SELECTED STUDIES

Volume 3, Issue 2
July 2000

Ailing healthcare system produces enviable results 

Cuban Healthcare:
An analysis of a Community-based model 

By Essam Farag

 

 “Cubans are people who are born in a third world economy and who
sicken and die of first world pathologies!”
- Prof. Theodore H. MacDonald, 1999

On a recent visit to Cuba, I became concerned about the marked discrepancy between the economic and health indices and how long the Cuban people can cope with a deteriorating economic state. There is no doubt that the participatory community-based healthcare system implemented in Cuba, with its skilled and well-trained personnel, succeeded to overcome many of the challenges the country is facing. Yet, the increasingly stringent economic embargo on Cuba poses a greater threat and burden on this healthcare system. Some researchers anticipate a dramatic decline in some health indicators as a consequence of this embargo.

“While the overall health of the Cuban population has not yet seriously eroded as a result of the economic decline, severe problems threaten to emerge in the future. Nutritional status could deteriorate if the food supply is not stabilized. Cuba could see resurgence of infectious diseases as a result of possible vaccine shortages and inability to properly maintain personal and community sanitation and a clean water supply. With insecticides in short supply, Havana is already seeing an increase in flies, mosquitoes and other disease-spreading vectors; these could become the source of disease outbreaks.” (Editorial, Lancet, 1996:1461).

Although this quote from the Lancet represents obvious pessimism for the future of Cuba, it seems that the survival capacity of the Cuban people is far greater than many had expected. Three years passed since this editorial article's publication, and health indicators in Cuba continue to improve against all odds. During my recent two-week visit to Havana, many people seemed convinced of the notion that the Cuban people had somehow acquired an immunity to different shocks and disasters, documenting their survival throughout the past four decades as clear evidence. They enumerated the chronology of conflicts that faced them since the 1959 revolution, with emphasis on the exodus of physicians, the US embargo, the dissolution of the USSR, the neuropathy epidemic and the unforgiving hurricane Andrew! The struggles not only of daily lives but those of much greater and far more drastic situations have become a norm for the Cuban people. This is especially pertinent to  medical personnel, who despite all circumstances have the passion, confidence and endurance to consistently uncover the revolutionary solutions to all challenges, past, present and future. It was most intriguing to observe a population that was not only determined to find solutions to all obstacles but did so with a great passion for communal welfare. 

This study will focus on the evolution of the healthcare system in Cuba, the obstacles that it faced from a historical context, and assess their respective overcomes.

I - Evolution of the healthcare system

Prior to the Cuban Revolution in 1959, healthcare statistics revealed a national profile common to impoverished third world countries. It was characterized by urban-rural contradiction, with the majority of physicians in Havana and Santiago de Cuba, and the antagonism within the medical profession between a privileged minority and marginal majority (Demers et al.1993:164, Danielson 1979:130).

During the early 1960’s, there was 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 (Claudio 1999:A249, Danielson 1979:129). To deal with this vacuum of health professionals, volunteer doctors from other Latin American countries and Cuban medical students in their training years filled the gaps. Beginning in 1960, the Ministry of Public Health (MINSAP) sent teams of doctors to towns and villages where no doctor had ever been seen (MacDonald 1999:13). Cuba was building an entire healthcare system from the ground up. 

The goal of the new regime was to remedy the inequities in healthcare and to establish a rapid, transitional, free, and comprehensive national service that reaches the urban, rural and mountainous populations in all 14 provinces. They established polyclinics, regional medical units and provincial hospitals. Despite the size of this new construction, the key element and most vital component to all these services was the family/community doctor, who was trained to offer community services with a community nurse, social worker and health educator. With this model in place, they sought to deal with health concerns in previously deprived rural areas. The evolution of the post-revolutionary medical services in Cuba could be divided into the early transformation, polyclinics, community medicine and family doctor phases (Danielson 1979:130-132, Santana 1987:116).

The early transformation phase (1959-1969): 

The new government began building rural health centers to replace the long degraded system of municipal sanitary chiefs. The new changes integrated prevention and cure, medicine and sanitation, physician and health team, professional and lay participation in health work and organize the community for active participation in health promotion. In 1962 the CDR (Committee to Defend the Revolution) and the FMC (Cuban Federation of Women) helped in mass vaccination programs, immunizing 4 million Cuban children. In 1963, there was an obvious movement towards the regionalization of medical services. The rural health centers were born in an era of delivering a set of health-related measures: new roads, improved agricultural methods, schools, improved diet and an end to seasonal unemployment (Danielson 1979:134). Focus was placed on maternal care, child health and control of infectious diseases.  The use of preventive medicine and immunization led to the eradication of polio in 1963, malaria in 1968, diphtheria in 1971, tetanus and human rabies. (Barry 2000:151, MacDonald 1999:15, Kuntz 1994:86). By 1970, both poliomyelitis and diphtheria had disappeared as causes of death. Malaria had been eradicated, whooping cough and tuberculosis mortality declined (Susser 1993:423).

  The polyclinic phase (1970-1974):

This phase is characterized by better distribution and more coherent organization of the healthcare services in all provinces and establishment of primary healthcare centers (polyclinics) as the basic Cuban unit of health services, while the larger hospital units continued to be the central trend of hospital organization (Danielson 1979:165). The central role of the polyclinic is to offer integrated curative-preventive and clinical-social-environmental dimensions to the people in the specified area. 

The polyclinics were staffed by primary care doctors specialized in pediatrics, internal medicine, and obstetrics/gynecology. Gastroenteritis, another common killer of third world infants was sharply decreasing during this phase. In 1962, it caused 4,157 deaths, but by 1975 there were only 761 deaths due to gastroenteritis (MacDonald 1999:15).  

The community medicine phase (1975-1984):

The focus on community medicine was designed to achieve comprehensive delivery, universal population coverage and the completion of the regionalization process. The Cuban model identified four levels of regionalization: area, region, province and nation. In 1975, the Cuban health budget was 300 million Cuban pesos, with 4 medical schools providing medical training. The health budget has risen to 1.7 billion pesos in 1999 with 21 medical schools. These numbers totally dwarf the 22 million pesos that were spent on healthcare prior to the revolution in 1958, when there was only one medical and nursing school in Cuba – both present in Havana (MacDonald 1999:19, Zacca Pena 2000:73). Its main feature was the restructuring of the polyclinic in order to carryout the responsibility for the total health services of a specific area and population, as well as for expanded teaching and research activities.

The family doctor and community-based healthcare system continues today since its establishment in 1984. It  represents a significant change from the previous system that centered on primary care polyclinic system to personalized community-based practices (Demers et al. 1993:165). Community-oriented primary care model is a process for making a healthcare system more rational, accountable, appropriate, and socially relevant to the public. This system requires a new hybrid practitioner with competences in primary care, prevention, epidemiology, ethics and behavioral science (Wright 1993:2547).

II - The obstacles that faced the healthcare system

One of the major obstacles which faced Cuba, was the imposition of a United States economic embargo in 1961, in an attempt to weaken Castro’s regime. Cuba resorted to trade with the Soviet Union and Eastern European states and became part of the COMECON (Community for Economic Cooperation). This pact substituted completely the 75% of trade that was being made with the US prior to 1961 and played a major role in the Cold War era. Since the dissolution of the Soviet bloc and COMECON in 1989, the 60% decline in Cuba’s GDP is one of the steepest ever recorded, and Cuba lost almost all of the 70% of trade done with the COMECON. On top of this disastrous economic crisis, referred to as the “Special Period” by Cubans, the US embargo continued to tighten - noted as the longest lasting sanctions in modern history. Cuba was losing $4-6 billion annually in subsidized trade (Barry 2000:151, Garfield & Santana 1997:15).

With the absence of trade from the former Soviet Union, and progressive tightening of U.S. sanctions in the 1990’s, Cuba’s model healthcare system has become threatened by serious shortages of medical supplies, leading to several public health catastrophes. These include an epidemic of blindness partially attributed to malnutrition, an outbreak of a neurological syndrome caused by a lack in chlorination chemicals, and an epidemic of esophageal stenosis in toddlers who inadvertently drank lye which is commonly found in Cuban homes due to the severe shortages of soap (Barry 2000:151). Mortality from diarrheal diseases per 100,000 inhabitants rose from 2.7 in 1989 to 6.8 in 1993 and by 1999 this mortality decreased to 3.4 (Zacca Pena 2000:41). The total mortality rate per 1,000 inhabitants rose from 6.4 in 1989 to 7.1 in 1999. Recently, there has been a notable rise in the rate of tuberculosis in Cuba, associated with the embargo, which rose from 5.1/100,000 in 1990 to 10.0/100,000 in 1999 (Zacca Pena 2000:49).

In 1992, the United States senate passed the Cuban Democracy Act which re-imposed controls on the trade of food and medicine with Cuba, with the reintroduction of third country sanctions prohibiting subsidiaries of US companies from trading with Cuba (Barry 2000:151). This was a major blow to the Cuban healthcare system and economy in general, especially when the country was still recovering from the effects of the dissolution of the USSR. Four years later, the Helms-Burton Act was conceded, placing a restraining effect on even non-US companies from trading with Cuba. There is increasing debate on the ethics of including humanitarian goods in sanctions, which may increase morbidity and mortality of civilians (Morin & Miles 2000:160).

With the major challenge of finding alternative trading partners to replace COMECON and enduring with the US embargo, the 1990s were not too bright. A series of tragic events faced the Cuban people, and tested the credibility of the free community-based healthcare system. In the midst of the economic crisis in the early 1990s, a mysterious epidemic disease known as neuropathy appeared and spread throughout the Cuban population (> 50,000), first appearing in late-1991. The disease takes two forms, both of which can occur in an individual. Optic neuropathy is a nerve disorder that causes progressive loss of vision and peripheral neuropathy that leads to limb weakness, tingling and loss of coordination. Under-nutrition was the current major risk factor associated with this optic neuropathy epidemic, and the entire Cuban population received free daily vitamin B complex tablets that succeeded to combat the disease (Morin & Miles 2000:158, Kirkpatrick 1996:1491, Kuntz 1994:93, Cotton 1993:421).

In March 1993, Cuba was struck by hurricane Andrew, known as “Storm of the century”, that caused an estimate $1 billion in damages to Cuban infrastructure, which created a great financial load on Cuba, and an added burden threatening the healthcare system  (Kuntz 1994:92).

III - The Cuban community healthcare system: a solution to the obstacles

The transformation of the new Cuban family practice model into an actual community-based healthcare delivery system led to the change of the disease profile, diminution of infectious disease mortality and the ability to overcome obstacles. As a measure of success, the infant mortality rate was 70/1,000 births in 1959, 38.7/1,000 births in 1970, and has fallen to a rate of 6.4/1,3000 births in 1999. Also, used as the main indicator of the human development index (HDI), is the under-five mortality rate (U5MR), which has also been decreasing in Cuba. The Cuban official medical statistics show a drop from 43.8 deaths/1,000 births to 8.3/1,000 in 1999 for the U5MR (Zacca Pena 2000:25). Another important health indicator is the life expectancy that was 75.4 in Cuba and only 68 in all of Latin America (New Internationalist, May 1998:24). Indicators of the extraordinary improvement in the Cuban healthcare over past four decades show that both infant mortality rate and life expectancy has achieved first world standards.

Community-oriented primary care is not a concept or theory, it’s an organizational design which leads to increased access and improved outcomes (Wright 1993:2546). Cubans have developed a national healthcare system that has its basis in family practice, and provides a model which could be emulated not only in less developed, but also in more developed countries. The family doctor program represents a large investment in human resources. Family physicians and community doctors have been the gatekeepers of the Cuban healthcare system and its success since 1984.

A critical analysis of the latest Cuban Ministry of Public Health statistics represents the shifting of the Cuban disease profile where communicable diseases, prevalent in developing countries, were replaced with modern diseases found in developed countries (e.g. cancer, diabetes, hypertension, and heart disease). Cuba has been able to break the usual bond between economic power and health standards. The Cuban government still continues to concentrate on and prioritize healthcare and education as basic human rights, regardless of the country’s economic situation. The series of harsh challenges that Cuba faced throughout a 40-year period provided the people with the amazing ability to devise solutions with the least resources. This phenomenon can be directly used to express the success of the healthcare system in Cuba, authenticated by the improving health standards, despite the many setbacks it faced and continues to face. Therefore, it is fair to say that the free community-based healthcare system in Cuba has essentially saved the county's population from possible large-scale catastrophes.  

“Food and other human necessities should not be used as a tool of
foreign policy except under extraordinary circumstances.”
- President Clinton, 1998 (M. Albright 2000:155)

Acknowledgements:

Thanks to Prof. John Kirk and Ms.Marian McKinnon from Dalhousie University and Prof. Marina Majoli from Habana University, Cuba for their continued support throughout my visit to Havana and in preparing this study.

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Essam Farag is a 4th year BA student majoring in International Development Studies and History at Dalhousie University, in Halifax, Canada.

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