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

1. 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

2. “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)

3. FACT OR FICTION ANY GUESS IS BIASED IN THIS CURRENT STATE OF POLITICAL MISINFORMATION

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

6. ● 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 Geography

7. 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

8. 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

10. The Irony of Cuban Health Care “Because Cuba has so few resources, prevention has become the only affordable means of keeping its population healthy.”

11. 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)

12. 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 • 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.

14. 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.

15. 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 2000;92:547–9.

16. Expenditures • Health expenditure per person is $193 in Cuba compared with $4540 spent in the United States • Cuba’s 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? countrycub&indicatorstrPcTotEOHinIntD2000& • Language English.

17. Comparison of Health Statistics and Gross National Product Cuba vs. U.S. and other LatinAmerican Countries

18. “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.

19. Cuban Medical & Public Healthcare Infrastructure

20. 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.

21. 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”.

22. “The battle against disease should be based on the principle of creating a robust body – not creating a robust body through a doctor’s 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.

23. 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

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

28. 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.

29. 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.

30. 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

31. 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)

32. 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.

33. 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

34. 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

35. In the 1990’s, 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.

36. 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.

37. 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

38. 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

39. Medical Education and Diplomacy • 3,400 medical students from 23 Latin American, African, and Caribbean countries are being trained in Cuba, at Cuba’s 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 @ Latin American School of Medicine

40. 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

41. 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.

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

44. Prevention and promotion require relationships – not purchasing power.

45. 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

46. Cuban International Medical Cooperation 1963-2006 100,000 Cuban health professionals in 101 countries February, 2007: 29,809 Cuban healthprofessionals in 69 countries Source: International Cooperation Unit, Ministry of Public Health, Havana

47. 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

48. Workforce • The size of the Cuban workforce relative to its population is several times larger than the UK’s. • The doctor: patient ratio – 1:172 in Cuba* (1:480 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

49. Physicians per 10,000 Population

50. Switzerland: 1 physician for every 277 people. That’s 25,921 doctors for 7.2 million people Malawi: 1 physician for every 50,000 people. That’s 266 doctors for 12.8 million people.