Life

Is Cuba the answer?

Cubas annual total health spend per capita is only $251 Responses to this article (1) In this article: Controversial, but impressive Doctors in the community Public health and polyclinics And still I dont 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 100000 in 1995 (5 cases per 100000 in 1989), and, from 1992 to 1994, more than 51000 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 peoples access to information as it controls the islands internet servers, printing presses, and broadcasting transmitters.[9] Since 1995 Cubas 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 By: James Gardiner Published: 13 December 2011 DOI: 10.1136/sbmj.d7460 Cite this as: student BMJ 2011;19:d7460

>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 Cubas 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, Cubas 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] Cubas 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 worlds first meningitis B vaccine; created the national biomedical internet (INFOMED); and has one of the worlds 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. Cubas 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, Cubas 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. Hes 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, wasnt 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 dont see a doctor early enough. In Cuba, it can be hard to avoid your general practitioner.[18] Dr Hitchin touched on Cubas community watch system, the Committee for Defence of the Revolution. In Cubas system, there is a nominated person in each neighbourhood in charge of organising public health mattersfor example, ensuring that people get vaccinations. This also serves as a comprehensive evacuation serviceCuba 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 Cubas 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] Cubas strategy is preventative: treating illnesses before they become advanced and costly. This contrasts with the UKs 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 dont 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 coveragethats roughly seven times the population of Cuba, he said. Dr Hitchin said, Weve mainly talked about the positives when it comes to Cuba. There are also many negatives. Ive read about it for years and I still havent made up my mind. A common Cuban saying is: Ive lived here all my life and still I dont 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, Cubas healthcare system controversially lacks some cornerstone values, such as the right to privacy, right of informed consent, and right to refuse treatment. Nevertheless, the islands 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: Cubas infant mortality rate, proportion of low birthweight infants, and life expectancy all compare favourably. These are only a few of the indicators for which Cubas 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 Cubas 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. References 1. Cuban history timelineCuba solidarity campaign. Facts about Cuba. www.cubasolidarity.org.uk/resources/Cubanhistory-timeline.pdf. 2. Was the revolution successful?Cuban revolution of 1959.https://glazersspace.wikispaces.com/Wastherevolutionsuccessful%3F. 3. Nayeri K, Lpez- Pardo CM. Economic crisis and access to care: Cubas health care system since the collapse of the Soviet Union. International Journal of Health Service 2005;35(4):797816. 4. Denial of food and medicine: The impact of the US embargo on the health and nutrition in Cuba. American Association for World Health report. Summary of findings. March 1997.www.cubasolidarity.net/aawh.html. 5. De Vos P, Bonet M, Van der Stuyft P. Health and human rights in Cuba. Lancet 2004;364:2177.www.thelancet.com/journals/lancet/article/PIIS01406736(04)17582-X/fulltext. 6. Hirschfeld K. Re-examining the Cuban health care system: towards a qualitative critique. Cuban Affairs Quarterly Electronic Journal 2007;2:3. 7. Kleinman A. Social origins of distress and disease: depression, neurasthenia and pain in modern China. Yale University Press, 1986. 8. Nevarro L. Tropical depression. The Virginia Quarterly ReviewWinter 2009:2647.www.vqronline.org/articles/2009/winter/navarro-cuba-depression/. 9. Wilkinson D. The new challenge to repressive Cuba. Human Rights Watch. 19 Aug 2010.www.hrw.org/en/news/2010/08/19/new-challenge-repressive-cuba. 10. Whiteford LM, Branch LG. Primary health care in Cuba: The other revolution. Scarecrow Press, 2009. 11. World Health Organization. World Health Statistics 2009.www.who.int/whosis/whostat/2009/en/index.html. 12. Cuba solidarity campaign. Education in Cuba. Fact sheets on Cuba. www.cubasolidarity.org.uk/resources/EducationinCuba.pdf. 13. Yudkin JS, Owens G, Martineau F, Rowson M, Finer S. Global health-worker crisis: the UK could learn from Cuba. Lancet 2008;371:13979. www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60608-X/fulltext. 14. Central Intelligence Agency. Country comparison: Life expectancy at birth. CIA factbook.www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html. 15. Offredy M. The health of a nation: perspectives from Cubas national health system. Qual Prim Care2008;16:269-77. 16. Harris J. Keeping Cuba healthy. BBC News, 1 Aug 2006.http://news.bbc.co.uk/1/hi/programmes/newsnight/5232628.stm. 17. Mckellar J. Differintegration. Healthcare in Cuba. 19 Apr 2011.http://differintegration.com/2011/04/19/healthcare-in-cuba/.

18. Carroll R. First world results on a third world budget. Guardian 2007 Sept 12.www.guardian.co.uk/world/2007/sep/12/film.health. 19. Healthcare for London. Delivering healthcare for London: An integrated strategic plan 20102015. First stage report. January 2010.www.london.nhs.uk/webfiles/Corporate/First%20Stage%20Report.pdf. 20. Lister J. The Darzi report: the critical gaps.www.healthemergency.org.uk/pdf/Darziresponsecriticalgaps.pdf. 21. Campbell D, McNicoll A. NHS cuts: the first casualties. Guardian 2011 April 11.www.guardian.co.uk/society/2011/apr/11/nhs-cuts-first-areas. Cite this as: student BMJ 2011;19:d7460