by The Traveller

In 2,000, Kofi Anan, then Secretary General of the United Nations, referring to international health stated: “Cuba should be the envy of many other nations…”. In 2006, the BBC had a panegyric of the health care system in Cuba, as “one of the world’s best public services”. A year later, this praise was backed by Michael Moore, cineast and liberal, in Sicko, an exalted documentary comparing the health care system in Cuba to the American health care system. It was food for deep thoughts.

The United States of America, with 4.5% of the world’s population, consume 40% of all goods and services on the planet. The American health care delivery system is considered the most sophisticated, the most advanced and the most expensive. The U.S spends 17.4% of its GDP on health care, i.e 2.62 trillion dollars a year, amounting to $7,960 a year per citizen. The Republic of Cuba, small Caribbean nation, as per the World Health Organization, spends 12% of its GDP on health care, that amounts to $495 (others say $251) per citizen, per year.

What is surprising is that Cuba’s outcome and vital statistics are better than the ones obtained in the U.S. Let us compare three major parameters. As per the CIA, infant (less than one-year old) mortality rate per 1,000 is 4.83 in Cuba, 5.9 in the US, and 52.4 in Haiti. As per the United Nations, life expectancy at birth is 78.3 years in Cuba, 78.2 years in the U.S, 64.7 years in India. And the list goes on, unabashed. That makes Cuba a health care miracle. How do the Cubans achieved this feat, mostly considering that after the communist revolution and the brain flight that followed, only 3,000 physicians and 16 university professors remained behind to serve a population of 8 million people?

Our foray into Cuba and our investigation of the island’s health care system point toward several factors that may explain such miracle. They are called planning, dedication, education, prevention, community medicine, integrative care, cost containment, productive research, ground organization, and traditional medicine.

From the outset, the theorists of the Marxist Revolution decided that its grandest goals would be health care and education. In 1960, Che Guevara, MD, wrote: “The role that is today entrusted to the Minister of Health and similar organizations is to deliver public health services for the greatest possible number of persons…” Article 50 of the 1976 revised Constitution confirms: “Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care…”

In Cuba, health care is more than a profession; it is akin to a sacerdotal career. Eliminating monetary gains as a reward for the health care workers and for hospitals takes away the first step toward an escalation in cost. The physicians (at least until recently) earn $22 a month, slighter higher than their nurses and technicians.

It goes the same on the patient side. They trust their healthcare team, and they have no intent of suing them even when things go wrong. The absence of the malpractice conundrum from the system does away with the added cost of repetitive or useless tests and procedures.

One of my co-travelers reflected that “It seems that everyone in Cuba has a master’s degree.” In medicine, the level of competence is astounding; everyone is overqualified; that creates quality magnet care, all across the spectrum. During a hospital visit, I expected that the pretty girl, in her early 30s, standing by me, to be the nurse in charge for the evening shift. Nope; she was the hospital Vice President, with a long a list of university degrees from for a sub-specialization in OBGYN to a Masters in Business Administration, and no child, in a population with a negative growth rate.

Medical prevention plays a large role. From grade school, children learn about sexually transmitted diseases (STDs) and all communicable diseases. Immunization is quasi-universal. Diet and exercise are encouraged. Since few people own a car, the average Cubans cannot offer the luxury of a sedentary lifestyle. On a more controversial note, an abnormal looking or tested fetus is more often aborted than not.

Community medicine is paramount. The country is divided into 25 sanitary districts, each one headed by an official. Their role is to address specific problems of specific populations at specific locations. Every neighborhood has a polyclinic available to the population, for free. An aggressive, proactive stance on secondary prevention is taken, by finding and confronting the health problems that can be treated with $20 before they become a $20,000 tertiary hospital case. Care is rationed; the very elderly, the completely demented, and terminally ill are allowed to die, without the burden of millions in no-avail expenses.

Physicians and nurses also play the roles of psychologists and social workers. The routine diagnosis of a medical patient includes an axis for psychological assessment, and a determination of the patient’s social status, beyond alcoholism and nicotine addiction. The understanding that a patient’s family situation (divorce, etc) or depression are often harbingers of serious complications such as suicide or lifestyle deterioration saves money to the system and add years to lifespan.

Cubans have been on the fore of medical research. They invented the meningitis B vaccine. They popularized the use of the oral polio vaccine in areas where the disease was eradicated. They have recently developed nimotuzumab, a monoclonal antibody against the epidermal growth factor receptor( EGFR). It stands as a potential curative advance of some forms of malignancy such as diffuse pontine glioma and lung cancer. Locally, Cuba manufactures generics of different popular medications such the molecules of highly active anti-retroviral therapy (HAART) for AIDS.

The Cuban health care system does not rely solely on scientific Western medicine. Herbal and medicinal remedies occupy an essential space. From elementary school, Cubans learn the virtues of several plants of their flora, and the way to use them to cure minor ailments or severe afflictions. Natural healers, Santeria priests, acunpunturers, and other adepts or experts of alternative medicine play their active part as well. As an illustration, there is, on the Cuban market, a popular, and somehow efficient remedy against new lesions of vitiligo, an ointment called Melagenina.

Above all, the Cubans have enough hands to do the job of medicine. There is no scarcity or shortage of physicians. While in the USA, we have one physician available for 434 people, the average in Cuba is one physician for 170 inhabitants, the best ratio in the world beside Italy. Furthermore, there are no less than 30,000 Cubans physicians working in 68 countries, from Haiti (at 70 miles from their shores) to Guatemala to Ethiopia and Eritrea. In Venezuela, Cubans have been prominent in the re-organization of the health care system under Hugo Chavez, with whom they work as the most useful instruments of two successful programs: Mission Barrio Adentro and Operacion Milagro.

Cuba offers a first class standardized medical education in all of its 25 medical schools, one of them essentially reserved to foreign students from all over the world, but mostly from South America and the Caribbean.

Medical tourism brings important hard currency to the Cuban economy. Indeed, many an American now travel to Cuba for better and less expensive care of varied conditions such as Parkinson disease, glaucoma, or for plastic surgery. This trend is popular in South America, where a popular belief holds that Cuba does it better. Is it surprising to you that Hugo Chavez have cancer chemotherapy and Diego Maradona detox for cocaine addiction in Havana?

Is this undeniable success a real miracle? It is in fact the product that comes from fifty years of planning and implementation. Now, it has become second nature in Cuba. However, we should not ignore the calls of detractors and dissidents who claim that some of the statistics are manipulated. We should not ignore the effect of the 52-year U.S economic embargo. Because of inadequate resources (moslty during the Post-Soviet Special Period) there has been a shortage of medications, and of material in all Cuba health centers.

Dr. Jose Portillo y Garcia, a top Cuban official of the National Health Services, who came to Hotel Nacional to visit us, shares his wonderment of the American system with whomever would listen. During his visit to Mayo Clinic, he was told that the annual budget of the cardiology department hovers around 50 million dollars a year; he calcutated that is the sum that any of the 15 political provinces of Cuba would spend in a year for its entire population.

I told him that the budget of Jackson Memorial Hospital, only 340 miles away from Havana, is 1.6 billion dollars a year. That is one hospital operating on 2% of Cuba’s GDP, on 21% of Haiti’s GPD, on a budget higher than the GDP of Liberia. Skeptic, he shook his head and asked me, “What do you guys do with all of this money?” I thought of the ICUs and the ERs in America, I thought of the above comparative statistics between the two countries, I too shook my head. I had no answer to his question.

(The Traveller, Friday, October 12, 2012)

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