In the office of Dr. Alex Carreras near downtown Havana, water drips from a patched ceiling, a window is missing glass and a broken machine for sterilizing instruments lies idle. The phone rings constantly as Carreras explains that his only nurse is out for the week.
Carreras and the nurse care for 120 families in the neighborhood. Living and working in the community is essential to understanding patients' needs, he said. Recently, after a patient said he had stopped smoking, Carreras was suspicious and went to the patient's house.
"I could see the cigarettes on the table," he said with a shrug.
Carreras keeps track of the community's health with handwritten charts, noting basic indicators such as who has high cholesterol, who has diabetes and who has a drinking problem. "You know everything," he says.
While Cuban doctors might not actually know everything about their patients, they come closer than their counterparts in many areas of the world, including the United States. Their ability to track patients' histories, ensuring that children get their immunizations and that older patients stay active in the community, has made this country a model for primary medical care for other impoverished countries and even areas of the United States.
The Cuban system involves an extensive network of family doctors scattered throughout its countryside and cities. Primary care doctors become very familiar with the neighborhoods they live in and generally have no more than 500 patients. (By comparison, some U.S. doctors might have several times that number of patients in their care.) If patients need more than basic care, the doctors refer them to rural and neighborhood hospitals.
To be sure, the system has its drawbacks: frequent shortages of medical supplies and long waits for complicated procedures that require hospitalization. Yet basic health care for all of Cuba's 11.2 million residents is provided, unlike in the United States, where an estimated 40 million Americans lack health insurance.
"Everybody is in the system. They do a lot better in teaching preventive care than most countries," said Dr. Stephen A. Schendel, chief of plastic and reconstructive surgery at Stanford University Medical Center.
Schendel has made many trips to Cuba in the last five years to perform reconstructive plastic surgery on children and to train Cuban physicians in advanced techniques.
Cuban physicians, such as Carreras, say what the country lacks in up-to-date technology and journals, it makes up for through its extensive network of family doctors. The country has 58.2 doctors for every 10,000 people, as contrasted with 27.9 doctors per 10,000 in the United States, according to the Pan American Health Organization.
Cuban doctors' closer relationships with their patients also allow them to diagnose diseases early, decrease smoking and deliver healthier babies, according to Bob Schwartz, executive director of Disarm Education Fund, a nonprofit medical assistance program based in New York.The country may be one of the poorest nations in the world, but its inhabitants report health indicators that rival those of rich countries, such as the United States. For example, the average American's life expectancy is 77 years, while in Cuba it is 76. Cuba reports infant mortality rates of 6.4 deaths per 1,000 births, compared with a U.S. rate of 7.3 deaths per 1,000 in 1999. Immunization rates for children older than 1 are roughly equal in the two countries, at about 95%.
Cuba's system is the product of significant investment in national health reform that Fidel Castro began after taking power in 1959.
Today, the Cuban health system serves as an international model for rural health care. Poor communities throughout Latin America and Africa have been influenced by Cuba's health system, according to the Center for Cuban Studies in New York.
The country has sent thousands of physicians abroad to live and work, providing free medical care in countries including Nicaragua, El Salvador, Honduras and South Africa.
In the early 1980s, Cuba's health-care system influenced the development of rural health-care programs for Native Americans in California, said Mario Gutierrez, who was executive director of the California Rural Health Board for five years. Under his term, health clinics in rural areas became more like community centers than outpatient facilities.
The centers established community health representatives who are still a feature of the programs today. The representatives know every family in the area near the clinic. They drive people to and from doctors' offices, make home visits after surgeries and ensure that children receive all immunizations, said Gutierrez, who is now director of strategic programs at the California Endowment in Sacramento.
Dr. Debra Johnson, a plastic and reconstructive surgeon in Sacramento, has visited Cuba three times and says she learns something during every visit.
"It's sort of a duct tape and bailing wire kind of medicine," said Johnson, who is married to Gutierrez.
"The Cubans are the absolute best at doing something with nothing."
Dr. Henry Vazquez cares for about 480 people in and around the mountain village of Boquerones. He has no computer or X-ray machine. He sometimes fashions home remedies from an herb garden when medicines are unavailable. Once, when no car or truck was available, he rode a village mule to transport a sick patient to the nearby rural hospital four miles away.
When the 27-year-old family doctor walks through this tiny village of tin-roofed row homes, mango trees and chickens pecking the dirt, young men stop to greet him and women wave from their doorways. He fondly pats them on the back and talks about their past illnesses.
Vazquez can rattle off statistics about this community without hesitation: There are 45 patients older than 60. Eight patients are younger than 1. About 20 babies are born annually. There are no cases of HIV or AIDS.
The doctor says he likes primary care and believes he is prepared to take care of any emergency health problems at his small office in the village. However, in a few years, he may ask the government to move him to a more exciting post. Maybe even emergency medicine in the city.
"If I choose to move," he said, "I'll feel like I've left my mark."
Sarah Lunday is a freelance writer in Atlanta who recently traveled to Cuba as part of the Kaiser Media Fellowship program.