The World Health Organization (WHO)’s definition of health as a “state of complete physical, mental and social wellbeing, and not only the absence of disease or infirmity,”2 embraces basically the same principles associated with human rights and development, since all three seek to improve both the human condition and the fulfillment of the human potential. In the 1990s the interrelationship between democracy, development, and rights was agreed by consensus in the United Nations (UN). The symmetry of the rights framework was embodied in the proposition that “all human rights are universal, indivisible, interdependent and interrelated” and must be treated “globally and in a fair and equal manner, on the same footing, and with the same emphasis,”3 including the right to comprehensive health care and integral health state.
Integral health state can be viewed within this social context as a high complexity function of multiple physical, mental and social ability and wellbeing factors, specific to each individual, family and community, and of general societal and medical factors. Within it, population-based health is the result of the interaction of health factors at each level of human organization with broad factors such as all living standards of development, as well as health care. This includes personnel, infrastructure, scientific base, drugs, technologies and management factors. Different forms of interaction among these factors can improve, preserve or worsen integral health state.
In 2009–11 Cuba was ranked among the top countries worldwide in sub-indexes derived from the “human development index” (HDI), by the U.N. Development Program (UNDP) measuring health and education together. Such sub-indexes exclude economic growth dimensions, in which Cuba lagged significantly. 4 The UNDP has said that “Cuba’s substantial achievements were possible because of the slow growth of its income was separated from the processes determining progress in other non-income dimensions of human development.” Although since 1992 Cuba opposed the construction by the UN of human rights indicators, in 2010 the UNDP measured them in 156 nations. With respect to these indicators, Cuba scored 0 in the dimension of democracy (scale 0–2); 3 in rights violations (scale 1–5); and 94 in violations of freedom of the press (scale 0– 116), with 22 journalists imprisoned, first place in the world with respect to number of reporters jailed relative to population. With the collapse of Sovietstyle totalitarian-socialism in 1989, the world was reoriented to democratic-capitalism and with it to the less violent and effective human values, principles, institutions and paths for gradual development, increasing dignity, justice, peace and equity. North Korea and Cuba maintained the obsolete system. Unsurprisingly, North Korea integrally involuted, but Cuba’s “health achievements” are paradoxical.5
The hypothesis in this paper is that universalization of the access to partial healthcare and education does not justify the sacrifice of human rights, democracy, and development. Cuba in 1728–1958 showed exceptional trends on integral growth of ideas, institutions, medicine, health, education, freedoms and other living standards. Even with slow GDP per capita (GDP-p) growth after the U.S. Great Depression in the 1930s, Cuba’s health and education levels were high in 1958. Cuba, unlike the USSR, China and Korea had a long tradition of scientific health care. UN statistics show that Cuba’s health, education and other living levels grew under a system of U.S.-style democratic-capitalism during 1902–58 (including dictatorships in 1929–33, 1952–58).6
In the Moncada Manifesto (1954), Fidel Castro stated that at the time Cuba had extremely low health and other living levels. Its author, in power since 1959, has taken credit for building and upgrading Cuba’s health facilities. Since the Soviet-style system was implemented in Cuba in 1959, the political focus changed from self-sustainable development to exporting of this model to all neighboring nations. In the meantime the former Yugoslavia and later China abandoned this system due to scarce practical efficiency and lack of economic coherence.
In 1980, analysts at the U.S. Bureau of the Census detected an unpublicized rise in infant mortality rate (IMR) in 1970–77 in the USSR. The life expectancy at birth (LEB) and of elderly (LEE) had also been falling since 1965, when the USSR had the world’s highest density of physicians per population. This showed that a large number of physicians is not a sufficient condition to preserve health. At about this time, Cuba was reporting an apparent “first health miracle” improving IMR and LEB. The world’s left movement shifted to Cuba to showcase socialist-style universal healthcare “supposedly comprehensive, free, and equal for all with high humanitarian solidarity.” In 1983, Cuba endorsed the Soviet theory of social advances and happiness with slow income growth. In the 1990s, Cuba’s economic collapse, liquidity problems, scarcity of credits, and lack of political will to set free its captive people and adapt its economy to follow world trade rules, consciously reanimated an insane class war, and exacerbated chronic malnutrition, poverty, helplessness, and oppression. This caused the return of old epidemics and the emergence of others, at the population physical and psychosocial health levels.
In 1993, new transparency in Russia after the end of the Soviet regime exposed a greater decline in LEB than previously estimated.7 Meanwhile, oppressed and impoverished Cuba reported an apparent “second health miracle,” still lowering IMR and rising LEB thanks to “top political will maximizing health with minimum costs.” Hidden behind these claims were decades of political violence by an oversize government on freedoms, health, education, income per capita, and other living levels of Cubans, justifying most failures by U.S. aggressions and blockades.
What are Cuba’s reported health achievements? Many outsiders think that they are “high degree of equity in access to good health care and better health status through a commitment by the state to public health through a top cost-effective system, with continuous evaluation and community participation.” The views of many respectable foreign scholars are based on censored and biased reports about Cuba’s alleged “healthy, educated, equally poor, stable, and resilient society.”
There has been much research about the contribution of improved living standards on health and vice versa by health income, but relatively little on the effect of long-term worsened living standards on health. The impact of Cuba’s half-century of totalitarian- socialist very slow development on health care and health status has not been studied yet.8 The aims of this study are: to examine the relationships between Cuba’s access to integral health, freedoms, other living standards, development systems, and health achievements in 1902–58 and 1959–2010; to identify the political will to prosper and violence to redistribute integral health, freedoms, and other living standards; to calculate measures of freedom for both periods, reformulate, and calculate a freedomadjusted HDI for four nations; to compare the HDI and its dimensions of democratic and totalitarian Cuba with those of colonial Korea and democratic South Korea.
FACTS, DATA AND METHODS
The author lived firsthand the changing facts of access to health, education, freedoms and other living standards as a citizen, patient, and physician in Cuba in 1945–2010. He experienced health exchanges assistance offered from abroad—(COMECON) Moscow 1982, 84; (WHO) Geneva, Bangkok 1999– 2001; and other cities’ institutions 1996–99. He served as a consultant in Managua 1988–90, accessing the UN, WHO, and Harvard University libraries. In 2000–10, he conducted anthropological and epidemiological research on Cuba’s health policies, systems and outcomes, complementing them with available statistics for 1492–1958 and 1959–2010. Censored University of Havana, Cuban Academy of Sciences, and UN libraries were also consulted, as well as world databases despite the difficult access to the Internet, and some results were published.9 The author maintained private exchanges of information with hundreds of health, science, and education officials in Cuba as well as with hundreds of U.S. and other foreign professionals visiting or analyzing Cuba. In 2010–12, the data was verified with unlimited and uncensored access to the Internet and the UM Richter and Calder Libraries.10
The study rests on six basic concepts: (1) education and (2) health defined by UNESCO and WHO, 1945, 1946; (3) human rights-freedoms defined in the U.N. universal declaration, and covenant on economic, social and cultural rights, 1948, 1960; (4) UN definitions and measures of 13 standards of wellbeing, 1954, 1961; and UNDP definitions of (5) human development and of (6) HDI 1987–2011.11 Cuba’s population access to health and other living standards’ variables were included in the study with an approach to observe the degree of their balance with the results of Cuba’s systems focused on selfsustainable growth or on foreign military-ideological goals. They allowed assess results on physical, mental and social ability, wellbeing and health changing levels over the years in a framework of facts with trend analyses and predictions, to understand how diverse development models have worked. Due to lack of data, public equity, inequity, and secret inequity of access to health and other living levels were qualitativequantitatively estimated, within and among the main population social groups in Cuba in 1902–58 and 1959–2010 with nominal-ordinal scales. Each rightfreedom was evaluated according to violation or not with a dichotomous scale (1,0). This was done collecting and analyzing the perceptions of facts in both periods of Cuban officials and foreign observers; of the author and wife personally; and of several Cuban independent on-the-ground sources through books, papers, and online reports about the freedoms and living levels defined.12 The HDI used in 1987–2009 was reformulated integrating in it proportionally a fourth human development core dimension: mean percent of real access to rights-freedoms. Freedom adjusted HDI estimates were calculated and their variations contrasted with crude HDI estimates for Cuba, China, South Korea and UK in 2007, using homogenous national estimates of mean individual freedoms for 2006. Weighted HDIs by LEB, adult literacy percent, and GDP-p for Cuba in 1800, 1900, 1957; and Korea in 1900, 1957 were estimated with the simplest formula UNDP used in 1987– 90.13 Influence of depressed living wellbeing levels in the quantity, duration, and quality of health and life development in Cuba is discussed, as well as the not full yet association between WHO health statistics and definition.14
The Health Paradox Begun in Democracy Was Accentuated in Totalitarianism
Table 1 shows how democratic Cuba (1902–57) had reached excellent ranking worldwide in mortality reduction: 14th-17th and 25th place in low IMR and maternal mortality ratio (MMR), and 32nd in high LEB. Totalitarianism (1959–2007) worsened Cuba’s performance, rising to 34th place in IMR and 68th in MMR, and to 43rd in LEB. It also stagnated in 36th place with respect to low birth-rate, reached the 4th place in high abortion ratio and an unknown (but very high) place in women sterilization-ratio (both compulsory); Cuba ranked in 170th place, driving down a top MMR/IMR dimensionless ratio from 3.5 to 10.
In 1902–57, Cuba occupied 5th place in the Americas and 26th place worldwide regarding physician density per population; 3rd and 16th places regarding dentists; 3rd and 14th places regarding midwives; 5th and 26th regarding pharmacists; and 6th regarding nurses and 3rd regarding hospital beds (public plus private) in the Americas, all devoted to serving the health needs of Cubans. Cuba reached one of the world’s top places regarding physician density per population (2003– present) and also of troops (1962, 1990)—a high percentage rented to perform humanitarian-ideological, and mercenary slave work abroad. Cuba’s GDPp doubled in 1902–57, reaching the 31st-44th places worldwide, while in 1959–2007 it worsened to the 97th-110th places, despite heavy subsidies and failure to pay a large external debt since 1986. Estimated violations of freedoms-rights in 1902–1952 fell from 75% to 13%, with 10 freely-elected presidents. In 1959–2007, violations increased to 90% under a leftwing dictatorship. One of Cuba’s democratic governments (1948–1952) was a promoter and signatory of the UN declaration on universal human rights, while the left-wing dictatorship (1959–2012) did not sign the UN human rights covenants of 1976 until 2008.
Since 1990, whereas the IMR and LEB continued very slow improvement, Cuba re-suffered at the physical health level: epidemic optic and peripheral neuritis (not seen since Weyler’s “Reconcentration” during of the Independence War in 1898); epidemic dengue fever (not seen since the 1950s; it returned hemorrhagic in 1977 and it seemed eradicated in 1981); epidemic hemorrhagic conjunctivitis (considered eradicated in the 1970s); and quarantinable cholera outbreaks in 2012 (not seen since 1882). Cuba has also suffered an increase in morbidity of tuberculosis, syphilis, viral hepatitis, leptospirosis, and other infectious and parasitic diseases. In addition, at the psychosocial health level, Cuba has suffered other types of epidemics: hopelessness, despair, definitive emigration by sea, often at the risk of life, and temporal emigration for purportedly humanitarian missions, but really ideological and mercenary in other nations, though these epidemics have been endemic in Cuba since 1959.
Table 1. Demographic, Health, and Socioeconomic Indices, and World Rankings, Cuba 1800–2007
Redistribution of Access to Fragmented Health, Freedoms and Other Living Standards
Table 2 shows high and gradual improvements in distribution of access to health and other living levels achieved in 1902–58 for each Cuban population stratum: poor (~66%), middle (~33%), and affluent (~1%). There was a narrowing of differences between strata at both ends, with a growing middle stratum. In 1760, all world nations had a high degree of inequity: ~1% affluent and ~99% extremely poor, with high equity at the bottom. In Cuba, the poor included African slaves, who were freed during 1868–80, Caribbean and Latin American immigrants, and creoles. In 1902–58, the size of Cuba’s extreme poverty layer fell, with many moving to moderate and borderline- levels of poverty as a result of increasing employment and living levels. At the same time, there was also positive movement within the middle stratum from the low to the high layer, which encompassed high-wage workers and those who owned small-medium businesses. The affluent stratum composed of European immigrants and selected creoles was newly populated by entrepreneurs and individuals associated with the top businesses.
Cuba’s poor workers gradually gained access to increasing quantity, duration, and quality of integral health—measured indirectly by demographic, morbidity—through growing access to health care and other indexes, with the latest U.S. vaccines, sanitation and therapeutic means increasingly available to them. Prospering through social mobility was the main determinant of the growing access to resources, which encouraged higher productivity and sustainable development. This system resulted in better living standards and little emigration. Rights violations declined from about 75% in the colony to 13% in democratic Cuba.
Table 2. Estimated Trends of Access To Living Levels Within and Among Social Strata According to a Democratic, Multi-Party, and Private-Public Property System, Cuba 1902–1958
Table 2. Estimated Trends of Access To Living Levels Within and Among Social Strata According to a Democratic, Multi-Party, and Private-Public Property System, Cuba 1902–1958 (continued)
Table 3 shows the sharp redistribution in 1959 of access to integral health and other living standards achieved in democracy for the two Cuban population strata that were prevalent after the revolution: mass (~99%) and leaders (~1%). The previous powerful middle and affluent strata had their freedoms and properties limited and were essentially eliminated and agglutinated with the poor, in a very large and amorphous mass of poorer people. This mass has suffered a half-century of deprivation and of declines of previous living levels they had achieved. Meanwhile the newest affluent totalitarian socialist leaders enjoy high and rising living levels. The social mobility mechanism changed from contributing to Cuba’s integral progress to absolute loyalty to a leader in power, unethically justifying depressing living levels with actions against the regime by the United States.
Table 3. Estimated Trends of Access to Living Levels within and Between Narrow Spectrum Social Strata According to a Totalitarian, Unique-Party and Public-Property System, Cuba 1959–2010
Table 3. Estimated Trends of Access to Living Levels within and Between Narrow Spectrum Social Strata According to a Totalitarian, Unique-Party and Public-Property System, Cuba 1959–2010 (continued)
The captive mass gained universal access to a physician—trained in large numbers, with very scarce scientific exchanges abroad—poorly equipped, using WHO vaccines, old and scarce means, due to the elite’s diversion of funds for other purposes. In 1959 Cuban patients lost access to the latest clinical tests, drugs and procedures, except for some women when pregnant and some newborns and infants. In spite of an exclusive 21–month intensive care formula for pregnancies and newborns, the improvement of the IMR, MMR, LEB and LEE indexes has slowed down at the same time that there has been stagnation and rise of elder and adult mortality rates (EAMR), especially in men, whose care is very poor after four years old. The mass has suffered from increased rationing of food and other basic needs: sub-nutrition camouflaged with excess of sugarcane, declining husked rice, and scarce proteins; misinforming and below-par education; overcrowding in unfurnished, run-down housing, endless blackouts and lack of running water; generalized under employment, with a US$0.50 mean daily-wage, unpaid forced overtime; poverty-level pensions of US$0.10 per day; low-quality, secondhand clothes; primitive recreation activities—smoking and drinking rum in streets; young workers emigrating to wherever there is an opportunity to go; expropriation of bank accounts and reduction in the value of the Cuban peso since 1961 from US$1 dollar to US$0.05; misinforming and censored media; cell phones were banned until 2009 (they are extremely costly) and access to the Internet is still banned; scarce and unscheduled subhuman transportation; and state regulated suppression of 90% of human freedoms, particularly political, economic and civil rights. Meanwhile Cuba’s leaders, and their families, have unlimited access to the best clinics, specialists, the latest tests, drugs and procedures, even covertly performed in top U.S. hospitals. They secretly enjoy all the living comforts of the world’s richest people in the “supposed paradise of social justice and equity,” avoiding the eyes and ears of the deprived mass, and buying the silence of Cuban officials and journalists. They secretly recreate luxuriously in isolated keys (banned to the masses) of Cuba’s archipelago and in valuable properties bought abroad. The Gini coefficients underestimate Cuba’s secret income inequality, which could be over 0.95. The leaders enjoy ~157 rights-freedoms at 100%: openly ~15 that are also allowed to the masses plus another ~142 to which the masses have no access.
Differences between Original HDI and Freedom- Adjusted HDI in Four Countries
In Box 1, the UNDP HDI is reformulated as a multi-dimensional (tetra-dimensional) measure, adjusting the original HDI to incorporate a measure of freedom. In addition to calculating a freedom-adjusted HDI for Cuba, the same has been done for China, South Korea and the United Kingdom. For Cuba, freedom-adjusted HDI showed a reduction of 24% from the original HDI value (0.863 to 0.653), worsening Cuba’s ranking from 51st place to 131st place, while China showed a reduction of 22% of the HDI, worsening from 92nd to 136th place; South Korea showed a very small reduction of 0.4%, worsening two places; and the UK showed a small increase of 1.4%, improving from 21st to the 12nd position.
Cuba’s Fragmented Underdevelopment and South Korea’s Comprehensive Development
Table 4 shows that Cuba’s LEB in 1900 doubled to 64 years by 1957, 11 more than South Korea; yet in 2007, it was 78 years, one less than South Korea’s. Cuba’s literacy rate in 1900 was almost doubled to 79% in 1957, about the 5th highest in the developing world, twice South Korea’s; yet in 2007, both were 99%. Cuba’s GDP-p in 1900 was doubled to $2,406 in 1957, twice South Korea’s $1,206; yet in 2007, Cuba’s $3,764 was one-fifth of South Korea’s $19,614.
Cuba’s development in 1902–57 with a U.S.-style system doubled its original HDI to 3rd place in the Third World after Argentina and Uruguay. With a Soviet-style system, in 2007 Cuba had 131% of its 1957 HDI, worsening from about 32nd place to 89th in 1994 and to 51st since the late 1990s. Korea’s doubled its HDI from 1900 to 1957, to a level only 67% of Cuba’s. In 1945 Korea was divided; the South adopted a U.S.-based development model and in 2007 its HDI was twice the level in 1957, reaching 12th place in the world in 2010. North Korea–which adopted the Soviet model—has been developing nuclear arms but meanwhile its HDI fell to the bottom, with famines in 1991–97.15
Universal Access to Fragmented and Distorted Health in Captivity, Hunger and Misery
The 1990–2011 HDI reports showed high non-income development for Cuba combined with low and slow growing income. This behavior deserves a comprehensive analysis to understand in depth what has really happened in Cuba. Censored and misinforming official reports and media communication on “health and education achievements” conceal the disintegrated nature of Cuba’s health and education contrary to the WHO and UNESCO definitions, which assume the countries are living in freedom. This is a main cause of most biased healthcare studies of Cuba. While there are some challenges related to the accuracy of the GDP-p’s, the challenges in measuring Cuba’s health and education dimensions are even higher. It is one thing to have universal access to a physician and a teacher in an environment of captivity, poverty, and oppression of most rights and suppression of living levels; and another is to have access to universal coverage of comprehensive healthcare with world standard tests, medicines, and procedures, and to a comprehensive education with world standard information and communication. Unfortunately, the HDI does not capture the fragmented and distorted health and education. Improving the sensitivity of the HDI is the main reason to adjust the HDI for freedoms.
Box 1. Original and Freedom-Adjusted Human Development Index, 2007
McGuire and Frankel in 2004 described integral health achievements in pre-revolutionary Cuba obtained in spite of slow growth rates of GDP-p. They described a healthcare system, institutions and living conditions favoring integral health even when universal access to a physician was not yet achieved in distant rural areas. However, it had universal access to midwives trained in aseptic practices. These authors showed how the revolution, starting from a privileged baseline in health levels, slowed previously improving trends in IMR and LEB, but much more the MMR and EAMR. They noted that the comparatively minor advances during the revolution were in spite of what they interpreted as greater “political will” on a state-run healthcare than on the pre-revolutionary private-mutual-state healthcare. But Mc- Guire and Frankel, as outsiders who never lived in revolutionary Cuba and did not experience the inferior status granted to citizens, were unable to understand that the main force acting was “political violence” instead of will. The revolution suppressed most rights that had been observed until the 1952 Fulgencio Batista coup, and depressed living standards (that had been growing even under the previous autocratic regime during until 1952–58), to levels below those humanly permissible.
Table 4. Original and Selected Freedom-Adjusted HDIs for Cuba and South Korea, 1900, 1957 and 2007
Since the 1960s, misinterpretations of the lessons of Cuba’s “political will” have proliferated, marked by the participation in healthcare of Soviet-style community paramilitary organizations and the popular power of the communist party, whose first goal is to spy and oppress the masses. Biased statistical contrasts of Cuba with the Philippines and other nations have been frequent. These studies have focused on physical survival indices of infants and pregnant women, ignoring Cuba’s privileged health baseline in 1958 to measure improvement after the revolution. Most of these studies have been blind to the fragmented healthcare policies, inequality in access to integral health, freedoms and living standards, and to the collateral damage due to abandonment of older children, elder and adult mental and social health. A constant has been to blame U.S. policies and the trade embargo for all revolutionary failures, overstating their impact and justifying suppression of freedoms and living levels. These evaluations, supported by 53 years of anti-American propaganda, have obscured a fact: that Cuba’s underdevelopment has been caused by the archaic and oppressive Soviet system.
Political Violence and Non-Income Human Development in Cuba’s Totalitarian-Socialism
Klugman et al make the point that the UNDP HDI challenges economic growth-centric thinking. It balances income and non-income dimensions of wellbeing as the objective of development policies. But they point out: “Human development is a process of enlarging people’s choices. In principle, the choices can be infinite and change over time. But at all levels of development the three essential ones are for people to lead a long and healthy life, to acquire knowledge and have access to resources needed for a decent standard of life. If these essential choices are not available, many other opportunities remain inaccessible.”
A challenge faced by the UNDP is the lack of complete operationalization of the WHO health and UNESCO education definitions to allow the HDI to integrate long and integral healthy, educated and creative life in freedom, with progress of decent income and living levels. The UNDP does not recommend that nations try to maximize the HDI. But the Cuban Health Ministry in 2007 expressed as a directive the priority to guarantee a LEB of 80 years very soon. This was critical since the revolution faced the structural impossibility of developing decent living levels and GDP-p growth rates based on the Soviet experience.
In 1957–70 Cuba suffered a civil war, massive executions, famine and impoverishment due to the confiscation by the government of all lands, industries, businesses, and other properties coupled with other wrong-headed policies. These worsened IMR, LEB, MMR, EAMR, and LEE. In 1960, Cuba launched rural medical services and a compulsory literacy campaign. In 1968 it started a campaign to stop the rising IMR and falling LEB—both also targets of the U.S.-promoted Alliance for Progress. To this day, these indices for 1956–69 are absent in Cuba’s health statistics reports. Over the period 1959–2010 Cuba suffered a setback in living standards greater than suffered by Myanmar, due to Cuba’s higher baseline reached until 1958. Cuba has regressed—by constant political violence—from a succeeding civilization to worse than outdated slavery.
Comparing trends of Cuba and Korea’s HDI measures it can be seen how Cuba’s underdevelopment resembles North Korea’s, also with an anachronistic Soviet-style system; meanwhile South Korea, starting from a lower baseline than Cuba in the 1950s, integrally developed under a U.S.-style development model. Cuba, allied with North Korea, fell to the third worst world place regarding rights and freedoms. If Cuba had freezing winters as does North Korea, it would have had in 1992–94 about a halfmillion deaths by a political inflicted famine. Cuba’s HDI is reduced by a quarter when it is adjusted for freedom, falling from 51st place to 131st place; meanwhile, South Korea’s HDI is reduced by 0.4% of HDI worsening from the 26th to the 28th place. South Korea’s rights have greatly improved from non-free to moderately free, though the UNDP deemed it to be a democracy with 40% of violations.
The differences between South Korea and Cuba with respect to all of the freedom indexes are vast, with Cuba ranking in one of the world’s last places in these dimensions. The UNDP reported that Cuba had only 60% of rights violations, instead of the 90% estimated here and even higher in other studies, apart from the violations of freedom promoted abroad exporting its oppressive ideology. The UNDP did not classify North Korea, but given its abysmal performance in freedoms (a score near to 0), its freedom- adjusted HDI would be 30% lower than whatever its HDI would be. The UNDP has focused its attention on Gini-style coefficients of income inequality and of other issues but has not considered freedoms. On the basis of studies by this author, if Cuba had not diverged from the democratic path it was following until 1952, it could have developed faster in integral health, education, and maybe in GDP-p, even than South Korea, Hong Kong and Singapore due its close relations with the U.S.
Interrelationships Between Health, Freedoms and All Other Living Standards
Physical health and demographic conditions, beyond the biomedical genetic and environmental view, and above all, the mental and social abilities, wellbeing and health levels, are strongly and directly interrelated with all other living standards, especially freedoms. Over the period 1959–2010, Cuba’s totalitarian- socialist government redistributed access to integral health and other living standards. It first worked violently to limit access to freedoms and then to comprehensive integral healthcare, education, income and other living standards from the relatively high average level reached by the middle class during the democratic period to a low level of a new huge poorer class, all in the name of social equity.
The right to an integral health standard cannot be fragmented and disconnected by political violence from other rights and living standards. All of them are positive or negative social determinants of human abilities, wellbeing and health progress or regression. Our results challenge the biomedical growth-centric thinking in public health and support a bio-economic- psychosocial model to better measure non-physical health dimensions. More research to operationalize health in a broader set of indicators to measure integrally its tri-dimensionality, especially the non-physical health ones, is needed. The amazing work done by the UNDP measuring human non-income development is the best example of what the WHO could begin to do.
In any society, high living levels are positive factors for progress of the health of individuals, families and communities. Low national living levels mean development delay. Increasing them can make a nation develop; the British in 50 years developed New Zealand and Australia and turned them into modern societies. In some instances, a country’s living standards instead of progressing and benefitting the population may be depressed by a retrograde system that relies on foreign subsidies. This is the case of Cuba. Cuba evolved over 60 years applying the successful Western model, but involuted with the Soviet one, taking advantage from Soviet and more recently from Venezuelan subsidies. Discouraging and weakening the action mechanisms of positive living level factors, converts them into negative risk factors, with depressing effects on previously achieved modern integral living and health levels.
This unexplored setback of Cuba’s rights and living levels has partially maintained physical health. Revolutionary Cuba has accentuated the first paradox begun in the republic, slowing improvements in IMR and LEB and GDP-p growth through selective policies. But it also has created a second paradox due to setback also of healthcare (hospitals, clinics, labs, etc) and public health infrastructure (water, sewage, sanitation services, etc.) and average health personnel preparation, allowing the return of physical health epidemics such as cholera even while maintaining progress in bio-pharmaceutical research and industries, and the emergence of psychosocial health epidemics (seen before in the Soviet Union, Germany, Italy and Japan).
The main cause of the psychosocial health epidemic is the constant class war. It has generated a spectrum of undiagnosed problems of the human cognitive, motivational and behavioral areas. These have lowered the integral health quantity—not measured yet—and the duration of periods of integral health, and have fragmented and distorted health quality. The problems range from mild to severe acquired and chronic mental and social health stagnation, regression, retardation, alienation, suffering and inability of adults and children to discern between fiction and reality, good and evil, to choose and act rationally. It has attempted to exterminate personal critical thinking, initiative, objective decision-making and action. It causes paranoid and fanatical hate for advanced nations’ libertarian and prosperity symbols, ideas, institutions, and successful people, with thoughtless and automatic behavior, bordering on socially induced psychosis. The WHO’s International Classification of Diseases (ICD) ICD has not included these disorders yet. Oppression of the poorest masses, chaotically surviving in fear, disintegrates human health, blocks contention, induces tolerance to inequities and acceptance of self-banishment, either definitive to any nation or temporal collaborating in other nations. Cuba’s people have been erroneously considered of “high social resiliency and stability,” by observers who have had no access to this unreported tragic health situation.
Cuba, instead of developing a holistic scientific medicine, has turned back from scientific medicine to pre-scientific holistic medicine. This cannot prevent or treat many health problems of a social or mental nature, and even physical ones, created by high psychosocial tension and stress, due to the massive regression to a pre-modern social rhythm in a nation with blocked channels for effective progress. This unnecessary sacrifice of the quality of health and life of millions of people has been caused by an anachronistic dictatorship seeking to maintain power in the face of a Soviet system that does not work. The 20th century demonstrated that even before food and shelter, human beings need open, full and free flow of information and communication to be able to achieve the satisfaction of their needs.
Finally, the measurement of health could evolve toward a more health-centered and balanced system complementing the disease-centered one, transforming healthcare. Since the 17th century, population health has been monitored indirectly in relation with years of life and negative health indices, such as crude and adjusted demographic and morbidity-related indexes of acute and chronic infectious and non-infectious diseases.16 It seems that a great devotion to vital statistics and nosologies from John Graunt to William Cullen has stagnated the health classifications and indexes. In this third era of health of Lester Breslow,17 the health of patients and nations could be estimated numerically (scale 0–100) solving Paul Backer’s patient’s health equation, balancing positive health resources with strains.18 An integral health quantity could be a complement to estimations of duration of healthy periods and health quality. A new set of health status indexes could be correlated with estimations of quality of care, time and costs, to increase the efficiency of the healthcare systems.
The evidence discussed in this paper supports the hypothesis that Cuba’s 1959–2010 fragmented, distorted and slow-changing health and education achievements are residual effects of high revolutionary violence exerted on levels of integral living standards and professional development achieved by pre-revolutionary Cuba. Rights to health and education for all were disconnected by political violence from other rights and decent living levels that were suppressed. Cuba’s oppressed, captive and impoverished masses have suffered—unlike their oppressors and wealthy leaders—a quasi-universal regression of living levels, greatest with regard to freedoms and income, but also significant with regard to integral health and education.
In 1967–95 Cuba achieved universal access to healthcare and education, through physicians and teachers working with scarce resources and information, along with miserable food, housing, transport, and living standards. Leaders’ extreme political violence regarding most freedoms and living standards has led to psychosocial regression in Cuba, producing a chronic syndrome of terrified and quasi-psychotic masses, unable to detect the truth in official speeches and writings and to effectively rebel against oppression. While Cuba shifted from democraticcapitalism to totalitarian-socialism and in so doing fragmented its development, South Korea and other nations below Cuba’s HDI baseline in 1958 adopted democratic-capitalism and launched fast, sustained, and integral development. The biomedical-centric model in healthcare is challenged by a bio-economic psychosocial model. Efforts could be made to improve the measure of integral health quantity, duration and quality of patients and nations.
1. The author acknowledges the encouragement of Jorge L. Romeu, Richard A. Dickey, Thomas E. Norris, Kent Bream, Sherri Porcelain, Rachel Libby, Westley Phillips of the Universities of Wake Forest, Washington-Seattle, Pennsylvania, and Miami, as well as of María C. Werlau, Jorge Pérez-López and René Costales of ASCE.
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