Doing a lot with little – health care in Cuba

Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.

Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.

Thirty U.S. surgeons recently spent a week in Havana to learn about Cuban health care. Participants on the trip responded to an invitation from the American College of Surgeons, although we funded the trip ourselves. We met with physicians at every level of the health care system, from primary care physicians, medical school faculty, trauma surgeons, general/oncologic surgeons, minimally invasive surgeons, officers in the Cuban Surgery Society, ministers of health, and representatives of the Cuban Institute for Friendship with the Peoples.

Although the Cuban government is a centralized, one-party state that follows the Marxist-Leninist ideology, every individual with whom we met answered our many questions with apparent candor. Perhaps our easy rapport was based to some degree on our common profession and our shared commitment to patient care. Although they were clearly proud of the quality of their free education and medical care, they were also quick to admit the shortcomings in their system: widespread poverty, shortages of food and advanced pharmaceuticals, and old medical facilities. We were not restricted in any way from moving around Havana or speaking with anyone, although our free time was admittedly limited because our busy schedule was crammed with at least two visits per day with the groups listed above.

We were interested in looking at how primary care was delivered in Cuba. We met with a primary care doctor in her office, which was situated on the ground floor of the apartment complex in which she and her patients lived. We also visited a polyclinic, two blocks from the primary care doctor’s office that serves as the next step up the chain and is the site where medical and surgical specialists come to consult with patients from 40-60 primary care practices clustered around the polyclinic. The walls of the polyclinic have posters that educate the patients about the importance of handwashing and prevention of hypertension and cancer. The polyclinic also has an epidemiologist who monitors such basic preventive services as immunizations and prenatal care, both of which achieve nearly 100% compliance in a society in which acceptance of these services is not optional. Pap smears are performed in the primary care clinics, as is comprehensive medical care.

The primary care doctor with whom we met cares for about 1,200 people. She visits them in their homes at least once a year but more often as is needed. Therefore she knows not only each family’s health status, but also their socioeconomic status and family dynamics, which are important determinants of health. If a family member needs hospitalization, they can sometimes be treated by the primary care doctor at home, with her making daily visits. All areas of the island are served by this system of primary care and polyclinics. Medical care is free to everyone at every level.

As interesting and impressive as we found the primary care clinics, it was the visits with the surgeons in their hospitals that intrigued us the most. The surgeons we met were modest and collegial, yet proud of what they had accomplished under challenging resource constraints. The hospitals that we visited were reminiscent of the city and county hospitals in the United States in which many of us on the trip had trained in the 1970s: older facilities that were clean and serviceable, but with older, basic equipment. Nevertheless, C. Julian F. Ruiz Torres, MD, has developed minimally invasive surgery in a hospital dedicated to such technological advances. Although he is 72 years old, he still works tirelessly to obtain the resources to build a state-of-the-art surgical simulation center, now under construction. Basic minimally invasive surgical procedures are available in most hospitals, although advanced procedures are restricted to centers such as Dr. Ruiz Torres’ facility, Centro Nacional De Cirugia De Minimo Acceso, of which he is justifiably proud.

For me, the highlight was meeting Martha Larrea Fabra, MD, president of the trauma division of the Cuban Surgery Society and chief of trauma at General Calixto Garcia University Hospital. Clearly revered by the staff, she radiates warmth and compassion. She has built a first-rate trauma center incorporating ACS guidelines. Each case is reviewed in an M & M – or morbidity and mortality – conference to identify potential improvements in care. She was proud of the fact that “everyone who comes here receives the same care and the same services without a charge.” Some of us labeled her the “Anna Ledgerwood of Cuban trauma.” It was inspiring to witness her dedication to training students and residents, improving trauma care, and providing a high level of service to patients. What they lack in the latest pharmaceuticals and equipment, they make up for in their plentiful medical staff members, who are universally cheerful, helpful, and professional.

In the short time that we were in Cuba, we obviously could observe only a fraction of their entire system. We were unable to determine how representative the health care workers we met were; those we did meet, however, were committed, hard working, and idealistic. Their rewards are clearly not financial, as they are equally (and poorly) paid, earning the same $70/month, no matter what their “rank” in the system.

Whatever the political realities of life in Cuba may be outside of the medical setting, we connected with our fellow physicians and bonded over our shared passion for patient care. This trip was about meeting them and gaining some understanding of their professional challenges and their efforts to work with what they have. Their system has evolved in the unique cultural, political, and economic circumstances of Cuba, and so of course, such a system could never work here. And yet, it was refreshing and inspiring to see medical professionals dedicated to the ideals of our profession – serving the people by delivering the best care they could for all of their patients. My hat is off to them for accomplishing so much despite their limited resources.

Karen E. Deveney, MD, FACS, ASC Surgery News

May 22, 2017

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

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