medicine in the community: the ideology and substance of community medicine in socialist cuba

MEDICINE IN THE COMMUNITY: THE IDEOLOGY AND SUBSTANCE OF COMMUNITY MEDICINE IN

SOCIALIST CUBA

Ross DANIELSON

Kaiser-Permanente Health Services Research Center. Portland. Oregon, U.S.A.

Abstract--‘Medicine in the community’ is the name grven in Cuba lo the dominant model for health services organization at the area and sector levels in the regionalized structure of Cuban health promotion. The recent historical evolution of the model is here analyzed in terms of ideological and structural factors. From this perspective. the origin of medicine in the community is found to be related lo a Cuban critique of commumty medicine in capitalist societies. But the substantive evolution of the concept is prmcipally explained by reference to a critique of revolutionary Cuban health organization itself. The strength of this Cuban critique and also the strength of the consequently formulated model appear lo be related to (1) social constituency formation in prior revolutionary years. (2) administrative separation of community health centers (or area polyclinics) from hospital administration, (3) commitment by the Ministry of Public Health to the area polyclinic as the focal unit of organization and (4) trends in Cuban society toward greater institutionalization, decentralization. and democratization of social forms. These trends coincided with increasing vitality of local government generally. The general elements of the model of medicine in the community are described and some implications are discussed.

INTRODUCTION

The concept of ‘medicine in the community’ emerged in the years 1972-1976 and is now firmly embedded in the ideology and activity of Cuban health promotion. In a formal sense. medicine in the community comprises a rationale and a model for the organization of health care which focuses on the interface of medical system and community. The elements of this model will be described below. But medicine in the community. like most concepts. is only partially interpreted by reference to its formal elements. A more complete understanding requires the elaboration of the concept by reference to its historical setting--the evolving health system in Cuban society. Thus. the primary purpose of this exposition will be to examine the meaning of medicine in the community in terms of its overall historical context.

My analysis of this context is based on 12 years of research on the history and organization of health care in Cuba. The methodology, which is elsewhere described in detail [ 11, includes first-hand data collec- tion in Cuba (1968 and 1976) as well as intensive library research and collaboration with other researchers.

Medicine in the community is nor a synonym for community medicine. The concepts reflect different historical contexts: community medicine originated in the capitalist world; the concept of medicine in the community is a product of socialist Cuba. In the dv- namic between socialist and capitalist systems. medicine in the community poses a critique of community medicine in the capitalist world while challenging the observer to evaluate all of Cuban medicine by reference to the goals of community medicine. More concretely and fundamentally. however. medicine in the community emerged as a critique of Cuban medicine itself.

In this paper. the term social and community medicine are used somewhat interchangeably. considering

the latter to be primarily a reformulation of the former. Social medicine, richly value laden with his- torically diverse meanings, defies simple definition, but for the present purpose the core of the concept is thought to be encompassed by its definition as the pursuit of an integrated and implemented understanding of both health needs and health services. giving attention to physical environment and human bio- logy, but emphasizing (1) optimal consideration of social. organizational. and economic factors insofar as they relate to health needs and effective services: (2) attention to and measurement of health status and health services within defined social and geographical categories; and (3) achievement of social equity in health.

HEGEMONY OF SOCIAL MEDW!“;;

The putative identity of Cuban medicine as community medicine derives from the socialist transformation and from the ideological hegemony of social medicine that was achieved early in the revolutionary years. Whether or not one agrees with the formula- tion of terms, it is important to appreciate the degree to which the Cuban revolution virtually ended private interest medical care and introduced a new ideology of health.

The perspectives of social medicine were present in Cuba before the 1959 revolution as substantial enclaves in the medical profession. private prepaid medical care, public health and medical education. The Institute of Tropical Medicine and Parasitology. associated with the medical school. was a stronghold of social medical perspectives, which were reflected in the institute’s Reristu KUBA de Medicina Tropicu/ I‘ de Parasitoloyiu. High aspirations for public health were formalized early this century in the legislation which created the Secretariat of Health and Social

239

240 Ross DANIELSON

hierarchical programs, and persistent graft frustrated public health aspirations Cuba. Prepaid after the mid-nineteenth Cuba, and in 1959 some one-half

under some kind of nongovernmental other cities,

these social medicine

major association Cuban Medical Federation, range of social which were editorialized

organ, the Tribuna Midica. This range of social medical philosophy-support for public health programs and critique of maldistribution of medical resources-was often compromised, however, by the federation’s defense of disparate and often conflicting interests within the profession [4]. A dominant sector of the medical profession was formed by physicians employed in mutualist and public medical programs and nurtured in university activism. Lacking exclu- sionary limitations on enrollment for medical education and effective public means for achieving optimal employment and distribution of medical resources, the medical profession (one physician per 1000 population in 1959) included many marginal practitioners who were crowded into Havana and larger provincial capitals. From this base within the physician class, as it was called in Cuba, the Medical Federation came to be dominated after 1945 by pro- gressives and socialists. The progressive Ieader- ship emphasized defense of contractually employed physicians, attended to the issues of medical ethics and variously championed social medical reform.

It was precisely these sectors of physicians who were recruited to direct the new government health endeavors after 1959.

By 1963, social medicine had passed from its roots in several minority medical perspectives to the status of official ideology. This ideology was affirmed in its implementation in the following:

-rural health programs; -regionalization of public health and hospitals; -regionalization of private prepaid medical care

programs; --creation and expansion of preventive medical

care programs (including the dramatic eradica- tion of polio);

-free medical care in all public institutions; -cost reductions, standardization, and regionaliza-

tion of pharmacy services; -expansion of epidemiology, biostatistics, adminis-

trative medicine, family medicine, and medical psychology;

-popular involvement in health work and health education ;

-comprehensive authority by the Ministry of Pub- lic Health over all health matters;

-recruitment of rural, poor, and nonwhite youth into the medical profession;

-required rural service by medical graduates; -formalization and expansion of nursing edu-

cation ;

-formalization and expansion of allied health occupations ;

-improved employment opportunities for physicians and other health workers.

Interpreting these developments within the history of social medicine, a 1965 document of the Ministry of Public Health prefaced its description of medical care organization by a review of social medical history [5].

In the following years, freestanding community health centers, called area polyclinics, were emphasized as the first point of access to physician services. Area polyclinics housed an increasing range of health services, including curative and preventive, personal and social, and clinical and environmental programs. Addressing the health needs of specified geographical areas, the area polyclinics became the conceptual focus of regionalized health care planning and administration. Area polyclinics were also used as teaching settings for medical education, preparing students for the practice of primary medical care in the community setting. After 1965, medical students not only trained in anticipation of postgraduate rural service but also, necessarily, in anticipation of public employment.

The years 1965-1970 were a period of system consolidation, integrating four somewhat competitive processes that had been set in motion in 1959-1964: (1) extension of the primary care base and periphery of the health system, notably the development of small, rural hospitals and health centers; (2) extension and regionalization of the hospital system, notably administrative integration and construction or expansion of services outside of Havana and the closure of small, redundant facilities; (3) integration/regionalization of the small private sector and the large metropo- litan mutualist sector, wholly incorporating them within the public sector by 1970; and (4) development of national pubii8iiZth campaigns invofvlng a range of health resources and community ‘mass’ organization.

The consolidation by 1970 of the Cuban health system could be summarized in the virtual extinction of medical practice outside the authority of the Ministry of Public Health. Comprehensive planning was effected in yearly and multiyearly planning cycles. In- stitutes of research, post-graduate education, programs of nonuniversity training, and traditional public health and sanitation matters were directed and planned within the Ministry. A comprehensive model guided the organization of health services everywhere; and the ambiguity and multiplicity of entry to the medical services system was significantly ended by making the area polyclinic the focal unit of the system.

COMMUNITY MEDICINE: SOCIALISM

VERSUS CAPITALISM

Thus, in 1974, when officials of the Cuban Ministry of Public Health began to prepare for an interameri- can conference on community medicine, they were struck by the contrast between Cuba and other American states in the context for community medicine. In Cuba the perspective of social medicine per-

Community medicine tn socralist Cuba 241

vaded the dominant ideology of the entire health system. but in other countries community medicine was a minor perspective within the larger medical system. While the Cuban Ministry of Public Health. guided by its social medical ideology. enjoyed comprehensive authority in all health matters, in other societies the role of community medicine was restricted to secondary tasks which seemed to derive from the failure of the dominant medical system to serve the entire population. Community medicine did not address the entire community in nonsocialist countries, but only a part of the community; operationally, community medicine was poor people’s medicine.

The very word ‘community’ had different meanings in different contexts; from one Marxist viewpoint it was argued that the profound class antagonisms of labor and capital meant that a true community could not exist in capitalist nations. Community medicine thus appeared to be an obfuscating misnomer. By contrast, the contradictions of iabor and capital were considered resoived in Cuba by the process of socialist transformation [6].

Given these differences of social context, Cuban medical leaders rejected the idea of developing a departmentalized, specialized role for community medicine, in the fashion of other countries. Cuban medicine sought to serve all the people, all the community. Therefore, Cuban medicine could proclaim itself to be community medicine.

CRITIQUE OF CUBAN HEALTH ORGANIZATION

Despite its somewhat self-congratulatory tone, the critique of community medicine in Cuba coincides with intense critique and experimentation in the health sector. After 20 years of profound social change new conditions had emerged which were analyzed in terms that were influenced by the prevailing ideology. This period of critical examination of the health sector (in 1970-1975) was favored by the con- current ambience of criticism and experimentation in the political and economic spheres. The new direc- tions which emerged from this period were embodied for the health sector in the concept of medicine in the community and for the political sphere, in the Social- ist Constitution of 1975.

THE SOCIALIST CONS~TUTION

The socioeconomic background for this critical period is given by the years known as the Revolution- ary Offensive, 1968-1970, which were dominated by the goal of expanding sugar production to 10 million tons in the harvest of 1970. The focus on sugar production contrasted with its deemphasis in the early revolution. However, departing from 1965, Cuban leaders focused on the realization that economic development had to depart from core productive areas (principally sugar) which yielded the foreign exchange required to import capital and technology for indus- trial development.

The year 1970 turned out to be critical. not only because it ended the Revolutionary Offensive. but because in significant respects the offensive had failed. Sugar production had increased but fell short of the

targeted 10 million tons. Meanwhile. the stress of the campaign had disrupted other economic sectors.

In the critical evaluation of the Revolutionary Offensive, it was concluded that the failure could not be attributed to lack of effort or enthusiasm by the Cuban citizenry. Rather. the failure was organizatjo- nal and political. The ma~itude of the effort was beyond the capabilities of political and economic structures. More effective economic decentralization was called for. but under Cuban socialism (already the most highly socialized economy in the world in 1968), economic decentralization required political decentralization, greater democratization and greater instjtutionaIization of legal/politicaI forms.

Structural proposals conforming to this line of criticism were experimentally implemented in Matanzas Province in 1972 and later revised and incorporated in the Socialist Constitution. Until 1975, the Cuban government was essentially a provisional government. The new constitution created the structure of a socialist state that was based on universal suffrage by secret baIlot and stepwise election of municipal assemblies, provincial assemblies and a national assembly.

The requirements for reform expressed themselves succinctly in local government. The revolution had modified local administration by establishing local authorities (‘poder local’) which administered basic municipal services. These locaf governing agencies were variously constituted, but were on the whole considered to have little autonomous authority; rather, they tended merely to react to the directives of national administrative organizations and to the Communist Party.

by contrast, the Matanzas Experiment and the Socialist Constitution of 1975 (as well as the First Party Congress in 1975) provided a clear delineation of authority and iesponsibility which placed local affairs in the hands of a municipal assembly composed of freely elected neighborhood (or precinct) delegates. The Party was admonished for having con- fused its leadership role with the task of government. which was to rest exclusiveIy upon the authority of elected officials.

EMERGENCE OF MEDICINE IN THE COMMUNITY

Reorganization, program development, and system consolidation in the health sector, 1959-1970. thus coincided with an era of provisiona revolutionary government, mobilization economy, political centralization and deep popular involvement. The conditions of this era, including flexible institutional structure and procedure, facilitated the experimentation and radical change that primarily shaped the present structure of health organization.

Conditions in the health sector were directly influenced by the political and economic spheres and to some extent. parallel characteristics and problems were observed.

In 1970, the following system-level characteristics presented themselves as potential tensions or antagonisms for change:

1. In administration and planning. a continuing interaction between the national centralization of nor-

242 Ross DANIELSON

mative responsibilities and the decentralized concentration of administrative. operative responsibilities in the provinces, regions and areas;

2. In medical services, a tension between the cen- tralizing tendencies of inpatient services and the decentralizing direction of outpatient services;

3. In the area polyclinic, a tension between its relation to the community and its relation to the hospital system;

4. In medical education, a tension between the community service philosophy of medical care and the dominant role of hospital-based learning experi- ences and specialty training;

5. In the community of medical workers, a differ- ence in perspective between physicians and nonphysicians; and

6. In the evaluation of health work, the continuing experience of service deficiencies and consumer complaints, notwithstanding the many well-intentioned efforts at resolving them.

The tensions of the health system particularly affec- ted the area polyclinic, which was soon to become the primary focus of medicine in the community. How- ever, it is critical to note that the area polyclinic was already the focus of the formal health system as it was conceptualized in 1965-1970 [7]. Indeed, the general characteristics and intended role of the 1965-1970 polyclinic have remained essentially the same.

It is similarly important to note how the polyclinic also became the primary focus of actual medical visits. While the combined total of medical visits to all medical facilities doubled in the period 1964-1969, the relative proportion of all Cuban medical visits which were recorded for polyclinics increased from 32.304 in 1964 to 63.3% in 1969. This represented an increase from 3,666,OOO polyclinic visits in 1964 to 13,818,OOO visits in 1979 [8]. A portion of this increase may be attributed to conversion of facilities (small hospitals, mutual clinics) to polyclinic function, but there remains a very substantial real increase in the polyclinic role.

At the functional, hierarchical periphery of the health system, the area polyclinic was necessarily a unit which on the one hand looked inward toward the health system and on the other hand looked outward to the community.

The community relationship of the area polyclinic (circa 1970) emphasized the following key elements: (1) an area health commission, chaired by the polyclinic director with representatives of health-relevant, program-relevant community bodies; (2) area institutions and organizations (external to the formal health system) with conscious health programs and specific ‘health responsible’ roles assigned to designated members; (3) interaction between lay health workers and professionals at the level of the sector (neighborhood category of regionalization, with some 10 sectors per health area-polyclinic).

The polyclinic was designed to provide, integrate, or otherwise be responsible for the provision of clinical services, environmental services, community health services, and related social services to a specify- tally defined area and population. Under the leadership of a physician-director, these functions were served by four health teams. With an average popula-

tion of 25.000 (in one instance. 60.000) in urban areas and sometimes as few as 7500 in rural areas. the health areas were intended to be small enough to be accessible and large enough to efficiently provide a substantial range of primary services. These primary services included the typical ‘public health’ tasks of sanitary control and community health work. organized and directed from the same organization that provided clinical and social services. Thus. the goal. predominant in all socialist societies. of integrating curative-preventative and chnicaILsocial-environmental dimensions was served in Cuba by the central role of the polyclinic. Polyclinic personnel were responsible for nine programs: women’s health, child health, adult medical care, dentistry. control of infec- tious diseases, environmental services. food control. school health services and occupational and labor medicine [9].

As the principal point of entry to the health system. it became the task of the polyclinic to define. orient and protect the relationship of the health area population to the system of hospital and specialist services. To foster such a relationship. Cuban health leaders determined that the polyclinic should enjoy administrative independence from the hospital. Unlike similar institutions in other countries. including Czechoslov- akia, the most directly relevant socialist prototype. the Cuban polyclinic was not be to be an administrative extension of a regional hospital but was. like the regional hospital. an administrative unit under the purview of the regional office of the Ministry of Public Health. It was with the plans, problems and proposals of the health areas, on the one hand and of the regional services on the other. that health plans were composed at the regional level, the bottom and increasingly most important level in the formal process of Cuban health planning.

Administrative autonomy of the polyclinic cis-&cis

the hospital was an extremely critical structural development, for its provided favorable conditions for the area polyclinic to develop its unique perspective and for health workers in polyclinics to evolve a sense of constituency interests and mission. This decision partly reflected political constituencies that had been formed in the early revolutionary (and highly politi- cized) process of periphery development. The setting and formation of the independent polyclinic determined that its leadership would be politically astute and committed to revolutionary goals. Independence from the hospital protected the polyclinic leadership from the tendencies of hospital technocracy while giving the Ministry of Public Health more direct influence over an important community-level institution.

Independence. however. did not imply isolation. The polyclinic director was a member. alongside other health officials, of the regional technical com- mittee which elaborated the primary operative com- ponent of national health planning. Hospitals and other health organizations. laboratories and epide- miological services were charged with specitic obliga- tions to the polyclinic. While each polyclinic employed a core of full-time staff. hospital physicians were required to work part-time in nearby polyclinics. providing primary services and specialist consultation. This measure was intended to tencourage a com-

Community medicine m socialist Cuba 243

hospital-based specialists. On the polyclinic side. staff physicians were required, when- ever possible. to serve for short periods in the regional or provincial hospitals. This requirement was facilitated, indeed the whole relation between polyclinic and hospital was thought to be facilitated, by the policy of training primary care specialists rather than comprehensive generalists.

Thus. the clinical team of the polyclinic included, in 1968-1971. physicians and nurses working in internal medicine. pediatrics. obstetrics-gynecology and dentistry. with primary and secondary care specialists who were available. on a part-time basis, from the staffs of nearby hospitals. In addition, many general practitioners moved from their solo office to the polyclinic. where they continued to provide traditional general services. Nurses, it seems under this al.rangement of organized primary services, began to assume greater clinical responsibilities. The polyclinic, then. in Cuba replaced the general practitioner (and comparable roles in private and mutualist clinics), but the core staff of the polyclinic consisted of primary care specialists. nurses and auxiliary personnel.

The direct neighborhood work of the polyclinic was organized geographically into neighborhood health sectors. with a growing national average in 1970 of 8.3 sectors per area. To each sector the polyclinic sought to assign a field nurse, a sanitarian. and sometimes a social worker. In addition to the unsurprising tasks of such personnel. it was partly through them that technical support was given and collaboration was maintained with the extensive health-related functions of lay neighborhood organizations. Depending on geographical conditions. first-aid posts could also be found in the sector. staffed by volunteers, auxiliary nurses. and. especially in rural areas. by teachers. Sig- nificant numbers of auxiliary personnel. as well as nontechnical volunteers. were also recruited from folk practitioners who were judged capable of enlarging their technical capacity. This was more the practice in rural areas where. for example. more than one thou- sand folk midwives were counted before 1962 in South Oriente alone [lo].

Unlike Eastern European countries, the Cuban Red cross was dwarfed in importance beside the voluntary health work of the mass organizations. Only in the cquntryside were Red Cross first-aid stations developed under that name. and they were frequently staffed by rural teachers. However, since 1969, the Ministry of Public Health and the mass organizations began to experiment with the Red Cross as a means of achieving greater institutionalization of the role of voluntary health workers at the health sector or neighborhood level.

Interestingly. in 1968. Cuban public health officials considered the development of the sector as a kind of final stage in the process of achieving regionalization.

Notwithstanding the conceptual harmony and achievements attributed to the area polyclinic by 1970. attention to user complaints and official studies of the polyclmic [ 1 l] began to reveal persistent short- comings. The increased use of polyclinics in medical education not onlk increased the visibility of problems but also intensified the search for models which would more closely approximate an ideal community-

PolYclinic relationship (and thus provide an priate teaching setting for new health workers).

appro-

One very important experiment. begun in 1972, was conducted in the new ‘Plaza Polyclinic’, named after the central Havana district and housing project adja- cent to the Plaza of the Revolution. Designed to serve an expanding population of prerevolutionary poor who were now occupying new housing in the area, the polyclinic was also intended as a teaching center

which could serve as a model of health care with a community focus. It was here that many of the features and roles of the contemporary model of medicine in the community were first introduced.

An explanation of the Plaza experiment rests on the newness of the facility and the expanding number of residents of the area who had not yet begun to orient their health care needs toward the polyclinic. Given the prerevolutionary concentration of medical resources in Havana, teaching activities were pre- viously located in established institutions, already passively receiving an abundance of patients. In the case of Plaza Polyclinic, however, there was a greater need-as had been the case with the rural health centers-to develop an active model of care. Unsurpris- ingly, the second polyclinic to implement the new models of service and teaching was ‘Alamar’, another new polyclinic in a town development of the same name, 10 miles east of Havana. As in any new facility. an opportunity existed to model the organization according to emerging theory. relatively unfettered by previous patterns.

The Plaza experiment, along with other studies of the health system [li], pointed not only to new patterns for medical training, but also to new models of work in the polyclinic, new models of relations with the community, and an implicit criticism of the prevailing patterns of health care.

ASSESSMENT COMMISSION FOR MEDICINE

JN THE COMMUNITY

In 1974, the Ministry of Public Health designated an interdisciplinary commission to elaborate the conceptualization of community medicine within the Marxist-Leninist and socialist ideology and character of the health system” [63. The commission began its work by first considering the different meanings of community medicine under capitalism and socialism. This analysis, already summarized in a previous section of this paper, concluded that the community aspect of medicine in Cuba was primarily a conse- quence of socialism. But while the need to invent a separate community medicine disappears,. another question, both technical and political, gains primacy: how is medicine to be integrated into the community? This question, conceived also as task. theory and practice, is what the commission then considered to be its area of concern-medicine in the community.

The commission vigorously pursued its evaluation and issued its assessment and recommendations. Coming from another quarter. the assessment might easily have been interpreted as an exaggerated attack on Cuban medicine. Reviewing user complaints. the commission noted: “insufficient appointments; inad- equate facilities: physicians frequently in bad humor.

244 Ross DANIELSON

hurried, and multi-referring~ cancellation or substitu- tion of consultations. ; waiting lists; and pilgrimage through different hospitals in search of technological support (complementary tests)“. A ‘tremendous’ press- ure was felt by the regional and provincial hospitals and institutes. and, the same report continued, “particularly worrisome is the overload to which emergency services are subjected, overutilized to treat problems which are not in themselves urgent” [S].

But how could such a situation exist in a country that had focused its attention on the area polyclinic? Precisely, the Commission on Medicine in the Com- munity answered, because the conceptual focus of the system was not adequate& matched by substantive focus. There was, in the words of the commission, “a noncorrespondence between the conceptual and the structural framework of the polyclinic” that was evi- denced in the polyclinic’s relative poverty of human and material resources. Idealistic staffing methods (somewhat similar to the mobilization methods in the ‘productive’ sectors) made it difficult for a patient to be seen by the same person. The opposite was true as well. Physicians had trouble foIlowing a single patient through the various stages of treatment. Due to the movement of personnel and a somewhat diffuse concept of teamwork, exactly who had responsibility for a given patient at a given time was sometimes unclear and easily overlooked. The tug-of-war between hospital and polyclinic had not gone easily for the latter, and meanwhile, the patient, in the middle, was suffer- ing.

Performing polyclinic duties only one or two days a week, physicians easily over-relied on referrals. And teaching physicians. who worked under the same conditions. were aiso pressured to work in the same fashion. removed from the community and its problems. Although the political interests of students were often successfully directed toward the community, this interest was soon frustrated by the noncorrespondence between concept and structure. Technical training and interests continued to be hospital-bound- even when they were developed in the polyclinic. fnsuffrcient training to understand the concerted activities of community health promotion contributed to a technical disinterest in primary care, and the hospital’s dominance of training continued the tendency to underrate the social, psychological and ecological aspects of health. The orientation toward prevention was similarly weakened. favoring in practice, if not in theory. the cure of disease over the promotion of health. The physician was in the polyclinic. but his mind was in the hospital.

The mediocre physician participation in the active in-the-community dimension of the area polyclinic rendered the physician essentially passive. The commission criticized this attribute in the strongest terms: “Although the purpose of our health system is to dis- pense increasing satisfaction of health needs of our people. the physician who is formed in the molds inherited from the past does not tend to practice this service-oriented medicine. Instead of serving, the physician tends to be served by the community and its people. in conformity with a medicine of consump- tion” C123.

Leaving none of the exalted concepts of Cuban soctalist health organization untouched. the com-

mission also castigated the polyclinic for deficient teamwork and the heahh system in general for incom- plete lay participation. The polycli& director was the only person who could be counted on with any cer- tainty to have a view of the whole task of the health area. and this limited distribution of organizational consciousness served along with other factors to stifle teamwork [12]. At the primary level of attention. there were thus few real health teams. and the feeble teamwork which existed had insufficient tie with the community, where the leadership capacity of lay volunteers remained underdeveloped. The latter shortcoming was declared unacceptable, not only in light of the objective of community-medical integration. but also from the view of the dominant ideology of Cuban socialism: “In our country mobilization of the people is significant in its own right. for it makes possible the construction of socialism and foments. with this social practice, the development toward a new revolutionary consciousness-community consciousness” [6], The community. declared the commission, should pass from object to subject of health programs, participating in planning, execution and control; the health team should adopt an advisory role. sharing its technical understanding and letting itself be transformed by this practice.

In order to avoid undue emphasis on the problems of the polyclinic as the source of agitation for reform. it should be noted that problems of discontinuity in hospital care were also considered and also pointed toward reform. For example. an analysis in 1970 of pediatric hospital readmissions led to a program of discharging high-risk children not to their parents but first to the area health facility, designating a specific heahh worker ~rsonaily responsible for the sub- sequent recuperation of the child. It was not merely the polyclinic, but also the hospital which stood to gain from an improvement of medicine in the community. But the thrust for new development, nonethe- less, came primarily from the polyclinic. or perhaps one should say from the tension between the hospital and polyclinic. In this sense, the outcome of the work of the Advisory Commission on Medicine in the Community could be considered the ideology of a ‘polyclinic movement’ which sought hegemony over the entire health system.

A NEW MODEL FOR THE AREA POLYCLlNIC

The changes proposed by the Advisory Com- mission and further refined in the planning process of the Ministry of Public Health were expressed in a new model of work for the area polyclinic. Many of its features were already present in the Plaza experiment and were soon applied in 1974-i975 in Alamar. By March 1976, there were tive model polyclinics in Cuba and at least 20 were targeted for 1980. Mean- while, all area polyclinics were mandated to develop plans to incorporate elements of the new model in accord with local conditions. This long-run transformation of Cuba’s polyclinics was expedited. no doubt. by the use of the new polyclinics as teaching settings. (I am recently informed by colleagues visiting Cuba that about half of all Cuban polyclinics now conform to the model of medicine m the community).

Community medicine in socialist Cuba 245

The new polyclinic differs from the previous model chiefly by its method of work. The polyclinic’s responsibility for the health of the people in its area is entrusted to full-time physician-nurse teams and the work of these teams is ‘sectorized’ in the fashion of a geographically-bound capitation system. That is, just like the community work of the sanitarian, whose work was already sectorized in the 1968 model, the work of each team is directed almost exclusively toward a specified geographical segment of the polyclinic’s area. A pediatrician-nurse team, for example, is thus responsible for the health promotion of all children in a specified sector.

Two kinds of activities replace the former requirement of hospital work. On the one hand, the physician-nurse teams are expected to spend a relatively large amount of time (about 12 hours per week) making home visits or doing related community work such as health education or liaison with community groups. On the other hand, the physician dedicates time to ‘intra-consultation.. . .’ That is, instead of referring patients away to specialists, the primary care physician participates directly as a third party in consultations between patient and specialists. Although the patient may consequently follow a course of treatment with the specialist or in the hospital, the primary team follows the case and continues to sche- dule appropriate intra-consultations. But following the case does not include, except in special circum- stances, the direct participation in hospital care by polyclinic staff physicians.

A number of consequences follow from the new approach to care. The patient no longer has to wait for a centralized clinic record room to draw his chart. Instead, she or he goes directly to the team office where all records of the catchment area are located. Although the internist, for example, may not be specifically trained in family medicine, the new organization of health care delivery is expected to promote a family and social approach, since the internist (who makes home visits) will deal with all the adult members in a dwelling and neighborhood. Health activities of lay organizations are also expected to be improved by the direct involvement of physicians and nurses. The staff of the polyclinic holds regular meet- ings with the citizens of each sector in order to ensure continuing community participation in the protection and promotion of health. Finally, an important conse- quence is that preferential, systematic, and aggressive attention is given to persons of high risk. On a visit to a primary health team. one therefore sees not only the actual patient charts, but also the card files of patients with appropriate flags indicating risk categories. For each category, the team follows a specific protocol of case review. Thus. the obstetrics-gynecology team will routinely request to see the mother of a high birth- weight newborn to be certain that the mother is not diabetic. And the hypertensive adult will be examined regularly by the adult medicine team (internist-nurse).

The polyclinic physician, then, is responsible not only for the patients who appear in the polyclinic but also for those who do not. The methodology for aggressively serving the community according to a prioritization by risk is called, after the Soviet fashion, dispensarizstion, but could be simply called, I think, active medicine. In the first six months of the Alamar

experiment in 1975, targets for adult medicine included: adolescents, the aged, heart disease, hyper- tension. diabetes, stroke, asthma, tuberculosis and cytological exams for cervical and uterine cancer [ 13).

Teamwork, which was regarded as deficient in the critique of the ‘old’ polyclinic, is subject to increasingly sophisticated analysis. This is due in part to psychologists and sociologists who are beginning to make contributions in health matters, particularly via the role of the medical psychologist in the model polyclinic. To the critique of the old area polyclinic, the social-psychological perspective added the concepts of atomization and alienation of the patient, closed professional hierarchies, and narrow technical vision. From this perspective, the new model was thought to resolve the contradiction between the pre- sumed psychological strength of the doctor-patient relationships under a solo-practitioner model and the criticized alienation of the doctor-patient relationship under the early polyclinic model. Under the former model, the patient may have felt better even when he did not get better. Perhaps the structure of the polyclinic, with its complex organization to integrate multiple levels of technical sophistication, should be scrapped? To this question, which was more than rhe- torical, a medical psychologist replied as follows:

Notwithstanding [the criticisms of the polyclinic. 1, we believe that the structure should not be modified a priori, for the failure is not to be found in the structure, but in the lack-at the base of the structure-of primary horizontal teams which may facilitate communication and integration of health activities. It is these teams, and the changes in the concepts of medical practice, that will be called upon in the future to modify or maintain the essence of the present structure of the polyclinics [12].

The primary horizontal teams, then, form the nucleus of the model polyclinic. In addition to having the usual characteristics of teamwork (practical understanding of interrelated, well-defined roles in the light of common objectives), these teams are expected to accept new members from time to time, according to specific task requirements, and even to let the lines of authority within the team shift according to the same requirements. In practice, the primary horizontal teams principally consist of physicians (internist, pediatrician, or obstetrician-gynecologist) and corre- sponding nursing staff. At the same time, these personnel are part of secondary horizontal teams, defined by overlapping work in a particular sector. For example, an internist-nurse team may work exclusively in one sector, but there may be only one obstetrician-gynecologist team and only one pediatrician team to serve two sectors. Thus, the secondary team of each internist-nurse includes a pediatrician-nurse and an obstetrician-gynecologist nurse; the secondary horizontal team of the pediatrician-nurse includes two internists-nurses and one obstetrician-gynecologist nurse; and likewise for the obstetrician-gynecologist nurse. Finally, the complete sector team also includes a sanitarian, perhaps a field nurse and lay health activists.

In this context, to be able to effect changes in the environment, the primary horizontal team tempor- arily includes a member from the environmental team; in other situations, a social worker, psycholo-

Ross DANIELSON

gist. or a hospital-based specialist may be included. But the same may be said of still other situations which call for lay participation (immunization. follow-up health education). In such conditions. the team is expected to flexibly modify the lines of its authority, even of its leadership. to meet the task at hand.

Departing from the nucleus of primary and secondary horizontal teams. the structure of the new polyclinic resembles the old. The polyclinic as a whole comprises the ‘basic team’ and is guided by a director, an administrative council, and the service assembly. The latter is the institution. common to all enterprise management in Cuba, of regular assemblies of the entire work-force. The administrative council includes the leaders of secondary vertical teams; clinical. laboratory. and environmental health and epidemiology, along with labor union representation. ‘Primary vertical teams’ include social work. psychology. sto- matology (dentistry). pediatrics. facility maintenance. statistics and so on.

This account of sectorization. active medicine and teamwork. even if somewhat idealized or conceptual. completes the discussion of the model polyclinic and the core ingredients of medicine in the community. To describe it in more detail would unduly concretize a concept which is in process of substantive development.

DISCUSSION

The new model for the polyclinic has a number of implications which may not be obvious. First of all. it requires the training of even more physicians than the number implied by the previous model. By creating a clear vocational role for a physician exclusively dedi- cated to primary service in the community. the new model resolves an ambiguity which was always expressed in previous years between the goal of training the ‘integral’ physician and achieving coverage by hospital-based specialists. between the goal of community service and the goal of integration between service levels. The previous strategy of vertical integration (via academic specialties and program categories) has been modified by the prioritized strategy of horizontal integration at the base. The replacement of hospital-polyclinic rotation by the mechanism of intra-consultation. together with the definition of horizontal teamwork, creates conditions for a new set of community-bound affective relationships for the integral physician. The same process favors the ad- vancement and integrated roles of other health workers. whose numbers and scope of training and responsibility were greatly enlarged in 1972. prior to the implementation of the new model of work. Although hardly for the first time. physician dominance is being concretely if not loudly challenged, modified by a criterion of teamwork which specifies situations where the physician is to yield team leadership to nonphysicians.

To a degree that cannot yet be specified. the turn toward medicine in the community seems to break a trend which maintained and even increased (by im- proving) the influence and prestige of clinical speciaf- izatton. The clinical specialists. powerful on the tech-

nical committees of the ministry. exerted a dominant budgetary claim. even when the social medical perspectives determined the overall philosophy and structure. The trend in the flow of resources to the parts of the structure seemed to favor the former. and with the always expansive appetite of hospital and specialist technology for greater shares of public funds, it seems inevitable that the polyclinic perspective would be constantly threatened. particularly if it did not assert and expand its role and particularly after the Cuban budgetary generosity of the sixties was tempered by the pragmatism of the seventies. Meanwhile, only an effective organization of primary services could protect the hospital system for its uniquely specialized contribution to health care.

Clearly there are parallels between the developments in the health arena and developments in the larger society, some perhaps circumstantial and others less so. Just as the economic sector suffered at the point of production from insufficient decentralization. so the health system suffered at the point of primary services from insufficient focus of resources in the polyclinic. Just as the large-scale mobilization approach in the economy created insufficient clarity of responsibility and accountability, so the assignment of physicians for certain hours or days to the polyclinic failed to sustain either the teamwork or the indi- vidualized accountability required for patient and community health affairs.

The conditions which pressed upon the society for criticism and experimentation in 1970 similarly affec- ted the health system. The Plaza experiment emerged in the initial period of post-1970 debate: the Alamar project coincided with the Matanzas experiment in elected government: and the third model polyclinic was implemented in Matanzas province itself. I was thus hopeful in 1976 that in Matanzas I would be able to see some of the first effects on the health system of the new sociopolitical organization. It was. however. too early to see major effects. and health services appeared directed through the usual lines of the Ministry. and not from the local government. The character of the health commissions was being influenced. however. by the participation of municipal assembly delegates and the assembly was setting up its own health commission. Local health matters were expected to fall more closely under local direction when the boundaries designated by the new constitution were implemented later in 1976. dividing Matanzas province into tw+Matanzds and Geron. Meanwhile. the voices of medicine in the community have heralded the moves toward decentralization and democratization as certain to enhance the full development of lay leadership in health. This is a reason- able expectation. for the new measures will introduce stability in lay influence. and the weight of a local institution such as the municipal peoples’ assembly will press heavily against the previous orientation of thinking in terms of multiple national-local hierarchies of authority. Lay influence will likely be favored by the tradition of administrative independence of the polyclinic from the hospital. for the area polyclinic IS now directly accountable to the mumct- pal assembly..

Under the developing hegemony of socialist and social medical perspectives. Cuba constructed a regio-

Community medicine in

for the area polyclinic in terms of internal

work organization. relation to the community, and relation to the health system. Given the organizational focus of the health system on the polyclinic, the new model demanded and effected far-reaching structural and philosophical changes in other health organizations. in medical education, and in health care occupations. Related models thus emerged for ‘the professor in the community’, ‘internal medicine in the community’. ‘pediatrics in the community’. and SO

on. The variety of these elaborations on the theme of medicine in the community is frequently expressed in Cuba’s medical press and, in particular, in the work of the new Institute for Health Development (Instituto para el Desarrolo de la Salud), which publishes the influential Recista Cubana de Administracidn de Salud. This institute. founded in 1975. and the similarly new scientific association, the Sociedad Cubana de Admin- istracion de Salud, seem to have inherited at once the accumulated ideologies of social medicine, Cuban socialism and medicine in the community.

Considering the far-reaching structural and institutional implications of medicine in the community, the concept has become much more than a model for work in the area polyclinic. As medicine in the community has come to broadly affect the entire health system, one again begins to think of medicine in the community as Cuba’s community medicine.

Acknowledgemenrs-Parts of this paper are excerpted from my book. Cuban Medicine. published in 1979 by Trans- action Books of New Brunswick. New Jersey. I am grateful IO the publisher who kindly granted permission.

REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Danielson R. Cuban Medicine. Transaction Books, New Brunswtck. NJ 1979. Rodriguez Exposito C. La primera secreturia de sunidod de1 mundo se creel en Cuba. Cuadernos de Historia de Salud Publica, no. 25. Ministerio de Salud Publica, Havana, 1964. Thorning J. F. Social medicine in Cuba. The Americas 1. 440, 1945. Fernindez-Conde. Biografia de la federacidn mPdica de Cuba. Colegio Medico de La Habana. Havana, 1946. Cuba. Ministerio de Salud Piblica. La Red Hospiral- aria (pamphlet). Mimsterio de Salud Publica, Havana. 1965. Fernandez Sacasas J. and Lopez Benitez J. El profesor en la comunidad. Revta cub. Admin. Salud 2, 1, 1976. Danielson R. The Cuban polyclinic: organizational focus in an emerging system. 1nquir.r 12 (suppl.), 86, 1975. Rojas Ochoa F. El pohclinico y la asistencia a pacientes ambulatories en Cuba. Revta cub. Med. 10, 214, 1971. Navarro V. Health. health services, and health planning in Cuba. Intern. J. Hlrh Serc. 2. 397, 1972. Font Pupo C. La salud del pueblo, preocupacion basica del la revolution. Cuba Social. 3, 41, 1963. Cuba. Ministerio de Salud Publica Direction Provin- cial Habana. Estudio estructural y funcional de 10s policlinicos de La Habana metropolitana. Mimeo- graphed, no date of publication, 1974. Barrientos Llano G. El equip0 de salud en el primer nivel de atencion. Revta cub. Admin. Salud 2, 12, 1976. Fernandez Sacasas J. A. ef al. Programa integral de salud para el adult0 segun el modelo de medicina en la comunidad. Recta cub. Admin. Salud 1, 155, 1975.

medicine in the community: the ideology and substance of community medicine in socialist cuba

Documents