Overmedicated? : An Excess of Success May Ail Cuba’s Top-Flight Health Care System : Science / Medicine

Thirty-two years ago, Cuba became the first Latin American nation to make health care a right for everybody. Today Cuba still is listed among the poor nations of the world, but it is among the richest in health care services for its 10.6 million inhabitants.

Despite a 30-year trade embargo by the United States, unsteady economic relations with the Soviet Union and lagging productivity by its work force, the Cuban government has never slackened its drive toward a top-flight health system.

But while the payoff in health has been spectacular, many foreign medical observers now see signs of weaknesses in the very things that have made the health system so successful.

For example, Cuba’s excessive use of doctors and the government’s reliance on highly trained physicians to perform tasks done by paraprofessionals in developed countries is seen as a serious defect in the system.

Also, American doctors who recently visited the country said some Cubans appear to be receiving unnecessary care, which could have a negative effect on the economy.

Nevertheless, the Cuban health care system has accomplished for the entire population what few if any of the 100 other developing nations of the world--and many industrialized countries--have attained. The system tries to take into account the social, economic and cultural factors that influence health as well as the biological ones.

The average life span in Cuba is 75 years, approximately the same as the 75.6 years in the United States.

Infants no longer die of diarrhea in large numbers as in many other Latin American countries, and childhood infectious diseases and malnutrition are well under control, by developing-country standards.

Virtually every pregnant woman receives complete prenatal care and delivery in a hospital by a physician. Abortions are on demand. The infant mortality rate is the lowest in Latin America and is rapidly approaching that for the United States (10.7 deaths per 1,000 live births, compared to the U.S. rate of 9.1 per 1,000 in 1990).

Before the 1959 revolution that placed Fidel Castro in power, Cuba had 6,250 physicians--half of whom left the country shortly afterward--to serve a population of 6.5 million. More than half of the population had no access to health care. Poverty, malnutrition, illiteracy and infant mortality were high.

Today Cuba has 38,000 physicians, more than half of whom are women. All doctors work for the government.

According to present plans, the country will have 68,000 physicians by the year 2000, a figure that could rank the nation among the highest in the world for ratio of doctors to population.

Cuba currently trains 4,000 doctors annually in 21 medical schools. Many doctors receive additional training abroad. A network of 422 fully staffed clinics and more than 250 hospitals covers all parts of the country. The major teaching and research hospital in Havana boasts 38 specialties and houses every conceivable piece of high-tech medical equipment found in any major U.S. medical center, including three magnetic resonance imaging devices.

A new program to provide everybody with a family physician has reached 58% of the population. By 1995, if plans succeed, Cuba will be the first country in the world to have comprehensive family practice coverage for 100% of its people.

But American physicians and health experts who visited Cuba early this year were struck by what they saw as the inefficient use of medical manpower and the overutilization of medical services.

In a visit to a rural preschool day care center, for example, it was learned that each of the 200 youngsters--all under 5 years old and all of them well--undergo weekly examinations by a pediatrician, a degree of care far beyond what is considered necessary in most other countries.

To Americans, the pay received by Cuban doctors may seem ridiculously low ($290 to $780 a month), but the cost to an economically strapped country of maintaining so many doctors drains money and resources that could be more useful for other social purposes.

Some American health experts fear that an overemphasis on physician care promises to dangerously inflate the cost of Cuba’s health care. Also, it may eventually have a negative effect on health through overtreatment and the shrinking of funds available for other social changes that improve health.

For example, it wasn’t until a year ago that the government opened the first residential school for the rehabilitation of physically and mentally disabled children. It has a capacity of 150 youngsters ages 9 to 18 years.

Although the government spent $2.25 million on the new school to teach disabled children how to live in the community, the special ramps and facilities needed to enable the handicapped to work and play with others in their home communities exist no place else in Cuba.

As a consequence, the children now enrolled in the school do not want to leave and the staff is faced with the prospect of releasing them into an inhospitable world. The American visitors--physicians from Kaiser-Permanente and private practice in California--wondered whether funding now going into overutilization of medical services might be better spent making life easier for the handicapped.

In addition, Cuba’s system for handling patients with AIDS has been strongly criticized in the United States because of its violations of human rights. The official policy is to do mass testing for the human immunodeficiency virus and to quarantine everyone who tests positive.

Patients are allowed to have visitors and some are allowed temporary passes, but at present it appears the intent is to isolate all HIV-positive persons from the rest of society in an effort to control the spread of the disease. The health ministry claims 4,000 new HIV infections have been prevented.

Despite the government’s support for preventive measures such as prenatal care, there is an obvious need for more programs on the health benefits of stopping smoking, wearing seat belts and controlling air pollution. In addition, much housing is in disrepair and there is a great need for improved street maintenance, especially in the older parts of Havana.

Another area of concern involves the tendency to make physicians the sole source of medical information, a trend that makes patients overly dependent on them. This trend has been enhanced by a de-emphasis on self-care and the steadfast refusal to allow community health workers and other non-physicians to exercise medical authority.

“A large part of what is called health education in Cuba consists of providing information that doesn’t really tell a person how to resolve a problem himself but constantly encourages going to the doctor for even the most minor ailment,” says David Werner, an international authority on health education who heads the Hesperian Foundation in Palo Alto. Werner’s observations, published in the early 1980s, are still valid.

The Cuban health ministry and most Cuban doctors have ready replies to each of these criticisms. Being able to visit a doctor often, they say, is proof positive that the government spares no resources to provide health care, especially for pregnant women and children.

“The purpose of the weekly doctor visit (at day care centers) is preventive,” a nurse in charge of one center said. “He looks for subtle signs of handicaps like mental retardation, for example. We are proud that we have so many resources.”

They defend the number of doctors by pointing out that modest salaries for doctors keep costs down and that they plan eventually to have a physician in every school, factory and day care center in the nation. “Why go for second-best (non-physician health workers) when you can have the best?” they ask.

Moreover, Cuba plans to have 10,000 physicians working abroad by the turn of the century. Some will assist developing countries (as they have in Nicaragua and some African countries) and some will earn hard currency for their homeland.

One of the main goals of the new family practitioner program is to counteract the effects of the rigid medical hierarchy that developed as a consequence of emphasizing medical specialties in the training of physicians.

Until 1984, when the family practice program was started, patients had only crowded specialist clinics to go to for care. Because each clinic was responsible for 25,000 to 30,000 patients, waits often were long and patients were unhappy because doctors spent so little time with them.

Under the new plan, a family practitioner and a nurse are assigned to take care of a patient load of 500 to 700 people, considerably fewer than had been previously assigned. The doctor lives in the same neighborhood as the patients. His office is in his house, but he does not work alone like old-time general practitioners. The clinic serves as a backup to provide him with consultation, laboratory and emergency services.

In 1984 the government also revamped the medical education program in ways intended to emphasize primary and preventive care and “humanize” the approach to patients. The doctor-nurse teams are expected to know each patient well, to act as community leaders at meetings with other local organizations and to be advocates for getting neighborhood improvements that improve health. They are expected to focus on reducing risk factors such as smoking, obesity, poor eating habits and alcohol intake.

“They are really trying to modify the image of a doctor to be a sensitive person who is a community leader,” said Dr. Milton Roemer of the UCLA School of Public Health, an authority on international health.

“True, Cuba is doctor-oriented, but it’s a totally different type of doctor that they are aiming for.”

Cuba: The Medical Revolution

While Cuba is still among the poorer nations of the world, it has made strong advances in health-care services. Before 1959, about 6,000 doctors served a population of more than 6 million. Poverty, malnutrition, illiteracy and infant mortality were high. Today, the picture has changed. Population: 10.6 million Average lifespan: 75 years Infant mortality: Lowest in Latin America. Number of doctors: 38,000 Medical schools: 21, in which 4,000 doctors are trained annually. Hospitals and clinics: 250 hospitals and 422 clinics. Family Care: 58% of population now covered by program that provides family physician. Drawbacks: According to some U.S. health experts, there is inefficient use of medical manpower and overutilization of medical services.