In a brief but intriguing visit to Cuba in December 2003, we saw how a first-world primary health care system operates in a country with third-world economics. During our eight-day visit, we participated in a leadership seminar organized by the Medical Education Cooperation with Cuba program that allowed us to meet with Cuban nurses, physicians, public health officials, and educators and attend discussion groups at a number of clinics and health care facilities. Although the brevity of our visit, a slight language barrier eased by interpreters and many Cubans' fluent English, and the constant presence of Cuban health ministry officials somewhat limited our information gathering, our impression was that Cuba's public health-primary care system sustains the overall health of its citizens at a first-world level, despite Cuba's being a developing country operating under tough economic sanctions. This article describes what we saw of what Spiegel and Yassi called the Cuban paradox-that is, that a poverty-stricken country can achieve health outcomes comparable to those of developed nations.1
The Republic of Cuba, an island nation 90 miles south of Florida, has a population of more than 11 million. Health care, education, and most industries are owned and controlled by the state. Political conflict between the United States and the Cuban government of President Fidel Castro, established in 1959, resulted in the placement of a trade embargo in 1961 that continues today, with resultant chronic shortages of such goods as medical and pharmaceutical supplies, food, and petroleum. Restrictions have also limited the interaction of Cuban and American health care professionals. Recently, educational travel restrictions have been further tightened by the U.S. government.
Nonetheless, Cuba has a comprehensive, highly collaborative public health-based national health care program that reports impressive outcomes. According to World Health Organization Core Health Indicator data for 2004, Cuba and the United States have identical average life expectancies (75 years for men, 80 years for women) and infant mortality rates (six per 1,000 live births).2 (See Table 1, page 77.) Total per capita expenditure on health care in 2003 was $251 in Cuba and $5,711 in the United States.2 The difference can be attributed to Cuba's emphasis on public health collaboration, easy access to primary care, mission-based goals and objectives, integration of health education, minimal administration and related costs (including provider salaries), and relevant and timely research and development.
|Figure. A remote clinic in the densely forested Pinar del Rio Province is surrounded by an herb garden. In some rural areas of Cuba, clinics are run solely by nurses. Photos courtesy of Linda Norlander.|
|Table 1. Health Data Comparison|
EDUCATING MEDICAL PROFESSIONALS
The Cuban revolution of 1959 caused nearly half of the country's physicians and two-thirds of its nurses to flee, and Cuba has rebuilt its health care workforce with free education for qualified students. Each graduate performs two years of community service. In 2002 Cuba had approximately 64,000 physicians and 82,500 nurses, with 30,000 physicians and 32,000 nurses practicing in community settings.3
Health care professionals are trained first in public health and population-based strategies. All physicians, more than 60% of whom, we were told by educators, are women, are trained as family practitioners, after which they can pursue specialized training.
In a rundown classroom at the Julio Trigo Lopez School of Medical Sciences, the country's center for nursing education, Dr. Daisy Berdayes, a nurse and dean at the medical school in Havana, told us about developing advanced curricula for nursing. In 2003 Cuba was only beginning to emphasize advanced training for nurses. The first class of nurses with master's degrees will graduate soon, and a PhD program is in development.
Like the United States, Cuba suffers from a shortage of nurses, and its recruitment and retention issues parallel our American challenges. An additional challenge imposed by the embargo and the country's limited financial resources is the scarcity of nursing journals and other nursing education materials for use in training.
Despite this paucity of resources, Cuba's well-developed medical education program shares its expertise with developing nations. Many physicians go to other developing countries to help them establish primary care systems. Ironically, Cuba is also training medical students from underserved areas of the United States to go back to their own neighborhoods to practice family medicine.4
CARING FOR THE PEOPLE
Cuba's primary care system emphasizes population health, preventive care, and health education. It has three levels of care:
* Health guardians-neighborhood-based physician-nurse teams
* Polyclinics-community-based multispecialty clinics
* Hospitals-acute care facilities
Health guardians. The most basic unit of caregivers in the Cuban system is a team of one nurse and one physician. They focus on early diagnosis and treatment of illnesses and prevention education. Health guardian teams generally care for no more than 150 families-450 to 500 people-through clinic visits, home visits, and community education. All community members are assessed and categorized as healthy or healthy with some risk factors such as tobacco or alcohol use (these patients are assessed annually), sick (treated and seen at least every three months), or chronically ill or disabled (treated and seen monthly).
Regular assessment allows the team to monitor the health care challenges in the population they serve. When public health issues arise, they institute community-based interventions, like developing what they termed a "coffee and condoms" education strategy at high schools to address teen pregnancy.
A family practice physician earns the equivalent of $30 per month; a nurse earns $25. One family practitioner, Dr. Jose Ramon, said of the wage, "It is what it is, and to get additional dollars, an evening taxi job works fine." Mercedes Ochoa, the nurse on Dr. Ramon's health guardian team, said, "I am here to care for my people and it is a fine balance for my life." Minimal wage disparity, clear role delineation for nurses and physicians, and steady demand for services seem to lessen tensions that often exist among U.S. health professionals.
Health guardians live in modest government apartments next to their offices. Maria Valdez, a clinic nurse in a suburb of Havana, showed us her small, modestly furnished apartment. Valdez explained that because many Cuban families have multiple generations living in one small home, government housing is a significant incentive. All Cubans get a monthly food voucher as well.
In suburban Havana, we visited several health guardian offices. Poster board displays in the small, sparsely furnished waiting rooms promoted smoking cessation, healthful eating, and breastfeeding initiatives. Immunizations are recorded on file cards and patient summary reports are entered into ledgers by hand. These summaries are sent weekly to the regional polyclinic for central reporting. Supplies were scarce in the exam rooms. Posters for teaching and counseling patients were pasted on all the walls, emphasizing the educational thrust of Cuba's primary care system.
We also visited the Canal Project Community Center in one of Havana's distressed neighborhoods. This project was developed in response to Dr. Migdalia Socarras's concerns about the high mental-retardation rates in some areas, most likely related to the use of lead-based paints, lead-contaminated soil, and poor nutrition. The local health guardian team and an urban planner organized the community to convert a rundown building and its property into a community center, health clinic, and garden. The initiative improved infant mortality and preterm birth rates, the incidence of low birth weights, nutrition, urban redevelopment, and community investment.
The pride these health guardian teams feel was evident. Clearly the monthly salary was not their sole motivation and reward. As Dr. Socarras said, "I carry the children on my shoulders, but I do not feel their weight."
At a remote clinic in the densely forested Pinar del Rio Province, the health guardian team worked in a sparsely furnished, solar-powered 15'x 15' structure. A medicinal herb garden, tended by the team, surrounded the building. The clinic was stocked with some basic medicines for emergencies and an oxygen tank. The only way to communicate with the nearest hospital or polyclinic was by a radio that was not working at the time. To transfer a patient who requires more advanced medical care, said the young physician, Dr. Sonia Gonzales, "when a vehicle comes by, we load the patient on and take them to the closest polyclinic." At 38 weeks of pregnancy, said Mercedes Tochoa, RN, pregnant women are "taken to San Cristobal to a maternity home to await the baby." Virtually all babies in Cuba are born in the hospital, one factor in their low infant mortality rate.
Rural health guardians are integral parts of the communities they serve, and they spend much of their time among their patients. The clinic site we visited was also the location of the community's television. Powered by eight car batteries, the television provided a critical link to the country's urban areas and latest news. The nurse plays a particularly strong role in rural clinics. In some of the remotest areas of Cuba, we were told, the clinics are run solely by nurses.
Polyclinics. Approximately 440 polyclinics are located at schools and job sites in both rural and urban neighborhoods. A hybrid of our outpatient clinic, complementary medicine clinic, and short-stay hospital, these centrally located community health clinics provide services such as pediatric medicine, internal medicine, dentistry, eye care, rehabilitation, and diagnostics. The 19th of April Polyclinic in Havana offered acupuncture, energy work, and mud and crystal therapies, as well as the usual physical, speech, and occupational therapies. We were told that the Cuban health care community researched and implemented nontraditional therapies as alternatives to scarce and costly traditional therapies and pharmaceuticals. Local health guardian teams follow up with patients who have specialty services performed at the polyclinics.
The primary complaint of staff we spoke with was the limited availability of high-tech devices such as computers and X-ray machines. For example, adjacent to the new ultrasonograph at the polyclinic was a 1940s manual typewriter used to issue the reports. Few computers were available, but each polyclinic still kept extensive records on national indicators (immunization status and health acuity, for example). Their data sets used a simplified national system of 283 diagnostic codes.
When we inquired about budgeting and financing, the administrative staff asked with baffled looks, "Budget? What budget?" They explained that their financial process revolves around determining how to accomplish their goals with the few resources they are allocated. Polyclinic personnel do not deal with finances. In fact, because health care is covered under a universal system, polyclinics do not have a billing department or business office.
Although the polyclinic's leaders expressed a need for more supplies and equipment, they offset the reality of having too little with a tremendous amount of creativity. They made do with what they had and focused on basic outcomes.
Hospitals and other facilities. Cuba has approximately 280 hospitals, but our tour was limited to a hemodialysis unit in San Cristobal. That hospital's director was proudest of their equipment and supplies imported from China. The patients we spoke with praised the staff and services, but what lingered in our memories was the starkness of the surroundings. Plastic buckets holding reusable supplies lined open shelves, awaiting the weekly dialysis of the patient whose name was scribbled by hand on each one. Another American team that toured general medical wards reported that the floor units were very basic, with metal gurneys and scarce basic supplies. The primitive surroundings were markedly different from U.S. hospitals. As many of the buildings in Cuba are, the health care facilities were generally shabby.
We were told that in addition to hospitals, there are 196 homes for the elderly, 220 maternity homes, a sanatorium for treating HIV and AIDS, and several homes for the severely disabled, as well as an abundance of day programs for the elderly at casas de abuelos (grandparents' homes). Investigators at Havana's Pedro Kouri Institute of Tropical Medicine conduct world-class research into tropical and infectious diseases, as well as biopharmaceuticals. In addition, health tourism, which caters to foreigners looking for inexpensive medical treatment, is a growing part of the Cuban economy.
Our glimpse of the Cuban health care system left us wanting more information. How do their trauma and emergency care indicators compare with those of other countries, for example? Do rural and urban disparities exist in other areas of health? We also wondered about the level and rigor of medical education-is it comparable to education in the United States?
When our questions extended beyond the realm of health care the information given to us was the "official version." We were usually accompanied by a representative from the health ministry, and out of respect for our hosts, we did not discuss politically sensitive topics.
What we saw was an effective health care system in which nurses play central roles in health education, health care, and health advocacy. We saw a system driven by political will, a clear mission and vision, and creativity. As many in the United States struggle to maintain outcomes with diminishing resources, Cuba provides an example of a system anchored on public health and education that works for the health care good of its citizens.