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Training the 5-Star Doctor: Medical Education in Cuba

Training the 5-Star Doctor: Medical Education in Cuba. Richard Quint, MD, MPH Health Sciences Clinical Professor (Emeritus), UCSF Medical Education in Cooperation with Cuba (MEDICC). Brief Chronology. 1959: Bautista overthrown 1960: Land reform and health system changes

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Training the 5-Star Doctor: Medical Education in Cuba

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  1. Training the 5-Star Doctor: Medical Education in Cuba Richard Quint, MD, MPH Health Sciences Clinical Professor (Emeritus), UCSF Medical Education in Cooperation with Cuba (MEDICC)

  2. Brief Chronology • 1959: Bautista overthrown • 1960: Land reform and health system changes • 1961: Literacy campaign; Playa Giron invasion (Bay of Pigs); U.S. initiates trade embargo • 1989: Soviet bloc dissolves • 1989-1995: The “special period”; Tightening of the embargo • 2000: The Elian Gonzalez affair • 2005: Travel restrictions tightened • 2009: What will Pres. Obama do?

  3. Health in Cuba Pre-1959 • Infant mortality > 50/1000 live births • Maternal mortality 125/100,000 • Life expectancy (1960): 65.1 years • Private medicine: urban centers • Poor nutrition • Clean water available to 35% of population Gilpin, 1991

  4. Health Care After 1959: Operational Principles • People’s right and a responsibility of the state • Integration of preventative and curative services • Universal: accessible and free • Coordination of health care, social services, and socioeconomic development • Popular participation is fundamental Ministry of Public Health (MINSAP)

  5. Conceptual Model of the Influences on Health in Cuba Health Service Determinants Accessibility Universality Comprehensive Quality Horizontal integration Focus on primary care Health promotion focus Non-Medical Determinants Education Housing Sanitation Clean air Nutrition Employment HEALTH OUTCOMES Social Mediators Social cohesion Income disparities J. Public Health Policy, 2004

  6. Basic Health Expenditures (2008) Country % GDP Per Capita ($US) Canada 9.6 3,500 Cuba 7.5 322 Mexico 6.1 379 USA 15.6 >7,000 WHO, 2008

  7. Life Expectancy 1970 2000 2006 Canada 77 79 81 Cuba 74 78 78 Mexico 70 73 74 USA 75 77 78 WHO, 2008

  8. Cuban Child Mortality Rates* YearNeonatalInfant1-4 years 1974 ------ 38.7 1.3 • 11.0 19.6 1.0 1990 4.6 10.7 0.7 1994 4.0 9.9 0.6 1998 2.8 7.1 0.5 2006 2.1 5.0 0.4 *= per thousand MINSAP, 2008

  9. Infant Mortality Comparisons 1990 2000 2006 Canada 7 5 5 Cuba 11 6 5.8 Mexico 42 32 29 USA 10 7 7 WHO, 2008

  10. Immunization Levels (2006) Percent immunized Country BCG DPT3 Pol3 Meas HepB3 HiB3 Brazil 99 99 99 99 97 99 Cuba 99 99 99 96 89 97 Haiti 75 53 52 58 NA NA Mexico 98 98 98 96 98 98 USA --- 96 92 93 92 94 UNICEF, 2008

  11. Maternal Mortality (2005) Canada 7 Cuba 30.2 (2007) Mexico 60 USA 11 WHO, 2008; MINSAP, 2008

  12. HIV Prevalence (>15 y.o./100,000) 2005 Canada 222 Cuba 52 Mexico 244 USA 508 WHO, 2008

  13. Developing the Infrastructure: 1960-1969 • Price reductions, nationalization of private facilities, hospital and clinic construction, increase and improve water supply • Rural medical service • Polyclinics: preventative and comprehensive services • Professional training: the Soviet model • Community education: the CDR and FMC Gilpin, 1991

  14. Health Care in Cuba: 1970-1979 • Dissatisfaction with hospital-based training • 1974: Medicine in the community, a promotion of health maintenance and improvement concepts • Polyclinics as teaching sites • Hospital construction: general and specialty centers • Production of medicines and vaccines Gilpin, 1991

  15. Toward Comprehensive Care: The Family Medicine Program1980-1989 • Primary care emphasis • New curriculum development • Community-based primary care team: MD and RN • Continuing medical education for older MDs • Secondary and tertiary care development • Expansion of number of medical schools: 25 in 2009 Gilpin, 1991

  16. RN-MD team in 95% of neighborhoods 120-150 families per locale Clustered around polyclinics Postings in factories, schools, day care centers, senior homes A New Kind of Family Doctor MEDICC Review Vol 10 No 4, 2008

  17. The Family Physician as a 5-Star Doctor • Caregiver: physical, mental, social • Decision-maker • Communicator • Manager • Community leader Boelen, M, WHO

  18. Educating the New Family Doctor:1990- present • Problem identification at local levels • Introduction of problem-based learning • Earlier introduction to clinical skills training • Teaching aimed at service learning • Family medicine departments in all medical schools • Practical exams Morales, IR et. al., MEDICC Review, Vol 10, No 4, 2008

  19. Training in multidisciplinary teams Integration of clinical medicine with population health Earlier contact with patients More Family M.D.s trained (44% of total) Educating the New Family M.D.: Advantages MEDICC Review Vol 10 No 4, 2008

  20. Generalist approach taught largely by specialists Hospital-based clinical training predominated Bias against family medicine skills and capabilities Educating the New Family M.D.: Shortcomings MEDICC Review, Vol 10, No 4, 2008

  21. Scaling Up for the 21st Century:Cuba and the Developing World • 2004-2005: 75% of medical training focused in polyclinics • 20,000-30,000 M.D.’s needed ASAP for home and abroad • Educating foreign medical students (ELAM) • 2008: introduction of new curriculum – “morphophysiology” MEDICC Review, Vol 10, No 4, 2008

  22. Human Resource Development in Health: Foreign Graduates From Cuban Medical Schools1966-2003 Source: Vice Ministry for Medical Education, Ministry of Public Health, Havana

  23. Latin American Medical School: Physicians for Developing Countries • 26 countries • 9,679 students • 101 ethnic groups • 51% women

  24. Different from Previous Scholarships: Aiming for Sustainability • Student selection: poor, indigenous, marginalized • Training geared to country of origin • Looking for commitment to underserved • Eventually replace Cuban doctors in-country

  25. FIN

  26. Turning the Corner: Cuba’s Family Doctor Program Family medicine put to the test: Healthy people in a resource-scarce environment Evolution of community-based models:Maximizing lessons for other developing countries

  27. Top Priority: Human Resource Deployment and Development Nationally: 68,017 physicians in 2004, 1 X 165 inh 380,576 health workers Internationally: 67,609 health professionals served abroad, of these 50,707 doctors Context: 156,300 Cuban professionals served in 160 countries (1960-2001) 40,000 foreign graduates from Cuban schools (1960-2001), 16,472 of these university-level

  28. Examples of Cuban International Disaster Relief 1960-2000

  29. Cuban International Medical Cooperation 1963-2002 Source: International Cooperation Unit, Ministry of Public Health, Havana

  30. Some Basic Indicators (2006) Country GNI*(US$) Percapita hlth. exp. (US$) Canada 36,280 2754 Cuba 1170 322 Mexico 12,000 217 USA 44,000 3074 NB: health expenditures are for public programs * = per capita WHO, 2008

  31. Challenges • Quality assurance of the teaching process • Adapting new models to countries with fewer resources • M.D. opposition to training on such a large scale

  32. Access to Water and Sanitation (2007)(% of Population) WaterSanitation Country Total Urban Rural Total Urban Rural Brazil 90 96 57 75 83 37 Chile 96 100 59 92 96 64 Cuba 91 95 78 98 99 95 Haiti 54 52 56 30 57 14 Mexico 97 100 87 79 91 41 USA 100 100 100 100 100 100 UNICEF, 2008

  33. Responding to the Special Period: 1990s and Beyond • Soviet bloc collapses, US embargo tightened • Economy shrinks by 35% • Available hard currency down by 70% • Daily caloric intake drops by 33% • Optic neuropathy epidemic of 1992-93 • Impact of primary care system on health • Refurbishing of polyclinics and construction of new centers of excellence • Infant mortality rate continues to improve MEDICC 2008

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