What Cuba Can Teach Us About Health Care
Just a morning’s boat ride from the tip of Florida is a place where medical costs are low and doctors plentiful. It’s Cuba, and Stanford University physician Paul Drain says it’s time for the United States to pay attention to our neighbor’s shoestring success.
Despite a 50-year trade embargo by the United States and a post-Soviet collapse in international support, the impoverished nation has developed a world-class health care system. Average life expectancy is 77.5 years, compared to 78.1 years in the
United States, and infant and child mortality rates match or beat our own. There’s one doctor for every 170 people, more than twice the per-capita U.S. average.
Not everything is perfect in Cuba. There are shortages of medicines, bBut it’s still a powerful feat. “In Cuba, a little over $300 per person is spent on health care each year. In the U.S., we’re spending over $7,000 per person,” said Drain, co-author of Caring for the World and an essay published April 29 in Science. “They’re able to achieve great health outcomes on a modest budget.”
With Fidel Castro’s reign as Cuba’s leader ending two years ago, relations with the United States have thawed.
President Obama eased restrictions on travel to Cuba last year, and the oft-introduced Free Trade With Cuba Act finally has a chance of passing Congress. Drain would like the Institutes of Medicine to conduct a full study of the island nation’s success.
“There are so many lessons we might be able to learn from Cuba’s health care and medical education system, but we don’t know too much about it,” said Drain.
Wired.com: How does Cuba keep health care costs so low?
Paul Drain: Partly by keeping physicians’ salaries low. Obviously, given the government they have, they can do that. But they also emphasize primary care and preventive care, addressing diseases and problems before they become major. It’s a very different approach to health care.
In the United States, we essentially do the opposite. We treat diseases when they occur. We’re not very good at the preventive component, which causes the costs of our health system to be much higher.
Wired.com: What are the origins of Cuba’s approach?
Drain: Starting in 1964, they encouraged all medical school graduates to do at least two years of service in a rural area.
That program became so popular that by the mid-1970s, almost all new physicians were doing rural service. From there, almost all medical graduates were channeled into a three-year family medicine residency. That’s where they do clinical training, making the transition to full doctor from medical student.
Almost all their residents do family medicine. They focus on primary care for all ages. Once everybody learns primary care, about 35 percent go on and specialize. It’s quite the opposite of what we have here.
Wired.com: How so?
Drain: Our medical students choose what they want to do. Only about 7 or 8 percent go into family medicine, which is our primary care system. In Cuba, everyone becomes a primary care doctor. They learn to prevent diseases.
Cuba also provides very good access. In the mid-1980s, they created a system of neighborhood doctors’ clinics. One doctor is responsible for a catchment area of a couple of city blocks. They get to know their patients well. If somebody has a problem, they can see the doctor in the clinic that day.
Wired.com: Could the U.S. government ever mandate a system like that?
Drain: It would be a big leap, but there are smaller steps that could be taken. We’re the only developed country without universal access to a nationalized health care system. Other countries have seen health care as a basic right and insured everybody. Everyone gets primary care. That would be a first step.
I saw someone in my clinic yesterday who hadn’t seen a doctor in 10 years. Her blood pressure was through the roof, and it’s probably been like that for a decade. She’s at tremendous risk for having a stroke or heart problems. If she’d seen somebody back when this started, it could have been controlled. But because of her high blood pressure, who knows what her future medical bills will be like.
If she were in the Cuban system, she would have had a visit scheduled yearly for the last 10 years. If she hadn’t shown up, someone would have gone to her home to see if she was OK. Blood pressure is an easy thing to check. It would have been controlled.
Wired.com: One problem in the United States is the shortage of doctors. How does Cuba train physicians?
Drain: Education is paid by the government, so students don’t have debt. In the United States, medical students come out $200,000 or $300,000 in the hole, which deters them from going into primary care.
Cuban doctors are making a fraction of what we make in the U.S., but most Cubans aren’t going into medicine to earn money. They’re going into it to treat people in their communities.
In 1999, Cuba created a school of medicine for Latin America. They bring students in, train them for six years, give them room and board and a stipend. Afterward the students are required to go home and practice in poorer communities. It’s a remarkable program, with 10,000 students now from 33 countries, and an interesting model for developing health care workers.
Wired.com: Do President Obama’s health reforms move the United States toward what’s seen in Cuba?
Drain: What we’re passing is starting to move us in a better direction. I’m an advocate for universal health care, and there’s still a long way to go. But I think we’ll eventually catch up to our western counterparts, and realize that we’re the only country not providing full equity in terms of accessing health care, and that’s reflected in health outcomes.
When you compare us against most developed countries, we’re near the bottom in most health indicators. Our life expectancy isn’t as good, our infant mortality rates are higher, and we’re spending twice as much money.