Download Medicina Cubana - International Programs

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
[email protected]
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Although I expected to find a "third world" health care system entrenched in an outdated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, preventionoriented 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.
2. 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.
3. 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.
4. Rojas Ochoa F, López Pardo CM. Economy, politics, and health status in Cuba.
Int J Health Serv 1997;27: 791 -807.[Medline]
5. Chelala C. Relations between the United States and Cuba: a proposal for action
[letter]. JAMA 1996; 275: 559 -960.[Medline]