January 31, 2013
Recently a group of editors from prestigious medical journals across the United States went to Cuba to investigate how a Third World country could have the same health outcomes as developed countries at a fraction of the cost.
Upon completion of the review, an editorial was posted in the Jan. 24 edition of the New England Journal of Medicine. In the first paragraph, the authors concluded:
"The Cuban health care system is unreal. There are too many doctors.
Everybody has a family physician. Everything is free, totally free - and not after prior approval or some co-pay. The whole system seems upside down ... Although Cuba has limited economic resources, its health care system has solved problems that ours has not yet managed to address."
There are many reasons for success. Perhaps the biggest is that "the first priority is prevention."
The authors conclude that "vaccination rates in Cuba are among the highest in the world," with 98 per cent of children fully immunized.
In comparison, only 73.7 per cent of children within the Saskatoon Health Region, and 69.3 per cent of children in Saskatchewan were fully immunized for measles in 2010. These numbers are overestimates because they do not include children living on reserves.
To achieve population health immunity, 80 per cent of children need to be immunized. It is incredible to think that a Third World country can immunize nearly all its children but we cannot.
Due to high rates of vaccination, the number of vaccine-preventable diseases are incredibly low in Cuba, if not completely eradicated. In fact, comparing incidence rates of pertussis between Cuba and the Saskatoon Health Region leaves one questioning which is the Third World jurisdiction.
When it comes to prevention, Cuba does its best to improve the social factors that predict health. However, it is a poor country that is also under a trade embargo from the United States, so its income levels are obviously low.
That said, the NEJM editorial states that Cuba's literacy rate is 99 per cent. In comparison, a report from Human Resources and Skills Development Canada found that 61 per cent of non-aboriginal residents of Saskatchewan and 37 per cent of its aboriginal residents are literate.
"Without doubt, the improved health outcomes are largely the result of improvements in education which address the social determinants of health," concludes the NEJM editorial.
Let's return to medical care. Cuba offers a multidisciplinary primary care system, in which the doctor is responsible for achieving patient wellness.
For example, the NEJM editorial states that "every patient is visited at home once a year and those with chronic conditions receive visits more frequently."
Why these visits?
"Such house calls and discussions with family members are common tactics for addressing problems with compliance or followup," reports the NEJM.
In Saskatchewan, most patients do not start evidence-based therapy. Of those who do, most quit anyway. Cuba uses fol-lowup visits and meetings with family members to address the important issue of non-adherence.
The cumulative effect of a highly structured, prevention-oriented system has produced positive results, the authors conclude.
For example, they discuss how Cuba reduced its infant mortality rate to only five per 1,000 live births from 80 per 1,000.
Cuba set a goal and then developed an evidence-based policy that included inter-agency collaboration. The infant mortality rate in this Third World country is 34 per cent lower than in Saskatchewan. In a previous article, I mentioned that Cuba has the same health outcomes as Canada, at 88 per cent less adjusted cost.
All that said, the NEJM editorial authors are careful to not romanticize the Cuban system. There is no private sector in Cuba, so patients have less consumer choice. The reviewers were able to find a hospital that did not gain access to a CT scanner until 12 years ago.
As well, the reviewers were also able to find a medical student who reported that he only had 30 minutes a week of Internet access.
That said, the authors were also quick to explain that many of these issues are due to the "long standing U.S. economic embargo."
In response to these challenges, the Cubans developed their own pharmaceutical industry.
Perhaps ironically, this reduced medication costs considerably.
The editorial concludes that the Cuban system, with "a physician for everyone, an early focus on prevention and clear attention to community health, may inform progress in other countries."
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