Is the Cuban Public Health System a Model for the U.S.?

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Is the Cuban Public Health Systema Model for the
U.S.?

• A Critical Examination
• for
• EMPH Hospital Management
• R. Andrews, M.D.
• 7 August 2008

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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 which has
achieved the most effective impact with
resources, though scarce, invested in the health
sector (Study on Human Development and Equity
in Cuba, UNDP, 1999)
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FACT OR FICTION

• ANY GUESS
• IS BIASED
• IN THIS CURRENT STATE
• OF
• POLITICAL MISINFORMATION

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Of all the forms of inequality, injustice in
health care is the most shocking and inhumane.
- Martin Luther King Jr.
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Geography

• ? Largest Caribbean Island
• 111,000 sq km
• 85 the size of England
• 3 times the size of Dominican Republic
• ? 3,700 km of coastline greater than all
  Caribbean Islands combined
• More than 1,000 fine sand beaches

• ? 90 Miles from the U.S. Coast
• ? Population of 11.3 million
• ? 97 literacy rate
• ? Natural resources cobalt,
• nickel, iron ore, chromium,
• copper, gold, salt, timber,
• silica, petroleum, arable land

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REPUBLIC OF CUBA

• Head of state and government
• Raúl Castro Ruz (replacing Fidel Castro Ruz)
• Population
• 11.3 million
• Adult literacy
• 99.8 per cent
• Amnesty international 2008 Report

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• Fourteen provinces and one special municipality
  (the Isla de la Juventud) compose Cuba.

• 8Sancti Spíritus
• 9Ciego de Ávila
• 10Camagüey
• 11Las Tunas
• 12Granma
• 13Holguín
• 14Santiago de Cuba
• 15Guantanamo

• 1Isla de la Juventud (Isle of Youth)
• 2Pinar del Río
• 3La Habana (Havana)
• 4Ciudad de la Habana (Havana City)
• 5Matanzas
• 6Cienfuegos
• 7Villa Clara

The provinces are further divided into 170
municipalities
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The Irony of Cuban Health Care

• Because Cuba has so few resources, prevention
  has become the only affordable means of keeping
  its population healthy.

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Cuba 48 years as a US enemy

• 1959 Fidel Castro The Cuban government passed
  the first Agrarian Reform Law
• 1960 President Eisenhower imposed a partial
  economic embargo
• 1962 President Kennedy expands embargo and
  prohibits travel to Cuba
• 1992 Cuban Democratic Act (Robert Torricelli
  Act)
• 1996 Cuban Liberty and Democratic Solidarity Act
  (the Helms-Burton Act)
• 2000 Trade sanction reform and export
  enhancement act (TSRA)

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Denial of Food Medicine

• The impact of the U.S. Embargo on Health
  Nutrition in Cuba
• Report from the American Association for World
  Health March 1997

Target Initial Year Type of Sanctions Precipitating Event Key Changes to Sanctions
Cuba 1960 Comprehensive trade and financial sanctions Castro-led takeover interventions in Africa (1980s) Repression of opposition Cuban Democracy Act restricts trade of U.S. subsidiaries abroad (1992), TSREEA (2000)

• The Helms-Burton Act threatened U.S.
  subsidiaries. Mostly those operating in Europe,
  Canada and Mexico.
• It further stated that no ship could dock in the
  United States if it had previously docked in Cuba.

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Mariel Boatlift

• Cubans depart from Cuba's Mariel Harbor for US
  between April 15 and October 31, 1980
• downturn in Cuban economy - via United States
  embargo result in internal tensions on the island
  -10,000 Cubans asylum in the Peruvian embassy
• Cuban government- anyone who wants can go exodus
  with assistance of Cuban-Americans
• negative political implications for U.S.
  President Carter -some exiles had been released
  from Cuban jails and mental health facilities
• exodus ended by mutual agreement in October 1980
• up to 125,000 Cubans had made the journey to
  Florida.

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Healthcare Expenditures

• The Cuban health system is of special interest
  because of its developed-country health outcomes
  despite its developing-country economy.
• Cuba spends just 7.4 of its gross national
  product (GNP) on health care, compared with the
  13.6 spent in the United States.
• Hood RJ. Cuban Health System offers an uncommon
  opportunity. J Natl Med Assoc 2000925479.

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Expenditures

• Health expenditure per person is 193 in Cuba
  compared with 4540 spent in the United States
• Cubas GNP per capita is one of the lowest in the
  Western hemisphere
• Nonetheless, Cuba, unlike most Latin American
  countries, has achieved health outcomes
  comparable with those of the US
• World Health Organization homepage on the
  Internet. Geneva, Switzerland World Health
  Organization
• c2005 updated 2005 cited 2005 Mar 19. Core
  health indicators Cuba about 3 screens.
  Available from
• http//www3.who.int/whosis/country/compare.cfm?
  countrycubindicatorstrPcTotEOHinIntD2000
• Language English.

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Comparison of Health Statistics and Gross
National Product Cuba vs. U.S. and other
LatinAmerican Countries
Country Life Expectancy at Birth Maternal Mortality (per 100,000 live births) Infant Mortality (per 1,000 live births) Gross National Product per Capita (US)
Cuba 76.3 34.1 7.2 2,270
United States 77.2 7.1 7.2 31,910
Haiti 54.6 523.0 80.3 1,470
Guatemala 65.3 111.1 49.0 3,630
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Let's not forget that the ultimate goal of
Medicare must be to keep people well rather than
just patching them up when they get
sick. -Tommy Douglas "father of" the Canadian
system of universal public Medicare Thomas C.
Douglas (1904-1986) was not a doctor he was a
politician from Saskatchewan. His contribution to
Canadian medicine was not due to a medical skill
or great discovery, but as "the father of
Canadian health care." He introduced socialized
medicine (state-sponsored and salaried-physician
medical care) to the province of Saskatchewan
during his 44-year political career.
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Cuban Medical Public Healthcare
Infrastructure
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Pre-Statehood

• As was true of the other indigenous societies of
  the Americas, Cuban traditional medicine existed
  before the Spanish conquest.
• High status traditional practitioners were called
  Bohiques.

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Pre-Statehood cont.

• After colonization, Cuban medicine followed the
  Spanish tradition which was inherited from the
  Moors, who drew upon classical Greek and Roman
  medical practices.
• Chinese medicine has also been practiced in Cuba,
  the most famous was the 19th century doctor Cham
  Bom Biam or El Medico Chino.

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The battle against disease should be based on
the principle of creating a robust body not
creating a robust body through a doctors
artistic work on a weak organism, but creating a
robust body through the work of the whole
collective, especially the whole social
collective. Ernesto Guevara, M.D.
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The Cuban Healthcare System

• Cuba - socialist country
• Central form of government.
• Ministry of Health (MINSAP)
• National health programs
• implemented throughout country
• -limited scope for deviation

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Structure

• primary care is provided in Consultorios
  (clinics)
• secondary care in Policlinicos (specialty
  clinics)
• tertiary care in Hospitales and Institutos
  (hospitals and medical institutes).

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Structure

• Consultorios address approximately 80 of the
  health problems and emphasize health promotion
• The current system of family medicine based in
  neighborhood consultorios was established in
  1984.

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Who Does The Work?

• Family physicians, paired with nurses, serve
  approximately 600 patients or 150 families in a
  defined geographic area surrounding their
  consultorio.
• The family physician and nurse live in housing
  units adjacent to their consultorio and are
  integrated into the community they serve.

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How They Do the Work

• Health promotion and disease prevention are
  emphasized, i.e. public health concepts are
  integrated with clinical practice
• In the morning family physicians typically attend
  to patients in their consultorio
• Afternoons are reserved for home visits to
  patients with acute care needs, rehabilitation of
  chronic conditions, and primary prevention

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Higher Level of Care

• Patients requiring care beyond the scope of the
  consultorio are referred to a policlinico
• There are 440 policlinicos throughout Cuba, and
  each policlinico serves 30 to 40 consultorios
  (30-60,000 people)

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Higher Level of Care

• Consisting of interdisciplinary teams,
  policlinicos offer specialty care in areas e.g.
  social work, pediatrics, internal medicine,
  dentistry, physical therapy, cardiology,
  pulmunology, endocrinology, ophthalmology,
  neurology, dermatology, and psychiatry.

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Higher Level of Care

• Many family physicians spend a half-day per week
  joining their patients for specialist visits in
  policlinicos
• Providing continuity of care
• Building collegial relationships between
  family physicians and specialists

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Economic constraints and restrictions on
medicines have forced the Cuban health system to
incorporate alternative and herbal solutions to
healthcare issues more accessible and
affordable to a broader population
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In the 1990s, the Cuban Ministry of Public
Health officially recognized natural and
traditional medicine and began its integration
into the already well established Western
medicine model

• What is called complementary and alternative
  medicine viewed as separate and not equal in
  the United States is designated natural and
  traditional medicine and essential in Cuba and
  is increasingly available throughout the country.
  

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Children begin studying the multiple uses of
medicinal plants in primary school, learning to
grow and tend their own plots of aloe, chamomile,
and mint.

• Alternative techniques used by the clinics and
  hospitals include flower essence, neural and
  hydromineral therapies, homeopathy, traditional
  Chinese medicine (i.e. acupuncture anesthesia
  for surgery), natural dietary supplements, yoga,
  tai chi, electromagnetic and laser devices.

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Aspects of Public Health in Cuba

• Highly integrated with therapeutic medicine
• Polyclinic teams of primary care doctors,
  dentists, nurses
• Provide health education, preventive care
• Health workers live in the community
• Physicians required to see every patient every
  year
• Records of preventive services

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Aspects of Public Health in Cuba cont.

• Prenatal, immunization, cancer screening, etc.
• Aggressive follow-up of missed appointments
• Vaccination rates 99 ()
• Community reinforcement of public health
• Neighborhood Committees for Defense of Revolution
  (CDR), Cuban Federation of Women, Circulos de
  Abuelos
• Surveillance data system to province to state

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Medical Education and Diplomacy

• 3,400 medical students from 23 Latin American,
  African, and Caribbean countries are being
  trained in Cuba, at Cubas expense
• In 2001, 8 American students, all from
  low-income minority families, began their free
  medical education in Cuba, on the condition that
  they return to their communities for service.
  Current enrollment is 93 US students.
• Fidel Castro has said that up to 500 American
  medical students may enroll eventually.
• Source Canadian Medical Association Journal,
  2001, 164(10) 1477and IFCO Medical School
  Scholarship Program _at_ Latin American School of
  Medicine

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• Scaling up
• The Latin American Medical School (1998)
• 29 countries
• 10,000 students, 3,000 first graduates (05-06)
• 100 indigenous populations
• 51 women
• Low-income students
• Commitment to serve
• Sustainability in countries of origin

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• The Latin American School of Medicine (ELAM)
• Free six-year medical education.
• Received over 11,500 students since 1998.
• Graduated over 4,000 since 2005
• Students are all foreigners from 29 different
  countries
• 101 ethnic groups are represented.
• 51 percent of students are women.

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• Focus on social environmental determinants of
  health
• Trained to work in low-tech environments
• ELAM Institutional ethics of service are stressed

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Prevention and promotion require relationships
not purchasing power.
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Different from Previous Scholarships Aiming for
Sustainability

• Student selection poor, indigenous,
  marginalized
• Bridging program
• Training geared to country of origin
• Looking for commitment to underserved
• Eventually replace Cuban doctors in-country

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US Medical Students in Cuba

• 93 at the Latin American Medical School
• Mainly from minority communities

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Cuban International Medical Cooperation 1963-2006
100,000 Cuban health professionals in 101
countries February, 2007 29,809
Cuban healthprofessionals in 69 countries
Region Countries
Africa 38
Americas 37
Europe 8
Asia/Mideast 18
TOTAL 101
Source International Cooperation Unit, Ministry
of Public Health, Havana
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Training Doctors for Global Health I think the
Cuban system of training could serve as an
example to the rest of the world if we wish to
have functioning health systems in the future.
The Cuban system trains doctors for communities,
willing to sacrifice for the welfare of others. I
think there is a need for such a paradigm
shift. Nestor Shivute, MD, WHO Country
Representative, Gambia
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Workforce

• The size of the Cuban workforce relative to its
  population is several times larger than the
  UKs.
• The doctor patient ratio 1172 in Cuba
• (1480 in the UK)
• -Advantage in administering free universally
  accessible healthcare to its population.
• -Contrasts with parts of Latin America where
  only wealthy afforded decent healthcare.
• World health organization. 2000 world health
  report. WHO 2000

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Physicians per 10,000 Population
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Switzerland 1 physician for every 277 people.
Thats 25,921 doctors for 7.2 million people
Malawi 1 physician for every 50,000 people.
Thats 266 doctors for 12.8 million people.
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WHO REPORT, 2006
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• Cuba has the highest family physician-to
  population ratio in the world, and it has a
  family physician-per-patient ratio of
  approximately 1600.
• In 2001, only 35 of Cuban residency graduates
  specialized further (including 8 who graduated
  in general internal medicine and pediatrics).

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• In the United States, only a third of physicians
  are primary care physicians, (i.e., family
  practice, internal medicine, and pediatrics
  physicians).
• Only 11 are family physicians.
• In the United States, the average family
  physician-per-population ratio is approximately
  13200.

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Number of surgeons per 100,000 population
Cuba 56 United States 51 Japan 31 Swede
n 29 Germany 13 China 10 Columbia 7
United Kingdom 6 South Africa 6 Philippines
1.5 Kenya 0.6 Tanzania 0.3
Bulletin of the American College of Surgeons,
1987 J. Perez, personal communication, 2000
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Vital Statisitics
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We have enough knowledge, money technology to
overcome most of the worlds health calamities.
-World Health Organization Annual Report, 2006
Many public health care systems are
underserviced, inefficient, and at times,
dangerous.
Prevalence of HIV Percentage of Population by
nation
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Infant Mortality RateSource PAHO 2000
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8 newborns per 1,000 die in the U.S. Thats
18.6 per 1,000 for the African American
population.
283 newborns per 1,000 die in Sierra Leone
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Infant Mortality in 2000
per 1,000 live births
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Europe 1 mother dies for every 20,000 live
births.
Africa 1 mother dies for every 100 live births.
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Life Expectancy at BirthSource PAHO 2000
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Life Expectancy in 2000
years
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In Canada, life expectancy is 80 years.
In Haiti, its 54.
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Indicators of Cubas accomplishments in public
health

• First country to eliminate polio1962
• First country to eliminate measles1996
• Lowest AIDS rate in the Americas
• Most effective dengue control program in the
  Americas
• High physician allocation-1 physician per 120160
  families
• Highest rates of treatment and control of
  hypertension in the world
• Reduction in cardiovascular mortality rate by 45
• Crude infant mortality rate of 5.8 per 1000

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Indicators of Cubas accomplishments in public
health

• Development and implementation of a
  comprehensive health plan for the Americas
• Free medical education for students from Africa
  and Latin America
• Support of 34 000 health professionals in 52 poor
  countries
• Creation of a national biomedical internet grid
  (INFOMED)
• Indigenous biotechnology sector producing the
  first humanpolysaccharide vaccine

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Example of Cuban Public Health AIDS

• Initial quarantine of HIV-positive patients
• Started with HIV soldiers returning from Africa
• Compulsory quarantine lifted, HIV sanitariums
  became voluntary
• Sanitariums in 13/14 provinces
• 70-80 newly diagnosed choose ambulatory
  treatment
• Epidemic helped by quarantine, travel
  restrictions. Lowest HIV rate in hemisphere
• Active screening, 2 million annual HIV tests
• Jinaterismo (prostitution) raises many issues

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Cuban Public HealthA Model for the U.S.?
NO

• Cuba is a socialist system.not transplantable
  to the U.S. !
• No private health care!
• No Financial Incentives!
• Surveillance requires intrusive social
  institutions .e.g. CDR!
• Public health may involve coercive policies,
  e.g. AIDS quarantine!

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Cuban Public HealthA Model for the U.S.?
Could be?

• There is no intrinsic reason for the separation
  of treatment and preventive (public health)
  services in the U.S.
• Integrated primary care is a cost-effective model
  (if we can get there)
• Prioritizing health resources to achieve social
  objectives (e.g. eliminate health disparaties) is
  effective
• Improving surveillance systems at the primary
  care level is important and possible

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We are still challenged to be dissatisfied
Let us be dissatisfied until every man can have
food and material necessities for his body,
culture and education for his mind, freedom and
human dignity for his spirit. Let us be
dissatisfied until the empty stomachs of
Mississippi are filled, and the idle industries
of Appalachia are revitalized. Let us be
dissatisfied until our brother of the Third
WorldAsia, Africa, Latin America(is) lifted
from the long night of poverty, illiteracy and
disease. Let us be dissatisfied until
brotherhood is no longer a meaningless word at
the end of a prayer, but the first order of
business on every legislative agenda. Dr.
Martin Luther King, Jr February 23, 1968