All featured images were taken by Laura LaRose in Aldecoa, Havana, Ciudad de la Habana
Despite Cuba’s polarized political climate, the country has developed a rather unique health care system that continues to deliver strong results, even with the challenges it has faced. Ex-president Fidel Castro believed a strong health-care system and biomedical science were “long-term mainstays of the Cuban economy”. Therefore, not only did Castro develop a system that produced a surplus of medical professionals –which became a source of foreign exchange- but he also made sure Cuba invested in constant biomedical research. This socialist, poor island has demonstrated that “through long-term, consistent investments in primary care and public health,” a country can solidify its social base, improve the quality of life of its citizens, and stimulate its economy.
The Island’s Health Rates are Outstanding in the Region
The World Health Organization (WHO) reports that the life expectancy rates in Cuba are the second highest in Latin America and the Caribbean, with men reaching 77 years and women reaching 81 years of age in average. Infant mortality rates on the island are lower than those of the United States, and the doctor-per-patient ratio falls second in the world, after Italy, with one clinician for every 170 citizens. Moreover, “Cuba’s leading health care problems—non-communicable diseases such as heart disease, cancer, and stroke—are typical of much more wealthy countries.”
An article by Human Rights Watch published last year states that “the UNESCO has concluded that (…) the country either met the Millennium Development Goals (MDGs) that the UN established in 2000, or came close by the 2015 deadline.”
I had the pleasure of speaking with Dr. William Ventres, a family physician and medical anthropologist currently teaching at the University of Texas Medical Branch at Galveston. Dr. Ventres stated, “As a family physician, some twenty-five years ago, I became interested in looking at systems of healthcare that promote community-based primary care. [In] the early nineties, Cuba was in the process of starting family medicine as an option for providing primary care.”
The organization of the Cuban medical system is highly systematic; the focus lies heavily on prevention, as opposed to many other countries’ systems which focus mostly on treatment. Dr. Ventres shared that Cuba has focused on two things: “on a clinical point of view, on primary care, and secondly, it seems to have a well-developed system of primary, secondary and tertiary care – that there is communication between these three levels.” Patients are divided in into five categories depending on the state of their health, from completely healthy to high-risk, which determines their government-sponsored individual health maintenance plan. Moreover, as Dr. Ventres explained, health care in Cuba does not only consist of physical care, but includes psychological and social elements as well. “They seem to have done a very good job,” He continued. “I am absolutely sure they have problems, no system is perfect, but Cuba seems to have done a good job, especially in relationship to other countries of relatively equal economic level.” The system also involves a once-a-year mandatory home-visit by a doctor to check on every patient’s state of health. These visits are often unannounced, in order to get the most genuine assessment possible.
After the revolution, inspired by the state-controlled, centralized Soviet system, the new leaders (including iconic Che Guevara) established an innovative network of polyclinics emphasizing preventive care across the country. Polyclinics are centers that provide simple, quick medical services such as X-rays and general examinations. Patients can also receive minor surgeries such as vasectomies, cataract repair, and dental services in these polyclinics, which allows them to avoid unnecessary hospital visits and particularly benefits Cuba’s rural population. Icela Casas spent the first 30 years of her life in Santiago de Cuba, but now lives in South Florida. She and her sister were admitted into the United States. as political asylees when she was 32, and today, they both work at Lynn University as system analysts. Ms. Casas shared her outlook with Open Americas:
Healthcare in Cuba is free. Officially, nothing needs to be paid for other than treatments and medicine that do not come from a hospital, for very low prices. There is a system of primary attention in which there is a health center in every neighborhood with a medic and a nurse who are supposed to check up on the elderly, children, pregnant women, and visit patients at their homes –but not always do. These health centers are meant for people with minor illnesses or those who just need a routinely check-up, while polyclinics and hospitals are actually meant for urgencies and patients with major illnesses. Patients are not responsible of paying for surgery, chemotherapy, transplants or any other procedure –it is always free.
Because of the Cuban health care system’s inclusiveness and effectiveness, many global leaders have publicly praised it. Dr. Margaret Chan, the Director General of the WHO, stated after a visit to Cuba in 2014 that “this is the way to go,” and acknowledged it as one of the model-systems of the world. Before that, in 2006, BBC news program Newsnight included Cuba’s medical system in a series called “The Best Public Services in the World,” stating in an article that then-Prime Minister Tony Blair “should go Cuban.” When the Consultoría Interdisciplinaria en Desarrollo (CID), a Costa Rican associate of the Gallup Organization, carried out a survey in Cuba asking whether individual citizens had confidence in their country’s healthcare system, over three quarters of all participants responded positively. Overall, the preventive approach and effective communication between the physical, psychological, and social levels, the high doctor-to-patient ratio, the engaging community-based structure and inclusiveness of all citizens (with outstanding success at taking care of the elderly), and the implementation of accessible polyclinics make the Cuban healthcare system an exemplary model.
Economic and Political Challenges
The Cuban health care system is managed by the Ministry of Public Health, which is also in charge of determining all public health policies on the island. Most medical services are provided to the Cuban people at no cost to patients, which is one of the main tools the Castro regime has used to promote the country’s socialist agenda; in fact, the effectiveness of the universal family health care system was one of the main factors that has continued to motivate domestic support for the Castro regime.
Due to the gradual crippling of the Cuban economy starting in 1991, when annual Soviet aid worth US $4 billion was revoked at the end of the Cold War, support for the healthcare system has weakened significantly. By 1993, the Cuban economy had declined by 35 percent and living conditions for the average citizen worsened as prices rose steeply and hunger became commonplace. Despite the government’s efforts to improve conditions in medical facilities, as well as to acquire medical instruments and medications, further progress has been tremendously difficult due to a lack of financial resources.
Hospitals and health centers across Cuba have been deteriorating over the past several years. The lack of financial resources is preventing the socialist government from implementing an effective plan of action to improve healthcare conditions, to upkeep medical facilities, buy medicine and medical equipment, and pay for health professionals’ wages. Ms. Casas proceeded to explain:
The health care system has deteriorated over the past several years; the is a huge lack of medicine, doctors (a huge group of them is either touring other countries or have simply fled our country) and resources in general, terrible sanitary conditions in hospitals (which are often infested with cockroaches and lack clean water and patient privacy), extremely poor organization, widespread corruption (as workers often steal medicine and gear to sell in the black market), and the salaries of the medics are a misery –approximately $50 per month.
Export of Professionals: A Talent Drain
Thousands of Cuban doctors are sent annually on a “tour of duty” to countries in need, mostly in Africa and Latin America. This practice has helped Cuba’s reputation in the international development field, as Cuban health professionals are known for being diligent first responders; the quality of their service is often praised in the international medical arena. However, due to the lack of available funds and resources to maintain the structure at home, many of these doctors decide to not return to Cuba after their tour is over. Ms. Casas explained:
The government trains doctors to export. Their salary is a misery. Almost every doctor is willing to go to the end of the world just for a little more to live on –to live better than in Cuba. They often try to use this way to permanently leave the country because the government normally does not let the medics leave, especially if they are specialists. They are lucky if they get permission from the Ministry of Public Health to attend a conference or an event in another country.
Today, there are approximately 50,000 Cuban medical workers living abroad. This is, partly, because Cuba’s centrally planned economy has been relatively stagnant; Jamaica, Ecuador and Puerto Rico are the prime examples proving it is the economic structure itself that does not allow Cuba’s financial landscape to develop. It is also due to the U.S. trade embargo on Cuba, which halted the import of medicine and medical technology into the island, making the decline of the healthcare structure even more pronounced. The Cuban government has been praised for delivering the results it does by spending only $2,475 per citizen on healthcare – considerably less than countries like the United Kingdom, France, and the United States — but the conditions to which health professionals are subjected to ought to be considered as well. Cuban doctors are paid between USD $30 and $50 per month, which is well above the national average but still insufficient to cover all necessities. Roberto de Jesus Guerra Perez, a journalist for the Institute for War & Peace Reporting, visited some of the most significant Cuban medical facilities and reported in 2013 that “the hospitals that ordinary Cubans go to are generally poorly maintained and short of staff and medicines. (…) The floors are stained and surgeries and wards are not disinfected. Doors do not have locks and their frames are coming off. Some bathrooms have no toilets or sinks, and the water supply is erratic.”
Patients in need of radiation as part of cancer treatment are put on a waiting list, and oftentimes they receive the phone call letting them know their time has come weeks or months after the treatment has actually been prescribed –that is, if the radiation equipment is fully functioning. Ms. Casas shared: “When my mother was receiving the treatment [for breast cancer] the machine would work some days, and it wouldn’t some others, partly because of the amount of people using it on a daily basis. Even my dad offered his help to get a certain cable that they were missing for the machine to work. It was exasperating. My sister and I had to think of ways to gather funds to donate equipment to the hospital.” Of course, the other side of it is that when the health service is for foreigners and government officials: “There is absolutely nothing missing there.”
The Cuban healthcare system model is a rather particular and highly controversial one. The challenges it faces overlap with many development challenges found in other nations with similar economic statuses, but because of the particularity of its political dynamic, many of these challenges are unique for the island. Because most of the limitations in the system are caused by economic distress and rather captious international policies (particularly with the United States), the Cuban government must incentivize further foreign investment in the country in order to increase and diversify its access to resources and, most importantly, reinforce the healthcare system’s sustainability. The U.S. embargo on the island has undoubtedly played a key role in the deterioration of the healthcare system not only by offsetting the economic landscape (along with the withdrawal of Soviet international funding in the early 90s), but also by bringing about scarcity of many, if not most, medicines and medical equipment that were previously acquired from North American private companies. Building progressively stronger and successful relationships with North American and other foreign private and governmental investors must be the first step to revitalize the Cuban medical system. Moreover, Cuba should reduce the amount of resources it invests in international solidarity programs and reserve them for health initiatives and programs at home. Recent changes in the Cuban social and political dynamics not only warrant, but allow the implementation of far-reaching, specific adjustments that are able to accommodate and serve the populace as a whole. “I am not an ideologue,” concluded Dr. Ventres:
I think that we need to see with our own eyes and listen with our own ears in any system. What is working well and what is not working well. Especially with Cuba, we cannot ignore that there are competing ideologies that are very powerful in terms of the lenses through which people see the system in Cuba. But I do think that as we move forward in this country and in Cuba, we have to look at what works, what doesn’t work in specific terms, in specific issues, over a population of people. Not just one person, but everyone who is involved. (…) I would hope that people can not just look back, but that they could look forward in a way that recognizes that health is important for people across the spectrum, and while healthcare is not the only thing that attends to health, that whatever system comes out of Cuba in the future is one that attends to the health of all the population.
The political polarization and the influence of the Western media makes progress more difficult, as the resourcefulness of the Cuban health industry and services heavily depend on imports. Like many others, I do not think the Cuban system is decadent; it has its problems, but it is a unique model that inevitably comes with unique obstacles and challenges. It may be struggling but I cannot think of any health care system around the world that isn’t struggling at some extent.