The Wrongologist

(This
is the 2nd of 3 columns about the Wrongologist’s 7 day visit to
Cuba. The primary purpose of the trip was to learn about the Cuban health care
system.)

What happens when you
build a healthcare system on preventative medicine, family care, and free universal
access? This is what was established in Cuba after the 1959 revolution. 

We met with Dr. Rosa López Oceguera, a professor at the
University of Havana, who indicated that in 1959, Cuba had about 6000 doctors,
half of which fled the country during the revolution. There were only 16 Professors who remained at the University of
Havana’s Medical College. The exodus required Cuba to rebuild its health care
delivery and health education system from the ground up.

The result is that
over a 50 year period, Cuba has built a system where many health outcomes are
comparable to most industrialized nations. The system was built gradually,
starting with free vaccination services and a program to improve sanitation in
the 1960’s and community-based health services delivery in the 1970’s. In 1976, Cuba’s healthcare program
was enshrined in Article 50 of the Cuban
constitution that
states:

The Cuban
system is based on the concept that doctors must live in the neighborhoods they
serve.  A doctor-nurse team are part of the community and know their
patients well because they live at (or nearby) the consultorio (doctor’s office) where they work.  The
local consultorios are
backed up by policlínicos (polyclinics)
which bring together nursing, medical specialists and diagnostic and health
services. The polyclinics offer laboratory services, x-ray, and emergency care.
The polyclinic model exists in many
countries,
including Russia, Germany and France.

Some
national statistics on Cuba’s health care system:

• 1
  Nurse per 117 persons

• 1
  Doctor per 143 persons

• 1
  Dentist per 878 persons

• 36,478
  MD’s in primary care in Cuba

• 11,
  492 local doctor offices in Cuba, of which, 2,167 are located in Havana

• 452
  polyclinics in Cuba

• 152
  general hospitals

• 142
  maternity homes (for high-risk pregnancies)

• 126
  elder day care facilities

• 26
  blood banks

• 13
  medical research institutions

• 23
  medical schools

We visited
the Polyclinic of Revolution Square, a center-city polyclinic. Here is a photo
of some of the nurses who were working at this clinic on the day we visited:

The
Revolution Square polyclinic we visited had the following statistics:

• 173,000
  people are served by this polyclinic

• There
  are 6 pharmacies in the area

• There
  are 16 local doctor offices in the service area

• There
  are 235 staff in total assigned to the polyclinic, of which 86 are doctors and
  52 are nurses

• There
  are 58 medical technicians assigned to the clinic, along with 56 in general
  services and 41 other staff

We also
visited a local doctor’s office (consultorio) about a block from the polyclinic. It has two
permanent staff, a doctor and a nurse. We were told that the office serves 136 multigenerational
households and was open 8 hours/day, 6 days/week. They receive around
30 patient visits per day, or about 180/week. The doctor lives above the clinic
and is available off-hours to its families. The doctor said that she can make
appointments for specialists to visit her office to see patients as needed. Here is the
outside of the consultorio building:

These translate
into interesting numbers: If we assume a family has 6 individuals (possibly
low), the local office has a potential patient population of 816. We were told
that each patient sees the clinic staff 3.3 times per year, or 2,693
visits/year.

House
calls seem to be routine. Usually, the local office does not schedule
appointments in the afternoon, in part because it’s the responsibility of the
doctor and nurse team to understand the health issues in the neighborhood. By catching diseases and health hazards before they get
big, the Cuban medical system can spend a little on prevention rather than a
lot later on to cure diseases, stop outbreaks, or cope with long-term
disabilities.

One value
of the community-based model is that Cuba has standardized immunization
nationally. This has eliminated polio, diphtheria, tetanus, rubella, mumps,
syphilis, tuberculosis, rabies, Nile virus, and yellow fever. It has controlled
meningitis, pneumonia, Hepatitis B, and leptospirosis.

In
addition, most of Cuba’s health indicators are at or near those of the OECD
countries. The CIA Factbook indicates that:

• Cuba’s
  infant mortality (under 1 year) was 4.78/thousand in 2012 while the US was 5.90

• Life
  expectancy in Cuba was 78.05 years, while it was 78.6 years in the US

• Health
  care expense in Cuba was 10% of GDP, while it was 17.9% in the US

The major
cause of death in 2014 is expected to be cancer, possibly because about 50% of
the population smokes, which causes high incidence of lung, throat, and head
and neck cancers. Dr. Oceguera told us
that this is a change from 2012, when the #1 killer was heart disease followed
by cancers and cardiovascular disease.

On the other
hand, most technology was antiquated. We saw a suction apparatus that probably
was new in the 1950’s and an EKG monitor which would have been new in the
1970’s. Here is a photo taken inside the polyclinic:

The medical
records are simple and handwritten, similar to those we used in the US 20 years
ago.

When we
asked the nurses what resources they needed, they asked for syringes. It is hard to imagine what Type I Diabetics use if the polyclinic is short of syringes.

We visited a facility
for high-risk pregnancies. It had 50 beds for in-patient care, but most women
visit on an out-patient basis. The facility serves 5 municipalities in Old
Havana. The usual process is for women at high risk of losing their baby to be
referred to the Hogar Materno. High
risk is defined as pregnant women over 30 years old, or under age 16, or having
a history of low weight births. The day we visited, there were 49 inpatients. The
officials we spoke with attribute Cuba’s marked improvement in infant mortality
to the attention paid to high risk pregnancies. Here is the waiting room of the
Hogar Materno:

As is visible in the
photo above, many mothers are using the facility on an out-patient basis. Birth
control is encouraged, and is free. Abortions are permitted with the agreement
of the father and mother, but it is seen as a failure of pregnancy prevention. Adoption
is difficult, with the government very involved in the process.

We also visited an
elder care day care center in Old Havana. Retirement is at age 65 for men and
60 for women. This facility was most
similar to what we would see in the US:

This facility provided services for cultural/social
activities, PT and rehab from falls, and eye care. In addition, it cared for 88
patients in their homes. We saw a modern eye care and eye glass production lab
in the elder care home. They made progressive and bi-focal lenses in about an
hour.

Medical
services as an export commodity:

Cuba started in the
1960’s to build a health care education machine. This was developed primarily
because so many health care professionals left the country during the
Revolution and the domestic need was so great. Since then, it has graduated
nearly 78,000 doctors, of which roughly 38,000 work in Cuba, while the rest
work in foreign countries. In total, 135,000 Cuban health care professionals of
all types have worked in foreign locations.

The genesis of the
export of health care services was Cuba’s medical services provided for the Chilean
earthquake of 1960. Today, Cuba is providing health care services in 66
countries and it is the #1 hard
currency earner for Cuba, outstripping tourism and exports of nickel.
The most recent estimate of income derived from medical services is $9 Billion
per year, more than double the earnings from the successful tourist industry. Here
is a chart from the World
Affairs Journal
showing the growth in Cuba’s service exports, virtually all of which are health
care related:

According
to World Affairs Journal, the host
government provides each doctor in overseas service with housing and a monthly
stipend generally between $150 and $500 for food and personal expenses. Cuba pays
the family back home their regular peso salary (equivalent to $25 a month on
average for a doctor) and a hard-currency bonus of around $50 to $120 monthly.

We visited the
Escuela Latin America de Medicina, (ELAM). This is Cuba’s medical school for training foreign medical students.
ELAM was founded in 1978 and trains only in family medicine. Currently students
from 98 countries are represented, including about 90 Americans. Roughly 1400
students are currently enrolled. These students pay tuition and fees to attend,
and that is another source of foreign currency.

Conclusions:

No one
should romanticize Cuban health care. The system is not designed for consumer
choice or individual initiatives,
yet
the Cubans we met, from patients to health care providers, were very proud of
their health care system.
Although
Cuba has limited economic resources, its health care system has solved some
problems that ours has not yet managed to address completely.

The fundamental question for the Cuban
government is whether the health care system is sustainable as constructed. Salaries for
doctors are going to double at some point in the spring. Salaries of other
health care workers are likely to rise as well. Medical technologies and
pharmaceutical costs will continue to rise, and all health care services are
free.

Cuba has
developed its own pharmaceutical industry and not only manufactures most of the
medications in its basic pharmacopeia, but also fuels an export industry.
Resources have been invested in developing biotechnology expertise, including production
of a drug to treat diabetic foot ulcers called herberprot-b.

Cuba’s
health care system — with a physician for everyone, free health services
including surgeries, an early focus on prevention and patient education, and
clear attention to community health — may inform both rich and poorer countries
as well.

 

Tomorrow, we will conclude
this 3-part report with a look at Cuba’s future and how its relationship with
the US may play out.