Healthcare in Cuba

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The Cuban government operates a national health system and assumes full fiscal and administrative responsibility for the health care of its citizens.^[1] No private hospitals or clinics are permitted. The present Minister for Public Health is José Ramón Balaguer. The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine.

[edit] History

As was true of the other indigenous societies of the Americas, Cuban traditional medicine existed before the Spanish conquest. High status traditional practitioners were called Bohiques. After colonization, Cuban medicine followed the Spanish tradition which was inherited from the Moors, who drew upon classical Greek and Roman medical practices. Chinese medicine has also been practiced in Cuba, the most famous was the 19th century doctor Cham Bom Biam or “El Medico Chino”. ^[2]

1900 The Hospital de San Felipe in Havana, a healthcare educational facility built by the religious order San Juan de Dios in the mid 19th century

The doctor's fame on the island gave rise to the expression “no le salve ni el medico chino” (noone can save him if not the chinese doctor) which was applied to those who had a terminal illness. Modern Western Medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th Century. ^[3] Cuba has had many world class doctors, including Carlos Finlay, who determined how Yellow fever was spread under the direction of Walter Reed, James Carroll, and Aristides Agramonte. During the period of U.S presence (1898-1902) yellow fever was essentially eliminated due to the efforts of Clara Louise Maas and surgeon Jesse W. Lazear. The University Hospital of the University of Havana, The Calixto Garcia Hospital, was expanded following Cuban independence in 1902 to become Cuba's largest hospital. In total, 72 hospitals on the island were in operation before the 1959 revolution.[2]

By the 1950s, the island had some of the most positive health indices in the Americas, not far behind the United States and Canada. Cuba was one of the leaders in terms of life expectancy, and the number of doctors per thousand of the population ranked above Britain, France and Holland. In Latin America it ranked in third place after Uruguay and Argentina.^[4] There remained marked inequalities however. Most of Cuba's doctors were based in the relatively prosperous cities and regional towns, and conditions in rural areas, notably Oriente, were significantly worse. ^{[4] [5]} Only 8% of the rural population had access to healthcare. ^[6]

Following the Revolution, the new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled "On Revolutionary Medicine", stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices."^[7] These aims were hampered almost immediately by an exodus of almost half of Cuba’s physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in University of Havana’s medical college.^[8] Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services. ^[8]

In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states "Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations." ^[9]

Cuba's doctor to patient ratio grew significantly in the latter half of the 20th century, from 9.2 doctors per 10,000 inhabitants in 1958, to 58.2 per 10,000 in 1999.^[10] In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox. Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care. Abortion rates, which are extraordinarily high in Cuba, increased dramatically during the 1980s, but had almost halved by 1999 and declined to near 1970s levels of 32.0 per 100 pregnancies. The rate is still among the highest in Latin America and also one explanation for the low infant mortality rate.^[10]

[edit] Present

[edit] Health indicators and issues

According to the 2000 World Health Organisation report, Cuba had the highest life-expectency in Latin America,^[11] and in 2002 was found to have the lowest infant mortality rate in the Americas along with Canada.^[12] Like the rest of the Cuban economy, Cuban medical care has suffered from severe material shortages following the end of Soviet subsidies and the ongoing United States embargo against Cuba. ^[13] However, data for 2004 show that Costa Rica, Chile, Virgin Islands, Guadeloupe, and Martinique now have a higher life expectancy for combined sexes from birth.[3]

Among adults less than 49 years old, accidents are the leading cause of death, though occupational accidents have declined significantly in the last decade. The suicide rate is 18.2 per 100,000 is higher and the homicide rate is 7.0 per 100,000. The rates of suicide in the island are the highest in Latin America and have been among the highest in the region and the world since the nineteenth century.^[14] Cuban-American suicide rates in Miami are lower than other Miami groups.^[15] Among older adults heart disease and cancer predominate as causes of mortality. General mortality has been "characterized by a marked predominance of causes associated with chronic noncommunicable diseases," according to the Pan American Health Organization. ^[16]

While preventative medical care, diagnostic tests and medication for hospitalised patients are free, some aspects of healthcare are paid for by the patient. Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. Prices are low, and subsidised by the state. For patients on a low-income, these items are free of charge.^[17]

[edit] Sexual health

According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990’s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment. ^[18]

In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world. ^[19] The UNAIDS reported that HIV infection rates for Cuba were 0.1%, and for other countries in the Carribean between 1 - 4%. ^{[20] [21]} Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education.

According to Avert, an international AIDS charity, "Cuba’s epidemic remains by far the smallest in the Caribbean." They add however that,

... new HIV infections are on the rise, and Cuba’s preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cuba’s prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs.

In recent years because of the increase in prostitution and lack of prevention, STDs have increased significantly.^[10]

[edit] Embargo

During the 90s the ongoing United States embargo against Cuba caused severe problems in Cuba due to restrictions of import of medicine.^[22][23] In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U.S. subsidiary trade, including trade in food and medicines, being prohibited. ^[22] The legislation did not state that Cuba cannot purchase medicines from U.S. companies or their foreign subsidiaries; however, such license requests have been routinely denied. ^[22] In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U.S. Government that such activities violate international law and has requested that the U.S. take immediate steps to exempt medicine from the embargo.^[24] The Lancet and the British Medical Journal also condemned the embargo in the 90s.^[25]

A report prepared by Oxfam America and the Washington Office on Latin America, Myths And Facts About The U.S. Embargo On Medicine And Medical Supplies, concluded that the embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U.S. firms or from non-U.S.sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba's medical system. It prohibited foreign subsidiaries of U.S. corporations from selling to Cuba, thus further limiting Cuba's access to medicine and equipment, and raising prices. In addition, the act forbids ships that dock in Cuban ports from docking in U.S. ports for six months. This drastically restricts shipping, and increases shipping costs some 30%.^[26]

However, in 2000 the Trade Sanctions Reform and Export Enhancement Act was passed, and the US is now the single largest source for imported food.^[27][28] The Cuban American National Foundation state that the US embargo does not include medicines and medical supplies to the Cuban people. It also states that should Cuba choose not to purchase from the U.S., it can purchase any medicine or medical equipment it needs from other countries. Such third-country transactions only cost an estimated 2%-3% more than purchases from the U.S. as a result of higher shipping costs.[4]

In a 2006 report to the U.N. Secretary-General, Cuba acknowledged the authorization of medicines, though stated that they were subject to severe restrictions and complicated procedures. Cuba is obliged to make payments in cash and in advance, and is precluded from obtaining credit funding, even from private sources. The sale and transportation of the goods require licences to be obtained for each transaction. Cuba cannot use its own merchant fleet for transporting these goods, but has to make use of vessels from third countries, primarily the United States. Payments are made through banks in third countries, since direct banking relationships are prohibited. The Cuban delegation concluded that restrictions on importing medical products were "so extensive that they make such imports virtually impossible". The World Health organisation/PAHO and UNFPA concurred that it was impossible for Cuba to purchase equipment, medicines and laboratory materials produced by the United States or covered by United States patents, even though those products were purchased through multilateral cooperation. Cuba was not able to purchase the isotope I-125 that is used to treat eye cancer in children. The companies manufacturing reagents and equipment are 70 per cent United States owned, which makes it difficult to purchase necessary medical equipment and other items^[29]

[edit] Medical staff in Cuba

According to the World Health Organization, Cuba provides a doctor for every 170 residents,^[30] and has the second highest doctor to patient ratio in the world after Italy ^[31]. All fiscal and administrative aspects of health care in Cuba are run by the state; no private hospitals or clinics are permitted, and medical workers are required to work for the state. Historically, Cuba has long ranked high in numbers of medical personnel; in 1957, before the revolution, it ranked third in Latin America and ahead of many European nations. Medical professionals are not paid high salaries by national or international standards. In 2002 the mean monthly salary was 261 pesos, thus 1.5 times the national mean. ^[32] The purchasing power of a doctor’s salary is about US$15-20 per month. Therefore, many prefer to work in different occupations, generally in the lucrative tourist industry, where earnings can be 50 to 60 times more.^[10]

[edit] Black market healthcare

The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba's burgeoning black market economy, sometimes termed "sociolismo". According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, "The doctors in the hospitals are charging patients under the table for better or quicker service." Prices for out-of-surgery X-rays have been quoted at $50 to $60 dollars. ^[33] Such "under-the-table payments" reportedly date back to the 1970's, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn know as the "Special Period" in the 1990's aggravated these payments. The advent of the "dollar economy", a temporary legalisation of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans were able to obtain medications and health services that would not be available to them otherwise.^[34]

[edit] Cuba and international healthcare

Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA), and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies ^[16]

Because the education of physicians came to exceed the country's internal requirements, Cuba has been able to export primary care practitioners and specialists for periods of service in other Third World nations. Cuban doctors have therefore played a role in many regions of the world. Cuba's missions in 68 countries are manned by 25,000 Cuban doctors, and medical teams have assisted victims of both the South Asian Tsunami and the Pakistan earthquake. ^[35] Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil. ^[36] Nearly 2,000 Cuban doctors are currently working in Africa in countries including South Africa, Gambia, Guinea Bissau and Mali.^[37] Since the Chernobyl nuclear plant exploded in 1986, more than 20,000 children from Ukraine, Belarus and Russia have traveled to Cuba for treatment of radiation sickness and psychologically based problems associated with the radiation disaster.^[38]

Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: "Mission Into the Neighborhood") social welfare program established in Venezuela under current Venezuelan president Hugo Chávez.^[39] The scheme, which is popular among Venezuela's poor and is intended to bring doctors and other medical services to the most remote slums of Venezuela, ^[40] has not been without its detractors. The Venezuelan Medical Association has criticised the appointment of Cuban doctors to high-ranking positions,^[41] and protests have taken place in the capital Caracas by Venezuelan medical staff who fear that the Cubans are a threat to Venezuelan jobs. Questions have also been raised by protestors about the level of Cuban medical qualifications, and there have been claims that the Cubans are "political agents" who have come to Venezuela to indoctrinate the workforce.^[40]

[edit] Operación Milagro

See also: Healthcare of Venezuela

Operación Milagro (Operation Miracle) is a joint health programme between Cuba and Venezuela, set up in 2005. The initiative is part of the Sandino commitment, which sees both countries coming together with the aim of offering free ophthalmology operations to an estimated 6 million people in Latin America and the Caribbean. ^[42] The scheme is also part of ALBA (Bolivarian Alternative for the Americas). Under the agreement, patients from Venezuela and other Latin American nations, most recently Panama, are flown to into Cuba for eye surgeries and other major treatments. In return Venezuela sends 90,000 barrels of crude oil per day at preferential rates.^[43] All flights, accommodation and food are funded by the Venezuelan government. The scheme was intended to expand to 500,000 operations a year in 2006. ^[44]

[edit] Health tourism and pharmaceutics

As well as its national health coverage, Cuba attracts paying health tourists, generating revenues of around $40m a year for the Cuban economy. In 2002 more than 5000 foreign patients travelled to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinsons disease, and orthopaedics. Most patients are from Latin America although medical treatment for retinitis pigmentosa, often known as night blindness, has attracted many patients from Europe and North America. Cuba also successfully exports many medical products, such as vaccines.^[45]

Some complaints have arisen that foreign "health tourists" paying with dollars and senior Communist party officials receive a higher quality of care than Cuban citizens. Former leading Cuban neurosurgeon and dissident Dr Hilda Molina asserts that the central revolutionary objective of free, quality medical care for all has been eroded by Cuba's need for foreign currency. Molina says that following the economic collapse known in Cuba as the Special Period, the Cuban Government established mechanisms designed to turn the medical system into a profit-making enterprise. This creates an enormous disparity in the quality of healthcare services between foreigners and Cubans leading to a form of tourist apartheid. In 1998 she said that foreign patients were routinely inadequately or falsely informed about their medical conditions to increase their medical bills or to hide the fact that Cuba often advertises medical services it is unable to provide. ^[46] The Cuban American National Foundation makes similar claims, also stating that senior Communist party and military officials can access this higher quality system free of charge.[5]In 2005, an account written by Cuban exile and critic of Fidel Castro, Carlos Wotzkow, appeared showing apparent unsanitary and unsafe conditions in the "Clínico Quirúrgico" of Havana.^[47] The Clínico Quirúrgico is reported to be one of the better hospitals available to Cubans ^{[citation needed]}; the article claims that health care for Cubans occurs in worse conditions in the rest of the country.

[edit] Alternative Healthcare

Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population ^[1] In the 1990’s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model.^[48] Examples of alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i.e. acupunctural anesthesia for surgery), natural dietary supplements, yoga, electromagnetic and laser devices.^[48] Children begin studying the multiple uses of medicinal plants in primary school, learning to grow and tend their own plots of aloe, chamomile, and mint, and later they conduct scientific studies about their uses. Radio and Television programs instruct people on how to relieve common stomach upset and headaches by pressing key points. ^[49] Cuban bio-chemists have produced a number of new alternative medicines, including PPG® (policosanol), a natural product derived from sugarcane wax that is effective at reducing total cholesterol and LDL levels, and Vimang® a natural product derived from the bark of mango trees.^[48]

[edit] See also

Cuba Portal

• Carlos Finlay
• Cuban Journal of Tropical Medicine
• Cuban Journal of Surgery
• Cuban Center of molecular immunology

[edit] External links

• Cuba AIDS Project — HIV and AIDS in Cuba
• Real Cuba
• Keeping Cuba healthy BBC Newsnight report
• Powerpoint presentation on Healthcare in Cuba by Dr. Peter Bourne
• Apartheid in Cuba's Health system
• UN HDI — Human Development Index for Cuba from UN

[edit] References