I have always found a romanticized Cuba ironic. In one of the world’s poorest countries, the streets are filled with automobiles from the 1950s, internet access is almost non-existent, and 20% of the population lives below the poverty level. But what is idealized is the nostalgia: the culture, a bygone time. Interestingly this is true of their medical system as well.
The last several years have seen reports on Cuba’s medical system and astounding outcomes: life expectancies that rival the U.S. and infant mortality rates that put ours to shame. I could not help but wonder if this is really true. And if so, how?
I have also recently shifted my focus to public health indicators and the relevant social determinants. Specifically in meeting Dan Buettner and hearing about his Blue Zones project, the question arose – is Cuba next?
With these questions in mind, I traveled to Cuba earlier this month with a delegation organized by Kraft Healthcare Consulting and had the opportunity to talk to healthcare practitioners, visit hospitals and medical schools, and talk to citizens.
What I witnessed was poverty and lack of resources compensated for by subsistence rationing and broad healthcare access and continuity. Indeed Cuban medical care warrants the nostalgia. Their system harkens back to the days of family physicians making house calls armed only with their deep personal patient knowledge and their stethoscope.
In Cuba, routine care visits are mandatory. Everybody has a primary care physician, and each doctor is responsible for a roster of about 1000 patients. Patients are seen at least once a year, often in their home. The entire population is risk-stratified as well based on characteristics such as smoking or existing disease, and higher risk categories are seen more frequently. Physicians are available 24/7 and dispense with 70% or more of all medical issues. All of this is provided at no charge to the Cuban national.
These physicians are paid practically nothing, may not have a nurse, an x-ray machine or access to the internet, but they know their patients intimately and respond to that knowledge. Emergencies are addressed immediately. Chronic conditions are identified and managed early.
The system works well, and it’s easy to see why. An overweight or genetically-vulnerable 33-year-old may have early signs of hypertension and a creeping blood glucose level. In the U.S.—with lack of access to or emphasis on preventative primary care—this patient may not even begin seeing a physician regularly until he starts to feel overly fatigued at 42 or has his first heart attack at 49. At that point, the damage is well underway. He will start multiple blood pressure medications, a medication for diabetes, and may need procedures as well. But catching a pre-hypertensive blood pressure in the patient’s early 30s, initially trying weight loss followed by a single blood pressure agent and titration over the next decade will likely prevent that first heart attack. The patient may still go on to die from heart failure, but it might be at 85 instead of 65 and he may largely avoid many of the medical complications of his disease by catching and intervening early.
This early intervention is possible because patients trust their doctors and are more likely to comply with treatment recommendations. I spoke with several primary care doctors and patients, and I was very impressed with their rapport. I found the doctors to be empathetic and compassionate. The pay for these neighborhood physicians is paltry. Their spouses working in a café may be paid more than they are. But they are dedicated and accessible. They are not encumbered by paperwork or bureaucracy. They truly love their work. As a result, their patients deeply respect and appreciate them. Over and over patients told me that their doctors really listen to them, and they are grateful.
While the primary care system may be idealized, the tertiary care system is definitely not. You do not want to be seriously ill in Cuba. The reason is simply a lack of resources. There are shortages of medicine, imaging equipment, operating rooms, and essential cancer treatments. Tertiary care is certainly underfunded, and the U.S. trade embargo has probably hurt that as well.
However, throughout Cuba healthcare is always mentioned in the same breath with education and social justice—socialism—as a major cultural priority, and the human capital investment in primary care is evident. It is remarkable to me that as one of the poorest countries in the world, no one was without access to food or provision of at least basic medical care.
Some of the statistics are largely supportive. The Cuban life expectancy is 78 years because they are not dying of infectious diseases or prematurely of chronic diseases. Instead they are facing the illness of wealthy countries: cancer.
On the other hand, I am very skeptical of the government’s reported infant mortality rate. There is tremendous pressure to report good results, and my anecdotal impression is that data are manipulated at all levels. However, national efforts at education on family planning and pre-natal care are exemplary and should be applauded.
Two other points that struck me as simple but potentially very impactful: healthcare literacy is highly-valued, and education on healthcare issues is a required part of public curriculum. Despite offering completely free care, the government posts costs of healthcare services at all hospitals and doctor’s offices. Though they do not pay for their own health services, Cubans are literate about healthcare and aware of what it is costing their government.
I would hardly advocate for the exaltation or emulation of the Cuban medical system, but there are certainly some lessons to be learned.
- Access to primary care and an emphasis on prevention are effective if they are made a priority of the system. In the U.S. this cannot happen until we change our current payment structure.
- Continuity of care is a valuable resource. We are moving away from family doctors and into the world of urgent care clinics and hosptialists, but we have to find a way to preserve some continuity to decrease costs. The solution is a heavy investment in healthcare IT.
- Physicians must be freed to be physicians. Increasing rules, regulations, and changes are driving many from the field and this is a threat to the future of our nation.
- Healthcare literacy is imperative. The best asset any patient has for their health is their own investment in and knowledge of their care. Patients have to be an active participant in their care.
- Transparency in cost can be a powerful tool in guiding decisions even in a situation where moral hazard applies.
If I were able to tell my father about my trip, he may have responded, “Well, of course!” This focus on personal primary care was certainly how he practiced medicine. Our challenge is to apply the principles that work while retaining our resources and advanced knowledge. A little nostalgia is not a bad thing. We must remember that more money, more drugs, and more procedures do not always mean better care; and a physician’s ears—in and out of her stethoscope—are her most important tools.