It’s a question at the front of mind for an American visitor but seems strange to senior Cuban medical officials. Set aside the picture of the totem pole with family doctors at the bottom. Think instead of a strong foundation on which everything rests. When we asked the medical director of the largest teaching hospital in Cuba if the specialists felt superior to the family doctors he was genuinely puzzled by the question. He said: “How could we look down on them? They are basis of the entire system. We completely depend on them.”

There is a strong ideological and pedagogical emphasis on family medicine. I was told that all medical students spend significant time in a family doctor’s office from the start of their training. At the end of the revolution in 1959 about half the doctors in the country left for the US, leaving fewer than 3000 doctors for the entire population. What had been one of the most sophisticated medical care systems in Latin America suddenly had to start over again almost from scratch.  Several core political decisions shaped the new system: the divide between rural and urban access to care would be closed; medical care would be free to all; the focus would be on prevention of disease; decisions would be based on the best science available; human personnel development would be favored over technology. (Cuba had people but not much hard capital for investment.) Building the system around a large base of family doctors was the logical result of these principles, and entirely consistent with the communal political structure emerging from the revolution.

Still, there had to be more to the matter. There is.

All physicians receive the same paltry salary from the State, regardless of specialty. Family doctors, however, are provided with a free house, often above their clinic.

The chance to work abroad is also a very strong attraction to being a family physician. Doctors are a major export industry in Cuba and a principal element in Cuba’s international political influence.  Cuban doctors staff many of the field stations during crises like Ebola and the hospitals in Haiti, Venezuela, Angola and other developing and oil rich nations. More than 37,000 Cuban doctors are working outside the country in a typical year.  The Cuban government is often paid handsomely for these services. Last year Forbes magazine reported that Cuba may receive as much as $8 billion a year from the oil rich countries where their doctors practice.  The doctors also earn much more working abroad than at home. They are able to accumulate resources and material goods to bring home—to the house the government has already given them. Cuban doctors returning home after a number of years abroad have the right to buy a car at deep discount—and the cash to do so.

For most doctors family medicine is their only choice. The Ministry of Health tightly controls access to specialty training. Each year it estimates the number of specialists the country will need at the time the incoming class will graduate and that is the number of admissions for the year.

Some of the experts we met expressed doubts and fears about the future of the family doctor based system. While doctors never made much money, they had a nice home and enjoyed the respect of their neighbors. Nobody else was making more.

Going into medicine was always at the top of the choices listed by high school students who wanted to go university. That may no longer be true. Cuba has opened about 100 job categories to “private” enterprise. People in these jobs can set up their own businesses and earn more money. As a result, Cuba’s best and brightest are increasingly selecting university training for careers in tourism, the arts and music. We were told repeatedly that engineers and doctors are driving taxis because they could not earn a living in their chosen careers. The government has raised doctors’ salaries but there is concern that it won’t be able to keep up with rising incomes in the new private sector. One of the specialists I interviewed said flatly that if doctors’ salaries did not increase, they would leave. She, for example, can open a practice in Ecuador and significantly increase her income immediately.