Health and Health Care In Cuba:
The Transition from Socialism to the Future
 
Antonio Maria de Gordon

• Executive Summary

• Introduction and Historical Background

• The Cuban health system

• Health care priorities during the transition.

• Notes and References

Executive Summary

Health issues have played an important role in the history of Cuba. Issues dealing with nutrition and survival were evident in the Spanish conquest. Infectious diseases were a determinant factor throughout the Spanish colonization and the First American intervention. It is therefore important to consider health and health care issues during the transitional process that is bound to occur in Cuba after four decades of socialist, monopartisan, and authoritarian rule.

Notwithstanding Cuba's health and health resources in 1959, health and health care during the revolution have been recognized and propagandized as major achievements of the revolutionary experience. Beyond any perceptions that may be prevalent outside of Cuba, it is important to appreciate that the Cuban people have been trained during the revolution to have access to health care and to expect appropriate health care. These expectations, despite important issues in terms of costs, resources, and organization or services, must be made a priority in order to effectively carry on, an probably improve health services during the transition and beyond:

The Cuban population is mostly young with nearly 22% of the people being younger than 15 years of age. Cuba had in the year 2000 the highest percent of population older than 65 years of age in the region. While the thrust of the health policies during the transition must address the needs of the young, attention must not be denied to the other end of the age spectrum.

Life expectancy has been increasing and infant mortality have been decreasing in Cuba. However, general mortality has increased appreciably. In the context of the transition, it is advisable to review all data gathering practices and policies of Cuba. This is the more important when one recognizes that the Cuban health services are under strong political control. Future evolution of Cuba's health services must be depoliticized, that is, taken out of the direct control of political parties.

The development of Cuban health services coming out from the current authoritarian, politically controlled administration cannot be left to chance. The spectrum of variables that have been reported by the countries in Eastern Europe suggest that proper planning be considered in terms of health services. The health priorities and the transition process must be organized and directed with a flexible but workable agenda. The goals for health care during and after the transition should include these following points:

a. A health services with access guaranteed to all.
b. A health service administered independently of political parties.
c. A health service administered with representation of the medical and other
health care professions, patient representatives, and legislative representatives
or the equivalent.

The transition process must include the provision of emergency services and a safety net for health and nutrition. The latter may be accomplished through a number of logistics.

However, there must be a goal to eventually evolve the "libreta de racionamiento" into the ability of most Cubans and Cuban families to obtain their nourishment without the requirement of the safety net.
Diseases that appear to be important in Cuba are cardiovascular disorders, cancer, diabetes, alcoholism and mental illness. Attention to all common disorders must be addressed. The prevalence and seriousness of asthma and hepatitis are increasing in Cuba. Proper environmental controls, provision of adequate hygiene and access to care will be important in the care of Cubans suffering from these medical morbidies. Cuba has become an important member of the WHO. During the transition and beyond, the role of Cuba's involvement in WHO activities should increase. It should be important to share with WHO and WHO countries the advances used in Cuba.

The use of the media in health care and health services should become routine. These services should be noncommercial providing a medium where the people could communicate with professionals thusly obtaining proper orientation and advice.

The investments made by Cuba in the field of biotechnology have surpassed 800 million dollars. Although Cuba is able to produce a limited number of biotechnology-produced vaccines, other countries in the region are indeed the leaders in this field.

It should be possible during the transition, however, to harness the vast investments and facilities in terms of both physical plant and human resources. Consideration should be given, in the setting of depoliticization of health services, to timed leases of certain biotechnologic facilities to private global companies involved in the production and development of drugs, diagnostics, and vaccines. These negotiations may provide a scenario where Cuba's resources may be made profitable rather quickly into the transition. At the same time, these negotiations must never be seen as a give away by
Cuba of valuable health resources.

In summary, Cuba's gains in health and health services have been accomplished through a system that is authoritarian and highly politicized. Progress through the transition out of this particular system of government requires study, planning, and organization so that health services - already considered important by the Cuban people -are maintained and improved through the transition in the near future.

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Introduction and Historical Background

Health has been an important factor in Cuban history. From the moment that the Spanish discovered the island, conquered it and began to populate it through settlements and migrations, health occupied a preeminent role in Cuban affairs. Among the factors that lead to such disastrous consequences for the Cuban Indians was the Spanish diet of the XV and XVI centuries.(l) The latter contained a very high content of saturated, animal fat estimated at 40% of the caloric intake.(2) This figure is three to four times greater than the estimated fat content of what may be called, the Cuban aboriginal diet. Health and nutrition were important factors in the extermination of the Cuban aborigines.

Health issues, particularly the epidemics of tropical fevers, proved the determining factors in the decision of the British to exchange Eastern Cuba for Florida in 1672. Many years later, at the end of the XIX Century, health issues occupied an important position in Cuban history. (3) Yellow fever was rampant in Havana during the XIX Century. In fact, yellow fever was the most dreaded of the various fevers that preferentially attacked newcomers and immigrants to the island.(4) Obviously, these tropical epidemics attacked the fresh Spanish soldiers brought into the island to put down the forces of Maceo and Gomez. The fevers also attacked the legends of American soldiers and sanitary personnel that arrived in Cuba. The fevers continued to attack during the first American intervention. From the military medicine standpoint, the Cuban theater of the war was relatively short resulting in 332 Americans dead.(5)

Immediately after the conclusion of the Spanish American War, journalists were reporting about 320 to 430 victims of yellow fever monthly. About thirty percent of these casualties died because there was no specific treatment for yellow fever.(6) It can be argued that one factor that led the United States to quickly pass the responsibilities of government to the Cubans was the perilous state of health in the island, i.e., the continued emergence of the epidemics of yellow fever. The Platt Amendment, an American amendment demanded to be added to the Cuban Constitution of 1901 by the Americans at the conclusion of the Constitutional Convention, included among several points, issues related to health and epidemic diseases.

In the context of these important political issues, Dr Walter Reed was assigned to head a commission to investigate yellow fever in Havana. After reaching a number of epidemiologic "dead-ends", Reed's commission sought information about the theories and experiments of Dr. Carlos J. Finlay. Soon, the theory advanced by Finlay regarding the transmission of yellow fever through a vector, the Aedes aegypti mosquito, was tested in the Columbia barracks near Havana. After proper implementation of public health measures essentially described by Finlay in 1881, (4) the mosquito population was controlled by William Gorgas. Havana was literally free of yellow fever in a matter of three months.

Cuba's health continued to improved through the first half of the XX Century.(7) By 1920, various writers were documenting the fact that Cuba was a safe country in matters of health. Cuba's health parameters at the conclusion of the 1950's were notable in Latin America suggesting that Cuba was indeed able to generate and implement effective health care.

Life expectancy at birth is an important health parameter because it is easily observable, it can be used in demographic comparisons and calculations, and it is a function of various important factors such as living conditions, access to health care, nutrition, and prevention of various common diseases. Life expectancy in Cuba was of the order of 60 years in 1950. Note that at that time in history, life expectancy was 70 years of age in Western Europe and 67 years of age in Eastern Europe. The average life expectancy in countries of the so-called Third World was of the order of 40 years of age. The demographic transition from rural to urban centers occurred in Cuba about 20 years before it happened in the average country of the Third World.

It is evident that among the various regions where developing countries are grouped, that Cuba's position was and is a relatively favorable one. It is also important to argue in favor of maintaining Cuba's lead in this and other health parameters during the current crisis and in the future.

Hence, it is not surprising that life expectance and other health related parameters in Cuba were better than in the average country of the Third World.

Table 1: Life Expectancy (yrs of age) in Cuba and Various Regions of the Third World. (8)

The Cuban revolution of 1959 led to an alignment of the island to the Communist block. The Castro regime assumed an increasing role in the government and politics of the island. Although Cuba had various health regulatory controls in place prior to 1959, these were literally overwhelmed by the control exercised by the State with the advent of the revolution. All aspects of Cuban society under the 44 year old rule of Castro - from the agricultural, education, military, urbanization, etc, to health and health care - have became centralized, socialistic, and officially part and parcel of the government.

Since the revolution, Cuba has been recognized in many circles including the United States Congress, the World Health Organization, and the Pan American Health Organization (9) as a model in State planned health service and for the delivery of health care.
A widely recognized problem in Cuba before the revolution was the access to health care. (10) The health access problem during the 1950's was summarily corrected during the early revolutionary experience. Although the total number of physicians in Cuba in the beginning of the revolution was somewhat adequate, approximately 6,600 doctors for a population of 6 million Cubans, their geographical distribution was not optimal. The discrepancies are evident from the data below (Table 2)

Table 2: Health Access in Cuba: Physicians and Hospital Beds, 1953. (11)

In 1953, 62.5% of physicians in Cuba worked and/or practiced in Havana. Ideally, the number of physicians in the capital city of a country should be proportional to the population residing and working in the capital. In numerical terms, one can define a 'distribution ratio' defined as the ratio of the percent of physicians who work in the capital to the percent of the population who resides and/or works there. (12) Ideally, this "distribution ratio" should be of the order of 1.0 meaning that the percent of doctors in the capital is identical to the percent of the population that resides and works there. In Cuba, however, the "distribution ratio" was 4.0 in the 1950's. By 1980, under the revolution, the "distribution ratio" was of the order of 1.2. The latter is obviously considered a more favorable parameter than the former. However, the numerical ratio does not include into the equation various individual freedoms, a competitive market economy, individual professional goals of young doctors, or separation of families and communities.

Before 1959, most physicians worked for the State or Province and also worked in private practice in various hospitals, clinics, and "consultorios". To be sure, the Constitution of 1940 provided a framework for regulations of the professions and the organization of a national and regional medical association (Colegio Medico Nacional etc.) All physicians were expected to be members of the latter and follow working, practice and ethical guidelines. The leadership of these institutions of professional regulation and quality control were democratic and all members were expected to participate in decisions from the grass roots to the top of their leadership in decision-making.

These regulatory agencies changed drastically in the early years of the revolution. The Colegio Medico National (13) and all regional organizations disappeared or went into exile. All Cuban medical graduates since the revolution became technical workers of the Ministry of Public Health (MTNSAP). They were also prohibited by law to engage in any professional, medical activities outside their official work description and sphere influence.

The distribution of hospital beds was equally uneven before the revolution (11) (Table 2) . There was also great variability and reliability in the access to any type of health care as a function of geographical location or rural versus urban centers. Most observers agree that the administrative and coercive measures taken by the totalitarian revolutionary government in order to achieve a nearly ideal distribution of physicians are undesirable and possibly unnecessary. However, these are complex issues which require study, discussion and assessment in the context of all aspects of Cuban society that are facing to undergo a transition process towards a more open, less blatantly coercive society.

Access to health care was variable in pre-revolutionary Cuba. However, Cuba was one of the first countries in the Western hemisphere to establish a social security benefit to attend health care needs. (7) Since the establishment of the Cuban Republic in 1902, health services were traditionally left to the provincial and municipalities governments. These official institutions usually maintained centers of immediate care known as "Casas de Socorros" (14, 15) The effectiveness of these centers varied depending on the funding available. Their number in 1958 was of the order of 200 centers for the 126 municipalities that existed in Cuba then. In the major urban centers including Havana and the provincial capitals, however, there were also several public hospitals dedicated to maternity, pediatrics, and general medicine.

The Cuban social security provided up to 1958 two types of risk protection: workman's compensation and maternity. Workman's compensation programs began in 1916. By 1933, the program was widely used whereby employers insured employees through one of several insurance companies.

The maternity program began in 1934. It was financed through contributions from both the employees and the employers. The benefits included medical and obstetrical attention during the pregnancy, through the puerperium, and post-partum. The funding of this program allowed many urban centers to build maternity hospitals and outpatient facilities for the care of women.

In 1950 there was a brief period when health insurance was available for some workers. The "Caja del Retiro Global Azucarero"(Sugar Workers Insurance Fund) was founded. The insurance covered disability, death, and health services. The health services included medical and dental care, inpatient and outpatient services, non-work related accidents benefits, and medications. The plan was probably too ambitious for the funding and structure that was envisioned. Very soon it was abandoned in the period of time when the Constitution of 1940 was essentially abolished in early 1952 through the "coup d'etat" that took Fulgencio Batista to power.

The best known of the health care delivery institutions of Cuba prior to the revolution were the mutualist medical centers (MMC). (15) These were not for profit organizations that owne and operated health care facilities. They originated in Cuba towards the latter part of the XIX Century. They arose from several ethnic Spanish groups, the Galicians, the Asturians, etc. The MMC's covered large groups of beneficiaries and their relatives.

Each beneficiary paid monthly dues, of the order of 2 to 5 Cuban pesos per person. All medical services were received and rendered at the institutions themselves. The costs of operating the facilities were the responsibility of each of the MMC's. All beneficiaries participated directly or through elected representatives in committees in the management of the MMC in the decision making process. That is, beneficiaries or their representatives were present in managerial and professional commissions where decisions were made regarding guidelines, practices, ethics, equipment, medications, benefits, etc. The MMC's also provided in many instances other educational and social services such as schooling, training in the trades, recreation and sports. It is estimated that less than half of the population in Havana belonged to one of the MMC's.

In the 1940's, another type of health care organizations began to spring up in Cuba. The so-called "medical cooperatives"(MC's) were formed by physicians. These organizations were not necessarily not for profit. The beneficiaries signed up for their sendees and paid monthly dues. Health services were probably equivalent to those provided by the MMC's but the beneficiaries in the MC's were not - directly or through representatives-participants in the management and decision-making process of the organizations.

The other sector of Cuban society that had medical benefits for themselves and their families was the military. Since the early XX Century the Cuban Army maintained military hospitals and outpatient facilities in all six Cuban provincial regiments. A new central military hospital, the Carlos J. Finlay Hospital in Havana, was erected in the 1940's and served as the tertiary medical care center for the entire armed forces. A Naval hospital was built in the 1950's. It was operational in the early years of the revolution. The extended health services delivered by the health care military facilities probably covered between active military staff, dependents and retired families approximately 300,000 persons in 1958.
Considering the fact that Cuba's demographic transition occurred in or about 1950 and despite the acceptability of the MMC's, the MC's and the military services, one can estimate the number of Cubans with easy access to health care in 1958 to be of the order of 30% of the population.

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Health and Health Care In Cuba:
The Transition from Socialism to the Future.

The Cuban Health System

Health and health care in Cuba appeared in the proceedings of the jury in which Fidel Castro and his comrades were judged after the violent events that underlined the attack to the Moncada Army Barracks in Santiago de Cuba in 1953. Health and access to health care were listed among Castro's motives for the failed attack and for the nascent revolutionary movement. Although Castro reviewed in his defense in appreciable depth all his stated motives, the number and types of casualties, injured, and dead in the attack, he failed to describe in detail the health measures that the revolutionary government would take to correct the health issues raised earlier. Instead, he gave some specific recommendations on agrarian reform but also fell short of specifics regarding land use, distribution of land, and employment. He concluded with the argument that once the agrarian reform would occur and Cubans were fully and gainfully employed all the other "motivations" for the rebellion would fall into "place," would be corrected, would be taken care of, however.

Since the end of World War II there had been a worldwide movement through which health care was being recognized as a right not a privilege. Inside Cuba, health care was recognized as a right through the revolution but behind the Cuban ideology, there were guidelines, goals, methods and policies provided by the United Nations and its health institution the World Health Organization (WHO). In Cuba, health care during the revolution was organized and controlled by the revolutionary movement and the Communist party. Eventually, all health care was consolidated including all services, workers, providers, and institutions.

At the onset of the Cuban revolution, rapid changes in the provision of medical care both at the individual and community levels were occurring in the world. There were also, in the global arena, important advances in the scientific understanding of various diseases and the emergence of effective pharmacologic treatments of various disorders. These advances were not necessarily part of the Cuban revolution but occurred at a time during which they seemed to be part of the revolutionary process in individual and public health. This process undoubtedly left a mark in Cuban health. Thusly, with the advent of potent drugs to treat tuberculosis, the WHO began to implement in all willing countries methods to control the dreaded infection. Other effective measures advanced the control of poliomyelitis through vaccination. WHO provided thusly the templates, organization and consultations for the control of a number of infectious diseases.

The Cuban health system under the Castro regime has been lauded as one of the major achievements of the revolution. Indeed, the Cuban revolution has attracted appreciable and worldwide attention because of these purported successes in health care access, infant mortality and life expectancy.
Cuban health data and those statistics reported to the international health organizations may be subject to political controls. Although there has been a number of publications (15) on how health statistics are collected, registered, and managed in Cuba, it is important to search for confirmatory data. Such confirmations up to now have been done indirectly by studying related subjects and adjusting Cuban data to parameters verified by independent investigators.

Advances in sanitation were also apparent during the revolution. The provision of clean water to Cubans has not been fully realized, however, in rural areas. Furthermore, with the advent of the "periodo especial" after the collapse of the Soviet block, the status of clean water provision in Cuba became worse. This was evident from the increased prevalence of infectious diarrheal diseases which peaked in 1991 with 10,982 cases per 100,000. (16) The chlorination of water was stopped in some areas during those early and difficult times of the "periodo especial." However, in terms of regional comparisons, Cuba's water and sanitation seems to be equivalent to those of Chile and Costa Rica in the urban setting. In the rural setting, Cuba's data seem better than those reported by Venezuela, a country with a higher per capita income.

Table 3: Comparison of Sewer, Water and Sanitation in Various Countries in the Region, 1998. (17)

In 1996, the coverage of liquid waste disposal was 91% for the entire country and 34% of the total population for sewerage services. Collection and final disposal of solid waste has been hampered by transportation and fuel supply problems during the "periodo especial".

Discrepancies between water and sanitation in Havana and rural areas were evident even in 2000. Water may be theoretically available in Havana for 100% and sewage 95% of the population. However, the probability of having water and sewer in some of Granma and the Eastern provinces was 71% in 2000. (18)

In summary, the main areas of advancement where WHO expertise participated were in the fight against tuberculosis, the childhood vaccination campaigns including the fight against poliomyelitis, and the organization of health services to cover all Cubans in all of Cuba. Obviously, the advances promoted by international organizations and the WHO in the delivery of health care provided further strengthening of the high level of control exercised by the central government.

Access to health care.

With the advent of the revolutionary government in 1959 and the entry of the Rebel Army in Havana and other metropolitan areas, the Rebel Army combatants themselves and their relatives began to receive health services in the military hospitals of Cuba. ' Indeed, during the first months of 1959, numerous cases of intestinal parasitism - a disease that was thought mostly eradicated in the urban centers in Cuba - were seen, treated and described in the Carlos J. Finlay Hospital of Havana and other facilities. Very soon, health expeditions were organized in which teams of physicians, nurses, and paramedical personnel traveled to rural areas in order to diagnose, treat and refer patients for medical care. Recognition of the disparities in health and health care between the capital city, other urban sectors and the rural sector became evident.

In the context of all social, political and economic changes (agrarian reform, urban reform, educational reform, etc), the health institutions were also reformed. In 1961, all health and health care institutions were joined together in the MINSAP (Ministry of Public Health). (13) That is, all health facilities were confiscated by the central government. Eventually, over the course of the next decade all facilities were reorganized. By 1969, all health care facilities in Cuba were consolidated under the "Sistema National de Salud." The latter provided a network organized along two main axes: First a horizontal, geographical axis extending from the nation, the province, the municipalities. The second axis was made up of those factors that covered the areas of health care proper: primary care, the specialties and institutes of health. Soon after the onset of revolutionary control, all Cubans theoretically had access to all health care.

Physicians. Nurses and Hospital Beds.

Beginning in 1960, health services in Cuba suffered a human resources crisis. According to official figures, more than 1000 physicians left the country between 1960 and 1964. The vacuum left by these health care workers was filled with medical graduates that were quickly made to undergo a rapid course and training program. By 1964, the number of physicians was returning to baseline. The new physicians pledged through an official oath (19) to be:

• Firstly and foremost Communists,
• To further Communism along with their medical knowledge and skills,
• To renounce to the private practice of medicine, and
• To be like Che Guevara.

The budget for health and health care was also consolidated for the entire country. Initially, in the early 1960's the budget was increased by more than four-fold in amount in when compared to the 1958 health budget to amount (US) $51.3 millions. The MINSAP began thusly as a conglomerate of all formerly governmental facilities, "Casas de Socorros", re-organized private institutions, MMC's, MC's, religious health care facilities, etc. During the time when the former URSS subsided Cuba's economy, the MINSAP's budget increased from 51.3 million pesos in 1960 to 1,015.6 million pesos in 1989. In terms of per-capita expenditures the values were 7.30 pesos per capita (1960) versus 96.66 pesos (1989). In 1989, health accounted for the fourth most important priority with expenditures of 4.3 % of the Gross Domestic Product (GDP). Health was behind education (7.9%), internal security and defense (6.1%), and social security (5.1%). Housing, an important factor in overall health and mental health in particular, was a lower priority with 2.0% of the GDP. Paradoxically, with the advent of "periodo especial" expenditures in health increased. In the PAHO report of 2002, the health expenditures in Cuba went up to 6.8% of the GDP. This amounted to $ 186 per person per year. . By 1999, the MINSAP's annual budget was of the order of 2,728 million dollars. (16, 20)
 

Going back to the early development of the MINSAP, when Jose Marti said that "el que paga ordena" he probably did not have health care in mind. However, MINSAP became the only payer in Cuba's health services and it obviously turned into the only one that "gave the orders." Since the MINSAP was from its inception run by the revolutionaries it follows that it was politicized. Health care in revolutionary Cuba became highly politicized throughout the various phases of the revolution. Physicians and other health care workers truly felt that their political position, ideology and acceptance of the revolution were extremely important and fundamental factors in their professional career and advancement.

MINSAP has claimed that it distributed health care facilities in an egalitarian manner throughout the country. The number of beds in Cuba has stabilized at about 5.1 hospital beds per 1000 population. A comparison with similar statistics in Latin America reveals that Cuba's health services have a higher than average number of beds per capita for the region. The distribution of these hospital beds is not entirely egalitarian throughout the island.

Table 4. Hospital Beds per 1000 population in Cuba. (15, 17)

The distribution of beds has not achieved an egalitarian distribution. In the year 2000, Havana had 9.2 beds per 1000 population. However, Sancti-Spíritus, Villa Clara and Guantanamo had 4.0 to 4.9 beds per 1000. Some of these discrepancies may be due to the availability of hospital beds for tourists and highly specialized, tertiary care services such as transplantation in Havana.

According to MINSAP data, in 1980 Cuba's hospitals had an occupancy rate of 80.4% and an average length of stay of 9.2 days. While the number of beds has not changed appreciably (Table 4), the occupancy rate has decreased to 69.4% in 2000. The average length of stay has not decreased as would be expected from better management and utilization. Instead, it increased to 9.4 days per hospitalization.

Cuba has more than fifteen times the number of nurses than Chile but about three fourths of the number in the US. Although Cuba has been criticized for augmenting the number of medical schools to nearly 22, it has achieved a physician to population ratio unrivaled in Latin America.(Table 6 )

Table 5. Nursing Personnel, 1997. (21)

Table 6. Physicians per 10,000 population in Selected Countries. (22)

General Mortality, Infant Mortality and Life Expectancy.

The population of Cuba in 2002 according to PAHO was 11,236,000 inhabitants. The GDP per capita at that time was 2,712. Cuba's population is younger than that of the United States but somewhat older than that of Costa Rica.

Table 7. Structure of Population(%). (23)

Crude mortality data for Cuba reveal that mortality for the entire population has been increasing steadily. In 2000, Cuba's general mortality was slightly higher than that of the United States.
 

Table 8. Mortality Rates in Selected Countries, (rate per 1000 population). (24)

In 1969, the MINSAP recognized that infant mortality was indeed increasing since the 1959, the year when revolutionary government control began. Soon after it was recognized that infant mortality was almost 44 per 1000 life births, approximately 20 % higher than the last data available before the revolution, a national campaign was launched to lower this important health parameter. (25) Now, in terms of public health, infant mortality is recognized to be a valuable and reliable index of four fundamental issues in health care:

1. Access of medical care including maternity and physician services,
2. Education of the population and in particular of the maternal, paternal and family circles.
3. Nutritonal status of the population and in particular of the women of reproductive age and those who are pregnant.
4. Communication and transportation in the community

The MINSAP did not seek to directly improve all of these fundamental areas. Instead, it brought together representatives of MINSAP's Institute of Childhood of Cuba, the Census Bureau, The Federation of Cuban Women (a Communist party mass organization), the Association of Small Farmers (ANAP), and the faculties of pediatrics and anthropology of the University of Havana. In 1969, abortion laws were liberalized in the context of the national campaign to improve infant mortality. By 1972, the infant mortality had dropped to 28 per 1000. Since then, the infant mortality in Cuba has been lauded among the achievements of the revolution. Although a "periodo especial en tiempos de paz" was defined when the Soviet Union and the CAME dissolved, the infant mortality has remained a priority for Cuban health authorities. However, the persistently low infant mortality rates in Cuba in the past 5 years suggest that these data may not be responsive or variable in terms of the usual parameters associated with infant mortality, ie., access, nutrition, etc. Despite the fact that the original campaign to lower infant mortality launched by the MINSAP in 1969 did not attempt to tackle the latter fundamental issues, Cuba has achieved a lower infant mortality as an isolated fact. Therefore, the empirically and sometimes artificially attained favorable rates of infant mortality attest not only to the determination of the MINSAP but also point in the direction where future priorities and goals must be.

Table 9. Infant Mortality in Cuba. (Rate per 1000 live births). (11, 26)