[This post was originally published in January of 2006]
In early December the editors of the Social Medicine Portal visited Cuba. This month we bring back some notes concerning Cuban health and health care.
Cuba’s health system is unique in the world. Built on a strong foundation in primary care, Cuba provides comprehensive health care to all residents of the island. Given extremely limited resources Cuba has amassed an impressive set of accomplishments in public health. The special position of Cuba is well seen in a graphic international comparison of deaths in children less than five prepared by the Karlolinska Institute.
Most health care is delivered by family physicians. Family doctors are responsible for a defined community and they typically live above (or near) the small consultorios located in the neighborhood they serve. The family physician we visited cared for some 800 people in the five blocks surrounding her consultorio. During the mornings she saw patients in the clinic; in the afternoon she did home visits.
For more complex problems, patients visit one of approximately 400 polyclinics distributed throughout the island. A polyclinic is similar to the outpatient department of a small hospital. Some emergency room functions (including administering Cuban-produced streptokinase) occur here, but primarily this is a place for specialist consultation, diagnostic procedures such as ultrasound and more sophisticated therapeutics (physical therapy, acupuncture).
Consultorios and polyclinics are considered to be primary care in Cuba. In the secondary care tier are the municipal and regional hospitals. Both WHO and PAHO provide health profiles on Cuba that are full of statistics. For a more political portrait, see Aviva Chomsky’s “The Threat of a Good Example: Health and Revolution in Cuba.”
As US clinicians, we are accustomed to the never-ending paperwork associated with figuring out what health services different patients are or are not entitled to; this exists because we have a two-tiered market-driven health care system. It was almost exhilarating to see a system in which such barriers to care did not exist and there was an overall health system. But is it was sobering to realize the enormous burdens under which Cubans work. Food is rationed (in a very thoughtful way), housing is in very short supply (particularly in Havana), many people wear used clothing from overseas and transportation is limited. Adding to these burdens is the embargo imposed by the US government. (see below).
The official Cuban website for health information is Infomed, a sophisticated site full of information. Unfortunately Infomed is available only in Spanish. Infomed provides links to the major Cuban health publications, including the Revista Cubana de Salud Pública. We were fortunate to meet its editor, Dr. Francisco Rojas Ochoa, a 2005 recipient of a PAHO Public Health Award. He shared with us a copy of their recent book “Salud para todos: Si es posible”, an explanation of how Cuba was able to achieve the goals of health for all through the development of a primary care system. English readers may wish to consult the website of MEDICC (Medical Education Cooperation with Cuba, see below) for more detailed information on the Cuban Health System.
Amongst the medical centers we visited was the Instituto Pedro Kourí (IPK) an internationally recognized center for research into tropical diseases. Science recently profiled an IPK researcher, Dra. María C. Guzmán for her work on dengue hemorrhagic fever and the development of a dengue vaccine. IPK hosts an international course on tropical diseases; US citizens, due to the travel embargo, can no longer participate in this course.
For several decades Cuba has sent physicians throughout the world as a form of solidarity. MEDICC Review now devotes a column towards the activities of these internacionalistas. As we learned during our trip many healthworkers have been sent to Venezuela to participate in that country’s Barrio Adentro health program.
One of the most visible expressions of this international solidarity is the Latin American Medical School or ELAM. ELAM was set up to train generalist physicians with a primary care orientation. It provides scholarships to students from the Americas and Africa; in August of this year some 10,000 students from 27 countries were enrolled in ELAM. MEDICC has published interviews with a number of them. Interestingly enough, there no less than 348 US medical students studying on full scholarship at ELAM. How US students ended up in Cuba is the subject of a fascinating short article by Fitzhugh Mullan in the December 2004 New England Journal of Medicine (“Affirmative Action, Cuban Style”).
Cuba & the US: The bad…
The US government embargo against Cuba has essentially frozen all relationships between the two neighboring countries. There is an extensive literature regarding the negative health impact of this embargo, see for instance “The Impact of the U.S. Embargo on Health Care in Cuba: A Clinician’s Perspective” by Javier H. Campos, MD, or the detailed report on the impact of trade sanctions on Cuba, Haiti and Iraq by Richard Garfield. The gel in Cuba-US relations is fed by the enormous misunderstanding among North Americans of Cuban realities (see Alfredo Prieto González’ “The Image of Cuba in the U.S. Mass Media” and Jane Franklin’s “Looking For Terrorists In Cuba’s Health System”).
And it is not possible to discuss health in Cuba without mentioning the disgraceful conduct of the US military-including medical personnel-at Guantanamo Naval Base located in southwestern Cuba. See “Doctors and Torture” by Robert Jay Lifton as well as “Doctors and Interrogators at Guantanamo Bay” by M. Gregg Bloche and Jonathan H. Marks; both of these articles were published in the New England Journal of Medicine.
Cuba and the US: …and the Good
A non-governmental organization, MEDICC (Medical Education Cooperation with Cuba) was founded in 1997 as a bridge between U.S. and Cuban clinicians, faculty, students and researchers. For many years MEDICC sent US medical students to learn within the Cuban medical system. MEDICC’s activities have been sharply curtailed by the recent tightening of the embargo; educational trips to Cuba are now prohibited. MEDICC is currently concentrating on its excellent online journal MEDICC Review.
Project Infomed, run by the US-Cuba InfoMed Project maintains an excellent page of links to Cuba resources. Medical Students for Cuba, at the University of Michigan Medical School, was set up to provide humanitarian and medical supplies to Cuba.