Healthcare advocates routinely compare the United States to countries in Western Europe and find that it spends more for less than its industrialized counterparts. But even a poor country such as Cuba, which has one-tenth the per-capita GDP (gross domestic product) of the United States and spends about one-twentieth per capita on healthcare, has better measurable results. Cuba’s childhood mortality rate (the number of deaths ages 0-5, per thousand live births, per year) is lower than that of the United States (six in Cuba, eight in the United States), and Cuban life expectancy is slightly longer (79 years to 78).
The reasons for Cuba’s success lie in its commitment to social medicine. As healthcare advocates push for an overhaul of the U.S. system, they should talk to voters about a preventive, rather than curative model.
Community Involvement and Prevention
Medical programs in Cuba deal with the factors that most contribute to good health–proper nutrition, potable water, sanitation, vaccinations, mosquito control–and less on expensive curative treatments. The focus is on disease prevention, directing scarce resources toward the groups most in need, especially expectant mothers, infants, and children.
Beginning in 1984, Cuba implemented a “one doctor plus one nurse team” approach, with each team caring for 80 to 150 families. Public health experts are now being added to the teams, focusing on mosquito abatement, monitoring potable water supplies, and inspecting sewer line hook-ups.
The healthcare teams live in the communities that they serve which helps them gain a better feel for the local health issues and develop strong relationships with the families that they treat. Usually the doctor’s offices are on the first floor of their neighborhood clinic where they treat patients most mornings. Upstairs are the team’s living quarters.
Rather than waiting for people to get sick and come into their offices the doctor/nurse/public health care worker teams spend their afternoons walking about their neighborhoods, medical bags in hand, stopping in to visit with families. In this way, the teams are more likely to notice medical conditions before they become too serious. Most teams see every individual in their community at least twice a month, whether they are sick or in good health.
Healthcare is best thought of a tiered system, moving from measures that do the least to lower general mortality to those steps that do the most to save lives. U.S.-style curative medicine ranks lowest in this regard. Preventive measures, such as care for pregnant mothers and routine childhood vaccinations, eliminate the need for pricey curative steps.
Today, the United States has an overall childhood vaccination rate of 70%; in Cuba it is 99%. Cuban parents cannot refuse vaccinations for their children. In the United States, as the current measles outbreak shows, not cooperating with childhood vaccination programs jeopardizes the health of the entire community and leaves vulnerable those too young or too ill to be vaccinated.
The Cuban healthcare model is different from the curative one which people in the United States are most familiar with. Cuban patients cannot expect the same sort of treatment they might receive in the United States. Cuba cannot afford to provide many remedies, especially given the U.S. economic blockade that makes it next to impossible to import prescription drugs, and expensive equipment and procedures are often well beyond reach.
Instead, in Cuba the health teams visit patients unannounced, demanding to know what they have been eating, insisting that the patient get a proper diet and regular exercise. Few people appreciate these probing personal questions and blunt directives, but this approach produces the best results for the money that Cuba can afford. If a patient ignores the counsel of their medical caregivers and ends up requiring costly curative treatments, they typically cannot expect much more than palliative care, especially if they are elderly and suffering from other complications. For families with aged and suffering loved ones, this sort of medical triage can seem astonishingly heartless.
Poverty, Inequality, and Poor Health
Poverty and inequality are the leading killers in the United States. The poorest U.S. families carry extra burdens of ill health, from higher infant mortality rates to shorter life expectancy.
Cuba’s good health is largely due to its successes in reducing poverty and income inequality. Healthcare, along with education, housing, transportation, and basic necessities, are all either free or come at a nominal charge.
Far from Perfect
Of course, Cuba has its own problems, and there are critical issues with some key aspects of its medical and economic system.
Cuban doctors are very poorly paid, yet the medical industry as a whole is one of the key income earners for the nation. Cuba relies heavily on income from its doctors working abroad in medical missions, from medical tourism (foreign patients who come to Cuba and pay for treatment at specifically designated facilities), and from the bio-medical industry.
Cuban families with access to dollars–either from finding some sort of employment in the island’s tourist industry or from family members living in the United States–have a marked advantage over families that don’t. Cuban doctors, looking to earn extra income in dollars, often work a second job, such as driving taxis or serving as guides. Cuban healthcare professionals serving abroad keep only a fraction of the income they earn, with most of the earnings flowing directly into general government revenue.
These arrangements raise legitimate issues over fairness.
Another key issue for Cuba is that shortages of basic necessities have become more acute in recent months, due especially to the sharp reduction of shipments of low-cost fuel from Venezuela. The resulting economic losses have resulted in stricter rationing of food.
Still, even during the depths of Cuba’s earlier depression, the 1990s economic free fall–the “special period” when the Soviet Union collapsed, ending the over $5 billion USD a year in aid–infant mortality rates in Cuba actually improved. Despite all the current problems, Cuba continues to outperform the United States in most population health metrics. The Cuban health system is not perfect, but this small island nation does better on public health measures than ours.
Lessons from Cuba
So, what can we learn from Cuba? Working to decrease income inequality, poverty, and food insecurity will do the most to improve our nation’s health. Focusing on disease prevention and emphasizing public health over curative medicine would make for a far less costly health care system and would achieve better results.
We should add the key lessons from the Cuban experience to the conversations here as we debate how best to approach healthcare reform.
In Cuba, healthcare is regarded as a basic human right, not a purchasable commodity. We should start with this.