Spring 2001

Report from Cuba, Home of the "Family Doctor Program"

It has been observed that "researchers who go to Cuba for one week write a book. Those who go for two weeks write an article, and those who go for longer don’t write anything." SDAFP members Dave Brechtelsbauer and Tom Dean and their spouses each spent a week in Cuba in late 2000. The following article is a collection of their observations regarding the Cuban health care system. Both the trips were sponsored by People to People, an organization founded in 1956 with the encouragement of President Eisenhower and originally a branch of the State Department. People to People is now a private sector organization. Dr. Brechtelsbauer’s trip was particularly focused on learning about the Cuban health care system, Dr. Dean’s more on economic development.

Both SD physicians were struck by the Cuban emphasis on primary care and the rural family doctor, and by the accomplishments of the Cuban health care system in meeting certain public health goals, providing access to care, and training generalist physicians. These generally positive impressions were tempered by observing food rationing, lack of medical supplies and pharmaceuticals, and an apparent shortage of gasoline. In spite of the problems, many Cubans we spoke with expressed pride in what has been accomplished and indicated that as difficult as things are, that they are better than before the revolution.

Throughout their trips both physicians were warmly welcomed by the Cuban people they met, and felt the tour guides were candid and honest in their reports and explanations. The trips included free time during which travel and conversation was unrestricted. Both heard comments about the difficulties between the US and Cuba, and statements that those difficulties should not impact our ability to relate as individuals. As honored guests, and as well-to-do North American tourists, the Brechtelsbauers and the Deans enjoyed luxurious accommodations, generous amounts of well-prepared food, and traveled in comfortable air-conditioned motor coaches. The hosting of foreign tourists is currently a major emphasis of Cuba’s centrally planned economy, and a major source of the hard currency necessary to carry on international trade.

Cuba puts a high priority (with the resources to back it) on health care. Castro, who assumed power January 1, 1959, has stated a goal of becoming a "world medical power" and a goal of providing access to quality health care for all of Cuba’s citizens. In the early 80’s an evaluation of the Cuban health care system led to the creation in 1984 of the "Family Doctor Program". The goal was to put a doctor and nurse team on every city block (yes, every block) and in every village and hamlet.

In many ways this program has been successful. In 1989 there were11,091 family doctors, most practicing in urban areas. Ten years later there are 29, 648 family doctors, many (we were unable to ascertain a credible statistic regarding urban-rural mix) practicing in rural areas. Given Cuba’s population of a bit over 11 million, this means there is one family doctor for every 375 Cuban citizens. The often mentioned quote is that each "Family Doctor Clinic"—a term used to emphasize the important role of the family nurse in addition to the physician—cares for from 120 to 150 families. Family Doctors make up 46% of the total Cuban physician population.

The typical day for the family doctor-nurse team is morning office hours and afternoon home visits. The typical rural office, built according to a design created in Havana, consists of four rooms and a bathroom. There is a porch-like waiting area, a reception/nurse office which includes infant and adult scales and patient education material, a doctor office which includes a desk, cot, and sparse reference materials. There are no files for medical records as they are kept by the patient. Lastly, there is a modest treatment room. The standard design includes a living area for the doctor upstairs. This later is an enticement to rural practice in Cuba, where housing shortages persist.

Hanging on the treatment room wall were four protocols, for the diagnosis and initial treatment of meningitis, convulsions, heart attack and stroke, and preterm labor. Four metal boxes contained the medications and supplies necessary to follow the protocols. There was also one liter of iv fluid, and a kit for repair of minor lacerations. There was no x-ray, very few medications (lidocaine, phenobarbital, diazepam, hydrocortisone, atropine, and epinephrine were all that were seen), and no possibility of doing on-site lab except for dipstick type tests. There were a number of bottles of "natural" medicines, also called "green medicine"; botanicals grown locally. Similar products were noted in the pharmacies we visited.

There was no evidence of a telephone in the rural office visited by Dr. Brechtelsbauer and Dean. Apparently if a person is going to be referred for secondary or tertiary care someone runs to get the driver. When in Havana the goal of providing more ambulances was mentioned.

A traditional reason offered for the lack of home visits by US doctors is that the technical equipment necessary to assess the patient is not available in the home. No such excuse can be offered in Cuba, and home visiting is common. Type 2 diabetics, for example, are to be seen every six weeks, with every other visit being a home visit.

Another unique facility used widely in Cuba is the "maternity home". These are residential facilities with medical attendants where women go when they reach approximately 37 weeks. There they await the birth in company of other women and free of the responsibilities of maintaining a household. After delivery new mothers and their babies generally come home on the first postpartum day (99% of deliveries occur in hospitals) and are seen in the home daily by the family doctor-nurse team for the next ten days. Then there is one office visit and one home visit for six weeks, then monthly visits. Should a diabetic or a new mother miss a visit, the doctor and/or nurse will call on the patient to see why.

Secondary care consists of "polyclinics" which house the offices of pediatricians, obstetricians, and medical and surgical subspecialists. These doctors also do inpatient work in the provincial (there are 14 provinces in addition to Havana) hospitals. Tertiary care is handled mostly in three regional hospitals, one each in the west, middle, and east part of the island, and in the specialty hospitals in Havana. The Deans’ had the opportunity to visit the central tertiary care hospital in Havana. It was a gigantic, well kept, 1000 bed, 27 story facility. According to the promotional material presented the hospital provided a wide range of high tech services including sophisticated imaging, transplants and complex prosthetics. No data were offered on the volume or outcome of these procedures.

This system of care has given Cuba immunization rates, infant mortality rates, and overall mortality statistics that are in the "first world" category. When the vice minister of health was proudly describing the current Cuban system, he used the phrase "guardian of the health of the community" to describe the role of the Family Doctor. The polyclinic role was described as "coordinating the actions taken by the various Family Doctors working within the jurisdiction of the polyclinic." The rural Family Doctor both Dr. Dean and Dr. Brechtelsbauer met, in responding to a question about keeping up, stated that he looked to the consultations by polyclinic doctors as a major source of CME.

The vice minister of health mentioned the following as current issues for the primary care system in Cuba:

• enhancing the teaching skills of the polyclinic physicians
• implementing more consistent home care programs and protocols
• developing the emergency system (ambulances)
• eliminating "bureaucratism" within the Family Doctor work system
• improving competence and professional performance
• increasing the "solution capacity"

He also stated that the central government planners felt research by Family Doctors was needed, presumably to help inform decisions being made in Havana about care to be delivered in the provinces.

The Cuban medical training program begins with six years of training following high school. The medical schools (there is one in each province and 5 (? I think, I cannot find this number in my trip notes) in Havana) appear not be affiliated with universities, and have a technical school flavor. Associated with the medical school we visited, and I presume each of the provincial schools, is a training school for nurses, pharmacists, lab and xray techs, medical social workers and other allied health personnel.

After six years of training every new medical school graduate is assigned as a Family Doctor. At the conclusion of two years of service as a Family Doctor physicians may apply for work in a new location, or for additional training, either as a "internal generalist", which sounds somewhat equivalent to our family practice residency training, or in other specialties. (Among the traditional specialties is geriatrics – as the success in achieving first world health statistics has fueled a demographic challenge similar to that seen here). The number of residency positions is strictly apportioned among the specialties, based on the perceived health manpower needs of the country.

It appears there is an emphasis on public health throughout the medical school and residency curricula. The importance of
"meeting the needs of the people" was mentioned wherever we stopped.

Another emphasis in Cuban medical education is "internationalism". The Cuban system is very open to trainees from other countries, particularly those from other Latin American countries and from Africa. Many of these countries look enviously at Cuban health statistics and are eager for their students to obtain medical training in Cuba. Cuba also encourages its graduates of consider international service in third world countries.

Overall Drs. Brechtelsbauer and Dean (and spouses) were favorably impressed by what they saw. The emphasis on access to care, outreach, public health, and service seems to have resulted in efficient care that has achieved many of the desired outcomes.

On the other hand, the status of physicians (and their pay) does not match that typical in the USA. One of the tour guides indicated that his income was just below the top wage earners (military officers and government officials) and was about the same as a doctor—approximately $15.00 (US) per month.

Access to high tech care is limited. Critics of the system state that political power and connection have a large influence on who receives the high tech care. There were 103 kidney transplants and 153 CABG’s performed in 1999, clearly not everyone who might have benefited from tertiary care in this island nation of 11+ million received it.

High tech care is also available to foreign—read "cash-paying"—medical tourists, as this provides the government with another source of hard currency. Deans spoke with a young man from Nassau whose aunt had just been in Havana for an orthopedic procedure. There charge there had been $7000 (US). The charge in Nassau would have been $30,000, and even more in the USA. The man indicated his aunt was pleased with the care and the outcome.

Looking back, perhaps most impressive was the power and cost effectiveness of appropriate primary care. The contrasts with the US situation was sobering and thought provoking. In the Cuban system there are clearly deficiencies. Nonetheless, what they have achieved in terms of health outcomes with a strong emphasis on primary care and despite absolutely meager investment does cause one to stop and think.

Dave Brechtelsbauer

Tom Dean

REFERENCES

Moses, Catherine Real life in Castro’s Cuba Scholarly Resources Inc. Wilmington, Delaware 2000.
Quirk, Robert E. Fidel Castro W.W. Norton & Co. New York 1993.
Allen ed A Reader’s Guide to Cuba
Starfield B. Is US health really the best in the world? JAMA v 284 pp 483-485, 2000.
Donini-Lenhoff FG, Hendrick H Growth of specialization in graduate medical education
JAMA v 284 pp 1284-1289, 2000.
Barondess JA Specialization and the physician workforce, drivers and determinants.
JAMA v. 284 pp 1299-1301, 2000
----CULTUREGRAM, Republic of Cuba
----The Impact of the U.S. Embargo on Health & Nutrition in Cuba, Executive Summary. American Association for World Health, March 1997.
Barry M, Effect of the US embargo and economic decline on health in Cuba Annals of Inter Med v 132 2000 pp 151-154.
Albright MK Economic sanctions and public health: a view from the department of state.
Ann Intern Med 2000; 132:155-157.
Morin K, Miles SH The health effects of economic sanctions and embargoes: the role of the health professional. Ann Intern Med 2000; 132:158-161.
Feinsilver JM Healing the masses: Cuban health politics at home and abroad University of California Press, 1993.

CUBAN HEALTH CARE SYSTEM
INTERNATIONALIST BY CONCEPT

UNIVERSIAL
ACCESIBLE
FREE TO ALL CITIZENS
EMPHASIS ON PRIMARY CARE
PROMOTION OF HEALTH HP/DP, PT ED
PREVENTION OF DISEASE OUTBREAK & DAMAGE TO HEALTH OF POPULATION (COPC)
TIMELY DIAGNOSIS AND TREATMENT – 95% BY FAM DOC, THEN REFER TO POLYCLINICS/HOSPITAL
COMMUNITY-BASED REHABILITATION, FOR PHYSICALLY & MENTALLY ILL

 "…our physicians are extremely eager to solve all the problems.’

PRIMARY CARE "ISSUES"

• create the polyclinic faculty (or facility???)
• implement home care
• develop emergency system
• eliminate bureaucratism within the family doctor system
• improve competence & professional performance
• increase the "solution capacity"

THE RURAL FAMILY DOCTOR
PUBLIC HEALTH GOALS/STATISTICS
INFANT-MATERNAL CARE

e.g. – the maternity home, fam doc home visits

COMMUNICABLE DISEASES

e.g. – special nurse for STDs, vaccines

NON-COMMUNICABLE DISEASES

e.g. – cardiac surgery 1999 – 153 CABG, 366 VALVE REPLACEMENT, 520 CONGENITAL HEART DISEASE – 1053 TOTAL IN 3 CENTERS (WEST, CENTRAL, EAST)

CARE OF ELDERLY
MEDICAL EDUCATION, TRAINING PHYSICIANS