a Medecins Sans Frontieres, PO Box 1001, 1001 EA Amsterdam, Netherlands
The health system in Cuba guarantees accessibility to the entire population, is free of charge, and covers the spectrum from vaccinations to sophisticated interventions. The results are impressive: Cuba's health figures are on a par with developed countries that have 20 times the budget. The country is experiencing a difficult period because of the collapse and loss of support from the Soviet Union; over 30 years' trade embargo by the United States; and the gradual change from a centrally planned economy towards more of a free market system. Shortages are experienced in every sector, and maintaining health care services at the current level is too expensive. Doctors and nurses continue to work towards the goal of health for all Cubans, even though their salaries are minimal. Signs of negligence or corruption, often seen in other socialist countries where incentives for output are lacking, are unknown. Topics such as family planning and AIDS deserve immediate attention.
"Cubans were the first 'medicos sin fronteras,'" the government representative answers with a smile when we introduce ourselves at the Ministry of Health. "We have always exported doctors to places where they are needed; at one time there were 5000 Cuban doctors abroad. No, doctors we are not short of, but we could use some help with drugs and supplies. The recent economic crisis makes it difficult to buy them and health should remain a priority for our people. Our system guarantees total accessibility, is free of charge, and covers the whole spectrum from vaccination to heart transplantation," he continues. "We started with 6000 doctors after the revolution; 3000 of them immediately left for the States. Now we have 60000 doctors, one for each 200 inhabitants," he says proudly.
Care in Cuba
Each year around 4000 students start their medical training at 23 different universities. The Cuban health system consists of three tiers. The first tier is the front line care provided by family doctors. Since 1980 there has been a training for family doctors. Now 22000 of them have been trained and they cover 90% of the population. Their main work is preventive: health promotion and offering basic curative care. The family doctors are backed up by 400 polyclinics, where specialists offer their services to about 30000 people. The 263 hospitals form the third tier of the Cuban system.
The progress Cuba made in the field of health is impressive. Cuba's health system always got priority, as did education. Health indices are on a par with developed countries, yet the total budget of the country is a tenth to a twentieth of theirs. Life expectancy is 77 years and infant mortality a mere 9 per 1000 live births. The common diseases of poverty have been effectively combatted. Malaria has been eradicated from the island and Dengue fever successfully reduced by an immense campaign in which the whole population participated. Leading causes of mortality are cardiovascular diseases, neoplasms, accidents, and homicides.
|
"Two issues make it difficult to keep up our standards," the government official continues. "First the trade embargo of the United States, already in place for over 30 years; secondly the dissolution of the Soviet Union, our most important trading partner--85% of our trade was with the Eastern bloc countries." The pivot of Soviet aid has always been the bartering of sugar for oil. The Soviets delivered as much oil as requested; the Cubans supplied them with sugar. In 1989 this deal abruptly ended and the inefficient, centrally planned economy collapsed, affecting every part of society.
We visited various health institutions to assess whether Medecins Sans Frontieres could offer assistance. We were impressed by the openness of the discussions; the warm reception; the high level of care and education; the genuine interest of the health personnel in the wellbeing of their people, deprived of any financial incentives; and the complete absence of ties and jackets.
A family doctor guides us enthusiastically through his practice. Together with a nurse he takes care of a community of 600 people. In the morning he does consultations, 35 a day on average; in the afternoon he makes home visits. "Is every request for a home visit granted?" I ask. "Of course," he answers with surprise. "If the need is not so apparent it is the right moment to give some health education. I also go on 'surprise visits' to keep in touch," he says. In fact every patient who did not visit his practice during the year will be visited at home.
The documentation in the practice is very detailed. The system seems to work well. There seem, however, to be few patients per doctor. It must be very costly to sustain this level of service, and I wonder whether it does not lead to overconsumption of medical care. His consultation room is full; there is a student doctor in his final year and a specialist on his monthly visit. The specialists visit the family doctors to support and supervise them according to a rotating schedule. Together they work their way through the difficult cases. If the patient needs admission the family doctor will become associated with the hospital and maintain responsibility for the treatment.
Doctors do all night calls themselves, 24 hours a day, seven days a week. "To be honest," he says, "I'm not called often, no more than five times in the last two years. The polyclinic is open 24 hours a day and people can also go there in case of emergency. No, it is not stressful." In the hospital I'm told later that patients often go directly to the hospital, and only 10% of the patients seen in the outpatient department are referred by the family doctor.
"We all have to strive to reach the goals of the revolution," a hospital director tells us. "I also have my booklet with rations. I'm entitled to buy eight pounds of rice monthly, four eggs a week, and 2.5 kilos of meat for 14 days. But I have to say, meat has not been available for months, nor has cooking oil or soap. Milk is only available for children and the sick, and butter is unheard of. But here you will not see a child dying because he cannot see a doctor. You will not find a child without schooling. You will not see shanty towns," he adds raising his voice. "Why? Because we are Cubans!"
The director explains that he earns 400 pesos, the equivalent of $12 on the black market. If he has to buy extra rice he has to go to the free market and pay 10 pesos, instead of the 38 centavos a pound in the subsidised government shop. "Look, I also have one pair of shoes a year"--he lifts his leg to show the sole of his shoe. Instead of complaining he seems proud of it.
In every other country I have visited, doctors have found ways to work their way up. Not so in Cuba; the solidarity is impressive. There is no sign of corruption or of the laissez faire attitude found in other socialistic economies, where the formal incentives are lacking. All the health workers we met stand for their job, their principles, and their people. Racial discrimination seems minimal; two directors of big hospitals we visited were black.
Health care facilities
The hospitals look in good condition, although they could do with some refurbishing. Portraits of Che Guevarra are seen on the walls. "Cytostatics and antibiotics are in short supply," a doctor explains; "so are disposables. Our equipment is getting old and spare parts are difficult to get. Here is an electrocardiograph--the factory stopped production 12 years ago but it is still working." He caresses the device tenderly. We see a computer stacked away, the only one in this referral hospital. "The country has two MRIs and in Havana there are six CAT scans; yes, they function well."
The number of nurses (76000) in the country is surprisingly low in comparison with the number of doctors (60000). "It is difficult to find them," explains a doctor; "they opt to work at home, due to the crisis." It also seems to be a matter of planning to us.
We try to find a taxi in the evening. A regular car stops and we get in. The driver happens to be a doctor. He needs the dollars to drive this 40 year old car. When he finds out we are doctors visiting the Ministry he is not keen to tell us his name. Motorised traffic in the street is scarce. The bicycles, recently introduced to respond to fuel scarcity, make driving dangerous. Bicycles are everywhere they should not be: on the left, on the right, without light in a tunnel and on the eight lane highway through the central part of the island. The highway seems to have been planned for the year 3000.
Caring for patients with HIV
"Don't worry, a Cuban will never do something against his will. Everybody is admitted voluntarily and everybody can leave if he wishes." The director of the AIDS sanatorium looks at me penetratingly but his arguments do not convince me. It seems a suspect method to intern everyone who is HIV positive. The more so as the Cuban health system is very much orientated to the community. Taking people out of their community seems to go against this principle. I argue cautiously that in every other country this method would not work, the patient would simply refuse.
Up to now only 1089 people have been diagnosed as positive. What about the undetected cases; what will the Cubans do when the figures rise; what about the lack of condoms and the tourism; what about the false positives? I pose too many questions to answer. "Come and I will show you the place and you talk to the patients yourself," says the doctor, grabbing me by the arm. "This is the dentist's room"--and he swings open a fully equipped treatment room. "How often does the dentist visit the place?" I ask. The doctor seems not to understand the question. It seems that the dentist is working full time for the institution which has 34 patients (and 58 workers). Quickly I calculate the tooth:dentist ratio (do they still have all their teeth?). The dentist cannot see more than three teeth a day; I'm visibly astonished.
The sanatorium is well kept, the living quarters are friendly. "This is our laboratory assistant," the doctor says and he stops a girl in the corridor. "She is also a patient." The girl smiles and walks on. There does not seem to be stigma attached to the disease. The doctor stops another boy in the corridor: "This is a patient too." "How long will you stay?" I ask the boy. He smiles too and answers that he does not know. The place is fine and he is well looked after. His salary is paid; why should he wish to leave? "It is better like this," he adds. "It is not lifelong," the doctor explains. "He is counselled and receives psychological assistance. If he copes he can go back to his family, but he should be able to live with his 'disease.' Some stay five months, others have been admitted for eight years."
"What do they do during the day?" I ask. "Well, there is a garden for growing vegetables; they read, they can go out to the village, they play dominoes, just what other people do in hospitals. And during the weekend he can go home. First with a 'guard' to supervise his behaviour; at a later stage a family member can take over this duty. You see, it's voluntary, just like vaccinations; everybody complies with it but it is not obligatory. Just because it is best, people will do it."
I'm surprised by the atmosphere in the sanatorium--certainly it is not a concentration camp. Still, I'm puzzled by the logic of the concept. From a mere epidemiological point of view, strict isolation (life-long?) could contain the epidemic in a closed society. In practice, however, the patients do have contacts outside the sanatorium. Furthermore, the island opened the doors to tourism, with a side effect of increasing prostitution. Both facts make the "isolation" porous, to say the least. The compliance must have to do with the Cuban culture, in which it is accepted that this is the best solution for society as a whole. To me the concept seems highly unsustainable; the costs must be outrageous.
Sexual health
Simple condoms, essential for protection, are not available in the country. I suggest that this is a problem that needs to be addressed, especially in light of the increase in tourism, but the doctor answers: "The tourists have their own responsibility; they should take condoms with them." "The few condoms that are available are used in pizzerias," I'm told jokingly by a Cuban in Havana. "The condoms are cut in pieces and spread on top of the pizza, ready to melt in the oven to resemble cheese."
"We Cubans do not like condoms," another doctor tells me. In fact condoms--or any contraceptive--are in short supply. Nevertheless, when I ask for the number of abortions it is surprisingly low, less than 1 per 100 deliveries. The reason why surprises me just as much: it seems that all women whose expected menstruation is late by two weeks are offered a microaspiration in the polyclinic. "It is mere menstrual regulation," the specialist explains. "We perform 700 regulations for every 5000 fertile women. We never see complications." Pregnancy tests are not performed as they are not available. It seems a rigid medical approach.
Society and economy
Castro still finds strong support among the population. If things are wrong most people will not blame the government--complaining is not the Cuban style. The biggest asset in the society is the absence of both an ultrarich elite and people who live in absolute poverty. Indeed, it has been impossible to become very rich in Cuba; a rich upper class as seen in other Caribbean or Latin American countries is unknown to Cubans. But shanty towns as seen in Haiti or Lima do not exist either, although due to the crisis the first marginal settlements have started to develop.
The introduction of the convertible peso, the start of a free market economy, and the stimulation of tourism are major changes in the system. For the past year farmers have been entitled to sell a part of their crops on the free market. Dollars mean luxury; without dollars no beer, no soap, no extra. Young people especially seem to be attracted by the promises of capitalism. So people open their doors and start a restaurant, even if they have only two tables.
The health system in Cuba is impressive and the effect on the population's health has been remarkable. The system, however, is under a strain and is no longer sustainable in this form. "Presently 12% of the country's expenditure is targeted to health care, of which 70% is spent on hospitals," an advisor to the health minister tells us. It is questionable whether health care financing should be maintained at this level. Having fewer doctors would still offer a good service to the people, without reducing the benefits. For the Cubans this seems difficult to accept: health care is for free and the more doctors the better. Cuba should try to maintain the good points of the system: free access for the entire population and the fabulous mentality of the health care workers.
Family planning and AIDS seem two topics that need further exploration. But we also have to prioritise resources, and many countries are worse off than Cuba. Even if their system is under strain, the Cubans seem to be able to cope. Health indices do not show a deterioration in health yet. As a doctor stated: "Cotton dressings we cut in two--it is still a dressing and we make do." Recruiting Cuban doctors for our projects abroad seems an unexpected option that deserves serious consideration.
No comments:
Post a Comment