8) Sources ……………………………………………………………… 16 ) HISTORY Modern Western medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th century and the first surgical clinic was established in 1823. Cuba has had many world class doctors, including Carlos Finlay, whose mosquito-based theory of yellow fever transmission was given its final proof under the direction of Walter Reed, James Carroll, and Aristides Agramonte. During the period of U. S presence (1898–1902) yellow fever was essentially eliminated due to the efforts of Clara Maass and surgeon Jesse W. Lazear.
In 1976, Cuba’s healthcare program was enshrined in Article 50 of the revised Cuban constitution which states “Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease.
All the population cooperates in these activities and plans through the social and mass organizations. Cuba’s doctor to patient ratio grew significantly in the latter half of the 20th century, from 9. 2 doctors per 10,000 inhabitants in 1958, to 58. 2 per 10,000 in 1999. In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox.
Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care. 1. POST-SOVIET UNION The loss of Soviet subsidies brought famine to Cuba in the early 1990s. In 2007, Cuba announced that it has undertaken computerizing and creating national networks in Blood Banks, Nephrology and Medical Images. Cuba is the second country in the world with such a product, only preceded by France.
Cuba is preparing a Computerized Health Register, Hospital Management System, Primary Health Care, Academic Affairs, Medical Genetic Projects, Neurosciences, and Educational Software. The aim is to maintain quality health service free for the Cuban people, increase exchange among experts and boost research-development projects. An important link in wiring process is to guarantee access to Cuba’s Data Transmission Network and Health Website (INFOMED) to all units and workers of the national health ystem. 2) PRESENT | | | | |WHO health statistics for Cuba | |[Source: WHO country page on Cuba] | |Life expectancy at birth m/f: |76. 0/80. (years) | |Healthy life expectancy at birth m/f: |67. 1/69. 5 (years) | |Child mortality m/f: |8/7 (per 1000) | |Adult mortality m/f: |131/85 (per 1000) | |Total health expenditure per capita: |$251 | |Total health expenditure as % of GDP: |7. 3 | Rank |Countries | |Statistic |Date of | | |surveyed | | |Information | |125 |167 |HIV/AIDS adult prevalence rate |0. 10% |2003 est. | |162 |175 |Fertility rate |1. 66 (children/woman) |2006. | |153 |224 |Birth rate |11. 9 (births/1,000 population) |2006 est. | |168 |226 |Infant mortality rate |6. 04 (deaths/1,000 live births) |2006. | |129 |224 |Death rate |6. 33 (deaths/1,000 population) |2005. | |37 |225 |Life expectancy at birth |77. 23 (years) |2006. est | |17 |99 |Suicide rate |18. 3 per 100,000 people per year |1996. | 3) COMPARISON OF PRE- AND POST-REVOLUTIONARY INDICES |Cuba: Public health 1950-2005 | | |Years | | | 1. HEALTH INDICATORS AND ISSUES Cuba began a food rationing program in 1962 to guarantee all citizens a low-priced basket of basic foods.
As of 2007, the government was spending about $1 billion annually to subsidise the food ration. The ration would cost about $50 at an average grocery store in the United States, but the Cuban citizen pays only $1. 20 for it. The ration includes rice, legumes, potatoes, bread, eggs, and a small amount of meat. It provides about 30 to 70 percent of the 3,300 kilocalories that the average Cuban consumes daily. The people obtain the rest of their food from government stores (Tiendas), free market stores and cooperatives, barter, their own gardens, and the black market.
According to the Pan American Health Organization, daily caloric intake per person in various places in 2003 were as follows (unit is kilocalories): Cuba, 3,286; America, 3,205; Latin America and the Caribbean, 2,875; Latin Caribbean countries, 2,593; United States, 3,754. The table below shows the relative seriousness of communicable diseases, non-communicable diseases (e. g. , heart disease and cancer) and injuries, in various parts of the world. Data is from the World Health Organisation and is for year 2004. Distribution of years of life lost by cause (%) | |Place |Communicable |Non-communicable |Injuries | |Cuba |9 |75 |16 | |World |51 |34 |14 | |High income countries |8 |77 |15 | |United States |9 |73 |18 | |Low income countries |68 |21 |10 | | | |Source: World Health Organisation. World Health Statistics 2009, Table 2, “Cause-specific | |mortality and morbidity”. | Like the rest of the Cuban economy, numerous reports have shown that Cuban medical care has long suffered from severe material shortages caused by the US embargo. The ending of Soviet subsidies in the early 1990s has also affected it. While preventive medical care, diagnostic tests and medication for hospitalized patients are free, some aspects of healthcare are paid for by the patient.
Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. When a patient can obtain these items at state stores, prices tend to be low as these items are subsidized by the state. For patients on a low-income, these items are free of charge. 2. SEXUAL HEALTH • According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0. 05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to
Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment. • In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world. The UNAIDS reported that HIV infection rates for Cuba were 0. 1%, and for other countries in the Caribbean between 1 – 4%. Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education. According to Avert, an international AIDS charity, “Cuba’s epidemic remains by far the smallest in the Caribbean. ” They add however that … new HIV infections are on the rise, and Cuba’s preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cuba’s prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs. • In recent years because of the rise in prostitution due to tourism, STDs have increased. 3. 3 EMBARGO
During the 90s the ongoing United States embargo against Cuba caused problems due to restrictions on the export of medicines from the US to Cuba. In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U. S. subsidiary trade, including trade in food and medicines, being prohibited. The legislation did not state that Cuba cannot purchase medicines from U. S. companies or their foreign subsidiaries; however, such license requests have been routinely denied. In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U. S. Government that such activities violate international law and has requested that the U. S. ake immediate steps to exempt medicine from the embargo. The Lancet and the British Medical Journal also condemned the embargo in the 90s. A 1997 report prepared by Oxfam America and the Washington Office on Latin America, Myths And Facts About The U. S. Embargo On Medicine And Medical Supplies, concluded that the embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U. S. firms or from non-U. S. sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba’s medical system. It prohibited foreign subsidiaries of U. S. orporations from selling to Cuba, thus further limiting Cuba’s access to medicine and equipment, and raising prices. In addition, the act forbids ships that dock in Cuban ports from docking in U. S. ports for six months. This drastically restricts shipping, and increases shipping cost some 30%. 3. 4 MEDICAL STAFF IN CUBA According to the World Health Organization, Cuba provides a doctor for every 170 residents, and has the second highest doctor to patient ratio in the world after Italy. Medical professionals are not paid high salaries by international standards. In 2002 the mean monthly salary was 261 pesos, 1. 5 times the national mean. A doctor’s salary in the late 1990s was equivalent to about US$15–20 per month in purchasing power.
Therefore, some prefer to work in different occupations, for example in the lucrative tourist industry where earnings can be much higher. The San Francisco Chronicle, the Washington Post, and National Public Radio have all reported on Cuban doctors defecting to other countries. 3. 5 BLACK MARKET HEALTHCARE The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba’s burgeoning black market economy, sometimes termed “sociolismo”. According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, “The doctors in the hospitals are charging patients under the table for better or quicker service. ” Prices for out-of-surgery X-rays have been quoted at $50 to $60.
Such “under-the-table payments” reportedly date back to the 1970s, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn known as the “Special Period” in the 1990s aggravated these payments. The advent of the “dollar economy”, a temporary legalization of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans was able to obtain medications and health services that would not be available to them otherwise. 4) CUBA AND INTERNATIONAL HEALTHCARE In the 1970s, the Cuban state initiated bilateral service contracts and various money-making strategies.
Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA), and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil. Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: “Mission Into the Neighborhood”) social welfare program established in Venezuela under current Venezuelan president Hugo Chavez.
The program, which is popular among Venezuela’s poor and is intended to bring doctors and other medical services to the most remote slums of Venezuela, has not been without its detractors. Operacion Milagro (Operation Miracle) is a joint health program between Cuba and Venezuela, set up in 2005. Human Rights Watch complains that the government “bars citizens engaged in authorized travel from taking their children with them overseas, essentially holding the children hostage to guarantee the parents’ return. Given the widespread fear of forced family separation, these travel restrictions provide the Cuban government with a powerful tool for punishing defectors and silencing critics. ” Doctors are reported to be monitored by “minders” and subject to curfew.
The Cuban government uses relatives as hostages to prevent doctors from defecting. According to a paper published in The Lancet medical journal, “growing numbers of Cuban doctors sent overseas to work are defecting to the USA”, some via Colombia, where they have sought temporary asylum. Cuban doctors have been part of a large-scale plan by the Cuban state to provide free medical aid and services to the international community (especially third world countries) following natural disasters. Currently dozens of American medical students are trained to assist in these donations at the Escuela Latino Americana de Medecina (ELAM) in Cuba. 4. 1 HEALTH TOURISM AND PHARMACEUTICS
Cuba attracts about 20,000 paying health tourists, generating revenues of around $40 million a year for the Cuban economy. Cuba has been serving health tourists from around the world for more than 20 years. The country operates a special division of hospitals specifically for the treatment of foreigners and diplomats. Foreign patients travel to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinson’s disease, cosmetic surgery, addictions treatment, retinitis pigmentosa and orthopaedics. Most patients are from Latin America, Europe and Canada, and a growing number of Americans also are coming.
Cuba also successfully exports many medical products, such as vaccines. By 1998, according to the Economic Commission for Latin America and the Caribbean, the Cuban health sector had risen to occupy around two percent of total tourism. Some of these revenues are in turn transferred to health care for ordinary Cubans, although the size and importance of these transfers is both unknown and controversial. At one nationally prominent hospital/research institute, hard currency payments by foreigners have financed the construction of a new bathroom in the splanic surgery wing; anecdotal evidence suggests that this pattern is common in Cuban hospitals. 5) ALTERNATIVE HEALTHCARE
Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population. In the 1990s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model. Examples of alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i. e. acupunctural anesthesia for surgery), natural dietary supplements, yoga, electromagnetic and laser devices.
Cuban biochemists have produced a number of new alternative medicines, including PPG (policosanol), a natural product derived from sugarcane wax that is effective at reducing total cholesterol and LDL levels, and Vimang a natural product derived from the bark of mango trees. 6) MEDICAL RESEARCH IN CUBA The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine. Because the U. S. government restricts investments in Cuba by U. S. companies and their affiliates, Cuban institutions have been limited in their ability to enter into research and development partnerships, although exceptions have been made for significant drugs. In April 2007, the Cuba IPV Study Collaborative Group reported in the New
England Journal of Medicine that inactivated (killed) poliovirus vaccine was effective in vaccinating children in tropical conditions. The Collaborative Group consisted of the Cuban Ministry of Public Health, Kouri Institute, U. S. Centers for Disease Control and Prevention, Pan American Health Organization, and the World Health Organization. This is important because countries with high incidence of polio are now using live oral poliovirus vaccine. When polio is eliminated in a country, they must stop using the live vaccine, because it has a slight risk of reverting to the dangerous form of polio. The collaborative group found that when polio is eliminated in a population, they could safely switch to killed vaccine and be protected from recurrent epidemics.
Cuba has been free of polio since 1963, but continues with mass immunization campaigns. In the 1980s, Cuban scientists developed a vaccine against a strain of bacterial meningitis B, which eliminated what had been a serious disease on the island. The Cuban vaccine is used throughout Latin America. After outbreaks of meningitis B in the United States, the U. S. Treasury Department granted a license in 1999 to an American subsidiary of the pharmaceutical company SmithKline Beecham to enter into a deal to develop the vaccine for use in the U. S. and elsewhere. 7) ANALYSIS In 2006, BBC flagship news programme Newsnight featured Cuba’s Healthcare system as part of a series identifying “the world’s best public services”.
The report noted that “Thanks chiefly to the American economic blockade, but partly also to the web of strange rules and regulations that constrict Cuban life, the economy is in a terrible mess: national income per head is minuscule, and resources are amazingly tight. Healthcare, however, is a top national priority” The report stated that life expectancy and infant mortality rates are nearly the same as the USA’s. Its doctor-to-patient ratios stand comparison to any country in Western Europe. Its annual total health spend per head, however, comes in at $251; just over a tenth of the UK’s. The report concluded that the population’s admirable health is one of the key reasons why Castro is still in power.
A 2006 poll carried out by the Gallup Organization’s Costa Rican affiliate — Consultoria Interdisciplinaria en Desarrollo (CID) — found that about three-quarters of urban Cubans responded positively to the question “do you have confidence to your country’s health care system”. In 2001, members of the UK House of Commons Health Select Committee travelled to Cuba and issued a report that paid tribute to “the success of the Cuban healthcare system”, based on its “strong emphasis on disease prevention” and “commitment to the practice of medicine in a community”. CUBA’S COMPREHENSIVE HEALTH PROGRAM: 1. Confronting the Real Disaster • Direct long-term medical care • Applying lessons from Cuban experience On-the-ground training of local personnel • Development and sharing of research • Academic training for Cubans at international sites • Trilateral cooperation • Scholarships for medical education • 29 countries involved (21 in Africa) 2. Direct Medical Services – Strengthening Health Systems • Bilateral government accords, identify needs • Bolster public health infrastructure, capabilities • Shared financial responsibility • Mainly remote, rural postings • Individual commitment/institutional commitment • Numbers of professionals enough to make a difference 3. Challenges and Opportunities – Bolstering Local Public Health Systems OpportunitiesChallenges ___________________________________________________________________ SustainabilityFrustration with local infrastructure Increase understanding locallyBend to local opinions Long-range perspective, understandingVulnerable to govt changes, political will Horizontal model, broad presenceIntegrate vertical programs Increase staffing for health systemCreate felt need in population Broad skill setMismatched, narrow skill set 4. Training Professionals for Global Health • At least 100,000 new doctors by 2015 • Second Latin American Medical School • Cuba has founded 11 medical schools and 2 nursing schools abroad • Cuban professors teach in a dozen others 5. Health Equity & Cooperation: Challenges They Face $$ Resources |Lacking |Wise use (still lacking…) | |Goals |Disease driven |Healthy people driven | |Programs |Silos |Blankets | |Models |Stand-alone |Building health systems | |Priorities |Donor driven |Effective local leadership | |Investments |In buildings |In people | |Reach |Pilot programs |Scaling Up | |Way |Independent |Real cooperation | |Movement |Band aids |Change | 8) SOURCES • The World Health Organisation, and its regional branch, the Pan American Health Organization, publish regular reports as well as making data available on the web. • World Health Organisation, World Health Statistics 2009 consists mostly of tables (. df format) of health indicators, for most countries, for selected years between 1990 and 2008. World Health Organisation, National Accounts Series consists of statistics on the financing of health care in various countries. Cuba tables covers years 1995-2007. • Pan American Health Organisation, Health situation in the Americas: Basic Indicators 2008. Table of health indicators for countries, one datum from a recent year (2000-2008) for each indicator. Pan American Health Organisation, Health in the Americas 2007 is primarily a text report; also contains tables. First section is on the region as a whole, second section is reports on individual countries, including Cuba.
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