US President Barack Obama made passage of health care reform a major effort of his first year in office. He claimed that the cost of health care in the US was rising so rapidly that it was threatening the whole economy. The president is certainly correct in saying that the cost of health care in the US is high. In 2006, for example, the cost of health care in the US was 15.33% of the Gross Domestic Product (GDP), or $6,714 per capita. This high expense does not lead to relatively good healthcare.
Of 13 countries in a recent comparison, the US ranked an average 12th (second from the bottom) for 16 health indicators. Some of the specific rankings were 13th in neonatal mortality and infant mortality overall; 11th for life expectancy at 1 year for females, 12th for males; 10th for age-adjusted mortality. The poor performance of the US was confirmed by the World Health Organization (WHO), which used a slightly different set of indicators and a larger sample of countries. The WHO report ranked the US 15th among 25 industrial nations. That is, the poor position of the US in health worldwide is not dependent on the particular measures used.
Clearly, relatively poor countries seeking to form an effective health service should reject the US model. Fortunately, there is a better model for these countries. It is the Cuban health care system which, deplorably, the US has worked hard to undermine. Thus in 1963 the US prohibited trade with Cuba in food, medicines, and medical supplies. But this embargo had little impact, mostly because of strong support for Cuba from the Soviet Union.
When the Soviet Union collapsed in 1989 its aid to Cuba stopped. Both the economy and health of the socialist island nation suffered. According to a valuable summary by Dr. Paul Drain and social scientist Michele Barry, Cuban adult "caloric intake decreased 40%, the percentage of underweight newborns increased 23%, anemia was common among pregnant women," and after a decade of steady decline, "Cuba's total mortality rate increased 13%."
The US Torricelli Bill of 1993 and the Helms-Burton Act of 1996 tightened the embargo further. Drain and Barry observe that medication shortages were tied to a 48% increase in tuberculosis deaths from 1992 to 1993, and "the number of tuberculosis cases in 1995 was threefold that in 1990." Although the US in 2000 ended restrictions on selling food to Cuba, restrictions on medicines and medical supplies were not repealed.
Despite the embargo, Cuba has produced better health outcome than most Latin American countries, outcomes that are even comparable to those of most developed countries. For example, Cuba has the highest life expectancy, at 78.6 years, and the lowest infant and child mortality rate, among 33 Latin American and Caribbean counties.
Drain and Barry think that these successes are the result of emphasis on disease prevention and primary health care, which have been cultivated during the embargo. They observe that "Cuba has one of the most proactive primary health care systems in the world. By educating their population about disease prevention and health promotion, the Cubans rely less on medical supplies to maintain a healthy population." With its strong emphasis on prevention, it's no surprise that Cuba has some of the highest vaccination rates anywhere. This is in interesting contrast to the US, which relies heavily on medical supplies and technologies to promote health, but at a very high cost.
Medical education in Cuba has emphasized primary care since 1960, when the country created the Rural Social Medical Service to encourage young physicians to work in rural areas. By 1974 all medical graduates were expected to spend up to 3 years practicing community medicine in a rural area. On completion of medical school, virtually all graduates enter 3 years of family medicine residency training, after which about two-thirds start practicing primary care medicine and the rest go into specialty training.
Cuba has supported primary care medicine with an effective health care infrastructure. In 1965 the country set up a system of 498 community-based polyclinics that promote primary care, speciality services, and laboratory and diagnostic testing. Cuba added another primary care level in 1984, establishing neighborhood-based family medicine clinics called consultorios. Every Cuban is scheduled to visit, or be visited by, a consultorio physician at least yearly. And of course care provided at the consultorios, polyclinics, and larger regional and national hospitals is free to patients.
Drain and Barry have concluded that the "emphasis on primary care, community health literacy, universal coverage, and accessibility of health service may be how Cuba achieves developed-world health outcomes with a developing-world budget."
Many developing countries bear a severe deficit in health, a deficit that they don't have much money to fix. Although success won't come easily, Cuba can serve as an effective and inspiring model for other nations to follow.
Given the poor standing of the US among developed countries in terms of important health indicators, it's clear that major change is needed. Adopting some of Cuba's successful health-care policies could be a step forward. This step could be even more broadly beneficial if it opened a new era of cooperation between US and Cuban health-care workers.
Photo by Sarah van Gelder/Yes Magazine