Cuban Public Health:A Model for the U.S.?

Marc Schenker M.D., M.P.H.

Outline

• Vital statistics• Health system performance• Recent history and organization of Cuban health

care• Public health organization

– Examples• Lessons for the U.S.?

Cuba is a

Country of Ironies

The Irony of Cuban Health Care

“Because Cuba has so few resources, prevention has become the only affordable means of keeping its population healthy.”

Vital Statistics

Life Expectancy* in 2000

76.8 76.3 72.8

52.4

0

10

20

30

40

50

60

70

80

U.S. Cuba Mexico Haiti

*years

Life Expectancy at BirthSource: PAHO 2000

Infant Mortality* in 2000

7 7.214.5

83

0

10

20

30

40

50

60

70

80

90

U.S. Cuba Mexico Haiti

*per 1,000 live births

Infant Mortality RateSource: PAHO 2000

Probability of Dying (per 1000), 1999

Source: World Health Organization, 2000.

COUNTRYUnder Age 5 Years

Between

and 59

Ages 15

Years

Male Female Male Female

Cuba 10 8 143 99

Haiti 120 111 481 360

Mexico 26 23 194 109

U.S. 8 8 148 85

GDP per Capita

31.9

1.7

8.1

0.50

5

10

15

20

25

30

35

U.S. Cuba Mexico Haiti

$1000/capita

National Health Expenditures per Capita (US $)

3858

106 160 90

500

1000

1500

2000

2500

3000

3500

4000

U.S. Cuba Mexico Haiti

Source: Pan American Health Organization, 1998.

Health Expenditure as % of GDP

-113579

111315

U.S. Cuba Mexico Haiti

Health Expenditures as % of National Budget in Cuba, 1990-1997

Source: Center for Financial Research of the Ministry of Finance, Cuba, 1998.

6%

7%

8%

9%

10%

11%

12%

1990 1991 1992 1993 1994 1995 1996 1997

Physicians per 10,000 Population

279

582

186

0

100

200

300

400

500

600

U.S. Cuba Mexico

Number of People per PhysicianSource: PAHO 2000

0 2000 4000 6000 8000 10000 12000 14000

Haití

Paraguay

Nicaragua

Honduras

Guatemala

El Salvador

Chile

Perú

Colombia

Panamá

Brasil

Bolivia

Costa Rica

Ecuador

México

Rep. Dominicana

Venezuela

Argentina

Uruguay

Cuba

Number of surgeons per 100,000 population

Cuba 56United States 51Japan 31Sweden 29Germany 13China 10Columbia 7United Kingdom 6South Africa 6Philippines 1.5Kenya 0.6Tanzania 0.3

Bulletin of the American College of Surgeons, 1987J. Perez, personal communication, 2000

Health System Performance

World Health Report of Health System Performance, 2000

Ranking of 191 countries using composite index – 25% level of health– 25% distribution of health– 12.5% level of responsiveness– 12.5% distribution of responsiveness– 25% financial contribution

World Health Report of Health System Performance, 2000

Cuba Ranking

• 33rd Disability adjusted life years• 41st Distribution of health care• 116th Level of responsiveness• 99th Distribution of responsiveness• 24th Fairness in financial contribution• 40th Overall goal attainment• 39th Overall performance

– Costa Rica, USA, Slovenia ranker higher– Brunei, New Zealand, Bahrain ranked lower

Health Systems Performance

Country Overall health system

performance (rank)

Health expenditure per capita

(rank)

Cuba 39 118

Haiti 138 100

Mexico 61 55

U.S. 37 1

Source: World Health Organization, 2000.

Rankings of 191 member states

Recent History and

Organization of

Cuban Health Care

Recent Cuban History

• 1959 Cuban revolution• 1962 Cuban missile crisis• 1960s-70s Cuban armed interventions Africa, Latin

America• 1989 Collapse of Communism, reduced Soviet

subsidies• 1990-95 “Special period” major austerity, 35% drop

GDP, 75% decrease in trade• 1993 Cubans allowed to have U.S. $• 1996 Helms/Burton Act tightens embargo

Cuban Healthcare History

• 1959 3000 doctors leave island• 1960s Ministry of Health (MINSAP) expanded

–Socialist healthcare system–Distribution of health care across Cuba

•Network of polyclinics•Hospital beds (Havana 62% -->38%)•National Immunization Program

–Medical schools increased from 1 to 4•2000 graduates per year

• 1984 Integral General Medicine program

“Physician migration from developing to developed countries has been criticized as a regressive subsidy paid for by poor nations that cover the costs of medical education while rich countries reap the benefits. The fact that the smartest minds are more prone to migrate makes this brain drain even more unfair.”

Diego Rosselli, Andres Otero, and Giovanni Maza, Universidad Javeriana Medical School, Colombia

Physician Migration

Source: Medical Education 2001;35:809-810.

• In January 2000, there were 2515 Colombian-trained physicians licensed to practice in the United States.

• This is equivalent to 6% of the national workforce.

• According to a study at Javeriana University Medical School, the U.S. migrants had higher grades than those who stayed in Colombia.

Sources: American Medical Association; Rosselli et al., 2001.

Physician Migration: Colombia

• Cuba is home to 60,000 doctors – comparable to Canada, which has 3 times the population

• Many of these doctors are assigned to work in developing countries

Cuba and the Export of Physicians

Source: Canadian Medical Association Journal 2001; 164(10): 1477.

• Over 20,000 Cuban doctors have been sent to 20 countries to help overcome physician shortages.

• When Hurricane Mitch struck Honduras in 1998, some 120 Cuban physicians were sent, and have since treated 1.2 million patients.

• 800 Cuban doctors currently work in Haiti.

• Cuban doctors have created an AIDS-prevention program in Uganda that the UN considers a model.

Accomplishments Abroad

Source: Canadian Medical Association Journal 2001; 164(10): 1477. Yan E. Castro Makes a Dream Offer. Newsday 28 February 2001.

• 3,400 medical students from 23 Latin American, African, and Caribbean countries are being trained in Cuba, at Cuba’s expense

• In 2001, 8 American students, all from low-income minority families, began their free medical education in Cuba, on the condition that they return to their communities for service.

• Fidel Castro has said that up to 500 American medical students may follow suit.

Medical Education and Diplomacy

Source: Canadian Medical Association Journal, 2001, 164(10): 1477.

Public Health in Cuba

Aspects of Public Health in Cuba

• Highly integrated with therapeutic medicine• Polyclinic teams of primary care doctors, dentists, nurses

–Provide health education, preventive care–Health workers live in the community–Physicians required to see every patient every year–Records of preventive services

• Prenatal, immunization, cancer screening, etc.–Aggressive follow-up of missed appointments–Vaccination rates 99+%

• Community reinforcement of public health–Neighborhood Committees for Defense of Revolution, Cuban Federation of Women, Circulos de Abuelos

• Surveillance data to province, state

Examples of Cuban Public Health, Infectious diseases

• Incidence of vaccine preventable infectious diseases lower than in any other nation at Cuba’s level of economic development.

• Immunization rates between 99% and 100%

• Compliance by routine epidemiologic surveillance at the neighborhood level (e.g. CDR)

Mortality Rates for Infectious Diseases

1960 1982

Diptheria 0.7 0.0

Tetanus 4.4 0.1

Pertussis 1.0 0.1

Measles 1.1 0.2

Deaths per 100,000

Examples of Cuban Public Health, Geriatric Care

• Geriatric rotation during residency training.

• Primary care physicians who elect to gain additional training in geriatrics provide services in network of old age homes.

• “Grandparents’ circles” (circulos de abuelos) provide neighborhood-based care and support.

Examples of Cuban Public Health, Medical Surveillance

• Data on acute and chronic illnesses pass from family physicians to municipal, provincial and national levels.

– Identification of epidemics

• Neuropathy between 1991-1993

• Dengue

Pesticide Spraying for Mosquitos

Examples of Cuban Public Health, AIDS

• Initial quarantine of HIV-positive patients

– Started with HIV+ soldiers returning from Africa

• Compulsory quarantine lifted, HIV sanitariums became voluntary

– Sanitariums in 13/14 provinces

• 70-80% newly diagnosed choose ambulatory treatment

• Epidemic helped by quarantine, travel restrictions. Lowest HIV rate in hemisphere

• Active screening, 2 million annual HIV tests

• “Jinaterismo” (prostitution) raises many issues

HIV in Haiti and in Cuba

Total population:

People living with AIDS (1999 est.) :

AIDS deaths (1999 est.) :

HIV/AIDS adult prevalence rate (1999 est.) :

Cuba: Haiti:

11 million 7 million

1,950 210,000

120 23,000

0.03 % 5.17 %

Source: CIA World Factbook, 2001.

Cuban Public Health:A Model for the U.S.?

• Cuba is a socialist system, not transferable to the U.S. No private health care.

• Surveillance involves intrusive social institutions, e.g. CDR

• Public health may involve “coercive” policies, e.g. AIDS quarantine, pesticide spraying

NO

Cuban Public Health:A Model for the U.S.?

• There is no intrinsic reason for the separation of treatment and preventive (public health) services in the U.S.

• Integrated primary care is a cost-effective model (if we can get there)

• Prioritizing health resources to achieve social objectives (e.g. eliminate health disparaties) is effective

• Improving surveillance systems at the primary care level is important and possible

NOWEVERNOWEVER

“There is a large body of misinformation and outright disinformation about the present state of health care in Cuba… The Cuban Government’s deliberate policy includes depriving its people of basic medical needs, while actively developing a closed, parallel health care system for the Communist Party elite, foreign ‘health tourists,’ and others who can pay for services in hard currency.”

U.S. Department of State, Press Statement, 1997

The U.S.:

Defending the Embargo

The Ultimate Public Health Irony in Cuba

http://epm-schenker.ucdavis.edu/cuba.htm

The End