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Cuban Public Health: A Model for the U.S.? Marc Schenker M.D., M.P.H.

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Presentation on theme: "Cuban Public Health: A Model for the U.S.? Marc Schenker M.D., M.P.H."— Presentation transcript:

1 Cuban Public Health: A Model for the U.S.? Marc Schenker M.D., M.P.H.

2 Outline Vital statistics Health system performance Recent history and organization of Cuban health care Public health organization –Examples Lessons for the U.S.?

3 Cuba is a Country of Ironies

4 The Irony of Cuban Health Care “Because Cuba has so few resources, prevention has become the only affordable means of keeping its population healthy.”

5 Vital Statistics

6 Life Expectancy* in 2000 *years

7 Life Expectancy at Birth Source: PAHO 2000

8 Infant Mortality* in 2000 *per 1,000 live births

9 Infant Mortality Rate Source: PAHO 2000

10 Probability of Dying (per 1000), 1999 Source: World Health Organization, 2000. COUNTRY Under Age5 Years Between and 59 Ages 15 Years MaleFemaleMaleFemale Cuba 10814399 Haiti 120111481360 Mexico 2623194109 U.S. 8814885

11 GDP per Capita $1000/capita

12 National Health Expenditures per Capita (US $) Source: Pan American Health Organization, 1998.

13 Health Expenditure as % of GDP

14 Health Expenditures as % of National Budget in Cuba, 1990-1997 Source: Center for Financial Research of the Ministry of Finance, Cuba, 1998.

15 Physicians per 10,000 Population

16 Number of People per Physician Source: PAHO 2000

17 Number of surgeons per 100,000 population Cuba56 United States51 Japan31 Sweden29 Germany13 China10 Columbia 7 United Kingdom 6 South Africa 6 Philippines 1.5 Kenya 0.6 Tanzania 0.3 Bulletin of the American College of Surgeons, 1987 J. Perez, personal communication, 2000

18 Health System Performance

19 World Health Report of Health System Performance, 2000 Ranking of 191 countries using composite index –25% level of health –25% distribution of health –12.5% level of responsiveness –12.5% distribution of responsiveness –25% financial contribution

20 World Health Report of Health System Performance, 2000 Cuba Ranking 33rdDisability adjusted life years 41stDistribution of health care 116thLevel of responsiveness 99thDistribution of responsiveness 24thFairness in financial contribution 40thOverall goal attainment 39th Overall performance –Costa Rica, USA, Slovenia ranker higher –Brunei, New Zealand, Bahrain ranked lower

21 Health Systems Performance Country Overall health system performance (rank) Health expenditure per capita (rank) Cuba 39118 Haiti 138100 Mexico 6155 U.S. 371 Source: World Health Organization, 2000. Rankings of 191 member states

22 Recent History and Organization of Cuban Health Care

23 Recent Cuban History 1959Cuban revolution 1962Cuban missile crisis 1960s-70sCuban armed interventions Africa, Latin America 1989Collapse of Communism, reduced Soviet subsidies 1990-95“Special period” major austerity, 35% drop GDP, 75% decrease in trade 1993Cubans allowed to have U.S. $ 1996Helms/Burton Act tightens embargo

24 Cuban Healthcare History 19593000 doctors leave island 1960sMinistry of Health (MINSAP) expanded –Socialist healthcare system –Distribution of health care across Cuba Network of polyclinics Hospital beds (Havana 62% -->38%) National Immunization Program –Medical schools increased from 1 to 4 2000 graduates per year 1984Integral General Medicine program

25 “Physician migration from developing to developed countries has been criticized as a regressive subsidy paid for by poor nations that cover the costs of medical education while rich countries reap the benefits. The fact that the smartest minds are more prone to migrate makes this brain drain even more unfair.” Diego Rosselli, Andres Otero, and Giovanni Maza, Universidad Javeriana Medical School, Colombia Physician Migration Source: Medical Education 2001;35:809-810.

26 In January 2000, there were 2515 Colombian- trained physicians licensed to practice in the United States. This is equivalent to 6% of the national workforce. According to a study at Javeriana University Medical School, the U.S. migrants had higher grades than those who stayed in Colombia. Sources: American Medical Association; Rosselli et al., 2001. Physician Migration: Colombia

27 Cuba is home to 60,000 doctors – comparable to Canada, which has 3 times the population Many of these doctors are assigned to work in developing countries Cuba and the Export of Physicians Source: Canadian Medical Association Journal 2001; 164(10): 1477.

28 Over 20,000 Cuban doctors have been sent to 20 countries to help overcome physician shortages. When Hurricane Mitch struck Honduras in 1998, some 120 Cuban physicians were sent, and have since treated 1.2 million patients. 800 Cuban doctors currently work in Haiti. Cuban doctors have created an AIDS-prevention program in Uganda that the UN considers a model. Accomplishments Abroad Source: Canadian Medical Association Journal 2001; 164(10): 1477. Yan E. Castro Makes a Dream Offer. Newsday 28 February 2001.

29 3,400 medical students from 23 Latin American, African, and Caribbean countries are being trained in Cuba, at Cuba’s expense In 2001, 8 American students, all from low-income minority families, began their free medical education in Cuba, on the condition that they return to their communities for service. Fidel Castro has said that up to 500 American medical students may follow suit. Medical Education and Diplomacy Source: Canadian Medical Association Journal, 2001, 164(10): 1477.

30 Public Health in Cuba

31 Aspects of Public Health in Cuba Highly integrated with therapeutic medicine Polyclinic teams of primary care doctors, dentists, nurses –Provide health education, preventive care –Health workers live in the community –Physicians required to see every patient every year –Records of preventive services Prenatal, immunization, cancer screening, etc. –Aggressive follow-up of missed appointments –Vaccination rates 99+% Community reinforcement of public health –Neighborhood Committees for Defense of Revolution, Cuban Federation of Women, Circulos de Abuelos Surveillance data to province, state

32 Examples of Cuban Public Health, Infectious diseases Incidence of vaccine preventable infectious diseases lower than in any other nation at Cuba’s level of economic development. Immunization rates between 99% and 100% Compliance by routine epidemiologic surveillance at the neighborhood level (e.g. CDR)

33 Mortality Rates for Infectious Diseases 19601982 Diptheria 0.70.0 Tetanus 4.40.1 Pertussis 1.00.1 Measles 1.10.2 Deaths per 100,000

34 Examples of Cuban Public Health, Geriatric Care Geriatric rotation during residency training. Primary care physicians who elect to gain additional training in geriatrics provide services in network of old age homes. “Grandparents’ circles” (circulos de abuelos) provide neighborhood-based care and support.

35 Examples of Cuban Public Health, Medical Surveillance Data on acute and chronic illnesses pass from family physicians to municipal, provincial and national levels. –Identification of epidemics Neuropathy between 1991-1993 Dengue

36 Pesticide Spraying for Mosquitos

37 Examples of Cuban Public Health, AIDS Initial quarantine of HIV-positive patients –Started with HIV+ soldiers returning from Africa Compulsory quarantine lifted, HIV sanitariums became voluntary –Sanitariums in 13/14 provinces 70-80% newly diagnosed choose ambulatory treatment Epidemic helped by quarantine, travel restrictions. Lowest HIV rate in hemisphere Active screening, 2 million annual HIV tests “Jinaterismo” (prostitution) raises many issues

38 HIV in Haiti and in Cuba Total population: People living with AIDS (1999 est.) : AIDS deaths (1999 est.) : HIV/AIDS adult prevalence rate (1999 est.) : Cuba: Haiti: 11 million7 million 1,950210,000 12023,000 0.03 % 5.17 % Source: CIA World Factbook, 2001.

39 Cuban Public Health: A Model for the U.S.? Cuba is a socialist system, not transferable to the U.S. No private health care. Surveillance involves intrusive social institutions, e.g. CDR Public health may involve “coercive” policies, e.g. AIDS quarantine, pesticide spraying NO

40 Cuban Public Health: A Model for the U.S.? There is no intrinsic reason for the separation of treatment and preventive (public health) services in the U.S. Integrated primary care is a cost-effective model (if we can get there) Prioritizing health resources to achieve social objectives (e.g. eliminate health disparaties) is effective Improving surveillance systems at the primary care level is important and possible NOWEVER

41 “There is a large body of misinformation and outright disinformation about the present state of health care in Cuba… The Cuban Government’s deliberate policy includes depriving its people of basic medical needs, while actively developing a closed, parallel health care system for the Communist Party elite, foreign ‘health tourists,’ and others who can pay for services in hard currency.” U.S. Department of State, Press Statement, 1997 The U.S.: Defending the Embargo


43 The Ultimate Public Health Irony in Cuba

44 The End

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