Medicina Cubana: a Fresh Perspective

West J Med
2001;175:129-130
Copyright © BMJ Publishing Inc.

Genesis

Voice of Students

Medicina Cubana: a fresh perspective

Christian Ramers, 2nd-year medical student1

1 University of California, San Diego, School of Medicine

Competing interests: None declared

Imagine a society in which healthcare is the right of every citizen and the responsibility of the state. Imagine being able to see your doctor as often as you wanted, free of charge. Imagine a solid foundation of primary care and preventive medicine with clinics on virtually every other street corner.

To find such a system, look just 90 miles south of the Florida coast to the island nation of Cuba. Last summer, as a participant in the MEDICC program (Medical Education Cooperation with Cuba), I was lucky enough to spend 5 weeks studying the Cuban health care system. The MEDICC program consists of didactic lectures and preceptorships with the system's most valued protagonist: the primary care physician, or medico de familia.

Although I expected to find a "third world" health care system entrenched in an outdated communist bureaucracy, instead I observed an efficient, community-based, prevention-oriented infrastructure. I was also amazed at the resilience of this system despite decades of economic isolation stemming from the US trade embargo and the collapse of the Soviet Union. However, as I followed the daily routine of Cuban health care providers within their community clinics, the realities of practicing medicine with a paucity of resources became evident. Cuba is a natural experiment that highlights the profound influence of international policy on human health.

To the apolitical eye, the benefits of the Cuban system are unmistakable. Citizens are guaranteed universal access to health care and can use primary care resources as often as they wish. The infrastructure that makes this possible is the presence in every neighborhood of consultorios. Throughout Cuba there are nearly 20,000 of these primary care centers, conspicuous in every town, city, and village. The top floor of these 2-story complexes serves as the physician's residence, and the bottom floor is the community clinic. The consultorios are staffed by most of the nation's 56,000 doctors, allowing each a caseload of around 150 families. Most physicians we met in consultorios grew up in the communities where they practiced, affording them both an awareness of their neighborhood's environmental conditions and a familiarity with the families under their care. When the power of this model was realized after its introduction in the 1960s, the Cuban government replicated it in virtually every city and town on the island.

After a couple of weeks with my community preceptor, I became aware of the manifold benefits that the consultorio model offered patients. Most importantly, they enjoyed extraordinary ease of access to health care. Patients had less than a half-mile walk to the nearest consultorio. Even when an adjacent consultorio was closed or the physician was unavailable, they could walk just 5 blocks to the next clinic. In Pinar del Rio, where I worked, patients would simply drop in (medical records in hand) and be seen in the order they entered. Regardless of how many showed up, the physician stayed until all questions were answered. Because health care is fully sponsored by the Cuban government, not once in 2 weeks of shadowing did I encounter talk of fees for services rendered, insurance, or billing.

After her daily office hours, my preceptor retired to her upstairs residence, but in no way did she relinquish to her duties as the neighborhood health care provider. People from the community would drop by to ask a question about diabetes, tell a story about their trip to the pharmacy, or most commonly, to share a fruit shake (batido) and chat about the day's events. My preceptor cared for her patients with casual comfort, demonstrating the power of community medicine. She was a constant and dependable influence on her community. Aside from her roles as gatekeeper, health manager, and first responder for emergencies, she served as an active source for health promotion within her community.

In no situation was this unique guise more evident than during terrenos, her semiweekly community rounds. Two afternoons a week, we headed out on foot to see patients within the context of their homes and daily living conditions. These visits did not resemble "house calls" in the 19th century American sense because there was often no chief complaint to address. Rather, their purpose was health promotion and education. Whether she was encouraging smoking cessation, describing how fatty diets lead to cardiovascular disease, or promoting the benefits of breastfeeding, my preceptor exemplified community medicine as she taught her patients about their health. After a full afternoon of terrenos, we returned to the consultorio to fill out substantial paperwork on each family we visited. As my preceptor later explained, it was the responsibility of the medico de familia to identify and track the community's risk factors before they manifested as disease.

As I marveled at the overwhelming sense of community in which the medico de familia worked, I wondered how Cuba's system has influenced health outcomes. Even in the face of a weak economy, the Cuban government has consciously diverted a substantial portion of its resources toward the primary care infrastructure and preventive medicine efforts such as immunizations and an extensive maternal-fetal health program. Our lectures enthusiastically touted the results of these expenditures when they proudly reviewed Cuba's impressive vital statistics. Cuba maintains an infant mortality rate of just 7.1 per 1,000 live births1 and a life expectancy at birth of 73 years for males and 78 for females.2 These numbers are far better than the rest of Latin America, and even comparable to most industrialized nations. When compared with some urban areas of the United States, the results are startling. A 1997 report of the American Association for World Health noted that the infant mortality rate in Cuba is nearly half that of the Washington, DC area.3 Although it is difficult to compare health outcomes, especially across societies with such disparate ideologic foundations, at the least, Cuba's vital statistics support the preventive medicine approach.

Remarkably, Cuba has built a healthy society despite decades of severe economic blows. When the Soviet Union fell in 1989, Cuba's economy was slashed by nearly 50% almost overnight.4 Previously able to trade its abundant sugar cane export for Russian food and oil, Cuba was forced to find other means to sustain itself. In the early 1990s, the government responded by constructing a remarkably advanced biotechnology industry that earned more than $100 million in exports in 1998.1 Recently, they have even begun to export some well-researched herbal remedies as well. But losing trading ties with the Soviet bloc is only 1 of the forces impinging on Cuba's financial repositories.

Perhaps the best-studied (and most controversial) strain on the Cuban economy is the US trade embargo against Cuba, originally instituted in 1960 by President Eisenhower. Shortly after Fidel Castro declared Cuba a socialist state, the US government severed diplomatic relations and imposed harsh economic sanctions. Over time, additions have altered the basic policy, mostly increasing the severity of the sanctions. In 1996 the passage of the Helms-Burton Law codified much of the previous legislation, making it difficult to change.

The net effect of economic isolation on the Cuban health care system has been a severe restriction of access to medications, biomedical information, supplies (eg, x-ray film), and spare parts for aging equipment.5 These shortages became real for me after some of our hospital and clinic visits. I was amazed when in the National Nephrology Institute we were shown a computed tomographic scanner rigged from spare parts originating in several different countries. In another hospital in Havana, we were shocked to discover 2 women bleaching a large pile of dirty latex gloves for reuse. Later, in the same hospital, our amicable physician-tour guide explained that whenever possible, patients are assigned a single new needle to be used for all blood draws. While in Pinar del Rio, I noticed how many times my preceptor was forced by the undersupplied pharmacy to go to her third or fourth choice of medication. These experiences illustrate the dramatic impact of international policy on the health of Cuban citizens.

Debate about the current state of health care in Cuba sits squarely at the intersection of medical philosophy, economic policy, and political ideology. Cuba's is a system with sound ideologic foundations and clearly effective investments in primary care and preventive medicine. Unfortunately, it has been seriously undermined by a lack of resources stemming from Cuba's economic isolation. But the most powerful lessons of my trip had less to do with policy and more to do with people. Cuban doctors display incredible courage caring for patients without regard for money, working overtime in declining facilities, and making medical devices work that we would have thrown out long ago. It was inspiring to see the trust that Cuban physicians and patients shared in an environment devoid of financial expectations and heartening to see their compassion, offering time and energy without concern for reimbursement. In many ways, these experiences demonstrated what it really means to be a physician. From the intimacy of a quiet patient interview to the vastness of international political jostling, if nothing else, Cuba offered a fresh perspective.

References

1. The Americas shift toward private health care. The Economist (US Edition) May 8, 1999, pp 27 -29.

1. Bureau of Inter-American Affairs, US Department of State. Background notes: Cuba, April 1998. Available at: www.state.gov/www/background_notes/cuba_0498_bgn.html. Accessed May 24, 2001.

1. The Impact of the US Embargo on Health and Nutrition in Cuba: A Report From the American Association for World Health. Executive Summary. Washington, DC. March 1997.

1. Rojas Ochoa F, López Pardo CM. Economy, politics, and health status in Cuba. Int J Health Serv 1997;27: 791 -807.[Medline]

1. Chelala C. Relations between the United States and Cuba: a proposal for action [letter]. JAMA 1996; 275: 559 -960.[Medline]