The extraordinary achievements of the Cuban health system could not have happened without the revolution of 1959 and the new social relations that resulted.
Despite the cruel blockade by the US – the longest trade embargo in modern history – and the resulting shortage of medicines and equipment, the Cuban healthcare mission has built a model that not only cares for all its citizens, but extends this particularly to the poorer parts of the world
In the year following the revolution, half the 6,000 doctors in Cuba left the country, many of them for Florida. The remaining 3,000 stayed to support the new strategy for health care that included setting up health centres in isolated countryside areas.
It included the training of large numbers of new doctors and nurses, who were encouraged to join the international teams of soldiers and medics that were sent to assist liberation struggles. Medical teams were also assembled to assist in natural disasters. Cuban teams were often the first to arrive and the last to leave.
Fitz says: “As Cuban society polarised (soon after the revolution), students were entering medical school with the expectation that they would be trained not for personal gain, but according to the needs of society. Renouncing private practice, students often commented they would go ‘wherever the revolution needs me’.”
The health system within Cuba was transformed from one of private provision, centred mostly in the towns, with hardly any doctors in the countryside or in the poorer east of the country, into one of universal healthcare for all. This transformation went through various phases, built around community polyclinics.
By the 1980s a system of consultarios was in place, where a nurse and doctor team would be responsible for a defined area of 600-800 individuals. They could refer patients, if necessary, to polyclinicos for further treatment. There were also specialist hospitals for patients with more serious illnesses.
The doctor-nurse team would live locally and become a part of the community. Home visits were prioritised by the teams at the consultarios. They would get to know the families in their area by visiting them and assessing their problems on site. Primary health care and preventive medicine were at the core of the system.
The book details how the health programme was able to continue evolving in spite of the huge problems caused by the American blockade, and by the collapse of the Soviet Union in the 1990s, to the point where Cuba now has, arguably, the best universal health care system in the world. It was given priority, together with education and literacy, while other services had to be cut back during the “Special Period” after Soviet support dissolved in 1990.
Remarkably, Cuba has still been able to send large teams of doctors and nurses around the world to sites of natural disasters without compromising the set-up at home. The international work is seen as an essential part, an extension, of the domestic programme.
In January 2010, Haiti was devastated by an earthquake that killed over 150,000 and left three million injured or homeless. Cuba soon had 1,500 medical personnel there, staying not in posh hotels, but with the victims, in tents in the open air. They arrived before the 550 medical military personnel from the US, they treated more than 227,000 patients, and stayed long after the Americans had left, and were still there when the cholera outbreak took hold. They treated patients but also helped to construct a new health care system and to train up new doctors.
It was an equally extraordinary story at Chernobyl, after the catastrophic melt-down of one of the reactors there in 1986. Twenty-five thousand patients, mostly children with cancer and blood disorders caused by the radiation, were air-lifted to a hospital site near Havana.
They were treated for an average of six months, some for several years, before being returned to Ukraine. Cuba covered all the costs except for the transportation costs of the patients, but “Ukraine never got around to paying Cuba,” Fitz writes. The cost of medicines and treatment alone was estimated at $350m million.
At the centre of Cuba`s international health model is the Latin American School of Medicine (ELAM). Set up in 2000, this school, located about 40 miles from Havana, has trained 20,000 foreign doctors from over 100 countries, many of them from Africa and Latin America, with the educational costs covered by the Cuban government.
From 1975 to 1991, Cuba brought over 50,000 students from around the world to study in its schools, covering the complete cost of their education. Almost 20,000 students came from Africa alone..
The book compares the health systems of Cuba and comes up with some startling statistics and conclusions. The cost of healthcare per person in Cuba is one twentieth that of the US. To take two statistics out of many quoted, the costs of a hip replacement in Cuba are $72.15 compared to the US figure of $14,263, and the cost of a kidney transplant in Cuba is $4,902, while in the US it is £48,758.
The reasons? Immense waste under the following categories: Insurance fragmentation; both under and over-treatment; sickness looping (when treatment leads to more sickness and then more treatment); drug looping (when drug side-effects lead to physicians prescribing more drugs); over-diagnosing (often with pressures from the drug companies); over-pricing of drugs; widespread profiteering, and very high salaries for doctors.
Cuba faces not only a physical blockade by its hostile neighbour to the north, but also a world-wide propaganda campaign emanating from Cuban exiles around Miami, Big Pharma, the insurance companies, and the US government. The blockade leads to shortages all round which are then used to attack the health system.
One of the criticisms of Cuban healthcare — when it is not ignored — is that the state makes money out of the many Cuban doctors and nurses working abroad. In many cases the money from foreign governments paid for the health teams goes direct to the Cuban state which then pays the salaries after taking a cut.
This is a constant refrain from doctors’ associations and the corporate press in the West, which are happy to see huge pay differences and inequalities, with the doctors riding high as in the US. The reality is that this policy flows from the aims of the revolution and, for the most part, with the agreement of the doctors who are taught early on in their training the basic principles of international solidarity.
Fitz notes: “Poor countries simply cannot afford such an inefficient health system (as that in the US). Well over a hundred countries are looking to the example of Cuba, which has the same 78-year life expectancy as the US and spends only 4 per cent per person of US health costs.”
One measure perhaps (not fully covered in the book because it was published in the middle of 2020) of the success of the Cuban health mission, may be found in the response to Covid-19. For the first nine months of the pandemic the numbers of infections were very low, compared to most of Latin America, at around 50 per day, but in November with the resumption of tourist flights, there was a spike.
By the end of January 2021, cases per day peaked at 1014, but have been declining during February. Total cases stand at 38,300, with 266 deaths, as at 10 February, out of a population of about 11.3 million. In the UK, after adjusting for the larger population, the equivalent figures are over 40 times as high. The Cuban government aims to vaccinate the whole population this year with its own vaccine, Soberana 2.
The book is a carefully researched account of the extraordinary Cuban health care story that grew out of the revolution. It will give inspiration to those who dream of a new kind of strategy for health provision in their own countries, under a not-for-profit system, free from Big Pharma and capitalist governments.
Cuban Health Care: The Ongoing Revolution, by Don Fitz. Monthly Review Press. Paperback, between £15 and £20