The U.S. is struggling with how we will provide healthcare for all of our citizens. Cuba has established a government-run healthcare system that is significantly less costly (Cuba's health costs are 7.3 percent of GDP, while the U.S. is at 16 percent) but with similar health outcomes to the U.S. health system. Infant mortality (average from 2008-2010) is 6.95/1,000 live births in Cuba, versus 7.07 in the U.S. Life expectancy is 77.9 years in Cuba, while in the U.S. it is 78.5 years.
The Cuban healthcare system is based on six principles. Healthcare is: a basic right; free, including dental care; accessible to all; a responsibility of the government; built on a foundation of primary care; and contingent on community involvement. Cuba's multilayer system includes neighborhood consultorios (clinics that serve 1500-2000 people); polyclinics that serve as small outpatient clinics; municipal and regional hospitals; and specialty hospitals such as rehabilitation or cardiovascular hospitals.
I was particularly impressed with the primary level of healthcare. Each neighborhood across the country has a clinic staffed by a family physician and nurse, who live above the clinic. Mornings are spent in the clinic; afternoons are spent conducting home visits with an emphasis on health promotion and disease prevention. A strong public health philosophy guides the model, with a commitment to equality in social services such as education, nutrition and housing, and how these factors impact health.
At the polyclinic we observed primary care and urgent care as well as OT and PT and natural health providers administering CAM such as acupuncture. We spent a morning at a natural medicine outpatient facility where healthcare workers were mostly providing Chinese medicine. This was a busy facility with many waiting to receive treatment. We also visited the national rehabilitation hospital in Havana, which has an impressive inpatient program including OT. Clients and at least one caregiver live at the hospital for 1 to 6 months to receive intensive services. All of the healthcare providers we observed seemed committed to their jobs, proud of their programs, open to questions and passionate about keeping their clients healthy.
While the general healthcare provided is impressive, especially in contrast to the inequitable care we provide, everything is not rosy in Cuba. Providers receive an unbelievably low salary (reportedly $20/month across disciplines), facilities have limited resources, some are in poor condition, and there is limited client privacy or informed consent. At the rehabilitation hospital there was no air conditioning (July in Cuba is quite hot!) and none of the therapy pools had water. At the natural medicine center the treatment rooms were crowded and hot.
Cuba's economy faces serious limitations due to the decrease of support from the Soviet Union (starting in the early '90s) and the negative impact of the U.S. embargo, which includes restrictions on the import of medicines and medical equipment. These factors create ongoing challenges.
Currently Cuba exports healthcare providers to 68 countries and has assisted with global disasters such as the South Asian tsunami and the Haitian earthquake. Cuba has created the Latin American School of Medicine (known as ELAM), which trains physicians from around the world (including Americans) for free. This institution is a six-year course of intense study with an emphasis on family practice and public health. Graduates are required to go back to their home countries and practice in medically underserved communities. At UNM, we have two ELAM graduates doing their residencies. I talked with Dr. Carman Landau, who will be working in a community women's health clinic in Albuquerque. She is an impressive professional with a "big picture" view of health and well-being who, no doubt, will provide healthcare in a caring, health-promoting manner.
Many of our assumptions about Cuba are inaccurate. However, after visiting Cuba there is much I do not fully understand. Cuban healthcare is multidimensional, with both good and bad aspects. I do think we can learn from Cuba about national health priorities. I hope as we progress as a country we embrace accessible and affordable healthcare for all of our citizens.
Terry K. Crowe, PhD, OTR/L, FAOTA, was founding director of the OT program at the University of New Mexico (UNM) and is currently a professor in the department of pediatrics (division of occupational therapy) at the UNM School of Medicine in Albuquerque. She has worked in Argentina, Bangladesh, Cambodia, Mexico, Thailand and Vietnam, and traveled in 51 countries. Reach her at email@example.com.