The Cuban Health System at the Dawn of Détente

Health Letter, August 2015

By Sammy Almashat, M.D., M.P.H.

The announcement last December that the U.S. and Cuba were establishing diplomatic relations for the first time since just after the Cuban revolution in 1960[1] prompted renewed interest in Cuba among the mainstream media, with much of the focus on the country’s health care system.[2],[3],[4] The pending rapprochement makes this an opportune time to take a closer look at the Cuban health sector, which, according to The New England Journal of Medicine, “has solved some problems that ours has not yet managed to address.”[5]

Cuba’s health performance

Cuba, a country of 11 million people, has achieved health outcomes that are the envy of the Third World. It has one of the lowest infant and young child (under age 5) mortality rates and longest life expectancies in the Americas, outperforming the U.S. on all three of these indicators[6] (although the maternal mortality rate is still considerably higher than that in rich countries[7]). This year, Cuba also became the first nation in the world that, according to the World Health Organization, had eliminated mother-to-child transmission of HIV and syphilis.[8] How has a Third World country, subjected to decades of economic sanctions, accomplished this?

Part of the answer lies in the post-revolutionary government’s establishment of a comprehensive, universal health care system — structured around primary and preventive care — with a network of physicians, nurses and home health workers generally living in the same community as their patients.[9]

To ensure adequate staffing for this initiative, the government invested heavily in medical education, which resulted in Cuba having nearly three times as many physicians per capita as the U.S.[10] This also enabled the country to send a self-reported total of 130,000 of its own health professionals to provide low- or no-cost medical care to patients in other Third World countries, with nearly 37,000 working in 70 countries as of 2008.[11] Cuba was among the first to respond to the past year’s Ebola epidemic, sending more doctors to Sierra Leone than any country besides Great Britain.[12]

The country’s universal vaccination programs eradicated many previously commonplace childhood and tropical diseases, including polio, measles and diphtheria.[13] Many of the vaccines, as well as other medications, are manufactured by a domestic pharmaceutical industry that was developed, in part, in response to the U.S. embargo. This biotechnology sector employs about 10,000 people and manufactures most of the medicines used in the country, including 33 vaccines, 33 cancer drugs, 18 drugs to treat cardiovascular disease and seven drugs for other diseases.[14],[15] At one point, Cuba was the leading provider of pharmaceuticals to Latin America and also supplied medicines to several Asian countries.[16] Its medical infrastructure is also relatively advanced, with 22 medical campuses and academic journals in all of the major medical specialties.[17]

Much of the progress made in improving the well-being of the Cuban population also traces back to policies independent of the health care sector, including universal education, guaranteed nutrition, clean drinking water and modern sanitation.[18] Perhaps more important were the Cuban government’s egalitarian economic policies that dramatically reduced the wealth inequalities that had existed prior to the revolution.[19] An extensive body of research shows that income inequality is closely associated with, and likely a critical determinant of, population health,[20] and Cuba is no exception.

The U.S. embargo

What makes Cuba’s health advancements all the more remarkable is that they were achieved under more than five decades of a stifling economic embargo. In 1962, three years after the Cuban revolution, the U.S. instituted the embargo to cripple Cuba’s economy,[21] in the hope that the pain inflicted on the Cuban people would spur them to overthrow the government. (The embargo was just one of several methods employed by the U.S. to do away with the Cuban government; see text box below for more details.)

In a comprehensive 1997 report documenting the impact of the U.S. embargo of Cuba, the American Association for World Health (AAWH) observed that it was “one of the few embargoes of recent years … that explicitly include[d] foods and medicines in its virtual ban on bilateral commercial ties.”[22] The report found that the tightening of the embargo during the 1990s had resulted in shortages of drugs, water treatment supplies and food, leading to malnutrition and waterborne diseases, among other problems.[23] The AAWH concluded that “[a] humanitarian catastrophe [resulting from the embargo] has been averted only because the Cuban government has maintained a high level of budgetary support for a health care system designed to deliver primary and preventive health care to all of its citizens.”[24]

Amnesty International followed the AAWH report with its own 2009 analysis of how the embargo had affected the “economic and social rights” of the Cuban people.[25] The report documented numerous instances in which Cuba was unable to import a range of medical supplies, including HIV and psychiatric medicines, vaccines and syringes, medical devices, diagnostic equipment, condoms, and pediatric nutritional products.[26]

The U.S. has long been isolated from the rest of the world on its policy towards Cuba. Every year since 1992, the United Nations General Assembly has voted overwhelmingly (188-2 was last year’s tally) in favor of a resolution calling on the U.S. to end the embargo.[27] Nevertheless, The New York Times claimed in an editorial last year that it was not the U.S. but Cuba that suffered from a “beleaguered international standing.”[28]

Looking ahead

Cuba’s health system is not perfect, and the government’s medical internationalism is not born entirely of altruism. But the country’s achievements in improving the health of its population to levels otherwise seen only in rich countries are indisputable.

Whether Cuba can maintain these achievements after relations with the U.S. are normalized remains to be seen. It is possible that the diplomatic — and, crucially, economic — opening will create pressure on the Cuban government to privatize state-owned industries, including the health sector. To gauge the implications of such a move, Cubans need look no further than the U.S. experience to realize that a fragmented, for-profit health care system would likely reverse many of the achievements of its own universal model. One can only hope that this will not come to pass.

Whose Terror?

In May, it was widely reported that the U.S. had removed Cuba from the State Department’s list of state sponsors of terrorism.[29] Cuba had been added in 1982 as retribution for its support of resistance movements against U.S.-backed regimes in Latin America and southern Africa, including then-U.S.-ally apartheid South Africa.[30],[31],[32]

Yet major U.S. media outlets made no mention of the U.S. government’s now-acknowledged terrorist campaign (code-named “Operation Mongoose”) against Cuba during the 1960s, after the failed Bay of Pigs invasion.[33] The campaign initially was managed by then-Attorney General Robert F. Kennedy, who, according to historian and close Kennedy associate Arthur Schlesinger, intended to unleash “the terrors of the earth” on Cuba.[34]

In subsequent decades, the U.S. provided sanctuary to Florida-based terrorists who carried out attacks against civilian targets on the island.[35] The most notorious mastermind, Luis Posada Carriles, is accused of blowing up a Cuban civilian airliner, killing 73 people, in 1976. To this day, Carriles remains free in Florida.[36]

Although reliable figures are hard to come by, it has been estimated that, since 1959, the U.S. has carried out 5,780 terrorist attacks against Cuba and that these and other terrorist operations may have killed 3,478 and permanently disabled 2,099 Cubans.[37]


References

[1] Trotta D, Holland S. U.S., Cuba restore ties after 50 years. Reuters. http://www.reuters.com/article/2014/12/18/us-cuba-usa-gross-idUSKBN0JV1H520141218. Accessed June 30, 2015.

[2] Stone J. Cuba’s surprisingly cost-effective healthcare. Forbes. December 22, 2014. http://www.forbes.com/sites/judystone/2014/12/22/cuba-cost-effective-healthcare/. Accessed July 1, 2015.

[3] Sanger-Katz M. Can Cuba escape poverty but stay healthy? New York Times. December 18, 2014. http://www.nytimes.com/2014/12/19/upshot/can-cuba-escape-poverty-but-stay-healthy.html?abt=0002&abg=1. Accessed June 30, 2015.

[4] Patel N. Cuba has a lung cancer vaccine — and America wants it. Wired. May 11, 2015. http://www.wired.com/2015/05/cimavax-roswell-park-cancer-institute/. Accessed June 30, 2015.

[5] Campion EW, Morrissey S. A different model — medical care in Cuba. N Engl J Med. 2013;368(4):297-299.

[6] The Pan-American Health Organization/World Health Organization (PAHO/WHO). Health Situation in the Americas: Basic Health Indicators 2014. http://www.paho.org/hq/index.php?option=com_content&view=article&id=2470&Itemid=2003&lang=en. Accessed June 30, 2015.

[7] Campion EW, Morrissey S. A different model — medical care in Cuba. N Engl J Med. 2013;368(4):297-299.

[8] World Health Organization. WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba. June 30, 2015. http://www.who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/. Accessed July 14, 2015.

[9] Campion EW, Morrissey S. A different model — medical care in Cuba. N Engl J Med. 2013;368(4):297-299.

[10] The Pan-American Health Organization/World Health Organization (PAHO/WHO). Health Situation in the Americas: Basic Health Indicators 2014. http://www.paho.org/hq/index.php?option=com_content&view=article&id=2470&Itemid=2003&lang=en. Accessed June 30, 2015.

[11] Gorry C. Cuban health cooperation turns 45. MEDICC Review. 2008;10(3):44-47. https://www.citizen.org/sites/default/files/mr_22_1.pdf. Accessed July 1, 2015.

[12] Freeman C. Cuban doctors take leading role in fighting Ebola. The Telegraph. January 29, 2015. http://www.telegraph.co.uk/news/worldnews/ebola/11375422/Cuban-doctors-take-leading-role-in-fighting-Ebola.html. Accessed July 1, 2015.

[13] American Association for World Health. Denial of Food and Medicine: The Impact of the U.S. Embargo on Health & Nutrition in Cuba. March 1997. https://www.citizen.org/sites/default/files/the_impact_of_the_u.s._embargo_on_health_amp_nutrition_in_cuba.pdf. Accessed June 30, 2015.

[14] Campion EW, Morrissey S. A different model — medical care in Cuba. N Engl J Med. 2013;368(4):297-299.

[15] Brookings Institution. The Cuban Biotechnology Industry. May 2012. http://www.brookings.edu/~/media/newsletters/pres_letter/052012/cuba_biotech_report. Accessed June 30, 2015.

[16] Starr D. The Cuban biotech revolution. Wired. December 2004. http://archive.wired.com/wired/archive/12.12/cuba.html. Accessed June 30, 2015.

[17] Campion EW, Morrissey S. A different model — medical care in Cuba. N Engl J Med. 2013;368(4):297-299.

[18] World Health Organization. Action on the Social Determinants of Health: Learning From Previous Experiences. March 2005. https://www.citizen.org/sites/default/files/action_sd_1.pdf. Accessed July 1, 2015.

[19] Zimbalist A. Cuba’s revolutionary economy. Multinational Monitor. 1989;10(4). http://www.multinationalmonitor.org/hyper/issues/1989/04/zimbalist.html. Accessed July 1, 2015.

[20] Pickett KE, Wilkinson RG. Income inequality and health: A causal review. Soc Sci Med. 2015;128:316-326

[21] Amnesty International. The U.S. Embargo Against Cuba: Its Impact on Economic and Social Rights. 2009. https://www.citizen.org/sites/default/files/amr250072009eng_1.pdf. Accessed June 30, 2015.

[22] American Association for World Health. Denial of Food and Medicine: The Impact of the U.S. Embargo on Health & Nutrition in Cuba. March 1997. https://www.citizen.org/sites/default/files/the_impact_of_the_u.s._embargo_on_health_amp_nutrition_in_cuba.pdf. Accessed June 30, 2015.

[23] Ibid.

[24] Ibid.

[25] Amnesty International. The U.S. Embargo Against Cuba: Its Impact on Economic and Social Rights. 2009. https://www.citizen.org/sites/default/files/amr250072009eng.pdf. Accessed June 30, 2015.

[26] Ibid.

[27] United Nations. As General Assembly Demands End to Cuba Blockade for Twenty-Third Consecutive Year, Country’s Foreign Minister Cites Losses Exceeding $1 Trillion. October 28, 2014. http://www.un.org/press/en/2014/ga11574.doc.htm. Accessed July 1, 2015.

[28] Editorial: Cuba’s impressive role on Ebola. New York Times. October 19, 2014. http://www.nytimes.com/2014/10/20/opinion/cubas-impressive-role-on-ebola.html. Accessed June 30, 2015.

[29] Schwartz F. Cuba officially removed from U.S. state sponsor of terrorism list. Wall Street Journal. May 29, 2015. http://www.wsj.com/articles/cuba-officially-removed-from-u-s-state-sponsor-of-terrorism-list-1432913160. Accessed June 30, 2015.

[30] Congressional Research Service. Cuba and the State Sponsors of Terrorism List. May 13, 2005. https://www.citizen.org/sites/default/files/rl32251_1.pdf. Accessed June 30, 2015.

[31] Brooke J. Cuba’s strange mission in Angola. New York Times. February 1, 1987. http://www.nytimes.com/1987/02/01/magazine/cuba-s-strange-mission-in-angola.html. Accessed July 1, 2015.

[32] Gerstenzang J, Darling J. Clinton gives apology for U.S. role in Guatemala. Los Angeles Times. March 11, 1999. http://articles.latimes.com/1999/mar/11/news/mn-16261. Accessed June 30, 2015.

[33] Council of Hemispheric Affairs. The Terrorist List, and Terrorism as Practiced Against Cuba. April 22, 2013. http://www.coha.org/22355/. Accessed June 30, 2015.

[34] Wills G. Fierce in his loyalties and enmities. New York Times. November 12, 1978. https://www.nytimes.com/books/00/11/26/specials/schlesinger-robert.html. Accessed July 1, 2015.

[35] Council of Hemispheric Affairs. The Terrorist List, and Terrorism as Practiced Against Cuba. April 22, 2013. http://www.coha.org/22355/. Accessed June 30, 2015.

[36] CBS Miami/AP. Cuba sees Obama terror promise as healing of historic wound. February 19, 2015. http://miami.cbslocal.com/2015/02/19/cuba-sees-obama-terror-promise-as-healing-of-historic-wound/. Accessed July 1, 2015.

[37] Lamrani S. Fifty years of US terrorism against Cuba. Voltairenet.org. December 15, 2005. http://www.voltairenet.org/article132624.html. Accessed July 8, 2015.