Room for a view : Our man in Havana

The usual mishmash of uncontrollable circumstances found me on June 28 in Havana, discussing with colleagues over dinner the remarkable success of the Cuban health care system. Quite suddenly, at around 8 pm, the entire corps of waiters and chefs fled the dining room, and dinner and conversation came to a halt. I followed the staff to the bar, where the attraction was, of course, a CNN newscast in Spanish of a small white airplane landing at Havana‚s Jose MartI airport and the subsequent appearance, before relatives and schoolchildren waving small Cuban flags, of little Elian Gonzalez and his father. As they watched, the hotel staff variously applauded, cried, and smiled with quiet pride at this victory for Cuban identity. Cubans have some cause for their national pride. The World Bank ranks Cuba among the ”lower middle income” nations, that is, among those with a per capita GNP of US$761-$3030 (www .worldbank.org/data/). Economically, this places Cuba somewhere in the bottom third of nations. Yet, even with a rapidly increasing population (now 11 million), Cuba ranks near the top in terms of health. Life expectancy at birth is 76 years, and the infant mortality rate of 6.4 per 1000 live births is lower than that of the United States and is surpassed, with very few exceptions, only by the most affluent countries. This success appears to arise from two interrelated factors: a goal-driven health care system with an almost exclusive emphasis on primary and secondary prevention, and a motivated and abundant corps of doctors, nurses and other health care workers. The Cuban health care system is actually, not just theoretically, based on primary care. Although centrally planned, administration is decentralized to the municipal level. Each of Cuba‚s 169 municipalities has a hospital with specialists in the major disciplines, several primary care centres and between 20 and 40 family medicine clinics, each of which is staffed by a solo physician and a nurse who live in the clinic or nearby and care for approximately 130 families in the vicinity. The result is that these physicians and nurses get to know each and every one of their families. This, coupled with a set of standard forms for record-keeping, leads to outstanding primary and secondary prevention. Vaccination rates are over 99%, and screening rates are also high. Central planning seems to be working. But the good results in health care also stem from an ample supply of health care providers who, in spite of low wages, appear to be well trained and dedicated to their work. There are 21 faculties of medicine in the country, which boasts 65 000 practising physicians, of whom 30 000 are family doctors. By my calculation, this works out to 1 doctor for every 180 inhabitants. (In Canada, this ratio is 1 per 541.) I write this as I attend the inaugural meeting of the International Society for Equity in Health. Cuba has certainly achieved equity — both of income and of health. But what about efficiency? The current system is anchored in the ideals of the Cuban Revolution, which led to the overthrow of the Batista regime in 1959. Many leaders and directors of the health care system appear to be in their 50s or 60s, and most, such as Dr. Cosme OrdoNez, the influential director of a major clinic in Havana, participated in the revolution. OrdoNez was captain of his high school basketball team, which also included Fidel Castro. During the revolution, while his wealthy family fled, OrdoNez stayed to bring about fundamental changes in the organization of health care, including the abolition of the equivalent of a College of Physicians and its replacement with a syndicate of health care workers. The rhetoric of Cuba‚s leaders is peppered with the catchwords of that era: ”comradeship,” ”revolutionary Public Health Ministry,” ”peasants, workers and students,” and so on. ”Efficiency” and ”competition” are not part of that vocabulary. But the Cold War has ended and the US blockade on medical equipment and supplies is likely to be relaxed. With this will come money and investment and, eventually, more wealth for the average Cuban. The enthusiasm and altruism of Cuba‚s physicians and health care workers will be strained by an increasing desire for affluence and growing disparities in income. From my limited vantage point, I doubt that the Cuban health care system can be maintained at its current low level of efficiency. Once the usual targets are gone, the rhetoric will be less persuasive. One can only imagine that Cuba‚s remarkable health care system will be tested over the next few years. I hope its spirit and altruism survive.

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