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Observations from September 2015 Cuba Trip

By Senator Bill Frist, M.D.

I recently traveled to Cuba from Sept. 27 – 30 with the Nashville Health Care Council, and had the opportunity to learn about the health care system, visit the new U.S. Embassy, and experience the social and economic culture of Cuba. 

 I regret not being able to join the Advisory Board luncheon due to a conflicting board meeting, but wanted to share some perspectives from my third trip to Cuba.  I plan to return again this coming January.

Daily Life in Cuba and Response to Recent Changes

  • The Cuba landmass is the size of Tennessee.
    • 15 provinces and 169 municipalities.
    • The distance from the USA is 93 miles.
  • Population: 11.2 million.
    • More than a million Cubans are living abroad.
    • 3 million tourists come to Cuba each year.
  • The currency is the CUC (convertible peso) and it is pegged to the US dollar 1:1. In addition there is a national peso which is the national money used by locals.
  • Religious beliefs are complicated but most are folklore which originated from Africa in Nigeria. Officially 59% are Roman Catholics.
  • Everybody in Cuba gets a ration book once a year. Every person gets the same – man, woman or child. It includes 5 lbs. of rice, 3 lbs. of chicken, 5 eggs/month, a lb. of sugar, a liter of cooking oil, salt, matches, 2 pieces of bread/day, 2 bars of soap and a tiny bit of detergent.
    • This is enough to “keep you alive and not starving.”  When I asked the average person how far this goes, they said it lasts about 2 of the 4 weeks. It has been cut back again and again. Cigarettes were on the list until 2012 and then were removed.
  • Every person does 2-3 years of military service.
  • Only about 5% of the population has access to the full Internet
    • It’s very expensive and beyond the financial reach of most Cubans, about two dollars for one hour of access, very slow.
  • Now that private business is allowed, there is a fear that entrepreneurs will be rewarded more than others and inequality will increase. There is a fear that people will lose their healthcare system as Cuba opens up. The inequalities are increasing in housing, in education and in jobs particularly over the last two years.
    • 500,000 have their own businesses. This was unheard of 3 years ago. People very much want to keep their social benefits but increasingly want to keep what they earn and get paid for earning more. They are looking for increased opportunity through private enterprise now that private businesses are allowed.
  • Increasing focus of the economy is on Latin America and no longer Russia. For decades dependent on Russia and sugar - one product. Now increasing activity with other countries and diversification beyond sugar.
    • When I asked people what the future was for Cuba, people said:  1) biotech, 2) tourism, and 3) the Mariel port.

Cuban Health Care System

  • Cubans take great pride in their healthcare system and feel their family doctor truly cares for them.  Healthcare considered a right and is embedded in the constitution.  
  • The system is universal, free to the patient, easily accessible at the primary care level, highly regionalized with neighborhood clinics.  There are no barriers to entry.  And although they say it’s comprehensive, the secondary and tertiary care is poor by U.S. standards. 
    • Much of this is due to a lack of supplies including pharmaceuticals and devices and even the most basic medical resources like band aids and aspirin. The country is poor and resource starved and it is reflected in the cleanliness and adequacy of the hospitals.
    • Cuba medical school graduates number between 8,000 to 10,000 per year.  A striking number considering U.S. graduates approximately 18,000 medical students per year.  
  • Health care system organization:
    • Health delivery is organized around hospitals and polyclinics.  Reporting to the 152 hospitals are 451 polyclinics. Polyclinics are organized regionally, and each serve about 24,000 people.  Reporting to the polyclinics are the family doctor offices.  A polyclinic might have 25 family practice doctors and their neighborhood clinics reporting to it.  There are 11,500 offices with a total of 13,400 doctors.  The polyclinics are the level with the material resources and supplies to make diagnoses and treatment.  They handle about 80 percent of all health needs.  The family doctors’ offices have almost no resources other than that for a basic physical exam.  The family doctor’s office does not have medicines but writes prescriptions for medicines and supplies to the patient who goes to a local pharmacy.  Everything is free. 
    • A typical family doctor would see about 1300 patients, the median being 1,000. The family doctor works with a single nurse as part of a team. The doctors live in the neighborhood. The clinic is staffed six days a week by a doctor and nurse, with two of those days spent making home visits.  Specialists come to family doctor offices to see patients based on a schedule.  The conditions are quite Spartan. There might be three rooms: a waiting room, a doctor’s interview room and office, and an examining room. Nothing else. Records are all by hand in an open file in the office. Every patient has extensive records. The family doctor knows everything about the children and their siblings, their parents and grandparents. They even know what pets they have. There is heavy emphasis on prevention.  This neighborhood approach is powerful.   When we talk about primary care and promotion of health, Cuba’s “magic sauce” lies in this neighborhood relationship with family physicians who get paid very little but who have great empathy. 
  • Infant mortality in Cuba is 4.6 deaths per thousand live births. May be slightly underreported, but still better than U.S. average (6.17/1,000). 
    • I believe the infant mortality is better because of the comprehensive and universal prenatal care given by the family medical doctors assigned to each family. They practice in the neighborhood and assiduously track down each mother and ensure that they have at least 9 pre-natal visits and most say they actually receive 12 over course of pregnancy.  For high risk pregnancies, family doctor will see them every week or 15 days – often traveling to their home.
    • Rather than patients being responsible for seeking out a doctor, in Cuba the family doctor is in charge of seeking them out.  According to my meeting with a physician in one of the local community clinics, she is responsible for 393 families in a neighborhood, and has to register every single mother before 12 weeks of pregnancy. Within 15 days of registering the expectant mother, she sets the patient up with an appointment with the obstetrician and refers her to genetic specialists as needed.  She sees every single pregnancy in the community.
  • The lifespan is 78.8 years in 2013, on par with U.S. (78.7). 
  • 19% of population is greater than 60 years in age.  There are 448 geriatrician doctors.
    • When asked what one of the biggest challenges to healthcare is in future, repeatedly people come back to elderly/senior care.  The demographics with such a senior concentration in a poor country will increasingly be challenging.

 

By the numbers

Cause of death, 2013:        

  1. Cancer
  2. Cardiovascular disease
  3. Neurovascular disease
  4. Pneumonia and influenza
  5. Accidents

 Personnel:

  • Medical doctors: 134,000 (plus 25K overseas)
  • Nurses: 96,000
  • Family doctors covering 100% of population: 13,400
  • Dentists: 15,200
  • Technicians in 78 fields: 88,300
  • Of all of the above health personnel, 70% are women

Facilities:

  • Polyclinics: 451
  • Medical doctor offices: 11,500
  • Hospitals: 152
  • Dental clinics: 118
  • Maternity homes: 142
  • Homes for elderly: 126
  • Blood banks: 27
  • Research institutions: 15

Cuban Healthcare as an Export:

  • In Cuba, doctors are routinely sent overseas to engage in charitable healthcare and medical diplomacy, and for revenue generation for the government.  This is termed “Cuba Cooperation.” 
    • From 1963 to 2015, there have been 140,000 “cooperators” in 108 countries. 
    • 2015: 25,000 Cuban doctors overseas in 68 countries.
  • Cuban doctors are willing to go overseas because it is the only way for them to make money. 
    • Average pay for a Cuban physician is $50-$80 USD a month in Cuba.  Less for a new doctor who is working at a family clinic, higher end for a specialist who is also a professor at a teaching hospital. 
  • Because Cuba trains a disproportionate numbers of doctors, other countries pay to “lease” these doctors. For example, Brazil pays the government of Cuba $48,000 for a doctor for a year. The doctor is sent to Brazil and receives $1,245/month. Another $600/month is put into a fund for the doctor back in Cuba, but he/she cannot claim it unless they return to Cuba (this is used as an incentive for the doctor to return, although many choose not to).  The remaining $25,000+ is profit for the government. Thus healthcare is the number one revenue generator for the government today.
  • Total exports: $12.7B
    • Healthcare exports: $9.1B (largest Cuban export)
    • Tourism: $2.5B
    • Other: $1.0B

Education:

  • Didn’t get to explore in depth, but initial impressions: Literacy rate is high but the social psychology professor we met with said that there is huge deterioration in the schools because of lack of resources, bad teachers and the fact families are no longer involved (sounds familiar). 
  • At 17 years of age Cubans take an exam.  About half of all students go to university at this age and half do not. From the exam you are given a choice of a career such as being a diplomat or being a computer specialist. Then you are channeled into appropriate schools.
  • The typical Cuban is relatively educated and trained compared to other Latin American countries.