Life

Is Cuba the answer?

Cuba‟s annual total health spend per capita is only $251

By: James Gardiner

Published: 13 December 2011

DOI: 10.1136/sbmj.d7460

Cite this as: student BMJ 2011;19:d7460

Responses to this article (1)

In this article:

Controversial, but impressive

Doctors in the community

Public health and polyclinics

“And still I don‟t understand this country”

Lacking cornerstone values

With the 1959 revolution, Cuba was transformed from an open offshore dependent island into a

communist state.[1] Healthcare and literacy were now controlled by a government that had to

battle against a US embargo.[2] This, together with the fall of the Soviet bloc countries in the

late 80s and early 90s,[3] seriously affected the economy. It also strained its healthcare system

and resulted in a deterioration in the health and nutrition of a substantial proportion of Cubans

as the import of food and medical supplies was restricted.[4]

By the early 1990s, per capita calorie and protein intake had fallen by 40% and 42%,

respectively.[3] Mortality increased in those aged >65 years to 54.9 per 1000 (48.4 per 1000 in

1989), and the proportion of low birthweight infants rose to 9% (7.3% in 1989). Also, the

incidence of tuberculosis had risen to 15 cases per 100 000 in 1995 (5 cases per 100 000 in

1989), and, from 1992 to 1994, more than 51 000 Cubans were affected by an epidemic of optic

neuropathy associated with low levels of vitamin B[1 ]and toxic behaviours.[(3)] [5] Top

Controversial, but impressive

Patients in Cuba do not have a right to privacy in the physician-patient relationship and they

have no right to informed consent, to refuse treatment, or to protest or sue for

malpractice.[6]Dynamics such as these can cause emotional and psychological

trauma.[7] According to WHO, the island has the highest rates of depression and suicide in the

Americas, and second only to China.[8] The Cuban government also seriously intervenes in

people‟s access to information as it controls the island‟s internet servers, printing presses, and

broadcasting transmitters.[9]

Since 1995 Cuba‟s economy has grown, following a government initiated series of market

reforms.[3] Health indicators have started to recover, and by 2003 mortality among those aged

>65 and the proportion of low birthweight infants had dropped to 47.5 per 1000 and 5.5%,

respectively, both below their values of 1989.[5]

However, economic reforms alone cannot explain Cuba‟s miraculous feats in healthcare. With

regard to its healthcare systems, Cuba has earned international praise from WHO, Unicef, and

the Pan American Health Organization.[10] Since the revolution, Cuba‟s infant mortality rate has

dropped to 5 per 1000 compared with 6 per 1000 in “high income countries” and the US,[11]and

life expectancy has increased to 77.7 years (just below that of the US at 78.37).[12]

Cuba‟s ratio of number of doctors to population is higher than any other country,[13] and its

percentage of literate adults, which was 56% before 1959, now stands at 98.8%.[14] Cuba has

also eliminated polio, diphtheria, measles, rubella, and mumps; produced the world‟s first

meningitis B vaccine; created the national biomedical internet (INFOMED); and has one of the

world‟s lowest national rates of AIDS.[15] In 1988, WHO presented its Health for All award to

Fidel Castro in recognition of Cuba reaching all the WHO health goals set for developing by the

year 2000.

Cuba‟s annual per capita expenditure on healthcare is only $251 (£160; €186), compared with

$2389 in the United Kingdom and $5711 in the US.[16] This can be attributed to their vertically

integrated system, which starts with a family doctor. US healthcare lacks this, which is a major

problem leading to increased costs with multiple tests. However, Cuba‟s relatively low costs are

also because their medical facilities are much older and doctors receive far less than $1000 a

year, compared with the six or seven figure sums paid to doctors in the US.[17] Top

Doctors in the community

Luis Enrique and his British wife Moira own a Cuban restaurant, La Cubanita. Luis is from the

city of Santiago in Cuba and is also a professional singer. He‟s lived in the UK for six years.

“In Cuba the hospital conditions were terrible. I remember the smashed windows and dirty

sheets. However, doctors are very helpful and natural with you. They regularly come to your

home and speak to you normally. I was appalled when my wife sliced her finger in Britain and

had to wait for a very long time, wasn‟t checked, and then later almost developed septicaemia

and therefore had to go to A&E [accident and emergency],” said Luis.

Stephen Hitchin, senior house officer at the Royal Liverpool Hospital, has an extensive

professional and family perspective on both the UK and Cuban medical systems. He trained at

a British medical school and his wife and children were born in Cuba. He also has experience of

the US system, having spent time in both Chicago and New Orleans.

He spoke about the wide availability of doctors in Cuba: “In Cuba they have an idea of „GPs in

each neighbourhood.‟ In terms of ratio, they train more doctors in Cuba than in the UK. They

have one doctor for every 175 people compared to 435 in Britain. Doctors come to do home

visits with nurses and midwives to check patients‟ homes and take a proactive approach. This

happens far less now in the UK. Also, these doctors and nurses live in the neighbourhood and

know the people they are treating. Some live above the clinic. However, doctors work 80 hour

weeks for only $25 a month in Cuba. This can potentially open the system to corruption as

people give doctors gifts in return for a better service.”

In the UK, there is a relatively poor prognosis for women with breast cancer living in deprived

areas, and one of the factors is that they don‟t see a doctor early enough. In Cuba, it can be

hard to avoid your general practitioner.[18]

Dr Hitchin touched on Cuba‟s community watch system, the Committee for Defence of the

Revolution. “In Cuba‟s system, there is a nominated person in each neighbourhood in charge of

organising public health matters—for example, ensuring that people get vaccinations. This also

serves as a comprehensive evacuation service—Cuba suffers a lot of hurricanes but their

casualty rate is a lot less than other surrounding Caribbean islands. In fact, Ray Nagin, the

former mayor of New Orleans, came to Cuba after Hurricane Katrina to study this system.”

Dr Hitchin went on to say: “However, this has some human rights implications. CDR [Committee

for Defence of the Revolution] officials keep a personal record on each person in the

community, recording whether they attend certain revolutionary celebrations and parades. This

can affect job and university applications.”

Maria Aleida, representing Instituto Cubano De Amistad Con Los Pueblos at a meeting for the

Cuba Solidarity Campaign, emphasised the feeling of community-doctor affinity that seems to

be present in Cuba.

“In Cuba, when you are pregnant, there are doctors present all of the time and you have

constant contact with them. Also, because my husband is a doctor, people knock on our door at

two in the morning asking for help and he goes out to help them and brings them to hospital.

The doctors in Cuba have a lot of humanity. This makes me very proud to be Cuban,” said

Maria.

Top

Public health and polyclinics

There is an apparent closeness between doctors and their patients in Cuba. Patients have

plentiful, ready access to medical personnel, who themselves seem to be firmly embedded

within the community. The dynamics of the Cuban healthcare system promote this affinity.

Dr Hitchin talked about Cuba‟s admired public health programmes and polyclinic system.

“Cuba has excellent public health messages and programmes. The people there receive regular

public updates via TV and radio, billboards, and messages at work informing them about the

current state of certain health matters such as the H1N1 swine flu,” he said.

Dr Hitchin went on to explain: “In Cuba they have polyclinics which are like mini hospitals in the

community that offer minor treatment or surgery for things like hernias, colonoscopy,

endoscopy, and treatment for diabetes and chronic conditions. This frees up hospital beds.”

Public health doctors from Britain have visited Cuba to see how they manage their

success.[18]There is a plan to have 102 polyclinics in London by 2013; 10 of these polyclinics

have already opened.[19] Polyclinics offer extended opening hours and provide up to half of

outpatient treatment currently carried out in hospitals.[20]

Cuba‟s strategy is preventative: treating illnesses before they become advanced and costly.

This contrasts with the UK‟s healthcare system, which some say is not a national health service

but a national sickness service focused not on keeping those that live in Britain well, but on

keeping them alive.[17] Top

“And still I don’t understand this country”

Dr Hitchin also drew on his experience in the US to emphasise further the success of Cuban

healthcare.

“In America, I experienced people actually being afraid of receiving healthcare because of the

fear of being in debt afterwards as prescriptions and treatments are all very expensive. Cuban

healthcare is provided for everyone at a much lower cost. In the US there are 70 million people

that have inadequate healthcare coverage—that‟s roughly seven times the population of Cuba,”

he said.

Dr Hitchin said, “We‟ve mainly talked about the positives when it comes to Cuba. There are also

many negatives. I‟ve read about it for years and I still haven‟t made up my mind. A common

Cuban saying is: „I‟ve lived here all my life and still I don‟t understand this country.‟ Cuba is so

controversial. It will always remain the most divisive place in the world.”

Top

Lacking cornerstone values

In a Western context, Cuba‟s healthcare system controversially lacks some cornerstone values,

such as the right to privacy, right of informed consent, and right to refuse treatment.

Nevertheless, the island‟s healthcare achievements are astonishing in spite of a crippling

blockade and spending only a pittance on health per capita, in contrast to the UK and US:

Cuba‟s infant mortality rate, proportion of low birthweight infants, and life expectancy all

compare favourably. These are only a few of the indicators for which Cuba‟s healthcare system

has received worldwide acclaim.

A widely integrated system, making full use of polyclinics, and an excellent public health

programme are apparently the major components behind this success. Given these times of

economic constraints, where cuts to the NHS are starting to bite,[21] Western healthcare, like

the NHS, should re-examine Cuba‟s system for inspiration. James Gardiner, second year medical student 1 University of Liverpool, Liverpool, UK

Correspondence to: md0u91cc@liverpool.ac.uk

Competing interests: None declared.

Provenance and peer review: Not commissioned; not externally peer reviewed.

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Cite this as: student BMJ 2011;19:d7460