1 asking the right questions: lessons from the cuban healthcare system

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Peter G. Bourne, M.A., M.D.

In his famous speech “History will Absolve Me,” given during his trial for the attack on the Moncada barracks in 1953, Fidel Castro pledged to bring health and education to the deprived and oppressed people of Cuba. Later, as a guerrilla in the mountains he had ample opportunity to reflect on the goals of his revolution. With three physicians, including Che Guevara, fighting along side him specific plans for uplifting the health of the people began to emerge. After he came to power in January, 1959, he honoured that commitment enshrining the right to universal, accessible, and free health care as a right of every citizen under Article 49 of the new Cuban constitution.

“Everyone has the right to health protection and care. The state guarantees this right.

- by providing free hospital and medical care by means of the installation of the rural medical; service network, polyclinics, hospitals preventive and specialized treatment centres;

- by providing free dental care;

- by the health publicity campaigns, health education, regular medical examinations, general vaccinations, and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations.”

An equally cherished goal was the provision of education. And a campaign to achieve universal literacy, implemented early on and widely applauded by the international community as a monumental accomplishment, proved a crucial pre-cursor for the health program, especially in rural areas.
Prior to the revolution there were approximately 6,000 doctors in Cuba, all white, virtually all in private practise and almost entirely in the cities. In the rural areas only 8 % of the population had any access to health care whatsoever. In the year after Castro came to power more than half of the physicians left the country. It was a mixed blessing because it allowed the creation of a completely new system without much of an entrenched medical establishment to oppose it. From the beginning Fidel Castro took an active personal interest in the health of the Cuban people making it clear to everyone that he considered it, along with universal education, a defining element of the revolution.. In any healthcare system there is no substitute for this degree of political will at the top. The result has been that Cubans, forty-five years on and no matter what their life circumstances, are among the healthiest people in the world.
The System

The fundamental question that was consistently asked was “How do we improve the population’s health?” A single, unified, government-run system is driven by a focus on outcome measures and results rather than on process issues such as waiting lists, the number of hospital beds, or enhanced budgets or the quantity of administrators system. infant mortality, life expectancy, disease incidence and prevalence. In an effort to see that everyone at least had access to basic care, so-called polyclinics were established all over the country. Four hundred and forty were put in place in the first decade. These centres offered primary care but also had specialists in the general areas of internal medicine, pediatrics and obstetrics and gynecology. They further provided backup for family doctors who were increasingly introduced into the community. A network of 270 hospitals eventually also served the tertiary care needs of the country.

There are 12 research centres working in such fields as immunology, cardiac disease, and biotechnology and bio-engineering (particularly relating to studies of the use of recombinant DNA.) These facilities mean that Cuba is able to stay at the cutting edge of international medical research.
Universal access to care was the initial primary goal. It was matched with another vital element-the integration of treatment services with public health strategies. Physicians were not only responsible for delivering direct care but also for leading preventive programs in the catchment areas they served. Working with the “community health committees” they insured that no pregnant woman could go without antenatal care, that one hundred per cent of children were vaccinated against the basic childhood diseases, that the people in the community were regularly screened for breast and cervical cancer, as well as chronic diseases such as hypertension and diabetes whether or not they were symptomatic. The physicians and nurses in the polyclinics were also responsible, especially in rural areas, for environmental health issues such as insuring the quality of the water supply to which the community had access and the elimination of mosquitoes. The cost effectiveness of preventing rather than treating disease was thoroughly understood and animated the way physicians view their the responsibility. It is the philosophical and practical integration of service delivery and public health that is the real hallmark of the Cuban health system.
Prior to the revolution there was only one medical school in Cuba; in Havana. In the sixties and seventies at least one medical school was started in each province so that today there are 21 medical schools. Originally under the ministry of education they were, in the early eighties, placed under the ministry of public health to make them more responsive to the countries health service needs. Today Cuba has the highest ratio of physicians to population of any country in the world. Because of limited resources for the purchase of high technology equipment and expensive drugs, medical education in Cuba places a high priority on physical diagnosis, a skill in serious decline in the medical schools of many industrialized nations, as well as clinical judgement.
Beginning in 1980 the Cuban health leadership began an extensive review of other health systems worldwide as well as looking at medical education in other countries including the US and Britain. From this exercise they gleaned a number of new ideas that they used to modify the system. The most significant conclusion they came to was that perfecting a primary care system was crucial to improving a country’s health. To this end they increased significantly the number of doctors they trained to become family physicians. Today there are more than 30,000 family physicians, working with a nurse partner, each being responsible for around 150 families. In most instances these physicians have a nurse working with them. These doctors are not just general practitioners in the traditional sense, but have done a minimum of three years post doctoral training in family medicine. A requirement was also instituted requiring doctors, after they finished their training, to spend two years in an under-served areas such a the mountains in Oriente province.
The high ratio of doctors to population has meant that these family physicians have ample time to spend with each patent providing them with fully comprehensive attention. They are also expected to know each family intimately keeping them healthy with the same degree of attention as they apply to treating them when they are sick. There is currently a debate in Cuba as to how much responsibility these family physicians should take on and how much they should be screeners referring any serious illness to the polyclinic supporting them. A decision has been made to try to upgrade the skills of the family physicians, partly as they are the backbone of the entire system, and partly because there was a tendency for them to be looked down upon by specialists in the system. There is significant input from the community in terms of their satisfaction with the services they receive. Patients can provide feedback about their family physician via the local “community health committee,” and if the level of dissatisfaction the doctor may be replaced.
An important aspect of the Cuban system is the extreme dedication that is instilled into all its health professionals. Despite low pay, often a shortage of other drugs and supplies, and other frustrations the deep commitment, not just to individual patients, but to the health of their fellow citizens overall is striking. Everyone is made aware of the kind of humanitarian characteristics a physician should have. In secondary school students vote on which of their classmates they feel would make the best physicians and these peer evaluations carry significant weight in deciding who gets into medical school. The medical school curriculum places great emphasis on instilling caring attitudes and humanitarian concern in students. Cuban doctors, visitors regularly comment, are among the most dedicated to their patients they have seen anywhere in the world. A holistic approach to patients is emphasized integrating concerns for both psychological and physical well-being.
What constitutes the Cuban health system today is the result of a steady evolution that has been going on since the Fidel Castro came to power in 1969. Flexibility fostered by his personal interest has been important. There has been a conscious effort to keep the system under constant review modifying it based upon feed back at the consumer level and upon knowledge gleaned from the experience of health systems elsewhere in the world. Fear of the development of an ossified bureaucracy, the bain of several national health programs, has fed a drive for constant internal examination. Sometimes this has proven disruptive, but in the long run it has allowed a system of trial and error that has been beneficial in the long run.

The Results

From an infant mortality rate above sixty in 1959 it was, in 2002, down to 6.0 putting it on a par with most developed countries and half that of many American cities where per capita expenditures on health were many times that in Cuba. Similar transformations occurred in other health parameters such as life expectancy and maternal mortality. Interestingly there seems to be little difference in the statistics between those of African background and the rest of the population suggesting that with equitable access to health care, poor health could no longer be blamed purely on ethnic grounds. Most infectious diseases have now been eradicated. What is quite remarkable is that this was accomplished with very few resources and little high technology. Characteristic of the thinking that occurs in the Cuban system is what happened when there was concern about low birth-weight babies and its effect on infant mortality. Unlike many countries where the answer has been to spend more and more money on high technology neonatal units where babies of lower and lower birth-weight (but often brain damaged ) are kept alive the Cubans focussed on finding the causes of low birth weight including maternal health and sought to implement successful preventive programs at a fraction of the cost. This in turn led them to an understanding of the importance of enhancing women’s health throughout their lives and not just during pregnancy.

The measurable success of the Cuban system has led James Wolfensohn, president of the World Bank to say “I think Cuba has done-everyone would acknowledge-a great job on education and health...and it does not embarrass me to say it.” A United Nations Development Program Study summarized the situation “An evaluation of 25 countries in the Americas, measuring relative inequalities in health, revealed that Cuba is the country with the best health situation in Latin America and the Caribbean. It is also the country that has achieved the most effective impact with resources, although scarce, invested in the health sector.” Even the US Secretary of State, Colin Powell, has praised the health accomplishments of Cuba.
The United States Embargo

In 1964 the US included food and medicine in its economic embargo against Cuba- notwithstanding that it violated Article 4 of the Geneva Convention and Article 12 of the UN Charter on Human Rights. It was a provision not included in any other economic embargo including those against Iraq, North Korea, Viet Nam, or Libya. It has remained in force (with slight modifications two years ago) for nearly forty years. For the first twenty its effects were modest because the Soviet block could meet most of Cuba’s needs for pharmaceuticals and medical equipment. In addition the Soviets provided hard currency for Cuba to purchase from other countries those products it could not supply to it. In the early nineties a dramatic and nearly catastrophic change occurred. The collapse of the Soviet bloc meant Cuba immediately lost 80% of its foreign trade. The supplies of medical equipment and drugs stopped as did the supply of hard currency. At the same time, in an effort to tighten the embargo, the US Congress passed legislation banning European subsidiaries of American firms from selling to Cuba. To make matters worse it was a time when many US pharmaceutical companies were busy buying up many European companies. The Swedish firm Pharmacia had long been a major supplier to Cuba, but when it was purchased by Upjohn it was required to stop all shipments within three months. Even such things as Kodak film for the mammography screening machines, obtained previously from the companies European subsidiary, was cut off. Overnight one of the Cuban health system’s most successful preventive programs had to be suspended.

The initial impact was severe even though the financially strapped government pledged to maintain the same quality of care. There was, however, a brief dip in most health indicators in 1992-1994. Ironically in the long run the embargo may have done Cuba a favour. Faced with a lack of access to so many key pharmaceuticals a domestic industry was started which over the last ten years has grown dramatically, not only meeting much of Cuba’s domestic need, but also allowing the generation of significant hard currency through overseas sales. This is particularly true of the vaccine industry with Cuba developing the first vaccine for Meningococcus B and an effective cheap vaccine for hepatitis B.

Exporting the Cuban Model

As early as 1963, when they still had few physicians of their own, Cuba sent a small team of doctors to assist the government of Algeria. Partly through socialist solidarity but also as a vision of the role Cuba could play in improving the health of the impoverished worldwide it was the beginning of an extraordinary and little known function, of Cuba’s health system. Since this modest beginning in the nineteen sixties, Cuba has sent nearly 51,000 health workers (mostly physicians) to 91 African, Asian, and Latin American companies. Today there are about 4,000 Cuban physicians in more than 50 countries. There are 500 in South Africa and nearly 2,000 in Haiti and Central America.

Similarly Cuba had always been willing to take a certain number of scholarship students from developing nations into its medical schools. This changed dramatically in 1998 when, following the devastation caused by hurricane “Mitch” in Central America, it became apparent how great the dearth of physicians was in the countries of that region. A decision was made to create the School of Medical Sciences of Latin America housed in the elegant old buildings of the Cuban naval academy. It has so far taken in 6,000 medical students from every Latin American country, Mali, Nigeria and Equatorial Guinea. These students and their successors will, after completing their free-education, return home to provide care mostly in the rural areas of their countries. In addition Cuba has established medical schools, staffed by Cuban professors, in Guyana, Benin, Uganda, Ghana, Yemen and Equatorial Guinea so that some students can become physicians without leaving their own countries.

Cuba has also dealt as effectively as any nation with HIV/AIDS. Initially it received bad publicity because it approached the problem, albeit successfully, using a traditional public health model quarantining all infected cases. It was predicated on two assumptions, that there would be relatively few cases and that those infected would not live long. Its aim was to prevent further spread of the disease by those infected and to make the remainder of their lives as comfortable as possible. With the development of life-prolonging drugs and a continuing rise in the number of cases that this was no longer a viable strategy. This period coincided with the collapse of the Soviet Union and ordinary Cubans, suffering severe economic hardship, became angry at the pampered life style they felt these patients were enjoying when they were short of food another basic necessities. Now infected individuals are put into six weeks of intensive counselling after which they return to their previous life. All AIDS patients have free access to all of the latest anti-retroviral drugs which are made in Cuba as well as to continuing counselling. Extensive and highly regarded preventive program shave also been implemented.

As of the end of January 2003 in Cuba with a population 11 million had recorded:

Total number of case since the start of the epidemic 4,538

Living with HIV/AIDS 3,420

Persons asymptomatic 1,426

Symptomatic AIDS cases 1,994

Deaths from AIDS 1,053

HIV positive people who died of other causes 65
It is judged that 79% of cases are due to homosexual transmission. The incidence of HIV/AIDS in Cuba is the lowest rate I am aware of in a country of over 1 million people. Cuba has offered free anti-retrovirals to Africa as well as physicians to set up the necessary infrastructure for dispensing and monitoring this treatment..
The Shortcomings
While there is much to be said that is positive about the Cuban system, it is not without serious problems, many of which seriously limit the transferability of many of its successful strategies to other settings. They may have done much with limited resources but they are living on borrowed time financially. As a government institution they inextricably linked to the fortunes of the Cuban economy in general. It is in dire straights and without a significant infusion of resources the health system may face inevitable decline. Over the years money has been invested in the human resources of the system not in physical infrastructure. As a result hospital buildings in particular are in desperate need of repair and basic equipment is missing, not just because of the US embargo, because there is no money to spend. Doctors are paid quite well by Cuban standards but not compared to those in the rest of the world. Given the opportunity to freely migrate Cuba could lose a substantial part of its medical man and woman power. Lack of money also means that it is difficult for Cuban physians ro attend international meetings to stay on top of their fields, a problem compounded by US government restrictions.
A real weak ness of the system is that the health administration is severely under developed and in some hospitals the doctor directing the facility has to take to on too much of the administrative burden that detracts from the attention he can give to overseeing clinical care. The field of nursing is also under-developed.. Not only has a nursing shortage developed, but there has been in the past no career ladder for nurses nor any nursing specialization. These particular issues are now being addressed.
The Cuban system has much to be proud of and is one from which other nations can learn a great deal. It is quietly making its own impact in an array of developing countries largely unnoticed by the developed world.
In summary the major virtues of the Cuban system are:

  1. Strong decisive commitment at the top to making the Cuban system the best that it can be.

  2. Commitment to the idea of access to health care as a basic human right.

  3. A single unified government operated system

  4. Integration of service delivery with public health strategies

  5. Focus on making an exceptional primary health care the backbone of the system

  6. Very high ratio physicians to population

  7. Heavy emphasis on the humanitarian aspects of health care with a holistic approach integrating physical and mental well being.

  8. Flexibility to allow constant review and innovation

It is time that we in the developed world, where our health care systems are in crisis started to consider the lessons that the Cubans can teach us.

Peter G. Bourne .M.D., M.A. is Visiting Scholar at Green College, Oxford. He served as Special Assistant to the President for Health Issues in the Carter White House. He chairs Medical Education Cooperation with Cuba (MEDICC) which sends medical and public health students to Cuba for electives.

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