Saturday, August 15, 2020

3408. Book Review: Cuban Health Care; The Ongoing Revolution

By Ted Trainer, August 15, 2020

This book gives an excellent account of the nature, history and achievements of the Cuban health system. It is fairly lengthy, quite detailed, heavily documented, and easy to read. It has implications and lessons that go well beyond the health of people, to the nature of healthy social systems, dramatically evident in the comparison the book gives between Cuba and the USA. (This outline/review draws heavily on quotes from the book.)

Immediately after the 1959 revolution almost half of the doctors in Cuba left for the US.  This had good and bad effects, firstly in plunging the health system into great difficulties, but also in jolting those remaining into recognizing the need for radical reconstruction of the system …  and getting rid of those doctors most likely to obstruct change. The previous system had been largely made up of entrepreneurial doctors within an uncoordinated system, mainly serving richer regions and clients, and leaving rural areas with almost no medical services at all.

The core element in the system the book details us the basic health care unit made up of small teams of doctors, nurses, social workers, dentists and others who serve and live within small localized areas.  These teams are focused on community and prevention of illness. They take responsibility for the health of people in their area, knocking on doors to deliver integrated care, with much emphasis on preventative measures and education.  They visit schools, factories and neighbourhoods, carrying out campaigns such as vaccinations, occupational health and food safety, encouraging exercise, improving diet, and reducing smoking, alcohol intake, and obesity. 
“The most revolutionary aspect of Cuban medicine is that family doctors are responsible for everyone in a defined geographical area.” This  ”… would include 120 to 150 families, or 600 to 800 individuals, within two to three square blocks in most cities and towns.” ”The teams … see every patient at least twice a year.” 

A dengue fever campaign is illustrative. It found that open water tanks were a major source of mosquito vectors, so routine medical visits to neighbourhoods were able to observe and advise on remedial steps. “We are going door-to-door looking for symptoms of dengue fever and checking for standing water.”

The health effects have been remarkable. “They incorporated millions of Cubans into the health system who had never even seen a doctor before…” Rates of illness were dramatically reduced”  “The country eliminated polio in 1962, malaria in 1967, neonatal tetanus in 1972, diphtheria in 1979, congenital rubella syndrome in 1989, post-mumps meningitis in 1989, measles in 1993, rubella in 1995, and tuberculosis meningitis in 1997.” “Infant mortality began its consistent long-term decrease … In 2000 it was 6.3 per 100,000 live births when the U.S. rate was 7.1 …by 2017, Cuba’s infant mortality was 4.1 compared to the United States’ rate of 5.7. … By 1983, after a decade of community medicine, Cuban life expectancy had increased to 73.8 years from the pre-revolutionary figure of 58.8 years.”  In 2016 Cuban life expectancy was a little higher than that of the US. The WHO’s Millennium Development goals included lowering the 1990 under-five mortality rate by two-thirds by 2015. Cuba reached that goal by 2000. Later responding to the Aids crisis Cuba “…implemented a program … that was better than most countries’, and, in particular, superior to U.S. efforts. An article in The Lancet said that Cuba had “the most successful national AIDS programme in the world.”
The community focus is also central in Cuba’s capacity to respond well to emergencies. It can evacuate entire cities during hurricanes, largely because medical staff know everyone in the neighborhood and know who to call for help getting disabled residents out of harm’s way. 
The training of health workers
Radical changes were also made in the training of health workers. As well as increasing the numbers, previously “… it was almost impossible for black people to enter medical school. By the time the family doctor system had taken root, black communities were receiving the same medical services, and Cuba was training black doctors at a rate proportional to the island’s black population. After the 1959 revolution women poured into medical
school and by 1970 comprised the majority of medical students.

Overseas assistance

Perhaps even more impressive than these internal achievements have been the efforts to provide medical assistance to other countries.  Between 1975 and 1991 medical teams made up many of the over 70,000 aid workers who went overseas. Over the years, 6,000 Cuban medical staff have treated over three million Haitians. When Cuban health professionals intervened in Gambia, malaria decreased from 600,000 cases in 2002 to 200,000 two years later … Cuban/Venezuelan collaboration resulted in 1.5 million vision corrections by 2009. … Almost 2 million people throughout the world . . . owe their very lives to the availability of Cuban medical services. By 2008, in addition to 11 million people in their own country, Cuban doctors were providing medical care for over 70 million people.
When Ebola struck Sierra Leone Cuba was the first nation to respond with what was most needed: it sent 103 nurses and 62 doctors as volunteers.  Volunteers from other nations were trained at Havana’s Pedro Kourí Institute of Tropical Medicine. Cuba taught 13,000 Africans and 66,000 Latin Americans, how to treat Ebola without themselves becoming infected.
Chapter 3 details the sending of doctors to Angola to support the anti-imperialist struggle. At that time the entire country had only 14 doctors. Possibly in excess of 800 Cuban doctors were there at their peak involvement. By 1990 similar aid had been extended to more than a dozen African countries. More than two thousand Cubans lost their lives in the Angolan war.

“Assistance was also given civilian projects in Europe for instance such as for the Chernobyl disaster in the Ukraine. “In March 1990, the first group of roughly 25,000 patients arrived … mostly children …The program employed four hundred Cubans, including as many as fifty doctors and eighty nurses, and persisted through the worst crisis years (1993–94), with Cuba covering the costs of medical care, meals, lodging, and activities. Whereas most countries assisting the Ukraine focused on slowing the spread of nuclear contamination, Cuba worked to provide treatment.”
Cuba has sent over 124,000 health care professionals to provide care in 154 countries. At the end of the twentieth century one in three Cuban physicians were working overseas.
Cuba has been training Haitian doctors since the doors of ELAM (see below) first opened in 1999. The only requirement is that, when they graduate, Haitians agree to return home to take the place of Cuban doctors (rather than defecting to plush jobs in the United States or Europe.)
By 2010 Cuba has trained 550 Haitian doctors, and 567 Haitian students were enrolled in ELAM. As a result of Cuban efforts, Haiti saw a greater than 50 percent decrease in infant mortality, maternal mortality, and child mortality, and between 1999 and 2007 an increase in life expectancy from fifty-four to sixty-one years of age.
In response to the 1998 Caribbean hurriçane Mitch Cuba sent thousands of medical personnel. Of Cuba’s 21,000 medical students, 14,800 volunteered to help. Cuban teams remained in Central America for years, unlike those from other countries, which tended to remain only a few weeks. 
“The enormity of the hurricanes led Fidel to offer a thousand medical school scholarships to students from countries most damaged by Mitch. This led to the formation of the Latin American School of Medicine (now known as ELAM.) When it began in 1999 there were 1,929 students from 18 countries, most from low-income families. Cuba covered the cost of their tuition, textbooks, lodging, and meals. Students were expected to return to their countries and help the underserved.”
“The education offered at ELAM, geared to promoting medical care for all, contrasted sharply with the global trend toward privatizing medical care, which compels service providers to respond to market forces and neglect rural areas. … A requirement at ELAM is that medical students return to serve impoverished communities in their homelands. Thus Cuba is doing more than any other country in the world to reverse medical “brain drain.” A physician who leaves Sierra Leone for South Africa can earn twenty times as much money.”
Conditions at the school are frugal. “Running water is available only at certain hours, and toilets have to be flushed with a bucket. This reflects Cuba’s readiness Cuba to sacrifice superficialities in order to ensure that everyone has necessities.”
Don says the first requirement for acceptance is being able to document a history of commitment to social justice. “All the ELAM students I spoke with shared a desire to provide medical care to people who otherwise might not receive it. There was no discussion about becoming wealthy, which is a highly unlikely outcome for an ELAM graduate.”
“According to ELAM’s website, there are 52,000 Cuban medical workers offering their services in ninety-two countries. This means that Cuba has more doctors working overseas than either the World Health Organization or the combined efforts of the G-8 nations. Thus, “by 2008, Cuban medical staff were caring for over 70 million people in the world.”
The rejection of medical aid offers, and expulsion of personnel

The US and its compliant regimes have often refused or got rid of Cuban health teams working with poor people or assisting with disaster relief.  The US has been “…  eager to eliminate Cuban health brigades whenever possible.’’ For example in Grenada in 1982 a medical team of 20 Cubans was functioning, when the country had hardly any doctors. 

“The United States invaded Grenada in 1983, and the Cuban aid workers were expelled.Several countries with ruling classes aligned with the US … complied with expectations and expelled the medical teams. When Rafael Correa was president of Ecuador, over 1,000 Cuban doctors formed the backbone of its health care system. Lenin Moreno was elected in 2017 and Cuban doctors were soon expelled, leaving public medicine in chaos.  At the same time that Venezuela and Cuba had 27 COVID-19 deaths, Ecuador’s largest city, Guayaquil, had an estimated death toll of 7,600.”

“During hurricane Katrina the governor of Louisiana put out a call for help. Fidel Castro assembled 1,586 medical volunteers with tons of medical supplies ready and waiting to make the relatively short trip from Havana to New Orleans. Nevertheless, George W. Bush turned a deaf ear to the repeated offers from Cuba, even as the death count mounted to 1,800. Undoubtedly, Bush’s silence reflected the attitudes of many wealthy Americans who would prefer to see their poor countrymen suffer and die rather than admit that Cuba had a disaster response capability superior to that of the United States.”
Laboratories, research and drug development
The list of drugs developed in Cuban laboratories is impressive. “The patents for these and the vast number of other medical innovations are held by the Cuban government. There is no impetus to increase profits by charging outrageously high prices for new drugs, so these medications become available to Cubans at much lower cost than they would in a market-based health care system.”
There is also transfer of new technology to poor countries, so that they can produce drugs themselves. Collaboration with Brazil has resulted in meningitis vaccines at a cost of 95¢ rather than $15 to $20 per dose. (Contrast this with Rodelis Corporation which obtained the rights to Cycloserine, one of the few antibiotics available to combat drug resistant tuberculosis, and raised its price by 2,000 percent, so that a full treatment now costs $500,000.)
The comparison with the US health system
Chapter 12 details the staggering differences in cost and performance of the two systems. The US has the most costly system in the world, despite very poor outcome measures. 
 “Cuba, which despite being a poor country has indices of life expectancy and infant mortality similar to those of the United States. An Associated Press report found that, at the same time that the daily cost for inpatient hospital stays in the United States was $1,944, it was $5.49 in Cuba. The cost of hernia surgery in Cuba was $14.59 compared to the U.S. figure of $12,489; hip-fracture repair costs in Cuba were $72.15 compared to the U.S. figure of $14,263; and kidney transplant costs in Cuba were $4,902 compared to the U.S. figure of $48,758.
The United States is spending almost 20 times more per capita on health care than Cuba does. In 2018, Cuba was spending $431 and the United States $8,362 per person annually on medical care.
Don deals with some of the main causes behind the bloated US figures, the overtreatment, defining trivial conditions as illnesses, the power of doctors to charge what they can get away with, the similar power of the pharmaceutical industry, the outrageous incomes of health industry executives, and especially the insurance industry (which accounts for one third of health costs yet leaves millions uninsured.) The health sector provides a glaring illustration of what happens when you let profit and the market provide an essential service. (And Don refers to a large study involving 38 million patients which found that private for-profit ownership of hospitals is associated with a higher risk of death for patients.   P. 248,)
Thanks to Che
Don points out the role Che Guevara played in the development of the Cuban health system. As a young doctor he travelled through several Latin American countries and was struck by the lack of satisfactory health care for the poor.
“He envisioned a new medicine with doctors who would serve the greatest number of people with preventive care and public awareness of hygiene. A few years later, Che joined Fidel Castro’s July 26th Movement as a doctor and was among the eighty-one men aboard the Granma as it landed in Cuba on December 2, 1956.”
“The new Cuban Constitution included Che’s dream of free medical-care-for-all as a human right. An understanding of the failings of disconnected social systems led the revolutionary government to build hospitals and clinics in under-served parts of the island at the same time it began addressing crises of literacy, racism, poverty, and housing.”
Implications for justice and sustainability.
The significance of the system goes well beyond health and medicine.  Firstly it constitutes an overwhelming case that vital services must be under social control and not determined by corporations and entrepreneurs out to maximize their profits. The US system provides a glaring illustration of how the latter approach leads to snouts-in-the-trough inflation of costs, astronomical incomes and profits, Rolls-Royce provision for the rich few and appalling neglect for the rest.
Even more important are the implications for sustainability. The Cuban system demonstrates the importance and possibility of service provision involving very low use of the planet’s scarce and dwindling resources. Don has written previously on the need for large scale reduction in the rich world’s unsustainable resource-intensive ways, and makes the point again at the end of this book. Unfortunately most green thinking sees this only in terms of attempting to reduce personal consumption, or hoping for technical advances that will enable continued affluence and growth. Too few realise that we are so far beyond sustainable limits to growth that there have to be radical changes in systems as well as in lifestyles. For instance global agribusiness supply systems must be replaced by localized systems, transport systems must be replaced by highly self-sufficient local economies which do not involve much more than bicycle transport, growth economies must be replacd by stable economies, and (therefore) financial systems must be replaced by systems which do not charge interest. The Cuban health system provides a most impressive example of how vital services can be provided by systems that dramatically cut typical rich world resource use.  The key to this is in focusing the system on community need and on prevention. Rich world health systems provide first class and expensive (i.e., profitable) ambulance services at the bottom of the cliff, when the sensible option is to install cheap guard rails at the top. 
There is increasing recognition that demand-side solutions must centre on small-scale, highly self-governing, collective settlements in control of their own economies, interested in non-material sources of life satisfaction… with no economic growth at all and with no important decisions determined by profit or market forces. Only communities of this kind can get the per capita resource use rates right down to sustainable levels while providing a high quality of life.
Don has given us a thorough account of the very impressive Cuban health system, and of the generous humanitarian motivation behind it. It would be difficult to find a comparable example, in a world where ”aid” is so often intended to benefit the giver. It is most annoying that US-led determination to denigrate and eliminate anything Cuban has ensured that there is so little understanding or appreciation of this health system or its implications.

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