association of Small Farmers (ANAP).

During 1974-1975 the province of Matanzas was the site of the pilot study for the Poder Popular with subsequent incorporation into the Cuban Constitution and national implementation. The follow-up to the Plaza Experiment likewise took place in 1974-1975 in the newly developed Alamar District east of La Habana. By early 1976 there were five model community polyclinics functioning in Cuba and the implementation of the community medicine concept had begun. The transformation has been nominally made in all 397 existing polyclinics (Ministerio de Salud Pdblica, 1983) but in practice the process is a long term one. The tendency to use the model polyclinics as teaching settings will un- doubtedly expedite the transformation. Today all polyclinics are practicing the community medicine model in theory and they are all required to prepare plans to incor- porate these principles into their practice.

(5)

( 6 )

Distribution and Physical Plant By 1982, a total of 397 polyclinics were functioning throughout Cuba with distribu-

tion by provinces as indicated by Table 1 (Ministerio de Salud P~blica , 1983). The per- sistence of unequal distribution of the polyclinic facilities reflects the severity of the


problem prior to 1959. The rural hospitals also function as primary care facilities in the predominantly agricultural eastern provinces of Cuba. These 397 polyclinics accounted for an increasing number of outpatient visits throughout the 1970s. By 1980, nearly 22 million outpatient visits (76.6% of the total) took place at the polyclinics. In addition, the polyclinics handled nearly three million emergency visits during off hours, accounting for 19% of the total for the entire country (Ministerio de Salud P~blica , 1981).

Table 1 Distribution of Polyclinics in Cuba, I982

Total Teaching Population to Province polyclinics polyclinics polyclinic ratio

Pinar del Rio 18 1 36,265 La Habana 38 - 15,449 Ciudad Habana 74 5 25,840 Matanzas Villa Clara Cienfuegos Sancti Spiritus Ciego de Avila Camagiiey Las Tunas Holguh Granma Santiago de Cuba Guantanamo Isla de la Juventud Total

39 39 16 19 17 23

16 33 22 26 15 2

397

1

2 -

2 -

I

- 14

14,609 19,758 20,434 21,215 19,126 29,780 27,835 28,185 33,942 35,401 3 1,638 28,178

Note. Adapted from Ministerio de Salud Pliblica, 1983.

Table 2 Outpatient Visits by Medical Specialty* (Visits per 100 Inhabitants)

Specialty

General medicine 99.7 91.6 111.1 160.0

Medical subspecialties 15.6 19.0 34.6 NA

Psychiatry 3.6 5.2 4.8 N A

Pediatrics** 145.4 165.1 213.9 280.0

Obstetrics-gynecology*** 50.9 62.9 68.2 114.0

All surgical specialties 40.0 45.4 41.2 40.0

Notes. *Adapted from Ministerio de Salud Pliblica, 1981, 1982, 1983. **Visits per 100 children under 15 years of age. ***Visits per 100 women over 15 years of age. ****General medicine and medical subspecialties combined into one category for 1982.


The polyclinic facility is organized according to the primary care specialties of internal medicine (adults), pediatrics, and gynecology. Team offices and examining rooms are thus grouped by specialty with the appropriate equipment. Clinical laboratories provide basic complete tests such as blood counts, glucoses, and urinalysis; radiology services provide all of the basic x-rays (e.g., chest, bones, gastrointestinal series). A microbiology laboratory for bacterial and mycobacterial (tuberculosis) cultures exist and examination of specimens for parasites are routinely performed as well. An electrocardiogram machine staffed by a trained technician is also present. The psychologist, sociologist, and other nonphysician staff have office work areas within the polyclinic. Patient waiting areas are located at various points and they frequently serve for health education purposes as well. A conference room is present in all the teaching polyclinics where students rotate starting with the first year in medical school. The conference room is also used for various health education classes. The standard size urban polyclinic stands three stories and roughly encompasses a square block.

There are 14 community polyclinics in Cuba which are also designated as teaching settings. The staff physicians consist of residents in the three primary care specialties who remain at the polyclinic full-time for a minimum of one year. Patient load is lightened somewhat and attending physician supervision is provided. Residents are also budgeted for more time to carry out the needed community work and home visits. Medical students rotate to the polyclinics from the first year on. In the preclinical years of training the students participate in the work of the sanitary workers, the public health nurses, and the social workers. This is one of the mechanisms by which physicians are made to feel on an equal level with the rest of the health care team. Medical students not only learn about public health and social problems, but they also appreciate the important contributions made by the other health workers at the polyclinic. The clinical years of medical school now include a three-month block in the polyclinic in each of the fourth and fifth years of school. Overall, the teaching polyclinics function well and they stand as a model for the system in general.

The New Model in Practice The Plaza Polyclinic in La Habana is currently staffed by 20 physicians serving a

population of 23,000 adults and 7000 children. There are 10 internists, seven pediatricians, and three gynecologists, each of whom functions with a nurse as a team (P. Pons, personal communication, November 1981). Most adult women are followed by an internist as well as a gynecologist, and a family planning clinic operates in the polyclinic with all contraceptive methods available free of charge. Office hours are held in the mornings and early afternoons in order to allow the clinical teams time to carry out the community work. The schedule is open without assigned time slots and patients are taken in order of arrival on the given day of their appointment. The patient load is heavy; an average schedule is one patient every 15 minutes but as many as seven per hour may be seen by a given physician. Patients will often need to request a day off from work or spend the greater part of their day visiting their physician at the community polyclinic.

Several of the heavily criticized problems from the old model have been corrected in the community medicine polyclinic. MINSAP has allocated an appropriate amount of resources to the polyclinic both in material and human terms. Medical school and postgraduate medical education have been changed to include a substantial amount of time in the practice setting of the community polyclinic. Hospital physicians and subspecialists are required to render services to the polyclinics on an ongoing basis with the

COMMUNITY MEDICINE IN CUBA I33

purpose of teaching the primary care specialists and providing on-the-spot consultations. A system of “intra-consultations” has replaced the much criticized referral pattern

of the old model. Subspecialists regularly attend the polyclinic on a scheduled basis and patients are given appointments with the consultant at the polyclinic. The primary physician is encouraged to be present during the consultation and at the teaching polyclinics the residents are required to attend for didactic purposes. For example, at the Plaza Polyclinic a dermatologist visits three times a week, an orthopedic surgeon once per week, and a psychiatrist twice per week on a regular basis. These particular subspecialties have a high volume of primary care consultations. Subspecialists within the fields of internal medicine or pediatrics are consulted on a less frequent basis and scheduled on an as needed basis. For example, at the Plaza Polyclinic a cardiologist and a gastroenterologist attend once a month to see patients. General surgical and other surgical subspecialty (e.g., urology) consultations continue to be referred outside the polyclinic facility (P. Pons, personal communication, November 198 1).

The continuity of care principle has been applied to all polyclinic visits and a patient will continue to see the same physician and nurse as long as they work at the polyclinic. The hospitalized patients are loosely followed since each primary physician is only encouraged to visit their patient in the hospital during free time. As one may expect, the results vary depending on the individual physician’s time, interest, and/or concern. An exception to this pattern are the gynecologists who follow the pregnant women in the polyclinic and subsequently deliver the baby at the local maternity hospital.

The physician-nurse teams at the polyclinic have 12 hours per week set aside for home visits and community work. Every adult within a sector is supposed to be seen at least once a year by either member of the clinical team. If the individual doesn’t present to the polyclinic with a specific complaint, then, in effect, the polyclinic goes to the individual. The goals of periodic home visits are to check the blood pressure, update im- munizations, and most importantly evaluate socioeconomic conditions. These visits are most often conducted on weekdays between 4:OO and 8:OO p.m. or on the weekends in order to reach the working population at home.

The need for annual screening of healthy adults has been increasingly challenged of late and current recommendations in the United States have steered away from the annual check-up (Medical Practice Committee, American College of Physicians, 198 1). The Cuban model of medicine in the community appears to encourage annual screening, but in practice resources are far from sufficient to achieve this goal. For example, for a specific adult clinical team at the Plaza Polyclinic 10% of the specified population had not been seen at all during the year 1980. The majority of this group consisted of men between the ages of 15 and 40 years (R. Martinez, personal communication, November 198 1). The type of screening carried out at the community level in the home is somewhat different from the standard annual check-up that the North American population is ac- customed to.

The previously described system of dispensarizacibn categorizes patients according to diagnosis. Specific diagnoses carry certain risks and require a minimum follow-up that guides the polyclinic physicians. All patients with hypertension, diabetes mellitus, cor- onary artery disease, cerebrovascular disease, asthma, and other chronic diseases are programmed to be seen every three months at the polyclinic. If the patient fails to show up as indicated, a home visit by either the nurse or the physician is planned. The individuals who carry the diagnosis of a chronic medical problem are rountinely visited at home once a year as a complement to the scheduled polyclinic appointments. Adults over


the age of 65 are also routinely visited at home on an annual basis independent of their diagnosis.

As a consequence of the categorization of patients by diagnoses, persons at high risk are given systematic and preferential attention. The detection of these patients in the community often requires an active search on the part of the clinical team. For example, hypertension is a known major risk factor for cardiovascular disease, yet it is asymptomatic for years after onset. Within a sector, a clinical team knows the number of hypertensives who are being followed. They, in turn, compare this figure to the known prevalence of hypertension in Cuba, and if there is a major discrepancy in the sector’s prevalence, screening in the community is intensified. This active mode of detecting high- risk patients for the noninfectious chronic diseases is unprecedented. The future developments of this practice in Cuba will be watched with great interest, especially as more information regarding risk factors becomes available.

The community work of the polyclinic team transcends the medical purposes for home visits, Public health nurses and polyclinic pediatric nurses keep necessary im- munizations current for all children within a sector. During home visits nurses and physicians provide valuable educational material and information to all adults regarding health maintenance. Clinical teams also hold monthly didactic sessions for patients at the polyclinic with specific target groups in mind. For example, all diabetics within a sector are called to a meeting in which the knowledge that the patients have is reviewed and relevant issues to their daily care are discussed. Sanitary workers have been involved in community work since 1968 and they check on general hygiene, water quality, and pest control in the home. Social workers will also go into the home upon a referral from a clinical team in the polyclinic. They will arrange for payment of expensive medications by the state for patients with a limited income.

Health psychologists have become an integral part of the community polyclinic in the last decade. The Plaza Polyclinic has two full-time psychologists who provide intra- consultations on request, but some physicians tend to rely more on psychiatrists who come in from the outside for specific consults (R. Martinez, personal communication, November 1981). The psychologists follow their own panel of patients in the polyclinic, providing psychotherapy counseling and health education for this group. They have also played a crucial role in the evaluation of the polyclinic’s function and in conducting clinical research.

Community Involvement The direct participation of the people in the medicine in the community model of

health care is essential for the success of the program. It is the people through their mass organizations who coordinate the role of medicine in the community. The dengue epidemic in 1981 is a prime example of how Cuban society is able to mobilize its limited resources in a time of crisis. The 1981 dengue epidemic produced several hundred thou- sand cases on the Island and a minority were complicated by a hemorrhagic component, resulting in nearly 200 deaths (Pan American Health Organization, 1982). The disease vector is the mosquito, Aedes Aegypti, and a national mosquito control program was im- plemented virtually overnight. The mass organizations (CDR, ANAP, CTC, and FMC) mobilized the people to support the sanitary workers in clean-up campaigns. Physicians and nurses volunteered to present didactic sessions on the nature of dengue (symptoms, transmission, control) to unions, schools, neighborhood committees, or any organization. The mass organizations assumed the responsibility of organizing special


educational sessions on health topics and mobilizing the local population to attend. The containment of dengue within several months would not have been possible without this network of community organizations and the cooperation of millions of Cuban citizens.

On a daily basis the mass organizations help the polyclinic staff locate noncompliant or difficult patients. Persons with tuberculosis are a public health problem and effective chemotherapy is readily available. Thus if a patient misses treatment, the community will in effect bring the person in. Any patients with a medical problem that will benefit from therapy of some sort will at least be the object of social pressures when they fail to seek help on their own.

Area health commissions functioning for years with representatives from the mass organizations and the Cuban Communist Party have increasingly integrated their function into the Poder Popular. The increased nonphysician input has been welcomed by many but resistance by physicians has created some tension. Nevertheless, many of the significant changes that have taken place in the last eight years have resulted from evaluations by nonphysicians. The polyclinic director, usually a physician, sits on the health commission and remains the most influential member of the group. A thorough discussion of health policy decision making is beyond the scope of this article, but the trend in the last few years has been towards increased nonphysician participation. Some authors have warned of elitist tendencies within Cuban physicians who will then promote health policies in their own self-interest as a group rather than in the general interest of the population (Conover, Donovan, & Susser, 1980). The institutionalization of the Poder Popular and the strength of the mass organizations appear to be holding these tendencies (if real) in check.

Discussion The model of medicine in the community is only six years old and the long-term

results and effects on the community are as of yet unknown. The program is ambitious and its goals are admirable. The initial results are for the most part of a favorable nature, but problems and limitations are not lacking. The polyclinics are overcrowded and, as a result, the staff is overworked. This is partly a reflection of Cuba’s developing nation status and it is probably unrealistic to expect more at this time. If a physician has 50 patients scheduled to be seen in one day, the amount of time dedicated to cultivating a good patient-provider relationship has to be minimal. Effective community physicians need to get involved with problems other than the biomedical ones, but the constraints imposed by heavy schedules will be a limiting factor. The inappropriate use of medical facilities for minor problems also contributes to the overcrowding problem. One explana- tion is that there are no economic barriers to health care and, thus, people will have a very low threshold for visiting a physician. Since money is not a limiting factor for access to health care in the present Cuban system, the only way to begin correcting this problem is through more aggressive education of the general public. Thus, despite the already ex- ceptional ongoing efforts, health education needs to be intensified. The current polyclinic appointment system is inefficient and inevitably results in prolonged waiting periods which contribute to patient dissatisfaction. Another effect of the inefficient appointment system is that patients with nonemergency problems requiring attention will inap- propriately use emergency facilities during the day.

The communication between physicians of different specialties is often inadequate or even absent. Patients who are referred to another facility for an evaluation usually

I36 ELISE0 J . PEREZ-STABLE

return to the primary provider without a written report. There are no formal consultation forms required and obtaining feedback from a consultant will usually depend on the referring physician’s own initiative (R. Martinez, personal communication, November 198 1). This only applies to referrals outside the polyclinic because all intra-consultations are recorded in the chart. Medical records are kept at each institution and the events from one are usually not noted at another. The community polyclinic, by decentralizing care and providing physicians to a specified population, will eventually influence this practice for the better.

The dichotomy between hospital-based inpatient care and the polyclinic outpatient care continues to be a source of tension within Cuba’s health system. One of the net results of medicine in the community has been to reorient the health services system from the hospital to the community. The current practice is such that outpatient physicians in the community have little systematic contact with inpatient medical care and this eventually will result in a two-tier system. The potential consequences or advantages of this division of physician labor is an urgent issue for discussion. Community medicine should not stop at the hospital’s front door. The personal physicians of hospitalized patients make invaluable contributions to their care and, furthermore, act as patient advocates when unnecessary evaluations or therapies are contemplated.

The focus on medicine in the community has once again highlighted the importance of the primary care specialties. The decade of 1965-1975 witnessed an increasing trend towards subspecialization and appeared to reinforce the elitist tendency in the profession of medicine. The honors accorded to a plastic surgeon (Molinet, 1981), a cardiologist (Mart;, 1982) or an ophthalmologist (Fernindez, 1981) in the Cuban media have been virtually absent for the primary care physicians. The daily routine of listening to people complain and the ability to properly triage for serious pathology have not been con- sistently rewarded. The biomedical technological advances of the past two decades have produced sensational results in the eyes of the public, but the fact is that these advances have had a minor impact on the health status of the population. In Cuba nonphysician participation in health planning, limited resources, and the need for the medical profession to be responsible to society’s needs have contained the subspecialty elitist tendency. For several years in the early 1970s it was even possible for some graduating students to bypass the obligatory social service in order to directly enter into a subspecialty residency training program. With the advent of the community polyclinic and its essential principles the trend favoring clinical subspecialization seems to have been broken.

Conclusions In conclusion, the community polyclinic has been an initial success even though im-

plementation of the model is far from complete. One important implication for health services planning is the need to train many other physicians. Specifically, there is a need to train physicians with an orientation towards primary care and community work. Thus, qualitative features will be more important than mere numbers. As of 1981 there were over 16,000 physicians in Cuba with over 1000 students expected to graduate in each of the ensuing six years (Castro, 1981). President Fidel Castro has outlined very ambitious plans to graduate up to 3000 student per year with the goal of Cuba becoming a medical power or an international health center for the Third World. The preparations to meet the volume requirements have evidently been made. Assuming these physicians are ade- quately trained for the community polyclinic work, the question of physician satisfaction in this relatively new role will have to await the test of time.


Medicine in the community is challenging the traditional biomedical role of physicians. In cooperation with other skilled health workers, prevention of illness and maintenance of health becomes the priority. Home visits are certainly not new to the practice of medicine although they have become less common in recent times. The systematic approach to home visits in the Cuban model has projected the clinical team into the very heart of the community. The health or sickness of an individual in an office setting is one reality; the dynamics of an environmental situation where health and sickness interact with a socioeconomic setting and other individuals may be entirely different. The next several years will be an important experience to observe and learn from, as Cubans struggle with the problems of medicine in the community. The commitment to quality health care is present and there is a potential for great strides into the future.

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