Castro Addresses Family Doctor Congress
[Text] Comrades, I will be brief because I have not had the opportunity to participate in the other congress sessions, so I do not come to deliver conclusions. Instead, I will essentially have the great pleasure of meeting with you for a few minutes, saluting you, and congratulating you. I do not think any other health plan or program was ever developed so fully and so quickly, nor has it yielded so many results, as this family doctor idea and program. During this congress, you have commemorated the 10th anniversary of the creation of this movement. How easy it seems, or would seem, to talk about the importance of the program of the family doctor, and nurse -- you have correctly included them.
It seems like yesterday when the first steps were taken. I was touched when the diplomas and stamps were given out because I remembered the days when the first 10 doctors began at the Lawton Polyclinic, and when the first doctors began... [pauses] they were also doctors but were not directly in charge of the population. Instead, they studied the program that had been prepared. They studied and trained as family doctors at the polyclinics. There were two small groups -- I recall one was here in Havana and another one in Sancti Spiritus. It was not a single group; it was two groups, it was two groups. [repeats] Where? [unidentified woman states in the background: "It was in Fomento."] Fomento. Well, we began in two places.
I remember when we began the experiment with the doctors in the mountains because we conducted tests before going full steam ahead with this program. We wanted to test it; we wanted to see what happened. Therefore, we met constantly with the 10 doctors, and we asked them to tell us what happened, what was happening, how much confidence people had in them. We asked if they were treated with consideration, if they were appreciated -- or whether the people went to the polyclinic and the hospital. Based on the work carried out by those 10 doctors, we were able to see the population had welcomed them with enormous interest.
The families provided a small room or a garage. I even remember the case of a mother who had forbidden anyone to enter her son's room after he died. She said: I will give the room up for this. The family doctor was installed there because he had no facilities. It was obvious from the beginning that the people welcomed the family doctor with confidence. They no longer went to the polyclinic. In fact, one of the serious problems we had at the time was that no one trusted the polyclinics. They knew that the personnel with more experience -- meaning the professors -- were at the hospitals. Hospital outpatient clinics were crowded. Based on that experience, we saw that instead of going to the polyclinic, people went to visit the family doctors. They did not go straight to the hospital -- not by any means. This was one of the first results we could determine.
I remember other cases. Patients scheduled to see specialists later went to the family doctors, the first family doctors, to talk with them and ask if they considered what the specialist had recommended as correct. That was evident from the beginning. The experience acquired in the mountains was also important for reasons I explained a few minutes ago. Everything is more difficult over there due to the [lack of] communication and [rough] topography. It was necessary to change many things and many concepts.
We do not exaggerate when we say that the family doctor program was like a revolution in the country's health system. It revolutionized the country's health system. It changed everything; and it will continue to change everything in the future. However, it was necessary to struggle against many ideas and prejudices; concepts had to be modified, changed completely, so this program could move ahead. It was like... [pauses] at the time, the program was like a two- or three-week-old child at its mother's bosom -- not even two or three weeks, just one week. It had to grow.
First of all, we had to find doctors who were capable of doing that job. It was a completely new job; it was different from the usual thing, the traditional thing. Many people did not think this was possible -- above all, many doctors. Let us say that most of the medical faculty professors did not think this was possible. It was necessary to create a new program. Fortunately, this coincided with a time when many people had a bachelor's degree, to the extent that large-scale enrollment was possible, because the program demanded a large-scale formation of doctors; and a large-scale formation required quality selection, new programs. I see here the faces of some professors who helped us a great deal in developing those ideas, preparing the programs; and the programs had to be tested.
The students themselves did not fully agree with the program. Most of the students did not agree with the family doctor program. I repeat: It was necessary to struggle against many obstacles so the idea could progress. It was necessary to solve the issue of facilities, and we began installing family doctors in small offices. The first ones, like I said, worked in private homes and garages; we later built better facilities. Then we discussed the issue of providing housing for the family doctor. Once it was proven that the idea was good, once the necessary steps had been taken to develop it, we had to solve many other problems. The first one was the housing issue... [pauses] the family doctor's office and house. Then we remembered the nurses. This now involved the doctor's office and house, and the nurse's house.
We could do many things back then with the resources we had in the country. Along with the family doctor program, which we calculated would involve 20,000 doctors directly attending the population, we developed the program to build clinics and houses for 20,000 doctors and 20,000 nurses. The program called for the construction of 40,000 houses. They were being built, like many other things in the country, a great many things, before the catastrophe occurred abroad and led us to the special period. Let me tell you, I truly regretted what happened, not only because this affected the country and the people in numerous ways, but because it would affect our health programs. You know we were carrying out health programs, school programs -- they were being inaugurated by the dozen -- polyclinics, daycare centers, all kinds of schools. We were already thinking about refurbishing old schools and building new ones. No one can imagine the number of ambitious programs that were being implemented by the Revolution.
I think the family doctor program is an example of this, of what can be done with a revolution and a fair social system, of what can be done with socialism. Other countries have not done it; nor have they done anything that resembles this, although the idea of a family doctor program, the system is being discussed throughout the world. I wonder what is going to happen to the program and to many other things. There are many material things -- lots of plans for dams, irrigation systems, engineering projects, agricultural plans, housing plans, a great many things. How can you [implement those plans] without essential resources -- fuel, materials, cement, steel -- all the things you need for construction? They cannot be carried out with good will alone.
The family doctor program was of a human nature. The essential thing was man. When the special period began, the program already had 8,000 or 9,000 doctors... [pauses] between 8,000 and 10,000 doctors. The program was halfway down the road. We must say it is an extraordinary thing that, despite special period conditions, we were able not only to continue with, but also to develop the family doctor program. The students were in the universities -- being trained by the thousands -- and the program could not be stopped. The universities have not stopped either. Everything that depends on man can continue, even under the difficult conditions we now face. [A brief, high-pitched tone is heard in the background] What is that sound? What can it be? [smiles] Perhaps someone has a cellular telephone, or a doctor is being urgently paged. [laughter]
I was saying that the students were in the universities. We said: Let us continue the program based on what we have done so far; and if we again have to return to a room in a person's house, and if we again have to return to the garage, we will return to the room and we will return to the garage -- but the family doctor program cannot be stopped. Many ideas were submitted... [pauses] it must be said that many things have come up, many ideas have been submitted throughout this time. The program has been fruitful because it has resulted in many intiatives from the people. It was proven here, among many things, that there was a lot of hope when the program was conceived, and there was a great deal of certitude about its importance.
The program has amply surpassed our initial expectations because the doctors brought new ideas. For example, this led to the homecare issue; this led to initiatives regarding factories -- dealing with the people's safety, health, and accident risks -- and day care centers. The issue of medical specialties was also brought up. The specialty issue was part of the family doctor concept. Other initiatives were also discussed but they are too many to enumerate. For example, the one about....[pauses] when the special period began someone suggested sharing the existing medical facilities, some of the doctors' offices. That helped a lot.
Even today we continue to build outpatient clinics and houses, the so-called low income houses, although not in the main cities, the capital. We are still trying to solve the problem, and one day we will undoubtedly be able to continue the program for the construction of family doctor clinics and houses, slowly but surely. We had advanced so much in this program that a contest was held among architects to design not just one model, but 12 models of houses for the family doctor. There were prototypes of the houses in Diez de Octubre Municipality. They were what you might call luxury models for the construction of family doctor and nurse houses. We had advanced, it was being accomplished, and we would have continued if the socialist bloc catastrophe had occurred four or five years later -- let us say six years later; if it had not occurred when it did, when all of our programs were at their peak. This left us without markets, essential raw materials, fuel, large quantities of food, raw materials to produce food, spare parts, steel, and lumber.
If this had happened a few years later, many of our most promising social and economic programs would have been completed; and we would have completely finished the family doctor program [chuckles] in a few years. Despite the bitterness provoked by the interruption of many things within this program and others, we can at least say that such a movement, with its 22,000 family doctors and nurses, is now a source of satisfaction and true pride because it represents a feat accomplished through our efforts and determination. We have 22,000 doctors, and I imagine we also have 22,000 nurses working with those doctors.
I truly believe, without exaggerating, that our people achieved an extraordinary feat by being able to continue developing this program during the most difficult years of the special period. In my opinion, it seems that this program was designed for a special period. What would the condition of our public health and our people's medical care be today without those 22,000 doctors and 22,000 nurses who render their services in this program, not only in towns, but also in factories, schools, and polyclinics despite all the problems we have in the transportation sector as stated here; the problems with ambulances and medicine; and all kinds of problems? How could this level of medical care have been maintained without the family doctor and nurse program? There have been many brilliant ideas and solutions to these difficult circumstances aimed toward improving transportation and the problems with medicines.
The current medicine distribution program was mentioned here because there has obviously been so much speculation over medicine purchases. This resulted in certain situations -- for example, if two... [pauses] any amount of aspirin that arrived would last only a few days because of the excess currency in circulation and the activities of unscrupulous people who bought whatever medicine they could on the open market. There was no way to prevent this -- a whole shipload of aspirin would last only a few days. It was expedient and possible to do this within our system because of the Health Ministry's organization and family doctors' cooperation.
The idea of using traditional medicine, or herbal medicine as you call it, meaning plants, was also mentioned. We must develop all this, but those 22,000 outpatient facilities have been decisive in endorsing this type of medicine. Today we must resort to all these methods. If we remember our forefathers and the war of independence; if we remember the times of [Maximo] Gomez, [Ignacio] Agramonte, [Carlos Manuel de] Cespedes, [Antonio] Maceo, we will realize they had absolutely nothing. They cured people -- and they had many people to cure -- although they did not have the resources, the doctors, or the talents we have today. They solved many health problems with available natural resources. The situation is not exactly like that, but it somehow reminds us of it. We have been compelled to consider all the possibilities. A great effort is truly being exerted, I assure you, in the constant struggle to acquire or manufacture the necessary medicine and to distribute it in a more rational, equitable way.
We are also striving to acquire some of the components that have rendered ambulances inoperable. A comrade outlined the situation he faced. I think it involved batteries and tires. Comrade Teja explained that we would get a number of batteries and tires within three months to repair the ambulances. All of you who work with the rank and file know how difficult these hours, days, months, and years have been for us. You know how difficult the circumstances are. No one knows it better than you because you are there, waging that battle for the people's health, life. We must bear in mind an important thing, a very important thing. I have not seen you lose heart, regardless of the problems. I have observed during the hours I have spent here that morale is high among family doctors and nurses; it is a level of morale needed in these times.
I believe it is fair to call this an historic congress given the successes achieved, the experience acquired, and the circumstances and time in which the congress takes place. I am sure these years will be remembered as one of the most glorious pages in the history of Cuban medicine. The fact that we have reduced the infant mortality rate to nine... [pauses] to less than 10 [per 1,000] in 1993 is truly a great feat. I thought the goal was impossible, to reduce this figure to less than 10 during one of the hardest years of the special period. I wonder if this would have been possible without the family doctors' work. How could we have maintained the general health indexes, how could this have been possible without the family doctor's work -- the doctor and the nurse? But I am not going to constantly repeat this because I will run out of time. How would this have been possible without your work? We can say that no Third World country, or even First World country, can offer what we have in the health care sector during these difficult years.
We must bear in mind that the idea of a family doctor and nurse became generalized in Cuba and it has also become essential in many countries; it is expanding to other countries. Political leaders from important countries in this hemisphere talk about expanding [smiles] the Cuban family doctors' experience throughout their country. No one who talks about public health fails to mention this experience, even those who have achieved sophisticated levels in some areas of medicine. When they talk about medicine with a social character, when they talk about the ideal medicine or the ideal medical system, they talk about the Cuban medical system -- and they talk about the basic medical assistance we provide in our country. Cuba has become a model for this. Not only Third World countries, but developed countries as well talk about our medical system. Many developed countries are now discovering the defects in their own health systems.
During recess, a comrade told me that one of the best universities in the world -- I believe it is in the United States -- talked about the need to change its methods, style, and system for the training of doctors because, it claimed, doctors came in contact with or had experience with only 1 percent of the problems they later encountered. This is a mark of respect for our concept of the general practitioner; a concept that, as I previously said, emerged as the idea was implemented.
When we were ready to prepare the new program, we sent commissions of university professors to the most advanced countries to tap the best of their experience. In the future...[pauses to chuckle] they will have to come here, to our universities and to Cuba, and tap the best of our experience. However, it is fitting to ask: Would programs like this be possible within a capitalist system? Are concepts like this possible in a neoliberal economy? Can a system like this be implemented outside socialism? How? We are happy and satisfied that many want to tap at least a smidgen of our experience and take it to their countries. However, it is impossible to implement a system like the one Cuba has today in a capitalist society. It is absolutely impossible. That is what we mean when we say we must save the independence of the revolution and the achievements of socialism in these extremely difficult times.
We are not talking about continuing with the construction of socialism or being involved in a construction phase, amid the enormous problems which currently prevail and which will take us time to overcome. We can continue with things like this. We must defend by all means what we have achieved because programs like this one, like the health program, and like many other programs would be impossible under other conditions. We are doing things that are unavoidable in this special period we face. We have to introduce elements in the economy; we have to introduce formulas that allow us to face the current circumstances.
Yes, I know that the special period, the measures adopted in the special period, and the measures we have to adopt to perfect the efficiency of our economy -- a result of the reality which prevails in the world -- introduce elements of selfishness and elements of individualism. They introduce some of the elements of capitalism. You know this. Even though it hurts, examples like the one you set irrefutably show that -- despite the special period's conditions; despite the economic changes we must make; despite the mechanisms, procedures, and organizations we have to enforce -- society can maintain an extremely high dose of generosity, an extremely high dose of morals, and an extremely high dose of solidarity. That is why I sincerely think we must never, ever let elements of capitalism be introduced into our health system, our education system, or into many other things. [applause]
Private medicine did not disappear in Cuba as a result of a law. It was an initiative adopted by the medical students, an agreement reached by the medical students, and this became a tradition in our medical sector. I sincerely believe and am firmly convinced that we should never allow the introduction of private medical practice in Cuba or the polyclinics, hospitals, or any of those institutions because it would be incompatible. It would be the introduction of the capitalist elements we just mentioned. There are two sacred things, two sacred achievements that should be maintained at all costs and under any circumstances, just as we developed and created them, namely the right to health and to education.
Socialism was subject to much criticism, yet capitalist countries, which are far from solving their problems and which have tremendous and unsolvable problems, have never been able to adequately solve the public health and education problem like we have. Now everyone recognizes our people's education and preparation levels. In fact, many of the people who make investments that are necessary, that are essential, under the current circumstances comment on our people's education levels and our workers' education levels. That is why I address you -- who are having that experience, who are experiencing this situation -- with such clarity and frankness. There is something that should be engraved in the hearts and minds of all our doctors, nurses, and health personnel: We must never allow the destruction of things we have created, like this; we must never allow the prostitution of things we have created, like this; and we will see what the world does to solve its problems, how it manages to establish this health system.
It is known that whenever someone wants to achieve some progress in the medical sector, the first thing which occurs is a tremendous conflict with private medical practice. Veritable rebellions occur, and we have acquired some experience in recent years regarding progressive ministers who tried to implement certain reforms but were unable to because they found that doctors in highly developed countries, where medicine has achieved tremendous fame, have various public hospital rooms for their private patients. For example, when someone needs some kind of surgery, he must wait, sometimes three or four months, because the doctor's private patient has priority. I am convinced that a program like the one we have the privilege of enjoying cannot be implemented without an overall social change. It is impossible. That is why [words indistinct] people have adopted such an heroic attitude to struggle, resist as long as necessary, and to protect our achievements.
We see many examples -- it is obvious given our current situation -- of those whose morale fails, who incur acts of selfishness, who incur certain misdemeanors. We are all sorry to see this, but we also feel encouraged to see what has been seen here, what has been discussed here, and to hear words like the ones we have heard here. We must bear in mind the example of comrades who admirably fulfill their duty in the mountains, factories, and cities despite all kinds of difficulties. The family doctor and nurse have been called many things. The phrase guardians of the people's health has almost been coined for them, and that is how they were visualized. I think Manolo recalled that this was discussed in 1981. Above all, we said there would be no surplus of doctors, because there could never be a surplus of doctors. We could have a doctor in each factory, in each school. This was back in 1981.
In other words, we began to develop these ideas in the early 1980s, along with many other ideas in the medical sector. I have not reviewed them like they were reviewed here. Today we have an incredible situation. We will have a large number of doctors -- they are about to graduate, they are already in the universities -- and registration has been reduced. International circumstances have also...[pauses] It was always calculated that about 10,000 Cuban doctors would be cooperating abroad by 2000, but there were other ideas -- for example, the reserve of doctors. I talked with Pinon and other comrades and told them we should start thinking about what we will do with...[pauses] What we will do when we have covered all the family doctor positions. We thought there should a reserve of doctors who would devote their time to research while others take their place, meaning the so-called...[pauses] At the time, there was talk about the...[pauses] What is it called? [unidentified speaker says: "The sabbatical year."] The sabbatical year. We will invent a way of doing it because we must obviously bear two things in mind. We have several thousand students in the university; registration, which was 6,000 at a given time -- just imagine the momentum this program gathered -- is now limited to 2,500, and we will have to make do to optimize the use of those human resources in the medical sector. I am sure solutions will be found despite the special period's conditions.
I calculate that the number of family doctors -- including those in the schools, day care centers, factories, the reserve, everything else -- will always...[pauses to laugh] I remember one of the problems we had at the beginning. Many of the family doctors were women in the so-called fertile age so the number of pregnant women was relatively high -- there are still some who received their stamp and diploma with a guest that is about to enter the world [laughter] -- so it was necessary to create the reserve of doctors at the hospitals in case of sickness, maternity leave, and other absences. We always found solutions, and we must not be afraid of recently graduated doctors. Many times we have thought: Would it be correct to reduce registration even more? I think it would be dangerous to reduce the registration even more than we have done. We will have graduations of 3,000 and 4,000 students. At least two big graduations are still pending, and I think all the positions will be filled in two or three more years.
I am not up to date on the number of students who have graduated as general practitioners but...[pauses] How many? [unidentified speaker says: "5,400."] 5,400. That is a fabulous breakthrough, too. The other thing I wanted to say is that, as a rule, doctors never retire. [National Council of Scientific Societies President Jose] Jordan, I am not thinking about anything [laughter] because we would not let you retire under any circumstances but minutes ago you were telling me that you have celebrated your 50th year as a...[Jordan prompts: "A doctor."] as a doctor, and next year you will celebrate your 50th year as a professor at the medicine faculty. There is a good example. [applause]
The longer it is, the more experience and knowledge you have. There may be some areas where the task becomes difficult, but a vast majority of the doctors, particularly general practitioners, render their services for many years.
You cannot make calculations like you do with other professions or other activities, where you work for 30 or 35 years, although the world tendency is to increase because the tendency is to increase the people's life expectancy, but these factors must be taken into consideration. Which one of these people will retire? It will be difficult to tell. All this complicates the calculations concerning graduates, number of years in service, etc. However, it is better to have an abundance of doctors than a problem resulting from the lack of doctors, like we did once -- 3,000 doctors remained and we now have 51,000 doctors. Will it take us three years to have 60,000 doctors? Calculations called for the formation of 70,000 doctors, and see how much progress we have achieved. Like I said, the figure included 10,000 abroad and 10,000 doctors as a reserve.
I think those human resources must be protected like gold. They cannot be lost, but we must find the most intelligent way to use those human resources. The number of graduates will decrease, but in 2000 we will...[pauses] We will have more than 70,000 doctors in 2000. There is no doubt about this. What we must do now is use our imagination and intelligence to prepare plans. Of course, as time goes by, our conditions will improve. Let us not forget we are doing this when the socialist bloc, meaning the USSR, has completely disappeared; when we practically have no economic relations with those countries; and when the blockade is more rigorous than ever, when it is more difficult than ever, when it is more merciless. Yet we continue to struggle and I ask you: Did we or did we not do the right thing by resisting and struggling? I ask you. [people answer: "Yes."] Did we or did we not do the right thing when we adopted the decision to defend the homeland, the revolution, and the achievements of socialism at any price? [people answer: "Yes."]
We are doing this under difficult, harsh conditions. We are doing this under truly heroic conditions. We are not to be blamed for the catastrophes that others suffered in the world. We have fulfilled our duty and we have resisted for years, but you are there in the thick of things, in direct contact with our people. You must be not only guardians of the people's physical health but also guardians of the people's moral health, guardians of the people's patriotic spirit. You are there, on the front line of the struggle. You are the standard-bearers of the noblest cause. Give security to each citizen; give tranquility to each father, mother, son, and relative; give the most important comfort to a human being, meaning health; end suffering and pain. Is there a nobler and more human task for a human being? A human being's state of mind and moral health are also part of his comfort and must be supported, too. If any of you feel despair prescribe something for yourselves because you are the first ones who should maintain a high morale among the neighbors.
The revolution expects to have a veritable army not only dealing with health but also our people's best qualities, virtues, spirit, morals, generosity, and spirit of solidarity. Therefore, comrades, I congratulate you on the occasion of the congress, on the occasion of the 10th anniversary, due to the success achieved throughout 10 years, and I tell you that we feel unlimited confidence, infinite confidence in you. The family doctors and nurses will be in the forefront when the history of these heroic and glorious years is written. Socialism or death. Homeland or death. We will win! [applause]