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01/24/13 - The New England Journal of Medicine - A Different Model: Medical Care in Cuba

Edward W. Campion, M.D., and Stephen Morrissey, Ph.D. N

Engl J Med 2013; 368:297-299 January 24, 2013 DOI: 10.1056/NEJMp1215226

For a visitor from the United States, Cuba is disorienting.  American cars are
everywhere, but they all date from the 1950s at the latest.  Our bank cards,
credit cards, and smartphones don't work.  Internet access is virtually
nonexistent.  And the Cuban health care system also seems unreal.  There are too
many doctors.  Everybody has a family physician.  Everything is free, totally
free - and not after prior approval or some copay.  The whole system seems
turned upside down.  It is tightly organized, and the first priority is
prevention.  Although Cuba has limited economic resources, its health care
system has solved some problems that ours has not yet managed to address.1,2

Family physicians, along with their nurses and other health workers, are
responsible for delivering primary care and preventive services to their panel
of patients - about 1000 patients per physician in urban areas.  All care
delivery is organized at the local level, and the patients and their caregivers
generally live in the same community.  The medical records in cardboard folders
are simple and handwritten, not unlike those we used in the United States 50
years ago.  But the system is surprisingly information-rich and focused on
population health.

All patients are categorized according to level of health risk, from I to IV.
Smokers, for example, are in risk category II, and patients with stable, chronic
lung disease are in category III.  The community clinics report regularly to the
district on how many patients they have in each risk category and on the number
of patients with conditions such as hypertension (well controlled or not),
diabetes, and asthma, as well as immunization status, time since last Pap smear,
and pregnancies necessitating prenatal care.

Every patient is visited at home once a year, and those with chronic conditions
receive visits more frequently.  When necessary, patients can be referred to a
district polyclinic for specialty evaluation, but they return to the community
team for ongoing treatment.  For example, the team is responsible for seeing
that a patient with tuberculosis follows the assigned antimicrobial regimen and
gets sputum checks.  House calls and discussions with family members are common
tactics for addressing problems with compliance or follow-up and even for
failure to protect against unwanted pregnancy.  In an effort to control
mosquito-borne infections such as dengue, the local health team goes into homes
to conduct inspections and teach people about getting rid of standing water, for
example.

This highly structured, prevention-oriented system has produced positive
results.  Vaccination rates in Cuba are among the highest in the world.  The
life expectancy of 78 years from birth is virtually identical to that in the
United States.  The infant mortality rate in Cuba has fallen from more than 80
per 1000 live births in the 1950s to less than 5 per 1000 - lower than the U.S.
rate, although the maternal mortality rate remains well above those in developed
countries and is in the middle of the range for Caribbean countries.3,4 Without
doubt, the improved health outcomes are largely the result of improvements in
nutrition and education, which address the social determinants of health.
Cuba's literacy rate is 99%, and health education is part of the mandatory
school curriculum.  A recent national program to promote acceptance of men who
have sex with men was designed in part to reduce rates of sexually transmitted
disease and improve acceptance of and adherence to treatment.  Cigarettes can no
longer be obtained with monthly ration cards, and smoking rates have decreased,
though local health teams say it remains difficult to get smokers to quit.
Contraception is free and strongly encouraged.  Abortion is legal but is seen as
a failure of prevention.

But one should not romanticize Cuban health care.  The system is not designed
for consumer choice or individual initiatives.  There is no alternative,
private-payer health system.  Physicians get government benefits such as housing
and food subsidies, but they are paid only about $20 per month.  Their education
is free, and they are respected, but they are unlikely to attain personal
wealth.  Cuba is a country where 80% of the citizens work for the government,
and the government manages the budgets.  In a community health clinic, signs
tell patients how much their free care is actually costing the system (see photo
Poster Indicating the Actual Costs of Care Provided Free of Charge to Cuban
Patients.  ), but no market forces compel efficiency.  Resources are limited, as
we learned in meeting with Cuban medical and public health professionals as part
of a group of editors from the United States.  A nephrologist in Cienfuegos, 160
miles south of Havana, lists 77 patients on dialysis in the province, which on a
population basis is about 40% of the current U.S. rate - similar to what the
U.S. rate was in 1985.  A neurologist reports that his hospital got a CT scanner
only 12 years ago.  U.S. students who are enrolled in a Cuban medical school say
that operating rooms run quickly and efficiently but with very little
technology.  Access to information through the Internet is minimal.  One medical
student reports being limited to 30 minutes per week of dial-up access.  This
limitation, like many of the resource constraints that affect progress, is
blamed on the long-standing U.S. economic embargo, but there may be other forces
in the central government working against rapid, easy communication among Cubans
and with the United States.

As a result of the strict economic embargo, Cuba has developed its own
pharmaceutical industry and now not only manufactures most of the medications in
its basic pharmacopeia, but also fuels an export industry.  Resources have been
invested in developing biotechnology expertise to become competitive with
advanced countries.  There are Cuban academic medical journals in all the major
specialties, and the medical leadership is strongly encouraging research,
publication, and stronger ties to medicine in other Latin American countries.
Cuba's medical faculties, of which there are now 22, remain steadily focused on
primary care, with family medicine required as the first residency for all
physicians, even though Cuba now has more than twice as many physicians per
capita as the United States.4 Many of those physicians work outside the country,
volunteering for two or more years of service, for which they receive special
compensation.  In 2008, there were 37,000 Cuban health care providers working in
70 countries around the world.5 Most are in needy areas where their work is part
of Cuban foreign aid, but some are in more developed areas where their work
brings financial benefit to the Cuban government (e.g., oil subsidies from
Venezuela).

Any visitor can see that Cuba remains far from a developed country in basic
infrastructure such as roads, housing, plumbing, and sanitation.  Nonetheless,
Cubans are beginning to face the same health problems the developed world faces,
with increasing rates of coronary disease and obesity and an aging population
(11.7% of Cubans are now 65 years of age or older).  Their unusual health care
system addresses those problems in ways that grew out of Cuba's peculiar
political and economic history, but the system they have created - with a
physician for everyone, an early focus on prevention, and clear attention to
community health - may inform progress in other countries as well.