From March 26 through 31, 2018, we were part of a group of eight who visited Havana, Cuba as a small delegation from the American Bar Association Health Law Section. Our group included an electrical engineer, a healthcare administrator, a law professor, a consultant, and in-house and private practice attorneys. We had six J.D.s and three Ph.Ds among us, and three of us have wielded the gavel as Chair of the Section, including our delegation leader, David Johnson. We met with several professionals to learn about the Cuban government and its commitment to healthcare; we toured three medical facilities; and we enjoyed wonderful meals in private restaurants. While our group had divergent opinions and interests, questions and skepticism, it is probably safe to say it was a fascinating visit for us all.
As a Caribbean island nation, Cuba presents beautiful features. Havana overlooks the Gulf of Mexico and boasts some striking Spanish-colonial architecture, particularly in Old Havana. The music is lively and the people friendly. Cars from the 1950s are picturesque. But problems and poverty are also evident. Restored mansions stand next to collapsed buildings. Laundry hangs from the balconies of buildings that evoke the Soviet era. Opportunities appear limited.
Our trip came at an historic time for Cuba. The country had just elected a new Parliament, which in turn would elect a new President. For the first time since 1959 the President of Cuba would not be a Castro. Since our return to the United States, on April 19, 2018, Raul Castro has stepped aside and 57-year-old Miguel Diaz-Canel assumed the presidential mantel. Whether the younger President will bring changes to the country remains to be seen.
The economy is clearly a major concern in this single-party nation controlled by the Communist Party. Until recently, the government owned all businesses. Although the Cuban Constitution commits to provide food, housing, education, and healthcare for free, it is questionable how fully the government can afford to meet this commitment. It sounded as if the economy was more robust when the Soviet Union was involved in Cuba and subsidized the country’s crops of sugar and tobacco. But our hosts described a terrible economic crisis the country went through from 1992 to 1997 after the fall and withdrawal of the Soviet Union--they refer to it as the “Special Period.” The United States’ reopening of diplomatic relations with Cuba in 2015 and a surge of tourism fueled some private enterprise and increased income for some. Small businesses emerged to cater to the tourist industry, including private restaurants, taxi companies, and guesthouses. The Trump administration has reversed course, however, and discourages tourism to Cuba. This has reportedly led to an abrupt reduction in the tourist business from the United States, although we heard that a significant number of tourists are still coming from Europe and Latin and South America. Meanwhile, the Cuban government reportedly acted to curtail entrepreneurship in 2017 by ceasing to issue new licenses for businesses such as restaurants.1 Our group ate all of our meals in private restaurants that locals probably cannot afford, and not all of those establishments were full when we were there.
Against that backdrop, we met with a number of warm and hospitable professionals. Our delightful and knowledgeable in-country guide had been a professor at Havana University before refocusing his language and teaching skills on the more lucrative business of guiding tourists. We were hosted at the National Union of Cuban Jurists by Doris Quintana, who has a doctorate in international and public law, is a law professor at Havana University, and serves as secretary of the Scientific Society of International Law of the National Union of Cuban Jurists. In addition to Dr. Quintana, an environmental lawyer and a family lawyer from the General Prosecutor’s Office provided us with interesting information about the government, the Cuban Constitution, and the healthcare system. Dr. Jose Portilla, a former surgeon currently with the Ministry of Public Health, also discussed the Cuban healthcare system with us. They were welcoming and eager to share their country’s structure, ideals, and accomplishments. They were also clearly frustrated with the ongoing U.S. embargo and long for our countries to re-establish a relationship.
The focus of the Cuban healthcare system is different from ours in the United States. We have the right to life, liberty, and the pursuit of happiness, but not necessarily an express right to healthcare. Article 50 of the Cuban Constitution, in contrast, guarantees everyone a right to free healthcare as follows:
Everybody 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 and preventive and specialist 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 of the population cooperates in these activities and plans through the social and mass organizations.2
Cuba has a population of around 11.5 million people and much less to spend on healthcare than the United States has. Therefore, the Cuban healthcare system’s highest priority is preventive care, followed in order of priority by treatments for minor problems, chronic conditions, and finally serious illnesses. The Cuban healthcare system is often touted as a very good primary care system relying on preventive care that does much with less.3 According to the United Nation’s World Health Organization, it is an example for countries of the world.4 Further, it has been suggested that Cuba offers the best model for poor countries.5 It is certainly quite different in approach from U.S. healthcare, with its greater emphasis on tests, tools, and equipment for diagnosing and treating illnesses than on prevention.
The front line of the Cuban healthcare system is the family physician. We learned that after completing the equivalent of our high school, would-be Cuban physicians attend school for six years to become doctors, followed by a two-year residency in a family physician’s office and in a multi-specialty outpatient facility called a polyclinic. The training is free, and every Cuban-trained physician starts out as a family physician. It sounds as if most continue to practice as family physicians, while a few pursue specialty training, and only where there is a particular need.
Family physicians work in the neighborhoods where they live, and we learned that there are approximately 12,883 family physician offices in Cuba. These physicians typically have their offices on the bottom floor of a house and live in the upper floor or floors. A nurse and a technician work with each physician to serve their community. Through a combination of home and office visits, the family physicians are charged with knowing all of the families in their neighborhood and seeing every patient at least once a year. The family physicians also reportedly know the teachers at the local school; this connection enables physicians, teachers, and parents to work together to help children who develop health or behavioral problems. We visited a family physician who serves around 994 patients. His office and exam room were small and simple, and his records were kept on paper in vertical file cabinets, but he was proud to show them to us.
The next layer of the system is the polyclinic. Cuba has around 451 polyclinics, with approximately 18 family physician offices connected to each one. In addition to a small emergency department, the polyclinics offer radiology and laboratory services; gynecology, obstetrics, pediatric services, and psychiatric care; and more complicated treatments such as ozone therapy and minor surgeries performed with topical anesthesia such as lidocaine. Although the facilities of the polyclinic we visited were old and somewhat dilapidated, they appeared clean. We saw many patients sitting in waiting rooms or wandering through the halls. Our guide through the polyclinic was a family physician who had trained there 20 years before. She then stayed on at the polyclinic, treating patients and in turn training residents.
Inpatient care is provided in 151 community hospitals and numerous specialty institutes, of which there are 15 in Havana. While we did not visit a hospital, we spent some time visiting with the medical director at the National Institute of Oncology and Radiology. This delightful surgeon was very generous with his time and explained the principal services that his institute offered, including head and neck surgery and breast surgery. He also described a world of precision medicine in the future, that we too, in the United States, are pursuing. He noted that Cuba has about 300 oncologists, and that colon cancer and lung cancer were prevalent in the country.
Our hosts were understandably proud of Cuba’s many achievements. In part by registering every pregnancy with the family physician, providing ongoing prenatal care, and requiring births to occur in hospitals, they have lowered infant mortality from 60 per 1,000 in the 1950s to four per 1,000 today. This contrasts favorably to infant mortality in the United States, which the Centers for Disease Control and Prevention has reported as just under six per 1,000.6 Over that same period of time, Cuba has raised life expectancy from 60 to an average of 79, comparable to life expectancy in the United States.7 By requiring all children to receive 13 vaccinations, they have eradicated numerous diseases from polio to pertussis. In 2015, the World Health Organization validated Cuba as the first country to eliminate transmission of HIV and syphilis from mother to child.8 And Cuban researchers have developed new treatments to prevent amputation of diabetics’ feet and a lung cancer vaccine that is a promising form of immunotherapy.
At the same time, there are concerning drawbacks to the lack of resources in the Cuban healthcare system and its focus on prevention. Given the American embargo, it is difficult and expensive for Cubans to obtain pharmaceuticals and supplies for treatment because so many are produced in the United States and are unavailable to them. There is a striking lack of wireless access to the internet, and we saw no electronic health records (EHRs). The medical director of the National Institute of Oncology and Radiology noted that his institute had fiber optics, but not all institutes did, and Cuba has digital records only for clinical trials. Colonoscopies are not provided to screen for colon cancer, only to diagnose individuals who are already symptomatic. High-risk women receive mammography screening beginning at 40, but other women do not receive screening until 55. Certain types of cancer treatment modalities, such as proton accelerators, do not exist on the island. There are no shock trauma units. Many of the facilities do not appear to be state of the art in nature. Thus, the presence of high tech equipment and treatment for serious conditions appears to be quite limited, particularly in contrast with the sophisticated range of tests and treatments available in the United States.
The Cuban government appears to have taken deliberate steps to establish a healthcare system that enlists the community to focus on health and prevention, and that tries to achieve maximum effect with limited resources. It was fascinating to learn about their system in contrast to ours, with its greater focus on individual choice and treatment of illnesses.