Dr. Sosunmolu Shoyika is one of the doctors who went to Cuba with the Kelley School Business of Medicine Physician MBA Program in 2017 as part of the Global Healthcare Immersion course. These are his reflections from the experience.
The team visited a Polyclinic, where an overview of the Cuban health system was provided by Professor Alex Carreras, the head of the department of international relations at the Ministry of Health. Cuba provides free health coverage to all its citizens, with equal access and coverage of rural and urban areas.
The system is built on the principle that healthcare is a right for all citizens and that prevention of illness through strong primary care and health promotion across the entire population results in better outcomes and lower costs in the long term.
The basic health system unit is a “consultario” – a neighborhood clinic staffed by a nurse/doctor dyad living in the community (often above the clinic). This clinic is typically within walking distance for everyone in the neighborhood and serves 15-20 families. This team is intimately familiar with the population it serves; home visits are routine and encouraged to facilitate a thorough evaluation based on the bio-psycho-social model. This is possible due to the large number of providers: Cuba has 87,000 doctors, each of whom is trained in family medicine, pediatrics, PBGYN and basic psychiatry/psychology. With a doctor: patient ratio of 1:127, and a nurse: population ratio of 1:125, there is no shortage of family physicians.
According to Dr. Carlos, the director of the Polyclinic, 2nd tier medical facilities (aka “Polyclinics”) serve 300 families, are led by a family physician with at least five years of clinical experience and provide five basic services: emergency care, geriatric services, maternal and child care and prevention of communicable diseases. The population is classified according to health risk into four tiers: apparently healthy, some risk/illness, chronic medical conditions and those with complications or disabilities from their illness. Polyclinics provide contrast x-rays, labs, endoscopy, 24-hr dental care and a 24-hr ER. Each polyclinic is staffed by its own specialists.
The system boasts remarkable outcomes: Cuba has eradicated several communicable diseases including pertussis. At the local polyclinic, the team reported that there have been no maternal deaths in 12 years and no maternal-child HIV transmission in 12 years. The average life expectancy for women is 80 years and 78 years for men. Child mortality statistics are particularly impressive at 4.9/1000 births.
Cuba exports medical services to other countries (including Venezuela and the African continent), trains many physicians from countries around the world for free, has a thriving biomedical research industry which has produced several brand-new medications including Heberprot-A, (a growth-factor based agent which promotes diabetic foot ulcer healing and reduces amputation rates). The industry also manufactures and exports vaccines. The system also incorporates alternative treatments and has a separate department for Chinese and alternative medicines.
My main takeaway was that I was struck by Cuba’s simple, common sense, pragmatic yet effective health system strategy. It seems the strategy has delivered on the promise of improving quality and outcomes at lower costs.
This morning, we had a talk by Gail Reed, who is the executive editor of MEDICC, on the effect of the US embargo and ramifications for Cuba. Ms. Reed is a Chicago native and a graduate of the Columbia University School of Journalism who has lived in Cuba for 30 years and currently holds the status of “temporary resident.”
MEDICC aims to strategically connect US institutions with those in Cuba in order to bridge the US-Cuba divide. Its peer-reviewed journal, MEDICC Review, is available online and gets 40,000 article viewings (60% from the USA). MEDICC primarily works with academic (research) institutions but has also worked with members of the US Congress and executives from US technology companies.
Ms. Reed’s 1990s report on the effects of the US Embargo on nutrition in Cuba was used during the debate on lifting the food embargo on Cuba that ended with the food restrictions lifted. However, restrictions on travel and the export of medication have remained in place. The US embargo affects trade in many ways, including restriction on imports of medications or equipment with more than 10% US-made components or by companies partially or wholly owned by US companies. This has had a significant impact on the Cuban economy over time.
Pharmaceuticals remain one of the areas in which the effects of the embargo are felt the most. For example, a ban on methotrexate meant that for a period of time, only .25 of women with breast cancer got treatment in Cuba. Interestingly, it appears that Cuba began manufacturing its own medications, including antineoplastic and antiretroviral agents as a result of the embargo, including a ground breaking lung cancer treatment. The embargo has been offset to some degree by trade with other countries. However, imports from Europe and Asia remain expensive. The Obama administration made a great start in beginning talks aimed at resolving the dispute. For example, direct mail from the US to Cuba is now possible and bans on telecommunication have been lifted.
On the contrasts between the healthcare systems of the 2 countries, her view is that “Cuba has a different view of medicine: as a public service, not an economic vehicle” and that Cuba has eliminated disparities in healthcare, “mostly due to women’s/health education, prevention and a focus on community and population health”.
Later that morning, the team visited CENESEX, Cuba’s center for Sexuality education and strategy, which is led Mariela Castro. The Center’s director shared details of Cuba’s comprehensive program around sexuality, including school-based sex education, comprehensive and free contraception and a comprehensive program for transgender individuals. The discussion also touched on reproductive rights, sexual and domestic violence and human trafficking. Remarkable outcomes have been reported, including low HIV transmission rates.
That afternoon, we visited Cuba’s only Geriatric Center, in Old Havana. Founded in the 1990s when the government agencies realized that aging of the population was becoming a concern, the center provides comprehensive services for individuals aged 60 and above, including rehabilitation, medical, podiatry, physiotherapy, dental and mental health care. This service runs 8am-5pm daily and four hours on Saturday. It includes six meals a day and is free to all individuals. Staffing ratio is 1:2. Currently, there are 50 individual enrolled in the Center, although it has the capacity to serve up to 70. The visit concluded with a moving choral performance by the center’s residents, including some nice dance moves by the eldest resident, a 92 year old woman!
The team visited the Center for HIV Prevention, which was created as a response to the HIV epidemic to guide the country’s strategy for the prevention of HIV. In some ways, the center’s work is an extension of the work being done at Cenesex. The center has offices in every province and municipality in Cuba.
Consistent with what we had learned about the health system, Cuba’s strategy around HIV rests strongly upon prevention and leverages public education as a means to shape public attitude and behavior. This rests upon carefully crafted messaging targeted at promoting healthy behaviors (such as the use of condoms for safe sex) and preventing other behaviors (such as smoking). At-risk groups such as youth and homosexual men and women engaged in commercial sex work (“transactional sex,” in Cuban parlance) receive special attention. Among other results, the center reports that Cuba is the first county in the world to eliminate Syphilis transmission from mother to child.
We learned that that early efforts to promote condom use in Cuba were not overly successful. The condoms were imported from overseas, but uptake was low, mostly due to the perceived quality. Market research by the center engaged the populace in condom redesign, resulting in increased penetration of use.
The center maintains a confidential call-in line and sends teams around the country in vans. It also leverages clergy of the Afro-Cuban religion (Santeria) to educate adherents of that faith.
In the afternoon, the group visited the Francisca Rivero Arocha Centro Comunitario De Salud Mental (Community Mental Health Center) in Old Havana, where Dr. Baly and his team shared an overview of the Cuban mental health system. Set in a magnificent cathedral-style building with stained glass windows, this facility provides full-service mental health, addiction, sexology and other behavioral health services to over 115,000 Cubans.
In Cuba, the mental health service system is completely integrated with the rest of the public health system: referrals come from individuals, families, the “consultorios” (neighborhood clinics) and from the five polyclinics in the area. Staff (psychologists, social workers) from the MHC are also embedded within the polyclinic teams and provide screening and early diagnosis of mental illness, addictions and of developmental disabilities.
Although resource constraints exist (e.g. antidepressant choices are limited and there are only nine child psychiatry beds for the entire area, located in a general hospital), the system functions very well. Of particular note was the report that there are no waiting times to see a mental health professional; individuals needing mental health services are seen the same or following day and there is 24/7 access to a psychiatrist in emergency situations across the country.
Moreover, individuals can choose where they want to receive care, whether locally or in a different municipality or even province. Social workers are present in every clinic. Treatment includes all types of therapy (psychoanalysis, gestalt and group therapy were named) as well as medication management.
The same strong focus on prevention that runs through the general medical system is present in the behavioral health sector as well. There is active screening for mental illness and developmental disability, every pregnant woman gets screened for depression and all school children pre-K through secondary school receive screening. Care is coordinated and clinical information is shared between providers as standard practice. All of this is provided free to citizens.
Cuba’s mental health system is not without its own challenges. Suicide remains a significant problem, as do alcohol and tobacco use disorders. Medication management, including medication-assisted treatment for substance use disorder, is hampered in part due to the US embargo. However, according to Dr. Baly, stigma is less of a problem than in other countries, and individuals choosing to delay seeking care often do so due to a “macho” mindset/culture, rather than a stigma.
The final visit was to the Institute for Tropical Medicine, where a history and overview of the institution was provided. The talk ended with a discussion of opportunities for collaboration between Indiana University and the Institute.