When revolutionaries change the changes that came with revolution, that’s a “revolution within a revolution.” That’s how a director of the World Health Organization described Cuba’s turn 20 years ago to “comprehensive general medicine.”

The Cuban Revolution is serious about health care. At his trial after the crushed 1953 attack on Batista’s Moncada barracks, Fidel Castro told of Cuban children suffering and dying from preventable illnesses. After the 1959 revolution, the new government was threatened with the emigration of physicians — eventually half of them would leave. In 1961 the revolutionary government took special pains to induce medical educators to stay. It was beginning the process by which one medical school would become 25 schools, and 3,000 physicians, 68,000. By 1983, the New England Journal of Medicine reported, “Cuba has engineered a national medical apparatus that is the envy of many developing nations. For some of these nations, it is not Boston, but Havana that is the center of the medical world.”

But it takes more than medical research and specialty care to achieve favorable rates for infant mortality and life expectancy. A population’s health depends on skilled, accessible, and comprehensive first-line care, along with health education, health promotion, prevention, and rehabilitation services.

Cuba modeled its new primary care system on the polyclinics of the Soviet Union. By the 1970s, there were 332 multi-specialty clinics throughout the island, each one with pediatricians, internal medicine doctors, gynecologists, psychologists, and dentists working as a team.

The polyclinics, however, were unable to deliver continuity and coordination of primary care. People complained of long waits and impersonal attitudes, and they were not getting the care they needed. Many physicians seemed more interested in hospital work than in patients’ routine problems. Modifications were made, but by 1980 or so, it was apparent that radical changes were necessary.

Cuban health leaders deliberated with representatives of the entire population, political leaders, and experts on primary care throughout the world. They determined that the basis for effective primary health care lay in the community itself. Data would be found there on environmental factors and patterns of illness that could be used for health planning and even for clinical diagnoses. And health workers living in the community would be well placed to provide education, advice and support to their patients.

In 1984, 10 new “basic health teams,” each with a family doctor and nurse, started working in Havana. There are now 32,200 such teams, each responsible for 600–800 people, located in cities, on mountainsides, and in the country. They provide primary care for 99 percent of the Cuban population. Most family doctors and their families live upstairs in medical buildings built by voluntary community labor.

The doctors and nurses usually spend their mornings seeing patients in the offices for education, check-ups or medical treatment. Later in the day they visit people in their homes, or go to schools and factories. One family doctor told this writer in 1996, “I am like a priest. I know my people that well.” Epidemiologists carry out widely acclaimed research projects using data derived from health records kept by family doctors.

Health planners converted the polyclinics into a secondary level of health care, with each providing continuing education and patient-care consultations for 15-30 family doctors. And in the revamped medical education curriculum, the polyclinic specialists became teachers in residency programs for future family doctors. Having trained for three years, the family doctors are seen as specialists in “comprehensive general medicine.”

The family doctor system scores high on measures of public satisfaction and on superb statistical indicators of health. Family doctors get credit for bringing down rates of hospitalization, days patients spend in hospitals, and visits to emergency rooms. They have had a hand in achieving high immunization rates, making preventative programs universally available, and introducing sex education programs, teen programs and rehabilitation services.

Apparently the groundwork for becoming a family doctor, Cuban style, is laid early, and, we might suggest, even earlier in a young person’s development than medical school. Fidel Castro once commented on the effect of medical education on student attitudes. When they graduate, he said at a session honoring the Latin American School of Medicine, they are “like a shepherd, a priest, a missionary, a crusader for the people’s health and physical and mental well-being.”

The author, a physician, can be reached at pww@pww.org.