A Historical Account & Universal Legacy

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The teaching of medicine in Cuba began after almost two centuries of Spanish colonial rule, at the beginning of eighteenth century. References to medical activities during the previous centuries mention "barbers and surgeons" and "phlebotomists and bleeders" and Havana's first "doctor and druggist, Bachelor Gamarra, a graduate of Alcalá de Henares (1569), whose main practice consisted of bleeding. Such dearth of medical services continued until the eighteenth century, and even into the twentieth century in the most isolated and rural zones of the country.

A chronic shortage of doctors facilitated the proliferation of healers of all types, quacks that sold all kinds of potions, sometimes accompanied by uncertain "massages and strokes" and other supposedly healing formulas. Some of these remedies came from Spain, others incorporated African and Indocuban ways, and others were simply medical folly. From this empirical practice of medicine, "esoteric spells," "vague prescriptions" and soothing personal contacts" came into being and were passed down as the way to fight disease with the aid of magical devices and the consumption of herbs, some of which, in effect, had curative properties. Thus was the care provided to people who did not know any better, many of whom were left to die, undernourished and full of parasites.

An eighteenth century prescription (with possible Spanish influence) for the cure of jaundice recommended: Taking an ounce of rhubarb, half an ounce of cremor tartar and a half an ounce of Castile soap, Mixing it all with honey to make a jam that should be taken twice a day, a tablespoonful in the morning and another one at bedtime. Instead of water, the patient should drink chicory tea while the jam lasts.

Some formulas, perhaps with native influence, included animals like scorpions, cockroaches and frogs, e.g., for the "absorption of tumors": "Rub frog ointment and drink saline laxative."

Emilio Roig de Leuchsenring, a former Historian of the City of Havana, wrote around 1930: Physician and pharmacy are almost always several leagues away from where the guajiros (country folks) live, and for that reason, and for their poverty, the guajiros only go to the doctor in cases of extreme illness, when the country medical services themselves are bound to be ineffective.... Such absence of medical and sanitary services, unavoidably bring about the presence of healers.

That appalling medical homelessness began to change in the first decades of the eighteenth century, very slowly at that, thanks to medical training and other measures taken by the Spanish colonial government. According to an official document from the Havana town meeting, Don Francisco del Alamo y Martínez de Figueroa was authorized to offer medical classes in 1726. The real transformation began with the establishment of two important institutions: the Royal Court of the Protomedicato (1711) and the Royal and Pontifical University of San Gerónimo of Havana (1728). The University of San Gerónimo was run by the Dominicans and included a medical school.

The Protomedicato was a medical board whose functions included acting as medical examiners, regulating and defending the profession, while fighting all sorts of illegalities. It was founded in Spain by the Laws of Toro of 1371, and reorganized by the Catholic monarchs Isabel and Fernando. With its roots in medieval times, the Protomedicato had to govern all sanitary aspects of the kingdom, establishing and verifying by examination, the competency of a whole gamut of people who practiced medicine, from medical surgeons with university degrees to the so-called ministrants: learned surgeons (called Latin surgeons because they were university graduates who knew Latin) and practitioner surgeons (called romancistas surgeons because they only knew Romance languages, barbers, dentists, bleeders (phlebotomists) and midwives, among others, considered ministrants because of their being limited to practical knowledge. The druggists or pharmacists also required the authorization of the Protomedicato, which inspected their establishments, with the power to eliminate those medicines or potions considered harmful or unauthorized. The pioneering Protomedico in Havana was Francisco de Tenaza, who is credited with producing the first printed materials in Cuba: Tarifa general de precios de medicina (General Tariff of Medicine Prices).

The Protomedicato lasted in Cuba until 1834, when it was replaced by the Juntas Superiores Gubernativas de Medicina y Cirugía y de Farmacia that were soon also replaced, in 1842, when the first curricular plans for the islands of Cuba and Puerto Rico were put into effect.

As regards university studies in medicine and surgery, serious problems were faced during the 1700s, such as lack of professional proficiency and inadequate laboratories and hospitals. The initial curriculum included Physiology (Prime), Pathology (Vespers), Anatomy and Methodus medendi (Therapeutikes methodou). Even as late as 1805 the necessity to offer anatomy in the curriculum was being expressed. The medicine degree offered in Cuba under Dominican administration suffered, like education in general, from the narrow limits of Aristotelian scholasticism that the Order of Friar Preachers (O.P., Ordo Predicatorum), by agreement of Spanish Corona, dogmatically imposed. In Philosophy they prioritized the "eternal truths" of Aristotle and of St. Thomas Aquinas, Justinian in Law, and Galen, Hippocrates and Avicena in Medicine. Instruction was given in Latin, lasting throughout the nineteenth century, in spite of its substitution by Castilian Spanish in 1842.

At the time of the Enlightenment in France, the English "Industrial Revolution" and the Continental Congress in Philadelphia in North America, the most archaic and numbing methods and educational materials prevailed at the University of Havana. University admission was limited to children of "old Christians," those without a drop of "bad race" due to Jewish, Moorish or black ancestry. Students also had to be descendants of legitimate marriages for three generations. During the eighteen century at San Gerónimo University no classes were offered in Mathematics, experimental Physics or Natural Sciences.
 

The creation in Santiago of Cuba and Havana of the Sociedad Económica de Amigos del País ("Society of Friends"), composed of Cuban intellectuals and professionals interested in the economic and social development of the country, truly marks the beginning of a process of over-coming, as far as possible, backwardness in the classrooms and the total sanitary abandonment of the people.

It is in this context that we find the first great figure in the history of medicine in Cuba: Dr. Tomás Romay, "friend of the country," who, during the first decades of the nineteenth century, enjoyed the powerful support of the Bishop of Havana, an energetic and progressive Basque named Juan José Díaz de Espada y Fernández de Landa. Dr. Romay taught Aristotle and Medicine at the Protomedicato, the Bishopric and other institutions. He was also a journalist and a researcher of one of the first works in Cuba on yellow fever. He promoted, in collaboration with the bishop, the substitution of churches as places for burials with other burial grounds specially designed for this purpose. He earned his greatest glory for being named as director of a national smallpox vaccination campaign by the "Society of Friends" and Bishop Espada. He began by vaccinating his own family, in 1804. Romay is considered the founder of Cuban Medicine.

Significant signs that a new period was indeed beginning, without necessarily surmounting the many limitations in medical studies practice in Cuba, was the growth of student enrollment at the Medical School. The number of students graduating in Medicine grew steadily from 8% of the graduating class between 1728-1768, to 14% in the years 1768-1842. Other important events were the publication in 1797 of the first treatise of surgery, written by the Cuban Dr. Francisco Javier of Cordova, and the 1798 publication by Dr. Domingo Barrier Domingo of his Historico-Physical-Natural-Medico-Surgical Reflections, a book dedicated to the description of the life, customs and diseases of the blacks brought from Africa to the Americas. 

These achievements answered the call to urgent needs: sanitary needs by prohibiting burials in churches; anti-epidemic needs with the massive introduction of the Jenner vaccine and a concern about the ravages caused by endemic yellow fever; and socioeconomic needs with the study of the diseases of the black slaves brought from Africa.

In the initial four decades of the nineteenth century, enrollment at the Medical School reached an annual average of 16% of total student enrollment between 1800-1815, and an average of 23% between 1831-1842. Medicine became, after Civil Law, the preferred career at San Gerónimo, although we must recognize that the main progress was achieved at the Protomedicato and subsequently with the Juntas Gubernativas de Medicina y Cirugía y Farmacia. Those results paralleled the loss of social relevance of the Church and its dominant scholastic ideology. Before, in 1795, for example, out of 400 doctorates, 144 were in Theology, 110 in Philosophy and 70 in Canonical Law. That is, 81% of the degrees were in disciplines linked to the Church.

Also during these decades, liberal and cultured intellectuals, who belonged to the above-mentioned "Society of Friends," were nurtured and strengthened. Some of them were protomedics (Latin surgeons) and medical doctors, interested in the knowledge and the application in Cuba of the advances in medicine that were being achieved in Europe and the United States. From France, indirectly at the beginning and Later directly experienced by Cuban students in French medical schools, Cuba received, throughout the nineteenth century and during an important part of the twentieth century, the basic scientific foundation for the development of medical social practice. This French influence began with an important number of French doctors that came to Cuba from Haiti and Louisiana, or out of the ranks of the defeated armies that Napoleon Bonaparte sent to America, persisting in eliminating revolution in its rich colony of Saint-Domingue (present-day Haiti). Those doctors validated their degrees by examination before the Protomedicato and many of them even opted for Spanish citizenship and residence in Cuba. Among them we find one of Bonaparte's former physicians, Dr. Antomarchi, and Enrique Faber, a young romancista surgeon, who brought much scandal, and even came to the attention of Bishop Espada, when it turned out that "he" was a female. Enriqueta Faber became, in spite of the official regulations that barred it, the first woman physician in Cuba.
 

But foreign participation in Cuban medicine was not limited to the French. Spaniards and other Europeans and Americans, including English, Irish or North American Catholics, pioneered among themselves and Cuban doctors, a fruitful interchange of knowledge and experiences.

Clear examples of this favorable change, that did not include the University during these decades and received limited official support, were the creation by the Protomedicato of faculty chairs in practical Anatomy (with corpses) in 1820, in Physiology in 1821 and Surgery in 1824. Anatomy, Operations and Obstetrics courses were offered and, with the support of Bishop Espada, a class for midwives was approved at the Paula Women Hospital. For the latter, a Primer was prepared and published to facilitate instruction. In 1839, Dr. Nicolás J. Gutiérrez, who followed in the footsteps of Dr. Romay's exemplary work, established courses on "major surgical operations" and on clinical surgery, the first such courses in Cuba. In addition, in collaboration with Dr. Antonio Zambrana, between 1840 and 1843 Gutiérrez published Repertorio Medico, the first medical journal in Cuba. Also in 1839, courses on Hygiene, Epidemiology and Forensic Medicine were incorporated into the curriculum.

Along with these advances in Medicine, Pharmacy lost its medieval character during these years until it was also integrated at the University by the plan of 1842. Chemistry and Botany, with laboratory components, were also included until they became required subjects for Medical and Pharmaceutical studies. The primary interests for developing Chemical and Botanical studies were economic: to improve sugar production and agriculture. In 1838, under the administration of the Juntas Gubernativas de Medicina y de Farmacia, and with the help of the Junta de Fomento and the Sociedad Económica, courses of General Chemistry (under the direction of the Spanish scholar José Luis Casaseca) and Botany (under the direction of a French professor named Pedro Alejandro Auber) were offered. Both of these subjects joined the regular university curriculum in 1842. This integration of knowledge responded to Dr. Romay's proposal "to create integral doctors,” with a multidisciplinary approach, including such subjects as Medical Hydrology, that took advantage of the wealth of medicinal waters in Cuba.

Medicine in Cuba, and a few other sciences, was modernizing, and to the above names we should add other notable figures for their professionalism as well as their generous altruism: doctors such as Angel José Cowley, a therapist, Fernando González del Valle, a surgeon who became the president of the Royal University and Agustín Encinoso y Abreu, a pathologist. But the majority of the population of the country did not benefit from these achievements. For instance, the slaves in the plantations, in the fields and sugar mills, according to Domingo of Monte, had an annual average mortality of 8% in the 1830s. This meant the complete substitution of their population approximately every 10 years. Similar was the case for "free" peoples, black and white, devoid of resources to pay for private medical attention, or to gain access to the limited services available, mainly in the capital of Havana. Havana was known as the "Sewer of sailors" for the high number of them who died due to ignorance and lack of health, a situation that led to the establishment of the first private clinic of Cuba in the nearby town of Regla. It was mainly for foreigners, and included a cemetery as an annex.

The main cause of death was yellow fever, but the population as a whole suffered from many ailments: high fevers from various causes, tuberculosis, human rabies, tetanus (including newborns), leprosy, dysentery and cholera (from 1833). The situation was worsened by the terrible sanitary conditions and total abandonment in the few and rundown hospitals. They were full of dangers for those who were admitted, since they were centers for the contamination of diseases rather than their treatment or cure.
 

That was the situation of the country, and particularly in Havana, when the above-mentioned curriculum of 1842 for Cuba and Puerto Rico was put into effect. The 1842 Plan that transformed the Dominican University into the Royal University of Havana and commenced a new period in the history of Cuban medicine by eliminating Juntas Gubernativas, in order to unify these dispersed studies in a single center. The Plan was also part of a project by the Spanish government to gain a greater degree of centralization, with an accompanying increase in the persistent and cumbersome bureaucracy. In 1863 and 1880 other plans were promulgated and imposed, and reforms were put in place in 1871 and 1887. These changes were due to the crisis in colonial policy and internal events in Cuba. During this long period that lasted until 1898 when Spain lost the Island along with the rest of its diminished colonial empire, many dramatic and transcending acts took place: the end of slavery between 1880-1886 and two bloody wars for national liberation, between 1868-1878 and 1895-1898.

Meanwhile, the Medical School continued to grow, surpassing the Law School in student registrations. In the academic year 1864-1865, these programs enrolled 204 and 170 students respectively, with a faculty almost completely composed of Cuban liberals, whose teachings were described repeatedly by the colonial authorities as a "center of insurrection and subversion," anti-religious and antinational. That is why Spain tried to close the University, to force the students to seek higher education at Spanish universities, a goal that they did not achieve. These conditions led to an accelerated and increasing abandonment of the old Dominican convent, that continued serving as a university, and of the hospitals, as old and unsuitable as the Dominican University, a mere infected "deposit of patients." In 1888 it was reported that the Medical School at the Royal University of Havana did not have any "classrooms, neither laboratories, nor reading rooms, nor scientific equipment, not even water." And in 1894 its state was described as "frightful," a place lacking writing materials and a gas lighting system that had been condemned. Only at the new century, thanks to numerous bequests from private initiatives, Nuestra Señora de la Merced, a great hospital with spaces for the teaching of some practical subjects was established in the capital.

As in previous periods, but higher in number, the Cubans with sufficient means continued sending their children to study medicine abroad or to finish their studies in Cuba. Children with a Spanish father primarily selected Spain as the country for study abroad. They attended the universities of Madrid, of Seville (in Cadiz) and the highly preferred University of Barcelona. Cuban parents had a preference for French universities: Paris or Montpellier, and North American ones such as the Medical School at the University of New York, the Medical College of Pennsylvania in Philadelphia, or the College of Baltimore, among others. Medical knowledge gained from abroad continued to be fundamental to the progress of science in Cuba, for Cubans abroad contributed knowledge of the most recent discoveries, techniques, methods and bibliographies. Division and antagonism were also generated. During the last decades of nineteenth century, Chinese medicine was introduced, with lots of popular success for its efficacy by Chinese coming from Asia and the city of San Francisco, in the United States. Due to their ignorance, doctors in Cuba considered the professional practice of the Chinese doctors as backwards, mere quackery, and for this reason degrees attained in such studies could not be presented for certification at the Royal University.

Important institutions that fomented development, for introducing and analyzing the latest conquests of medical, pharmaceutical and natural sciences, were the Academy of Medical, Physical and Natural Sciences of Havana, established in 1861 after decades of requests for its creation by Cuban doctors led by the Dr. Nicolás José Gutiérrez, its first president, and by the Dr. Antonio Zambrana, the first secretary; and the Anthropological Society of the Island of Cuba, founded in 1878 according to the Madrid model, in the French scientific tradition of Paul Broca and Ernest Stomy. The Science Academy began to publish its Annals in 1864, under the direction of Dr. Antonio Mestre, another eminent Cuban doctor of the nineteenth century. The Anthropological Society was an expression of the humanist spirit that prevailed among Cuban scientists, with a vast membership, including physicians, anthropologists, natural scientists (chemists and physicists), philosophers and literati. The members of the Anthropological Society professed the positivist ideology headed by Herbert Spencer and Charles Darwin, with much social impact that extended into the first decades of the twentieth century. Institutions such as these organized events, made translations and published various specialized journals.

The university curriculum, in spite of insurmountable shortcomings within the framework of colonial subjection, was modified successively with the introduction of new specialties. As prescribed by the plan of 1863, the subjects were: Descriptive and General Anatomy; Private Hygiene; Clinical Obstetrics; Osteology Laboratory; Dissection and Surgical Pathology; Therapeutics; Prescriptions and Public Hygiene; Surgical Anatomy; Pathology and Medical Clinic; Obstetrics and special women and children Pathology; Forensic Medicine, Toxicology and History of Medicine and Physiology; Chemical Analysis applied to the Medical Sciences. The 1887 reform included Obstetrics and Gynecology in place of Obstetrics and Diseases of Women and Children, normal Histology and Histochemistry, Descriptive Anatomy, and courses in Dermatology, Ophthalmology, Otology and Neuropathy (and its mental effects). For Toxicology, the priority of the study of the Cuban medical flora was the work of doctors and botanists, and not pharmacists.
 

The social recognition attained by some Cuban doctors reached beyond national borders. Dr. Joaquín Albarrán Domínguez, a urologist established in Paris, was the creator of instruments and improved techniques for the treatment of the urinary tracts. Dr. Manuel Gonzalez Echevarría, who established his practice first in London and later in New York, was a specialist in madness and epilepsy. He took care of Pius IX, who suffered from epilepsy. Dr. Juan Guiteras Gener, clinician and pathologist, a graduate of the University of Pennsylvania, where he became a prominent professor and distinguished member of the staff at the Marine Service Hospital. Physicians now occupied the presidency at the University of Havana, beginning with Antonio Zambrana, between 1856-1861, and successively, from 1879 with Nicholas J. Gutiérrez, Fernando González del Valle, Joaquín F. Lastres and Leopoldo Berriel, the last president during the colonial Cuba and the first president in republican Cuba. This was the culmination of significant changes in academic administration: a substitution of the theologians by jurists, and jurists by physicians.

Two culminating events can serve to illustrate the situation of medicine in Cuba towards the end of the nineteenth century. The first one is political in nature: the execution on November 1871 of eight first-year medical students, unjustly accused of desecrating the tomb of the head of Spanish Volunteers Gonzalo de Castañón, who became symbol and flag of the divided Spanish in Cuba. About this crime, José Martí wrote: "There are hatreds like the one of 27 of November, that rise, drooling, from the belly of man." The second event was scientific in character: the discovery by Dr. Carlos J. Finlay, the highest glory in the history of Cuban medicine, of the Culex mosquito, or Aedes Aegypti, the transmitting agent of the mortal endemic that caused yellow fever, a fatal scourge as much for Cuba as for many other regions of the world. He also developed treatments for the control of yellow fever with extraordinary results, not only by saving hundreds of thousands of lives, but for making vast parts of the American continent habitable. The construction of the Panama Canal by the United States became feasible; earlier, France had to abandon the project because of the high cost in human lives caused by yellow fever.

The broadest application of Finlay's discovery took place in Cuba, especially in Havana, now under the first occupation of Cuba by the North American army after the defeat of Spain in 1898. One of the principal activities of the intervention government was to make Havana habitable. A sanitation project, with the help of capable Cuban and North American hygienists, was begun. Its success, thanks to Finlay's discovery, was achieved during campaigns of general cleaning of communities, immunization and treatment of disease.

Commander William C. Gorgas headed the Military Health Services of the American Army in Cuba and the Military Medical Commission was presided over by Dr. Walter Reed. The Commission, composed of doctors James Carroll, Jesse Lazear (who died of yellow fever) and the Cuban Arístides Agramonte, was charged with the eradication of the epidemic, that was causing losses in the North American army. After many delays, the disease was finally eradicated when General Leonard Wood authorized the application of the theory and treatment proposed by Dr. Finlay. Finlay's theory had been presented beginning in 1881 at various international Sanitary Conferences and the Academy of Sciences of Havana.

The complex and effective plan of sanitation that Gorgas supervised laid the foundations for the sanitary organizations in Cuba: the Department of Health overseeing the Sanitary Inspection of Houses and Public Establishments; a Department of Demographic Statistics, Public Ordinances; Archives and Correspondence; Disinfections and Cleaning Services, the Yellow Fever Commission, the Smallpox Vaccine Center, the Glanders Commission, the Tuberculosis Clinic (that began construction of a Sanatorium); Laws and regulations for quarantines and immigration; school and bromatological inspections. Juntas Locales, supervised by city councils and the Junta Superior de Sanidad, were established in the interior of Cuba. With the eradication of yellow fever, the Commission was transformed into the Commission of Infectious Diseases, headed by Dr. Arístides Agramonte. Also important for this radical stage in the history of the medicine in Cuba was the transfer of the university at the former Dominican convent to the Loma de Aróstegui (Aróstegui's Hill), today called University Hill. At this location "Military Pyrotechnics" facilities were created by 30 military orders in June 1900. Nearby, construction of a great university hospital, the Hospital General Calixto García was begun. It would take over the functions of the obsolete Hospital General Militar that closed in 1896.

Don Tomás Estrada Palma, the first President of the Republic of Cuba, named Dr. Diego Tamayo as first Secretary of Interior, and Dr. Finlay as head of the Department of Health. Taking advantage of a military order of July 1900, the Department of Charity was created, with national jurisdiction over hospital services, asylums, assistance, public charity, charitable societies, nursing organizations and, among others, children's services. During these same years attempts were made to take from Dr. Carlos Finlay his important scientific scholarship, proposing that the North American Dr. Walter Reed and the Franco-Venezuelan Dr. Luis Daniel Beauperthuy had discovered what Finlay had worked on for so many decades. After years of waiting, after many confrontations and protests by Cuban medical authorities, the Congress of the Pan-American Medical Association, meeting in Dallas in 1933, declared December 3 (Finlay's birthday "American Medicine Day." This was done in recognition of Dr. Finlay as the most representative doctor and scientist of the continent. But it was not until 1954, many years after Finlay’s death in 1915, at the 14th International Congress on the History of Medicine, in Kome-Salerno, that the debate was put to rest, ratifying Carlos I. Finlay of Cuba as the one and only discoverer of the mosquito as the vector of yellow fever and the application of this fact to a sanitation program for the tropics.
 

For these and other reasons Cuba was the first country in the world to create a Department of Public Health at the level of Secretariat or Ministry at a time when the prevailing state policy was the underestimation of the importance of the sanitary issues. The many other countries that began to consider public health as a high-priority followed Cuba's example. At the eighth Pan-American Sanitary Conference, celebrated in 1927, Public Health was recommended as the "only means for the exact execution of a national and international sanitary policy."

During the first half of the twentieth century, studies and medical research continued in Cuba with the construction of hospitals, sanatoriums, private clinics, laboratories, charity houses, first aid stations, specialized journals and meetings on various aspects of medicine. In Latin America, Cuba held one of the first places in the main indices of health; but that medical success was still far from satisfying the dire need of a country suffering from nonexistent basic services, particularly in rural areas, and worse still in mountainous zones, or by the lack of the economic resources required to pay for medical services and medicines. Medical services were insufficient and received low-level attention from the State. The few, private institutions were the only means available. The country lacked a national system of health. The services offered by the State were basically curative in nature, non-preventive. Medical education did not pay due attention to real social necessities. In 1958 Cuba had 6,250 doctors for a population of approximately seven million inhabitants: approximately one doctor per 1,121 inhabitants. Worse still was the fact that services (facilities and staff) were essentially concentrated in the city of Havana, with 62% of the total beds available for 16.1% of the total population. Forty-nine percent of the rural population lacked any medical services. In turn, 242 private clinics and associations provided 16,500 beds as opposed to the 12,036 at public hospitals; that is, 12 beds per 1,000 inhabitants for 25% of the total population, contrasting with 2.2 beds per 1,000 for the remaining 75% of the people. The budget for public health was 20,500,000 pesos: $3.02 per capita.

A summary of the public health situation in 1959 highlighted the following problems: absence of a national health system; poor medical services coverage; better quality at the private health services facilities than at the public ones; predominance of private medical practice; poor preventive medical practice; concentration of health services in the cities with no attention given to the countryside; flawed education system for the preparation of health personnel; a pharmaceutical market controlled by foreign labora-tories; scarce medical research and development (practically without any official support). In 1962 the mortality rate was 94.4 deaths per 1,000 inhabitants: 13.3% caused by infectious and parasitic diseases, 57.3% due to acute diarrhea. Life expectancy was 65.1 years and the birth rate 30.1 infants per 1,000 inhabitants. Child mortality was 21.5% for children under five years and 17.2% for those under one year. Childhood occupied the fourth place as cause of death, with gastroenteritis in fifth place. In addition to tuberculosis, malaria, diphtheria and typhoid fever were the causes of thousands of deaths.

In broad strokes, that was the public health situation in the country when the Revolution triumphed on January 1, 1959; 98 hospitals (one was rural), a Medical School at the University of Havana that granted about 300 degrees a year, a dental school that graduated about 50 dentists, seven nursing schools and an average of 25 new laboratory technicians per year. This situation was aggravated by the fact that about 3,000 doctors chose to leave the country after the Revolution, leaving the medical school with only 19 professors.

But subsequent medical advances became irreversible and permanent, thanks to the total support of the State, which in 2000 budgeted more than 1.8 billion pesos for public health for a total population of 11,187,673 inhabitants: 166 pesos for inhabitant. Currently, a high percent of women work in public health. The total number of health personnel is 359,653: 65,500 doctors, 10,000 dentists and 9,000 professors, who serve the whole population of the country at numerous facilities. There are 270 hospitals, 82 general hospitals, 13 research institutes, six clinics for the treatment of retinitis pigmentosa, 440 outpatient clinics, 162 dental clinics, 117 first aid stations, five medicinal springs, 258 maternal clinics and 24 blood donation points. Social services provide 269 homes for the elderly and 33 homes for the disabled. Health facilities also include units such as 113 laboratories for the production of medicinal plants, 14 provincial and municipal sanatoriums for the care of AIDS patients, 1,993 pharmacies, 182 hygiene and epidemiology centers and 44 electro medicine shops. The number of beds is currently 5.2 per 1,000 inhabitants.
 

Higher education is provided at four institutes of medical sciences (in the cities of Havana, Villa Clara, Camagüey and Santiago of Cuba), 21 schools of medical sciences (in all of the provinces), including eight in Havana and one in the Island of Youth, 16 branches of medical sciences and four dental schools. The enrollment for the 2000-2001 academic year was 13,589 students in medicine, 1,551 in dentistry and 8,979 enrolled in nursing. These figures include 1,760 foreign students in medicine, 77 in dentistry and 26 in nursing.

Beginning in Algeria in 1973, the internationalist contribution of Cuban medicine consists of hosting students from many countries of the world, mainly from Latin America and Africa and foreign duty by Cuban doctors and other public health workers to countries that request such aid. This generous program had (as of December 2000) staff in 26 countries in the Americas, 19 countries in Africa, four countries in the Middle East and North Africa, three sub-Saharan African countries, two countries in East Asia and the Pacific and four Central Eastern European countries. One example of this humanitarian work is Niger, where 64 Cuban doctors have taken care of 230,000 patients, performed 4,000 operations and assisted in 3,500 births.

A far-reaching outcome of the development of Cuban medicine, with its massive campaigns for the eradication or substantial diminution of infectious, parasitic and diarrhoeal diseases, is the decrease of these diseases as cause of death. In 2000 no deaths by diphtheria, poliomyelitis, measles, malaria or pertussis were recorded. Typhoid fever caused only two deaths. Tetanus and syphilis caused one death each and tuberculosis 38. During the period of 1962-2000, massive vaccination programs have been carried out for tetanic toxoid (T.T.), antipoliomyelitis (A.P.), antityphoid (A.T.), combined triple diphtheria-pertussis-tetanus (D.P.T.), double diphtheria-tetanus (D.T.), Bacillus of Calmette and Guerin vaccine (B.C.G., for controlling tuberculosis, triple measles-mumps-rubella (M.M.R., as of 1886), meningococcal vaccine (B type, as of 1988), hepatitis B (H.B.V., as of 1992) and H. influenzae (Hib, as of 1999).

At the present time the main causes of death are: diseases of the heart, followed by malignant tumors, cerebrovascular diseases, influenza and pneumonia, accidents, diseases of arteries, arterioles and capillaries, suicides and self-inflicted wounds, diabetes melitus, cirrhosis and other chronic diseases of the liver, and homicides. This change in epidemiological profile now places hypertension, asthma and diabetes at the top of the list.

The viral triple vaccine (for rubella, measles and mumps) has been administered to children under 15. Cuba is the first country to produce a vaccine against meningococcus B, with a computed efficiency of 70% in 1989. At the Institute of Hematology and Immunology, 70% of the children who suffer from the most frequent leukemia, the lymphoblastic, receive treatment. At all the blood banks in the country, ultramicroanalytic equipment (SUMA) with immunoassay technique is in use. Nuclear magnetic resonance (NMR) equipment, extra corporeal shock wave lithotripsy and SOMA-TON are also available. The use of diagnostic ultrasound equipment and echocardiographs are readily available. At the specialized Hermanos Ameijeiras General Hospital a linear accelerator, a cobalt pump and digital subtraction angiography have been added to the facilities.

For the prenatal diagnostic program, immunochemical and cytogenetic laboratories were created with the availability of genetic advising. For the neurophysiology program, the Medicit system 03-R is available, and Neurónica equipment is used for monitoring the state of the sensorial routes and for the study of auditory deficiencies in the newborn. In 1987 the Center of Genetic Engineering and Biotechnology was inaugurated, with a system for the diagnosis of AIDS and the development of the production of monoclonal bodies for the diagnosis of different autoimmune diseases.

Along with this progress in medical science in Cuba, the following new medical specializations, among others, have been added to the traditional anatomy and surgery fields: allergology; angiology, coloproctology, pneumotisiology, sport medicine and occupational medicine, logopaedia and phoniatry, intensive care, cytology, clinical genetic immunology.

In the public health arena, with a life expectancy of 75.7 years and a mortality rate of 7.0 per thousand live births, Cuba's place is equivalent to that corresponding to the most advanced nations in the world.

A Cuban innovation that has already served as model for some countries is the family doctor with an emphasis on preventive medicine at the service of the people in the neighborhood. With this program, started in the 1980s, hospital services have become a complement to the integral attention provided at the family level by facilities such as outpatient clinics, intermediate units. Medical services have been reorganized to provide the scientific and educational support for the family doctors, creating a support network that includes all of the national territory: urban and rural.
 

From healers, wizards and phlebotomists to Galen and Hippocrates, Dr. Romay, the Academy of Sciences and Dr. Finlay, medicine in Cuba, in a mere three centuries, traveled the millenarian way of western medical science. Cuban medicine today has arrived at a well-deserved and earned international reputation. It has attained many achievements and the highest level of scientific accomplishment, as well as recognition for its humanitarian, internationalist endeavors in favor of the least developed and most destitute people on our planet.