The principle upon which the fight against disease should be based is the creation of a robust body. Some day, therefore, medicine will have to convert itself into a science that serves to prevent disease and orients the public toward carrying out its medical duties. Medicine should only intervene in cases of extreme urgency, to perform surgery or something else which lies outside the skills of the people of the new society we are creating.Che Guevara, On Revolutionary Medicine, 1960[1]
Cuba’s achievements in social development are impressive given the size of its gross domestic product per capita. As the human development index of the United Nations makes clear year after year, Cuba should be the envy of many other nations, ostensibly far richer. [Cuba] demonstrates how much nations can do with the resources they have if they focus on the right priorities – health, education, and literacy.
Kofi Annan, Secretary General of the United Nations, April 11, 2000[2]
Introduction
A great deal of attention has been paid to Cuba’s health care system over the last forty years, and a large majority of it has been generally positive and complimentary. The praise has come from a wide variety of unlikely sources, ranging from documentary filmmaker Michael Moore in his 2007 film “Sicko”, to former World Bank President James Wolfensohn, and even the World Health Organization. A US based non-profit organization was formed in 1997 called MEDICC (Medical Education Cooperation with Cuba) to leverage the Cuban experience to support the “education and development of human resources in health.”[3]
Proponents have tended to cite statistics such as Cuba’s low infant mortality rate, high life expectancy, and impressive physician to population ratio, which meet and often exceed levels of some of the most developed countries in the world, including the United States. Spiegel and Yassi (2004) describe this as proof of the failure of neo-liberal policies pushed by The World Bank and the International Monetary Fund that link wealth and income generation to the physical health of nations.[4] Despite Cuba’s low GDP per capita, they argue, Cubans have achieved such admirable results thanks to the high value the government has placed on equality and universal access in health care, as well as its focus on preventive medicine through community based treatment and polyclinics.
This paper will examine the impact of the US embargo on the Cuban health care system and changes since the revolution in 1959 both in services and the health of the general population. It will look at to what extent the recent surge in natural and traditional medicine (called medicina natural y tradicional in Cuba, or MNT) is a response to the embargo versus a deliberate push by the Cuban Ministry of Health to provide more comprehensive health services.
Post-Revolution Health Care in Cuba – Equality and Accessibility
Prior to the Cuban revolution in 1959, Cuba looked very much like much of Latin America with respect to its health care. A small percentage of the population was covered by expensive private health care systems, while the majority relied on inadequate public health services. Most habitants of rural Cuba never even saw a doctor.[5]
This class separation was among the issues that stirred the revolution against Batista, and made universal health access one of the cornerstones of the Castro regime’s social agenda. Castro’s approach to health care involved the principles of universal and free access, as well as government control, which led to the nationalization of the health care system in 1961.[6] Shortly after, the “Servicio Medico Rural” program (Rural Medical Service) was launched with the intention of bringing health services to rural Cuba, an area that was abandoned in the decades leading up to the revolution.[7] Hundreds of doctors were dispatched to communities where health situations were the most precarious. This has been a source of tremendous pride for the government for four decades, and was seen recently in Castro’s offer to send more than 1500 of Cuba’s physicians to the most ravaged areas of New Orleans after Hurricane Katrina struck in 2005, an offer that was refused by the US government.[8]
Since then, through the development of a community-based clinic approach to health care, the Cuban government has over the last forty years been able to provide preventive and emergency health services to all 11 million of its citizens free of cost. It does so through the use of “polyclinics” which serve between 30,000 and 60,000 people each and act as hubs to anywhere between 20 and 40 family doctors’ offices that are staffed by a doctor and a nurse. Through this approach, the smaller local doctors’ offices handle the bulk of preventive and routine health issues, such as prenatal care, vaccinations, and prescriptions, and patients are referred to polyclinics or hospitals for emergency care and all surgeries.[9] This allows efficiencies in the use of expensive and often unattainable imported medical equipment. It also focuses health care on prevention, which is far less costly than treatment.
Currently Cuba has well over 70,000 trained physicians of whom approximately half are family practitioners, and the country maintains a physician to population ratio of 63 to every 10,000 inhabitants. That ranks significantly higher than even the most developed nations such as the United States, which has 26 physicians per 10,000 inhabitants as of the year 2000, or Denmark (36 per 10,000), and neighboring developing nations such as the Dominican Republic (19) and Jamaica (9).
Thanks largely to its number of well-trained physicians but also the government’s emphasis on regular, preventive medicine, Cuba has excelled in several key human development statistics. According to the United Nations Development Program’s Human Development Index, Cuba is considered a highly developed country. It ranks 51st out of 177 countries evaluated in the 2007/2008 report, above Mexico and Brazil and just below Costa Rica and the Bahamas. Among health and education related indicators the country has performed particularly well. Cuba’s life expectancy is 77.7 years compared to 77.9 years for the United States. Its infant mortality rate is at 6 deaths per 1,000 live births, which is equivalent to that of the United States. Where Cuba is dragged down in the Human Development Index is among economic performance indicators such as GDP per capita. In 2005 Cuba’s GDP per capita was $6000 in PPP terms (Purchasing Power Parity), which is among the lowest of all countries in the High Human Development category. Of the top 70 countries in its category, only one ranks lower than Cuba on a GDP per capita basis: Albania with $5,316. [10]
Overall, however, Cuba paints a remarkable picture where health and education have clearly been priorities. More Cubans die each year from chronic non-communicable diseases, such as cancer and heart disease, than infectious or parasitic diseases, a pattern that again makes Cuba more comparable to developed countries.[11] This is all while spending a fraction of what the United States spends on health care. In 2005 Cuba spent $333 per capita on health care in PPP terms while the United States spent over $6,300 per capita, almost twenty times greater. [12]
Challenging The Cuban Myth on Healthcare
Cuba’s impressive physician to population ratio has been challenged by several researchers, with some citing that many of those physicians are actually living outside of Cuba as part of the government’s commoditization of its healthcare.[13] It’s true that medical professionals are among the countries most important exports and are in a way used in place of hard currency. As of 2006, an estimated 20,000 Cuban physicians worked abroad, with most of them in Venezuela where Hugo Chavez remains a strong ally of the Castro regime.[14] This represents tremendous growth, as in 1976 there were only about 280 working outside of Cuba.[15]
Other researchers challenge the validity of any statistics that are generated by the socialist Cuban government, even though they are published and considered reliable by the United Nations and the World Health Organization. Katherine Hirschfeld from the Institute for Cuban and Cuban-American Studies at the University of Miami writes:
“In some cases it is likely that the socialist system did genuinely improve health and health care delivery. In other cases, it is likely that state power was used in a way so as to give the illusion that such positive changes were taking place by imprisoning dissident physicians, intimidating would-be critics, and manipulating health statistics.”
Hirschfeld spent several months in Cuba as a researcher and, ultimately, as a patient and provides a rare insight into the system. According to Hirschfeld, not only are the health statistics up for dispute, but also focusing on just numbers obscures the real conditions and problems Cubans are facing in health care. She describes a conversation with a physician who says her female patients are given abortions if there is any sign of an abnormality with a fetus, because otherwise “the infant mortality rate would go up.” She tells the story of a friend who was not given Novocain during a tooth extraction, and another who had to wait months for his painful wisdom tooth to be extracted because of a lack of supplies. [16]
Tania Jenkins from McGill University writes of a similar scarcity of medical supplies in Cuba, and says it leads to not only long delays for services but also to frustration among physicians who are like “carpenters without tools.”[17] This, she claims, has begun an exodus from the health care system, which has actually left a shortage of doctors, contradicting the claims that Cuba has among the highest doctor to patient ratio in the world.
A trip to Cuba’s Center for Genetic Engineering and Biotechnology (CIGB) highlights some of these contradictions. It is a state of the art facility that is a tangible testament to the country’s resilience and achievement despite its developing country status. Launched in 1986, the CIGB employs about 550 scientists and engineers to develop vaccines, which are now sold in over 50 countries. Cuba claims it will be the first country to completely eradicate Hepatits B by 2030 thanks to the work at the CIGB.
On the other hand, a tour of the CIBG facility also reveals outdated biomedical machinery from the 1980s, many of which display signs reading “Equipos que no están en uso” or “Equipment no longer in use.” Those signs refer to biomedical equipment made by LKG Produkter AB, which was acquired by General Electric in 1986. The doctor conducting the tour of the facility made a point to mention that the equipment had to be abandoned after Cuba could no longer purchase upgrades or repair services due to the US bloqueo (Cubans prefer to describe US sanctions as a blockade rather than an embargo, because they believe the term embargo implies wrongdoing on their part). In addition, several smaller computers are linked together to simulate a supercomputer, something that is again blamed on the bloqueo.[18]
Blaming the Embargo
An interesting debate has emerged as to the true impacts of the US embargo on health and health care in Cuba. It’s clear where the Cuban’s stand on the issue, as giant billboards permeate the landscape of the country quantifying the impact of the embargo on development. One sign reads that a single day of the embargo is equivalent to 139 urban buses that could have been bought.
According to some Cuban officials, the embargo has not only made it impossible to acquire medical devices from US firms, but also from non-US firms. Many medical devices, such as the Siemens Gamma counter used in nuclear medicine, requires American parts or computers. In addition, Cuban officials claim that many non-US firms such as Siemens have been pressured by the United States into not selling any of their equipment to Cuba.[19]
At the Group of 77 summit in Havana in April of 2000, Cuba’s public health minister Carlos Dotres claimed that the embargo’s constraints had cost Cuba’s health sector alone more than $2 billion. This is not only because of a lack of access to medical equipment and medicine, but also because the embargo blocked Cuba’s access to financial markets for credit. Without an ability to invest in sectors that bring hard currency into Cuba, such as tourism, the country has found it increasingly difficult to maintain free health services. [20]
Opposition to the embargo, therefore, has been growing. The US embargo against Cuba, which includes both food and medicine, has lasted almost fifty years and was reinforced in 1992 with the Cuban Democracy Act. During that time period, known famously as the Período Especial (or Special Period), Cuba was facing its most difficult economic challenges following the collapse of the Soviet Union and the Cuban Democracy Act only served to compound the country’s misfortunes.
The Cuban Democracy Act cites Cuba’s violation of basic human rights “as recognized by the Universal Declaration of Human Rights adopted by the General Assembly of the United Nations” as a primary reason for the embargo.[21] Ironically, an increasing number of member nations of the United Nations General Assembly have been voting in favor of lifting the US embargo. As of October, 2007, with a margin of 184 to 4 votes, the United Nations urged the United States to end the embargo which has prevented Cuba’s involvement with multilateral organizations like the International Monetary Fund, The World Bank and the Inter-American Bank.[22]
Physicians as well have opposed the embargo for humanitarian reasons. Michele Barry, a physician from the Yale University School of Medicine who traveled to Cuba in 2000, calls for health care professionals to “protest an embargo that engenders human suffering to achieve political objectives.”[23] That same year, the American College of Physicians published a position paper calling for “excluding from sanctions humanitarian goods, such as food and health related materials or medical supplies.” They went even further and called for countries that impose sanctions to provide “medical and health-related supplies and services to offset any increased morbidity caused by sanctions.”[24] Although technically the United States says that food and medical supplies are exempt from the embargo, there are largely insurmountable bureaucratic requirements in place whereby companies must prove the intended use of those products in Cuba. Companies, therefore, prefer not to engage in business with Cuba.[25]
Cuba’s Response: Alternative Medicine
A lifting of health and food related elements of the US embargo may fulfill a moral obligation, but it is unlikely to solve the problems faced by Cuba’s healthcare system. Cuba may lack access to medical equipment due to politics, but it also lacks the hard currency required to make those purchases, a problem that results from its underdeveloped economy. The revenue it generates from its tourism sector, which draws over two million people a year and includes an estimated $20 million a year from health tourism, has not been nearly enough. As evidence of this, Cuba’s hard currency spending on public health has dropped almost 70% in the last twenty years.[26]
Largely as a coping mechanism, Cuba incorporated a significant emphasis on Complimentary and Alternative Medicine (CAM), or Medicina Natural y Tradicional (MNT) as it is called in Cuba, into its services. In 1995, when the country was still recovering from the impact of the collapse of the Soviet Union, the Cuban Ministry of Health (MINSAP) established a state commission to develop MNT. A website was launched by the MINSAP to distribute literature and announce events related to MNT. Educational materials were distributed to practitioners throughout the country describing “green medicine” and its virtues.[27] The Cuban health system now incorporates MNT in virtually every medical consultation, and in many cases uses acupuncture as a form of anesthesia. In addition, 40% of all dental relief uses some form of acupuncture.[28]
According to Dr. Patilla Garcia, MD in Havana, the rise in MNT is attributed more to Cuba’s long tradition of folk medicine, the government’s relations with China and a comprehensive approach to health than as a substitute for scarce medical supplies. His statement presents an interesting attempt to diminish the impact of the US embargo and thereby strip its efficacy and legitimacy. However, the doctor later goes on to contradict himself by referring to the US embargo as a “genocide blockade” designed to impose a health crisis on a country that is economically inferior.[29]
The truth may include all of the elements described by Dr. Garcia, but it seems highly likely that the lack of access to medical supplies and medicines is the single most important factor driving the recent surge in MNT. It’s no coincidence that the push for MNT coincided with the collapse of the Soviet Union and the tightening of restrictions by the United States on sales by third countries to Cuba. A visit to a pharmacy in Havana, usually under stocked even with basic medications such as acetaminophen, also confirms that a locally made, plant based headache remedy is far easier to find.
Cuba’s success with MNT has been notable. If government reports are to be believed, then despite enduring one of the most difficult economic periods in its history where food rations were severely limited and 80% of the country’s development assistance disappeared overnight, Cuba has sustained its impressive health standards.
So respected is Cuba’s use of MNT, that The United Nations Development Program conducted a study on the use of MNT in Cuba as a testament to its efficacy and in the hopes of expanding the role of MNT in the world. The report hailed Cuba’s use of acupuncture, homeopathy, therapeutic massage, and herbal medicines as an integral part of its primary and secondary care. The main benefit, the report cites, is in the use of MNT in “zones of major deficiencies and poor health infrastructure where MNT is useful for extending protection to the poorest sectors of the population.” [30]
And there lies perhaps the biggest lesson to be taken from Cuba’s health care system. Cuba has demonstrated that with an emphasis on access and equity, and with a creative approach to the problem, universal health care need not be the enormous financial burden US politicians believe it to be.
Conclusion
In February 2008, Senators Barrack Obama and Hillary Rodham Clinton described how they would approach US-Cuba relations if they were President of the United States. Prompted by Fidel Castro’s announcement that he would step down and relinquish control of the island nation, the candidates shared their views during a democratic debate in Texas. Clinton took a largely status-quo position, saying she would be willing to meet with the new president only if steps were made to give Cubans more freedom. Obama had fewer preconditions and indicated a desire to reverse some of the harsher restrictions on travel and remittances imposed by the Bush administration in 2004.
It was a rare moment that elevated the dialogue on US-Cuba relations from a largely localized discussion among a small but influential Cuban-American population in Miami to the national stage. It was also startling because both candidates raised universal health care as a key component of their platforms, but have not attempted to extract any lessons from the Cuban example.
Although the decades long US embargo and the collapse of the Soviet Union have cost Cuba billions of dollars, the socialist island of 11 million inhabitants has made remarkable strides in healthcare. Cuba has consistently ranked at the top of developing countries in virtually all health related measurements since the 1959 revolution. Cuba has achieved this through an emphasis on preventive care, which is less expensive than emergency care, as well as the incorporation of Natural and Traditional Medicine. It has also done so by treating health and education as priority sectors, which are the last to undergo budget cuts.
Whether or not health statistics reported by the Cuban government are to be believed, it’s difficult to deny that Cuba has done more than most developing countries in assuring the physical health of its citizens, including those in remote, rural parts of the country.
Bibliography
Anderson, James. “Cuban Health Affected by Embargo,” Associated Press, 14 April, 2000.
Appelbaum, Diane RN, FNP, MS; Kligler, Benjamin MD, MPH; Barrett, Bruce MD, PhD; Frenkel, Moshe MD; Guerrera, Mary P. MD; Kondwani, Kofi A. PhD; Lee, Bennett B. MD, MPH; Tattelman, Ellen MD. Natural and Traditional Medicine in Cuba: Lessons for U.S. Medical Education. Academic Medicine, 81, December 2006, pp. 1098-1103.
Aitsiselmi, A. An analysis of the Cuban health system. Public Health, Dec2004, Vol. 118 Issue 8, pp. 599-601.
Barrett, Kathleen. The Collapse of the Soviet Union and the Eastern Bloc: Effects on Cuban Health Care. Washington, DC: Georgetown University, Cuba Briefing Paper Series, No. 2, May, 1993.
Barry, Michele. Effect of the US Embargo and Economic Decline on Health in Cuba. Annals of Internal Medicine, Volume 132, Number 2, January 2000, pp. 151-154.
Carrillo, Karen Juanita. Health care advocates call on Cuba for help. Amsterdam News, 7/28/2005, Vol. 96 Issue 31, p. 2.
Dale, Ralph Alan. “New Developments in Cuban Holistic Medicine: A Personal View.” The Journal of Alternative and Complementary Medicine. June 1, 1996, 2, pp. 299-305.
De Vos, Pol; De Ceukelaire, Wim; Van der Stuyft, Patrick. Colombia and Cuba, contrasting models in Latin America’s health sector reform. Tropical Medicine & International Health, Oct2006, Vol. 11 Issue 10, pp. 1604-1612.
Economist. What ails Cuba’s health service? 11/14/98, Vol. 349 Issue 8094, p. 40.
Elling, Ray. Is Socialism Bad for your Health? Cuba and the Philippines: A Cross-National Study of Health Systems. Medical Anthropology, 11, 1989, pp. 127-150.
Fraser, Barbara. Human resources for health in the Americas. Lancet, 1/20/2007, Vol. 369 Issue 9557, pp. 179-180.
Garfield, Richard and Santana, Sarah. The Impact of the Economic Crisis and the U.S. Embargo on Health in Cuba. American Journal of Public Health, 1997.
Gilpin, Margaret. Cuba: On the Road to a Family Medicine Nation. Journal of Public Health Policy, 12, 1991, pp. 83-103.
Grundy, Paul H. and Budetti, Peter P. The Distribution and Supply of Cuban Medical Personnel in Third World Countries. American Journal of Public Health, Volume 70, Number 7, 1980, pp. 717-719.
Hauge, Stephanie. Primary Care in Cuba. Einstein Journal of Biology & Medicine, 2007, Vol. 23 Issue 1, pp. 37-42.
Hirschfeld, Katherine. Health, Politics and Revolution in Cuba since 1898. New Brunswick: Transaction Press, 2007.
Hirschfeld, Katherine. Reexamining the Cuban Healthcare System: Toward a Qualitative Critique. Cuban Affairs, Vol. 2, Issue 3-July, 2007.
Human Development Report 2007/2008. United Nations Development Programme. Available at: http://hdr.undp.org/en/media/HDR_20072008_EN_Complete.pdf, Accessed on September 20, 2008.
Kirkpatrick AF. Role of the USA in shortage of food and medicine in Cuba. Lancet. 1996, 348, pp. 1489-91.
Morin, Karine and Miles, Steven. The Health Effects of Economic Sanctions and Embargoes: The Role of Health Professionals. Annals of Internal Medicine, Volume 132, Number 2, January 2000, pp. 158-161
Nayeri, K. The Cuban health care system and factors currently undermining it. Journal of Community Health, 20, 1995, pp. 321-335.
Nikelly, Arthur. Health Care in Cuba. Public Health, 102, 1988, pp. 19-25
Nordlinger, Jay. ”The myth of Cuban health care: Michael Moore gives it a powerful boost.(CUBA).” National Review 59.13, July 30, 2007, pp. 38
Roman, Gustavo C. Epidemic Neuropathy in Cuba: A Please to End the United States Economic Embargo on a Humanitarian Basis. Journal of Public Health Policy, Volume 16, Number 1, Spring 1995, pp. 5-12.
Suárez Jiménez,J. El sistema de salud en Cuba:Desafíos hacia el año 2000 [The healthcare system in Cuba:Challenges as we approach 2000]. Revista cubana de salud pública, 23, 1997, pp. 5-16.
UNDP brochure: Integración de las Prácticas de la Medicina Tradicional y Natural al Sistema de Salud. Available on: http://www.undp.org.cu/pdhl/ideass/BrochureMTNesp.pdf
Website of Medicina Natural y Tradicional of the Ministry of Health, Cuba: http://www.sld.cu/sitios/mednat/
Website of the Center for Genetic Engineering and Biotechnology, Cuba: http://gndp.cigb.edu.cu/
From a speech by Che Guevara in 1960. Text of entire speech can be found in John Gerassi’s book, Venceremos! The Speeches and Writings of Che Guevara, Simon and Schuster, p. 14.
Quoted from UN press release, available on: http://www.un.org/News/Press/docs/2000/20000412.sgsm7357.doc.html
See http://www.medicc.org/ns/index.php
Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the Cuban health paradox. J Public Health Policy. 2004, Page 89.
De Vos, Pol. “No One Left Abandoned:”: Cuba’s National Health System Since the 1959 Revolution. International Journal of Health Services, Volume 35, Number 1, p. 190.
See Cuba’s portal of Public Health: http://www.sld.cu/servicios/directorios/directorios_res.php?pagina=452&expresion=%24&select=1&base=1
CNN: http://www.cnn.com/2005/WORLD/americas/09/05/katrina.cuba/
Cuba’s rimary health care revolution: 30 years on. Bulletin of the World Health Organization, May 2008, page 86.
For a summary of the 2007/2008 UNDP HDI report rankings, see http://hdrstats.undp.org/countries/country_fact_sheets/cty_fs_CUB.html
Source: UNData database of WHO data, available from http://data.un.org
Nayeri, K. (1995). The Cuban health care system and factors currently undermining it. Journal of Community Health, 20, 321-335.
Carrillo de Albornoz, Sara. On a mission: how Cuba uses its doctors abroad. British Medical Jounral. Volume 333, 2006, p. 464.
Grundy, Paul H. The Distribution and Supply of Cuban Medical Personnel in Third World Countries.
Jenkins, Tania M. Patients, Practitioners, and Paradoxes: Responses to the Cuban Health Crisis of the 1990s. Qualitative Health Research, Sage Publications, 2008, Page 7.
From a visit to CIBG on May 14, 2008.
Barrett, Kathleen. The Collapse of the Soviet Union and the Eastern Bloc: Effects on Cuban Health Care. Washington, DC: Georgetown University, Cuba Briefing Paper Series, No. 2, May, 1993. Page 4.
Anderson, James. “Cuban Health Affected by Embargo,” Associated Press, 14 April, 2000.
http://www.state.gov/www/regions/wha/cuba/democ_act_1992.html
From UN News Release from 30 October, 2007: http://www.un.org/apps/news/story.asp?NewsID=24471&Cr=cuba&Cr1= Accessed on September 13, 2008.
Barry, Michele. Effect of the US Embargo and Economic Decline on Health in Cuba. Annals of Internal Medicine, Volume 132, Number 2, January 2000, p. 153.
Morin, Karine and Miles, Steven. The Health Effects of Economic Sanctions and Embargoes: The Role of Health Professionals. Annals of Internal Medicine, Volume 132, Number 2, January 2000, p. 160.
Kirkpatrick, Anthony F. Role of the USA in shortage of food and medicine in Cuba. Lancet, 1996, p. 1489.
What ails Cuba’s health service? Economist, 14 November 1998, Issue 8094, p. 40.
Appelbaum, Diane RN, FNP, MS; Kligler, Benjamin MD, MPH; Barrett, Bruce MD, PhD; Frenkel, Moshe MD; Guerrera, Mary P. MD; Kondwani, Kofi A. PhD; Lee, Bennett B. MD, MPH; Tattelman, Ellen MD. Natural and Traditional Medicine in Cuba: Lessons for U.S. Medical Education. Academic Medicine, 81, December 2006, p. 1098.
From a presentation by Dr. Patilla Garcia, MD in Havana, Cuba on May 27, 2008.
UNDP brochure: Integración de las Prácticas de la Medicina Tradicional y Natural al Sistema de Salud, p. 2. Available on: http://www.undp.org.cu/pdhl/ideass/BrochureMTNesp.pdf