Francisco Rojas Ochoa MD PhD
Those of us who worked in Cuba's countryside-even for a short time-still carry "rural doctor" as a badge of honor and pride.
A little more than 50 years ago, in 1960, I was one of the founders of Cuba's Rural Medical Service (RMS). It was the first of several public health programs implemented under the new revolutionary government and grew out of an initiative by our class of medical graduates, voting overwhelmingly to devote a period after graduation to serving in the island's rural and remote regions. There had never been anything like the RMS in those forgotten lands: free services for everyone, close-at-hand, and offered by qualified physicians who provided both preventive and curative care at any time of day or night, also dispensing free medications.
Rather than focus on its results for rural population health-which are well-documented elsewhere-I would like to give testimony on the RMS's impact on me as a professional and as a human being.
It enabled me to get to know the great cultural diversity of my own country. I thought I knew Cuba and Cubans, but I really only knew the urban areas and a small part of rural Cuba in the East. What first hit me was an entirely new topography: hills that rose straight up from the coastline to reach the height of mountains. Nothing like the expanse of rural plains, small farms and cane fields familiar to me. Instead, I found coffee and cacao plantations and dense hardwood forests.
But even more important than this new natural landscape was a new human landscape. The rhythm of planting and harvest was different; coffee mills were at the center of these communities. There were two classes, the plantation owners and farmworkers-most of the latter were seasonal labor, poor of course, without unions or associations, and continually in debt to the owners. If anything united them it was their customs: traditions, beliefs, ways of speaking, cooking, eating and celebrating. These were different from the ones I'd known, and people there used different concepts and language to refer to health and illness.
I absorbed all of this and considered it vital to my medical practice. It's essential to get to know people, both individually and in their community life. Otherwise, a doctor remains isolated, has no way to understand-or develop the necessary empathy with-patients, who don't understand the doctor, either. The RMS taught me that good medical practice without this acculturation is impossible.
It helped me mature as a professional. In my experience as a medical student and doctor once I graduated, I had always been part of a team in hospitals with specialized support and supervision. I rarely had to make decisions entirely on my own. Now the responsibility was mine alone, with no one to turn to for help. I couldn't make a mistake, or people would suffer. What's more, being wrong would damage my own reputation and also that of the new revolutionary health system being built to serve these communities. I had to do things right, and on the whole, those of us who served in the Rural Medical Service did. Such was the road to professional maturity: managing difficult situations, often alone, and thus gaining the population's trust. That was my true graduation: through the RMS I went from being a student to become a physician.
It confirmed for me the immeasurable value of clinical skills. Until I joined the Rural Medical Service, my experience had been in urban hospitals, where I was privileged to have excellent teachers, all internists with superb clinical skills.
In the rural areas at the time, we had no laboratory or radiology services. We depended solely on our own clinical training: our ability to listen closely to what patients told us, to take a detailed medical history, and perform a thorough physical examination. With such skills-medicine's most powerful "technology"-we accomplished what we set out to do and fulfilled our responsibilities in the RMS.
These are the same powerful tools used by Cuban physicians in community-based primary care programs in Venezuela and Bolivia, and in disaster relief and recovery missions in post-quake Pakistan, Haiti and elsewhere. Yet, seduced by the power of more modern diagnostic techniques, you often find younger generations of medical graduates relegating their own clinical skills to second place-something we should rectify.
It provided me the most solid political education possible. We often think of this as "book-learning" in schools and courses. Doubtless these offer a useful theoretical base, but nothing could have been more educational for me than practical work with rural people, and our struggle together for economic development, literacy and agrarian reform, as well as for our country's sovereignty. In short, the RMS served as a school in which I came to understand the intimate relationship between the multi-sector transformations we were making, public health and human development.
I came to know and practice human solidarity, commitment and discipline. These concepts are the daily bread of family medicine and global health cooperation, but their seed-fulfilling health care as a right-was planted in the Rural Medical Service by the doctors of my generation and thousands who followed us. It is this spirit, this "mystique," that has propelled the immense transformations in Cuban public health ever since, here in Cuba and in those contributions we have made internationally.
Submitted: November 14, 2011
Approved for publication: December 24, 2011
Adapted from an address at the 50th anniversary ceremony marking the creation of Cuba's Rural Medical Service, Camilo Cienfuegos Hall, Ministry of Public Health, Havana, Cuba, December 10, 2010.