CHAPTER 5: A HEALTH CARE SYSTEM THAT IS INCREASINGLY EFFECTIVE, ACCESSIBLE AND ADAPTED TO THE NEEDS OF EVERY CUBAN

In the wake of Cuba's revolutionary victory, the guarantee of free medical care for the entire population became one of the basic social paradigms.

Before the Revolution, hospital care and other forms of medical attention were marked by the predominance of private and insurance-based services. Health sector establishments and personnel were largely concentrated in the national capital (65% of the doctors and 62% of hospital beds). In the rural areas, which accounted for around half the population, there was virtually no medical care; there was just one rural hospital, with only ten beds and no doctor.

High incidences of parasite infestations (36.10%), tuberculosis (13.99%), typhus (13.25%) and malaria (30.03%) were accompanied by an infant mortality rate of over 70 per 1,000 live births. Life expectancy at birth was a bare 58 years. The state health service was inadequate; only 8% of the population got free medical care.

The Cuban health service improved dramatically after the Revolution, in stages:

• 1960: Setting up of the national health system. Creation of a rural medical service. Establishment of health areas and clinics. Vaccination with community participation.
• 1970: Devolution of education and the health sector to the provincial governments. Launch of the 'Mother & Child' programme.
• 1980: Inception of the 'Family Doctor' programme. Introduction of advanced technology. Accelerated development of the medical/drugs industry.
• 1990: Inception and development of scientific and technological breakthroughs. Confrontation of the double impact of the US embargo and the collapse of Eastern European socialism and the Soviet Union.
• 2000: Stage of consolidation, reform and modernization of the system. Increased community participation in health management and programmes.
• 2002 to date. New programmes building on the advances in medical care achieved. Programmes currently underway number twelve.
• Cuba's results in the healthcare sphere have meant compliance with the 'Health For All' criteria set by the World Health Organization (WHO) since as earlier as 1983.
• The more significant achievements in the field of public health in Cuba over the last decade include the following:

• 67% of the drugs used are produced domestically.
• Programme for prenatal diagnosis of congenital disorders, which has prevented the births of over 4,000 children with congenital malformations.
• Medical genetics programme to reduce Down’s Syndrome and other diseases.
• Improvement of prenatal, pediatric and adult intensive therapy.
• Increase in organ transplants.
• Obtaining of the anti-meningo-coccic Group B virus, unique in the world.
• Preparation of a vaccine against hepatitis B.
• Obtaining of PPG (ateromixol), preferred therapy for high cholesterol, a principal coronary risk factor.
• Reduction in advanced-stage cancer cases and increase in survival rate. Obtaining of monoclonal antibodies for treatment of cancer. Preparation of vaccination products against the disease.
• More accurate classification of leukemia and its treatment.
• Cure or containment of pigmentary retinosis.
• Obtaining of melagenin, a drug produced from human placenta for treating leukoderma.
• Production of high quality, low-cost medicines.
• Production of 'Neuronic' equipment (for intra-operative monitoring), 'Medicid' equipment (digital encephalography), Ozomed equipment (ozone therapy) and the SUMA (ultra-micro analytical system).

In Cuba, when citizens enter hospital, nobody asks how much they earn, or whether they have medical insurance or a credit card. They are not required to produce a voting card or declare their political affiliations before they can receive care of the quality they need.
Neither do they have to travel large distances to obtain the service, nor pay exorbitant prices for medicines, or accept negligent treatment provided in a humiliating way as public charity.

For all these reasons, Cubans have no hesitation in saying that there is no other country in the world whose health system more consistently than that of Cuba adopts an approach marked by prevention, effective equality of access coupled with quality and positive health. An important battle is being fought on the health front, through both investment and drug manufacture, as well as by the raising of medical services to standards of excellence, to reach the demanding goals we have set for ourselves.

The conjunction of these factors, feasible uniquely under socialism, is the only possible explanation for the high performance indicators associated with the service―comparable with those of the most advanced nations.

To maintain the achievements in public health and support new programmes designed to continue raising the quality of medical services, some 2,355 million pesos have been allocated to the service in the 2005 national budget, 9.4% more than in the previous year.

The system's human resources include 69,713 doctors (2004 figures), as well as 157,242 (2004 figures) nursing and technical staff. This vast potential, a product of the Revolution, has provided great benefits for our development and the quality of life of our people.

The biotechnology industry -of which the country is justly proud and which exemplifies how a small country with tenacity and an intelligent strategy can establish centers of scientific excellence - increased its exports and introduced new manufacturing technologies and medicaments. Twenty investment projects have been completed in this sector, increasing its capacity for industrial production.

New medicines launched in 2004 included

 The Hemophilus vaccine
 The quadruple DPT-hepatitis vaccine
 Over 20 pharmaceutical generics, including three for treating AIDS.
 Innovative drugs for treating cancer, including a Cuban therapeutic vaccine against lung cancer. In this latter case, the design of the vaccine production plant, its construction and operation are 100% Cuban.

An important and highly-symbolic aspect is an agreement between the Molecular Immunology Centre and the US CANCERVAX firm for developing and producing anti-cancer vaccines based on scientific research at the Cuban centre. Only the high quality of the Molecular Immunology Center’s work and the prestige won by Cuban scientists can explain the fact that an American firm fought its way through the jungle of red tape and other obstacles created by the US authorities complicating relations with Cuban institutions, in order to bring about this scientific-technical transfer in reverse. Unlike the usual pattern where less developed countries confine themselves to the role of passive recipients of technologies created by developed nations, in this case the technology originated in the small country and does not involve a brain drain or any other one-sided means of knowledge appropriation.

The main public health strategies

Realignment of the health system in favor of primary care and its cornerstone, the family medical practice

Cuba's family doctor programme involves 470 health areas, covering the entire country and employing approximately 33.000 doctors. At present, coverage by the family medical practice (doctor and nurse) system amounts to 99.4% of the population and is planned to reach 100% within the next few years. Maintaining a high level of medical care has been a target and strategic objective for the whole of Cuban society and the government.

Similarly, clinics were established as the first link in a public health chain rated by the WHO from 1997 onwards as one of the 28 most complete health services on the planet.

In 2005, an investment programme affecting the 470 existing clinics was planned; remodeling was completed on 145 of these and work was in progress at another 199. Similarly, services at these installations have been upgraded and augmented with the introduction of ultrasound, endoscopy, cardiology, life support, biliary drainage, comprehensive laboratory, child-allergy consultation, optometry, ophthalmology, stomatology and traumatology services, among others.

Changes have been made under a strategy aimed at moving medical care closer to where people live, while upgrading emergency services and aligning all services more closely to the nation's health pattern. Hemodyalisis treatment has been expanded with the opening of 47 new installations, while in 2005, 420 new ambulances have entered service. In those boroughs without surgical hospitals, 121 intensive-care units have been opened, a measure that has saved many lives in remote parts of the country.

Other measures have included the opening of 87 optician and 452 physiotherapy units, a service planned for extension to all clinics nation-wide during 2005.

Revitalization of hospital care

During the 1980s, the country dedicated great efforts to extending and modernizing the hospital services network, involving expansion of coverage and improvements in accessibility, capacity and comfort, as well as introducing state-of-the-art technology. Although considerable progress was made, the programme was cut short by the inception of stringent economic measures (the 'Special Period'). The enterprise is now being resumed, with renewed enthusiasm and more ambitious objectives. Cuba now has 248 hospitals and 54,295 hospital beds, representing a ratio of 4.8 beds per 1,000 inhabitants.

The year 2004 saw the start of work on repairing and modernizing 35 large hospitals, aimed at providing excellent service to the public together with extra capacity for the health-related tourism activity, making the latter more sustainable and progressive.

State-of-the-art technology programmes and research centers

Cuba has set in motion a series of primary care programmes to ensure continuity of health services to the public. These include programmes for: cancer prevention, diagnosis and treatment; care of patients with renal insufficiency; cardiology centers; early diagnosis of congenital disorders; comprehensive prenatal services; blood donation and blood-derivatives production.

'Genetics & the disabled' programme

This programme is staffed by 480 experts qualified as Masters of Genetic Counseling. Their mission includes advising sufferers from genetic diseases or congenital defects and working on prenatal and neonatal investigation programmes, as well as defining the clinical signs of specific genetic disorders among the members of a given family.

Based on an existing network that extends to the boroughs, Cuba is in a position to carry out complete epidemiological investigations, enabling identification of the incidence of genetic diseases (including the rarest) and use the results as the basis for action by the relevant agencies. The types of checks and surveys undertaken can be increased, while the specialty is well-placed to assimilate new technologies

Medical training & internationalist aid

In 1959, there was one medical school and one dental school in Cuba; now there are four higher institutes of medical science, 21 faculties of medical science and four of stomatology, 4 nursing faculties, 4 faculties for health technology, 21 medical sciences branches, 16 teaching units as well as a National Public Health School, the Latin American School of Medicine and the Basic Sciences and Pre-clinical Institute.

At time of the Revolution (1959), Cuba's doctors numbered 6,000, of whom 3,000 emigrated during the next few years to the United States, enticed away by Washington's blandishments designed to cripple Cuba's health services.

Other aspects of the development of Cuba's Public Health System

a) "Mother and Child' programme: A notable indicator is that for infant mortality: At the end of 2004, this stood at 5.8 per 1,000 live births, the lowest in the country's history and ranking Cuba 36th in the list of favorably-performing nations, according to UNICEF figures.

This is a result of the work of a multidisciplinary team of specialists ―family doctors, gynecologists, obstetricians, pediatricians, nurses, technical and other health service personnel― who monitor mothers-to-be from the first weeks of pregnancy. This care regime includes attention to the mother's nutrition, genetics and oral health, and rigorous surveillance of every minute of the prenatal development of every Cuban child.

Immediately after birth, every baby is tested to determine the presence of hypothyroidism. A few days later, a phenylketonuria examination is performed to detect the metabolic disorder that could cause mental retardation if it isn’t treated in the early stages. All babies are also immunized during the first few months against 13 diseases.

b) The National Vaccination Programme: Cuba guarantees one of the most extensive vaccination programmes in the world. All Cuban children are currently vaccinated against 13 infectious diseases, and 95% of the population has been vaccinated. As a result of this strategy, 5 diseases have been wiped out over the last 40 years: poliomyelitis in 1962, diphtheria in 1979, measles in 1993, whooping cough in 1994, and rubella, mumps in 1995 and 2 severe clinical forms of meningitis tuberculoses and neonatal tetanus.

Furthermore, since 1988, all those under the age of 30 have been vaccinated against meningococcal meningitis type B —Cuba is the only country in the world producing this vaccine. They are also vaccinated against type C, the vaccine for which is domestically produced. Since 1991, all those under the age of 25, as well as high-risk groups such as diabetics, family doctors and nurses, blood bank employees, people working at institutions for the psychologically disturbed, prisoners, and those infected and in contact with sexually transmitted diseases have been given a Hepatitis B vaccine genetically engineered in Cuba. A hemophilus influenzae type B vaccine produced in Cuba by chemical synthesis, the only one of its kind in the world, is also administered.

It is significant that the 26 most developed countries in the world, with a per capita gross domestic product that is 20 to 40 times higher than Cuba’s, have so far been unable to achieve similar results with their vaccination programmes and in developing such an extensive range of projects for other types of preventive and therapeutic vaccines for adults.

In 2005, the first Cuban tetravalent vaccine was used to protect people against four diseases (diphtheria, tetanus, whooping cough, and hepatitis). Research into the development of a pentavalent compound ―which would add hemophilus influenza type B antigens to the abovementioned vaccine and, if successful, would be the first vaccine in the world to protect against five illnesses— has yielded encouraging results.

Moreover, remarkable progress has been made in the search for a therapeutic vaccine for the Human Immunodeficiency Virus, as well as four therapeutic cancer vaccines, which are currently at the clinical trial stage in Cuba and other countries.

c) Chronic non-communicable diseases: The predominance of deaths from chronic non-communicable illnesses defines Cuba’s epidemiological profile. Heart disease, malignant tumors, cerebrovascular diseases and accidents are the cause of almost two thirds of all deaths in the country. Diabetes mellitus, hepatic cirrhosis, asthma and high blood pressure are also very common.

d) Communicable diseases: The main aim of this programme is to control communicable diseases so that the morbidity rate continues to fall and to control risk factors in order to avoid outbreaks and epidemics. Infectious diseases are the main cause of death worldwide; many of theses diseases are vaccine-preventable. A significant number of these illnesses have been wiped out in Cuba.

e) Caring for the elderly: Cuba’s National Care for the Elderly Programme is adapted to the requirements and needs of senior citizens.

In Cuba, a country with a life expectancy of 77 years, there are more than 2,500 centenarians. 78.7% (2004 figures) of the island’s current population live to be over 60.

According to research carried out by geriatricians and gerontologists, the majority of these centenarians have an adequate diet and the rate of obesity and malnourishment is not high. Very few people in this age group suffer from depression.

f) Smoking: As an indication of the Cuban government and people’s unequivocal commitment to promoting and protecting the right to health that all human beings share, Cuba signed the Framework Convention on Tobacco Control on 29 June 2004, the first international, legally binding instrument of the World Health Organization (WHO).

It is well known that health institutions and other state bodies, political, social and grassroots organizations, as well as other Cuban organizations and institutions are endeavoring to confront the harmful habit of smoking. This has included efforts in the areas of education and prevention, health care, surveillance of areas where smoking is prohibited and even price increases as a means of deterring consumption.

However, Cuba has drawn attention to the fact that price increases could have a negative impact on the economies of several developing tobacco producing countries, including our own. During negotiations, Cuban representatives called for the creation of an international fund to compensate for the damage caused and to find alternative forms of development for tobacco producers in South countries. No definitive answer has been given.

Cuba has urged the international community, and in particular the industrialized countries, whose giant tobacco companies have benefited most from more than five centuries of worldwide cigarette and cigar sales, to mobilize new and additional resources in an international fund to compensate tobacco producers in developing countries.

Main causes of death

At the time of the triumph of the Revolution, 14.2% of deaths were caused by infectious diseases. Today, deaths due to communicable and parasitic diseases have decreased to such an extent that they are practically nonexistent.. The main causes of death include heart disease, cerebrovascular disease and malignant tumors.

Although HIV and AIDS represent a real threat to the human race in many parts of the world, the fact that the government reacted quickly and created a group to coordinate the national response to the epidemic has slowed down the spread of the disease in Cuba.
Since the first case was detected in 1986, 6,073 people have been infected with the Human Immunodeficiency Virus (HIV) in our country. 1,222 people have died of the disease.

The epidemic has been classified as low level and as only 0.07% of people between 15 and 49 years are infected, it is qualified as the lowest rate in the Americas and one of the lowest in the world.

Thanks to the National Programme for the Prevention and Control of Sexually Transmitted Diseases and AIDS, every single person living with HIV or AIDS receives training, social security, free specialized medical care and their job is guaranteed. Therapeutic programmes ensure that 1,800 patients receive AIDS medication mainly consisting of six generic, Cuban-made antiretroviral drugs. The country also receives 6 other drugs as part of a cooperation programme financed by the United Nations World Fund for the fight against AIDS, Tuberculosis and Malaria.

Also under development is an educational programme which will include sex education in schools and programmes especially designed for vulnerable groups, adolescents and the general population, placing particular emphasis on prevention.

Cuba has managed to contain the pandemic, despite the fact that the country has limited access to 50% of the new drugs produced around the world, due to the fact that they were created by American companies or their subsidiaries. This restriction is result of the rigid economic, trade and financial blockade imposed on the island by the United States.

Despite all of the obstacles and challenges, Cuba is making progress towards further strengthening an excellent health care system, adapted to the requirements and needs of every Cuban and equipped with a highly qualified and profoundly supportive staff.