Cuba: A health system designed to serve to health of the people, not the profit of a few

I just returned from a week’s visit to Cuba with a group of medical journal editors and public health people. We met with many people in the medical professions including family doctors and nurses and people from highly specialized referral centers in pediatric cardiac and hepatobiliary surgery, nutrition, and diabetes, and with faculty and leaders from the school of public health and some of Cuba’s medical journals, including the Cuban Journal of Public Health. We met with US students from ELAM, the Latin American Medical School that trains (for free) students with social commitment and economic need from not only Latin America (and North America) but the entire world.

Much has been written on the Cuban medical system, and how it is structured. One of the best recent articles is by C. William Keck and Gail Reed in the American Journal of Public Health in 2012, “The Curious Case of Cuba”.[1] Keck and Reed are, respectively, Editor-in-Chief and Executive Editor of MEDICC Review, an academic journal that publishes research and commentary from both Cuban and US (and other international) authors about the Cuban health system and health status, and is part of MEDICC (Medical Education in Cooperation with Cuba). They were also leaders of our MEDICC-sponsored trip. I will not try to provide yet another in-depth description of the Cuban health system, with which many readers may be familiar, but will rather highlight some aspects of it that struck me as particularly important, and explain why.

First of all, the medical system in Cuba is a national priority. As a socialist country, its centralized nature exceeds that seen in the more-commonly described wealthy Western European nations, and it provides care for everyone. This is a positive, obviously, but also (of course) limits the access to some elective procedures for those who would be rich enough to afford it in another society. It also, of course, limits the ability of those people to be at the front of the queue, which is a particular irritation to the privileged, high-income people who are often those most critical of any type of equitable health system. The health statistics are excellent; several indicators, including infant mortality rate (4.8/1000 in 2013) are much better than in the US.

It is also very primary-care based. Teams of family doctors and nurses are in every neighborhood (in the densely populated parts of central Havana where we were, actually every few blocks) and are responsible for the health of a geographically defined population of 800-1800 people (depending on percent of older, high need people). They spend half their day seeing people in the office, and the other half making home visits, most frequently to those who are high-need because of chronic disease or recent mothers (the nurse sees almost daily). They also live in the neighborhood, frequently in or over the clinic, and are expected to be available 24-7 for any of the patients in their community who needs urgent help. Some of the doctors in these settings are residents in the second of their two-year FM residency, and they include those from other countries whose governments permit residency training in Cuba (we met a resident from Ecuador, who would be returning to his own country).

At the next level are polyclinics, also very neighborhood-based and serving a number of family medicine practices. Staffed with a family medicine professor as well as other specialists (pediatrics, IM, OB-Gyn, etc.) they see patients referred to them by the FM practices (and send them back for continuing care) as well as provide some procedural and imaging services. All physicians complete the 2-year FM residency, and then do residencies in other specialties; about 40% of doctors are FM. There are also hospitals, emergency / urgent care settings, and several levels of referral centers. The ones we visited in Havana for pediatric specialty surgery (including transplants of livers, although not yet hearts for children), nutrition, and diabetes were the most high-level referral centers in the country. At every level the centrality of the family medicine community practice for ongoing follow-up was emphasized. Specialty doctors have great respect for this system. In addition, although they make earn more than family doctors, the difference is small, and all earn far less in relation to the income of others in society than in the US. Doctors are not in it for the money. Public health is a much more prominent part of the health system in Cuba than it is in the US, and there are strong centralized efforts to integrate it more with the medical care, and particularly primary care, system. It remains underfunded relative to medical care delivery, but the inequity is significantly less than in the US where public health receives about 3% of the health care dollar compare to 97% for medical care.

In addition to the medical care that they provide to their own people, the Cubans provide care all around the world, and train doctors (as indicated above) from all around the world. Many poor nations have their health facilities staffed by Cuban physicians, and their human resource commitment to fight the Ebola outbreak in West Africa dwarfs any comparable effort by the US or other nations (see the article “Cuba vs. Ebola” on the MEDICC webpage). As noted above, ELAM graduates several thousand physicians from other countries every year, including the US. The students from the US, selected by the organization Pastors for Peace, are typically from lower-income families and ethnic groups under-represented in US medicine. The US students are required to have at least 2 years of college, and spend at least 6 years in the medical school, plus an extra one before if they are not fluent in Spanish. They are provided free tuition, room, and board. Life is not easy, and like most Cubans – even those working in the most advanced centers, including the National Medical Library – have limited and slow Internet access, a result, apparently of the lack of access to satellites resulting in the “low bandwidth” we heard about constantly. But the graduates are expected to enter primary care and work in communities of need that are like those they come from, and despite the inability of Cuba to enforce this, most of them do. Many have completed residencies in the US and others are currently training, predominantly in primary care. They tend to bring excellent history-taking and physical examination skills, although need time to adapt to the electronic medical record and the ability to “just order a CT scan”.

The hardest part for me about the US medical students at ELAM is that they are exactly the kind of students that every medical school in the US should be aggressively recruiting: from families and communities that have not typically produced physicians, from underrepresented groups, and with a passion and commitment to provide care for those communities. It embarrasses me that they have to go to Cuba to school, while our medical schools are filled with “more of the same”: privileged, generally majority, students with much more interest in high-specialization than primary care, and much more commitment to themselves than to the needs of society.

There are a lot of problems with Cuba, and even with their health system. It is very expensive, very dependent upon physicians, and upon paying relatively low salaries to health workers. It is handicapped by limited resources in a relatively poor country, even though the largest portion of that nation’s resources are spent upon health care and education. Its poor access to the Internet and lack of money for international travel limit the ability of its health professionals to collaborate and stay on top of what is happening in the rest of the world. But what the Cuban model shows is that it is possible to have a health system based on trying to provide needed health care, relatively equitably, to everyone in the society. It starts with primary care, and everyone gets that before anyone gets more; as time and resources progress, more people get more, but still equitably. The emphasis is that health and healthcare and medical care are for everyone, not for a portion of the population. It is based upon the presumption that everyone should get what they need before anyone gets what they do not.

Advocates of a market-based model for health care in the US may insist that they are not mean or selfish, but that the market is the best model for organizing everything, including health care. Their mantra is that “the market will provide”, presumably not just profit for the providers of services, but health to the people.

How’s that working for us?

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[1] C. William Keck and Gail A. Reed.  The Curious Case of Cuba. American Journal of Public Health: August 2012, Vol. 102, No. 8, pp. e13-e22. doi: 10.2105/AJPH.2012.300822

Dead Man Walking: People still die from lack of health insurance

At the recent meeting of the Association of American Medical Colleges (AAMC) meeting in Philadelphia, Clese Erikson, Senior Director of the organization’s Center for Workforce Studies, gave the Annual State of the Workforce address. It had a great deal of information, and information is helpful, even if all of it is not good. She reported on a study that asked people whether they had always, sometimes or never seen a doctor when they felt they need to within the last year. On a positive note, 85% said “always”. Of course, that means 15% -- a lot of people! – said “sometimes” (12%) or “never” (3%). Of those 15%, over half (56%) indicated the obstacle was financial, not having the money (or insurance). There are limitations to such a survey (it is self-report, so maybe people could have gone somewhere, like the ER; or maybe they asked your Uncle George who would have said always because he never wants to see a doctor even though you think he should for his high blood pressure, diabetes, and arthritis!) but it is not good news.

Of course, as former President George Bush famously said in July, 2007, "I mean, people have access to health care in America. After all, you just go to an emergency room." Many of us do not think that this is a very good solution for a regular source of care in terms of quality. Also, if you have had to use the ER regularly for your care and already have a huge unpaid stack of bills from them, it can make you reluctant to return. This likely contributes to the “sometimes” responses, probably often meaning “sometimes I can ride it out but sometimes I am so sick that I have to go even though I dread the financial result.” Following this ER theme, another leading Republican, Mitt Romney, declared repeatedly during the 2012 Presidential campaign, that “No one dies for lack of health insurance,” despite many studies to the contrary. And despite the fact that as Governor of Massachusetts he presumably thought it was a big enough issue that he championed the passage of a model for the federal Affordable Care Act in his state.

People do, in fact, die for lack of health insurance. They may be able to go to the ER when they have symptoms, but the ER is for acute problems. Sometimes a person’s health problem is so far advanced by the time that they have symptoms severe enough to drive them to the ER that they will die, even though the problem might have been successfully treated if they had presented earlier. Or, the ER makes a diagnosis of a life-threatening problem, but the person’s lack of insurance means that they will not be able to find follow-up care, particularly if that care is going to cost a lot of money (say, the diagnosis and treatment of cancer). If you doubt this still, read “Dead Man Walking”[1], a Perspective in the October 12, 2013 New England Journal of Medicine, by Michael Stillman and Monalisa Tailor (grab a tissue first).

We met Tommy Davis in our hospital's clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient's privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences.

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer.

Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation...“If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

The story gets worse. And it is only one story. And there are many, many others, just in the experience of these two physicians. “Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vulnerable; their care is erratic.”  And the authors are just two doctors, in one state, a state which (like mine) starts with a “K” and (like mine) is taking advantage of the Supreme Court decision on the ACA to not expand Medicaid, and which (like mine) has two senators who are strong opponents of ACA, which means, de facto, that they are opposed to ensuring that fewer people are uninsured. I cannot get their thinking, but it really doesn’t matter, because it is ideology and they have no plan to improve health care coverage or access. So people like Mr. Davis will continue to die. This same theme is reflected in a front-page piece in the New York Times on November 9, 2013, “Cuts in hospital subsidies threaten safety-net care” by Sabrina Tavernise:

Late last month, Donna Atkins, a waitress at a barbecue restaurant, learned from Dr. Guy Petruzzelli, a surgeon here, that she has throat cancer. She does not have insurance and had a sore throat for a year before going to a doctor. She was advised to get a specialized image of her neck, but it would have cost $2,300, more than she makes in a month. ‘I didn’t have the money even to walk in the door of that office,’ said Ms. Atkins.

In a recent blog about the duration of medical education, I included a graphic from the Robert Graham Center which show the increased number of physicians that the US will need going forward, mostly as a result of population growth but also from the aging of that population, along with a one-time jump because of the increased numbers people who will be insured as a result of ACA (this will, I guess, have to be adjusted down because of the states that start with “K” and others that are not expanding Medicaid). Ms. Erikson included this graphic in her talk at AAMC, with numbers attached. Just from population growth and aging, we will require about 64,000 more physicians by 2025 (out of 250,000-270,000 total physicians).The one-time jump because of the ACA is about 27,000, bringing the number to 91,000.

But, of course, there is a big problem here. The projection that we will need more doctors because we have more people, or because our population is aging and older people need more medical care, is one thing. But the need for more doctors because more people will be insured? What is that about? Those people are here now, and they get sick, and they need care now, no less than they will when they are covered in the future. I do not mean to be critical of the Graham Center or Ms. Erikson for presenting those data. I do, however, think that we should emphasize how offensive is the idea that we will need more doctors just because more people will have coverage. They didn’t need doctors before, when they didn't have insurance?

If there are people who cannot access care, we need to be able to provide that care. We will need more health care providers, including more doctors, especially more primary care doctors. We need health care teams, because there will not be enough doctors, especially primary care doctors. We need the skills of health workers who can go to people’s homes, and identify their real needs (see the work of Jeffrey Brenner and others (see Camden and you: the cost of health care to communities, February 18, 2012). We need to ensure that people have housing, and food, and heat, and education – to address the social determinants of health.

Decades ago, I heard from someone who visited Cuba a few years after the revolution. He said he mentioned to a cab driver the dearth of consumer goods, such as shoes, in the stores. The cab driver said “we used to have more shoes in the stores, but now we first make sure that they are on children’s feet before we put them in stores windows.” There was enough before the revolution, enough shoes and enough milk, as long as a lot of people were not getting any. The parallel is that now, in the US, if we seem to have enough health clinicians, it is because there are lots of people not getting health care.

This is not ok. It isn’t ok with the ACA, and it isn’t OK without it.

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[1] Stillman M, Tailor M, “Dead Man Walking”, Michael Stillman, M.D., and Monalisa Tailor, M.D.

October 23, 2013DOI: 10.1056/NEJMp1312793

Status Syndrome: an important determinant of health

This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.

In a recent blog (Keeping immigrants and all of us healthy is a social task), May 19, 2013), my good friend Josh Freeman wrote about the social determinants of health. When I commented that arguably the most important determinant was missing from his list he suggested that I write this book review blog as his guest. While I had long ago read quite a few papers on the topic of social determinants of health and health disparities that addressed the material that Josh covered in his blog, for me it was an eye-opening experience to read a book a few years ago by Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our Health and Longevity[1]. I found Professor Marmot’s explanations to provide a unifying idea that resonated with me.

Everyone knows that wealthier people are on average healthier than poorer people. However, it doesn’t follow that wealthier countries, including the United State (US), are necessarily healthier than poorer countries. For example, three countries that I am rather familiar with, Chile, Costa Rica, and Cuba, have life expectancies and other population health statistics that are as good or better than ours despite huge differences in average wealth.

Professor Marmot’s thesis is that, after a minimal threshold, it is not so much absolute differences in material means that makes wealthier people healthier, but rather their perceptions of their social status within their reference group. To quote him,

“The remarkable finding is that among all of these people [i.e. the groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome.”

Professor Marmot is a British physician and epidemiologist from University College, London. His book carefully presents the evidence that it is the psychological experience of how much control you believe you have and your opportunities for full participation in society that is at the heart of social determinants of health.  He presents evidence from many countries and comparisons between them, and evidence related to individuals within different types of social hierarchies, and finally ends with evidence that countries with less inequality are healthier than those with more.

One example that he discusses in detail is that British office workers at the bottom of the office hierarchy have a higher risk of heart attacks than senior managers at the top, while just a generation ago popular wisdom was that highly successful “type A” personality people in stressful jobs were more prone to coronary artery disease.

Before reading his book I had seen some documentaries on primates that suggested that lower status animals had poorer health and reproductive outcomes and shorter lives on average compared with high status animals that was relatively unrelated to sufficient access to resources such as food. In addition I lived for a number of years in Chile as a young adult; my middle class income by Chilean standards was dire poverty by US standards. I was an American expatriate, a status  that was highly regarded in Chile, and also during some of those years I was a medical student. Despite the fact that I was really poor by US standards I was happy and healthy and my children also seemed as happy and healthy as US kids. After returning to the US I read some papers that included data to show that the generation of newly arrived Hispanic immigrants enjoy relatively good health outcomes, which deteriorate in subsequent generations despite the fact that the families have acquired more material wealth in absolute terms. No good explanations were included for the findings in those papers. After reading The Status Syndrome it made sense to me. The initial immigrants were probably using their country of origin as the social reference and subsequent generations had a US social frame of reference. I concluded that minority groups in this country have health disparities in large part due to the experiences of inequality and discrimination relatively more than due to absolute access to material means or even specific services - including health services.

In the latter part of his book Professor Marmot demonstrates that the countries with the best health statistics in the world are those that are both relatively wealthy and more equal. Examples of such countries are Sweden and Japan. On the other hand, countries at the other end of the spectrum present a reaffirming contrast. He spends the latter part of the book arguing for a political agenda in favor of reduction in social inequality.

If you haven’t figured it out by now, I highly recommend this book. It will transform how you think about the social determinants of health.

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[1] Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health and Longevity. Owl Books. Henry Holt and Company. New York. 2004.

Who will care for the underserved? The role of off-shore medical schools

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I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.

Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?

In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?

Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.

While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.

The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.

Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
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