Healthcare in Cuba

# Overview
The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of its citizens. No private hospitals or clinics are permitted. The present Minister for Public Health is Jose Ramon Balaguer.

# History
As was true of the other indigenous societies of the Americas, Cuban traditional medicine existed before the Spanish conquest. High status traditional practitioners were called Bohiques. After colonization, Cuban medicine followed the Spanish tradition which was inherited from the Moors, who drew upon classical Greek and Roman medical practices. Chinese medicine has also been practiced in Cuba, the most famous was the 19th century doctor Cham Bom Biam or El Medico Chino.
Modern Western Medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th Century and the first surgical clinic was established in 1823. Cuba has had many world class doctors, including Carlos Finlay, who determined how Yellow fever was spread under the direction of Walter Reed, James Carroll, and Aristides Agramonte. During the period of U.S presence (1898-1902) yellow fever was essentially eliminated due to the efforts of Clara Maass and surgeon Jesse W. Lazear.
By the 1950s, the island had some of the most positive health indices in the Americas, not far behind the United States and Canada. Cuba was one of the leaders in terms of life expectancy, and the number of doctors per thousand of the population ranked above Britain, France and Holland. In Latin America it ranked in third place after Uruguay and Argentina.  
There remained marked inequalities however. Most of Cuba's doctors were based in the relatively prosperous cities and regional towns, and conditions in rural areas, notably Oriente, were significantly worse. Only 8% of the rural population had access to healthcare.
Following the Revolution, the new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled "On Revolutionary Medicine", stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices." These aims were hampered almost immediately by an exodus of almost half of Cubas physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in University of Havanas medical college. Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services.
In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states "Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations."
Cuba's doctor to patient ratio grew significantly in the latter half of the 20th century, from 9.2 doctors per 10,000 inhabitants in 1958, to 58.2 per 10,000 in 1999. In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox. Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care.
In 2007, Cuba announced that it has undertaken computerising and creating national networks in Blood Banks, Nephrology and Medical Images. Cuba is the second country in the world with such a product, only preceded by France. Cuba is preparing a Computerised Health Register, Hospital Management System, Primary Health Care, Academic Affairs, Medical Genetic Projects, Neurosciences, and Educational Software. The aim is to maintain quality health service free for the Cuban people, increase exchange among experts and boost research-development projects. An important link in wiring process is to guarantee access to Cuba's Data Transmission Network and Health Website (INFOMED) to all units and workers of the national health system. 

# Present

## Health indicators and issues
Like the rest of the Cuban economy, Cuban medical care has suffered from severe material shortages following the end of Soviet subsidies and the ongoing United States embargo against Cuba that began after the Cuban Missile Crisis.
According to the World Health Organization (WHO), the chance of a Cuban child dying at five years of age or younger is 7 per 1000 live births in Cuba, while it's 8 per 1000 in the US. WHO reports that Cuban males have a life expectancy at birth of 75 years and females 79 years. In comparison, the US life expectancy at birth is 75 and 80 years for males and females, respectively. Cuba's infant mortality rate is better than the US with 5 deaths per thousand in Cuba versus 7 per thousand in the US.  Cuba has nearly twice as many physicians as the U.S. -- 5.91 doctors per thousand people compared to 2.56 doctors per thousand, according to WHO.  
Abortion rates, which are high in Cuba, increased dramatically during the 1980s, but had almost halved by 1999 and declined to near 1970s levels of 32.0 per 100 pregnancies. The rate is still among the highest in Latin America and also one explanation for the low infant mortality rate.
Among adults less than 49 years old, accidents are the leading cause of death, though occupational accidents have declined significantly in the last decade. The suicide rate is 18.2 per 100,000 is higher and the homicide rate is 7.0 per 100,000. The rates of suicide in the island are the highest in Latin America and have been among the highest in the region and the world since the nineteenth century. Cuban-American suicide rates in Miami are lower than other Miami groups. Among older adults heart disease and cancer predominate as causes of mortality. General mortality has been "characterized by a marked predominance of causes associated with chronic noncommunicable diseases", according to the Pan American Health Organization.
While preventive medical care, diagnostic tests and medication for hospitalised patients are free, some aspects of healthcare are paid for by the patient. Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. When a patient can obtain these items at state stores, prices tend to be low as these items are subsidised by the state. For patients on a low-income, these items are free of charge..

## Sexual health
According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment.
In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world. The UNAIDS reported that HIV infection rates for Cuba were 0.1%, and for other countries in the Caribbean between 1 - 4%. Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education.
According to Avert, an international AIDS charity, "Cubas epidemic remains by far the smallest in the Caribbean." They add however that,
... new HIV infections are on the rise, and Cubas preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cubas prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs.
In recent years because of the increase in prostitution and lack of prevention, STIs have increased significantly.

## Embargo
During the 90s the ongoing United States embargo against Cuba caused problems due to restrictions on the export of medicines from the US to Cuba. In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U.S. subsidiary trade, including trade in food and medicines, being prohibited. The legislation did not state that Cuba cannot purchase medicines from U.S. companies or their foreign subsidiaries; however, such license requests have been routinely denied. In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U.S. Government that such activities violate international law and has requested that the U.S. take immediate steps to exempt medicine from the embargo. The Lancet and the British Medical Journal also condemned the embargo in the 90s.
A 1997 report prepared by Oxfam America and the Washington Office on Latin America, Myths And Facts About The U.S. Embargo On Medicine And Medical Supplies, concluded that the embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U.S. firms or from non-U.S.sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba's medical system. It prohibited foreign subsidiaries of U.S. corporations from selling to Cuba, thus further limiting Cuba's access to medicine and equipment, and raising prices. In addition, the act forbids ships that dock in Cuban ports from docking in U.S. ports for six months. This drastically restricts shipping, and increases shipping costs some 30%.
However, in 2000 the Trade Sanctions Reform and Export Enhancement Act was passed, and the US is now the single largest source for imported food.  The Cuban American National Foundation state that the US embargo does not include medicines and medical supplies to the Cuban people. It also states that should Cuba choose not to purchase from the U.S., it can purchase any medicine or medical equipment it needs from other countries. Such third-country transactions only cost an estimated 2%-3% more than purchases from the U.S. as a result of higher shipping costs.
The US government states that since 1992, 36 out of 39 license requests from U.S. companies and their subsidiaries for sales of medical items to Cuba have been approved. The dollar amount of these sales is over $1,600,000. Furthermore, the U.S. government licensed more than $227 million in humanitarian donations of medicines and medical supplies to Cuba between 1993 and 1997.  There are other factors beside the embargo explaining the lack of imports, in particular Cuba's lack of hard currency. Those with dollars can easily buy medicines and food in Cuba from Latin America and Canada. Cuba defaulted on its debt to Western banks in 1986 and lacks access to the international credit system in order to get foreign currency. In addition, the collapse of the Soviet Union caused the loss of several billions of dollars in yearly subsidies and overnight required hard currency for all imports.
In a 2006 report to the U.N. Secretary-General, Cuba acknowledged the authorization of medicines, though stated that they were subject to severe restrictions and complicated procedures. Cuba is obliged to make payments in cash and in advance, and is precluded from obtaining credit funding, even from private sources. The sale and transportation of the goods require licences to be obtained for each transaction. Cuba cannot use its own merchant fleet for transporting these goods, but has to make use of vessels from third countries, primarily the United States. Payments are made through banks in third countries, since direct banking relationships are prohibited. The Cuban delegation concluded that restrictions on importing medical products were "so extensive that they make such imports virtually impossible". The World Health organisation/PAHO and UNFPA concurred that it was impossible for Cuba to purchase equipment, medicines and laboratory materials produced by the United States or covered by United States patents, even though those products were purchased through multilateral cooperation. Cuba was not able to purchase the isotope I-125 that is used to treat eye cancer in children. The companies manufacturing reagents and equipment are 70 per cent United States owned, which makes it difficult to purchase necessary medical equipment and other items

## Medical staff in Cuba
According to the World Health Organization, Cuba provides a doctor for every 170 residents, and has the second highest doctor to patient ratio in the world after Italy. All fiscal and administrative aspects of health care in Cuba are run by the state; no private hospitals or clinics are permitted, and medical workers are required to work for the state. Historically, Cuba has long ranked high in numbers of medical personnel; in 1957, before the revolution, it ranked third in Latin America and ahead of many European nations.
Medical professionals are not paid high salaries by national or international standards. In 2002 the mean monthly salary was 261 pesos, thus 1.5 times the national mean. A doctors salary is equivalent to about US$15-20 per month according to the official rate of exchange between peso and dollar. Therefore, many prefer to work in different occupations, generally in the lucrative tourist industry, where earnings can be 50 to 60 times more.

## Black market healthcare
The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba's burgeoning black market economy, sometimes termed "sociolismo". According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, "The doctors in the hospitals are charging patients under the table for better or quicker service." Prices for out-of-surgery X-rays have been quoted at $50 to $60. Such "under-the-table payments" reportedly date back to the 1970s, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn know as the "Special Period" in the 1990s aggravated these payments. The advent of the "dollar economy", a temporary legalisation of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans were able to obtain medications and health services that would not be available to them otherwise.

# Cuba and international healthcare
Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA), and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies
Because the education of physicians came to exceed the country's internal requirements, Cuba has been able to export primary care practitioners and specialists for periods of service in other Third World nations. Cuban doctors have therefore played a role in many regions of the world. Cuba's missions in 68 countries are manned by 25,000 Cuban doctors, and medical teams have assisted victims of both the South Asian Tsunami and the Pakistan earthquake. Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil. Nearly 2,000 Cuban doctors are currently working in Africa in countries including South Africa, Gambia, Guinea Bissau and Mali. Since the Chernobyl nuclear plant exploded in 1986, more than 20,000 children from Ukraine, Belarus and Russia have traveled to Cuba for treatment of radiation sickness and psychologically based problems associated with the radiation disaster.
Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: "Mission Into the Neighborhood") social welfare program established in Venezuela under current Venezuelan president Hugo Chavez. The program, which is popular among Venezuela's poor and is intended to bring doctors and other medical services to the most remote slums of Venezuela, has not been without its detractors. The Venezuelan Medical Association has criticised the appointment of Cuban doctors to high-ranking positions, and protests have taken place in the capital Caracas by Venezuelan medical staff who fear that the Cubans are a threat to Venezuelan jobs. Questions have also been raised by protestors about the level of Cuban medical qualifications, and there have been claims that the Cubans are "political agents" who have come to Venezuela to indoctrinate the workforce.

## Operacion Milagro
Operacion Milagro (Operation Miracle) is a joint health programme between Cuba and Venezuela, set up in 2005. The initiative is part of the Sandino commitment, which sees both countries coming together with the aim of offering free ophthalmology operations to an estimated 6 million people in Latin America and the Caribbean. The project is also part of ALBA (Bolivarian Alternative for the Americas). Under the agreement, patients from Venezuela and other Latin American nations, are flown to into Cuba for eye surgeries and other major treatments. This is part of a package which includes the Cuban personnel sent to Venezuela (see above) and the fact that Venezuela sent 90,000 barrels of crude oil per day at preferential rates. In late 2005, Operacion Milagro was extended to Panamanians, and in June 2006 to Nicaraguans. All flights, accommodation and food are funded by the Venezuelan government. The scheme was intended to expand to 500,000 operations a year in 2006.
Opponents of the Cuban government accuse it of sending the doctors to Venezuela for political motives. 

## Health tourism and pharmaceutics
Cuba attracts nearly 20000 paying health tourists, generating revenues of around $40m a year for the Cuban economy. Cuba has been serving health tourists from around the world for more than 20 years. The country operates a special division of hospitals specifically for the treatment of foreigners and diplomats.  Foreign patients travel to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinsons disease, cosmetic surgery, addictions treatment, retinitis pigmentosa and orthopaedics. Most patients are from Latin America, Europe and Canada, and a growing number of Americans also are coming. Cuba also successfully exports many medical products, such as vaccines.

# Alternative Healthcare
Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population In the 1990s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model. Examples of alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i.e. acupunctural anesthesia for surgery), natural dietary supplements, yoga, electromagnetic and laser devices. Children begin studying the multiple uses of medicinal plants in primary school, learning to grow and tend their own plots of aloe, chamomile, and mint, and later they conduct scientific studies about their uses. Radio and Television programs instruct people on how to relieve common stomach upset and headaches by pressing key points. Cuban bio-chemists have produced a number of new alternative medicines, including PPG (policosanol), a natural product derived from sugarcane wax that is effective at reducing total cholesterol and LDL levels, and Vimang a natural product derived from the bark of mango trees.

# Medical research in Cuba
The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine. Because private investment is prohibited and the only possible source of funds for research is the government, Medical research has not been able to expand beyond the Cuban governments ability to fund the research.
In April 2007, the  The Cuba IPV Study Collaborative Group (Cuban Ministry of Public Health, Kouri Institute, U.S. Centers for Disease Control and Prevention, Pan American Health Organization, World Health Organization) published an article in the New England Journal of Medicine which established that inactivated (killed) poliovirus vaccine was effective in vaccinating children in tropical conditions. This is important because countries with high incidence of polio are now using live oral poliovirus vaccine. When polio is eliminated in a country, they must stop using the live vaccine, because it has a slight risk of reverting to the dangerous form of polio. The Cuba collaborative group found that when polio is eliminated in a population, they could safely switch to killed vaccine and be protected from recurrent epidemics. Cuba has been free of polio since 1963, but continues with mass immunization campaigns. 

# Praise for the Cuban Healthcare System
In 2006, BBC flagship news programme Newsnight featured Cuba's Healthcare system as part of a series identifying "the world's best public services". The report noted that "Thanks chiefly to the American economic blockade, but partly also to the web of strange rules and regulations that constrict Cuban life, the economy is in a terrible mess: national income per head is minuscule, and resources are amazingly tight. Healthcare, however, is a top national priority" The report stated that life expectancy and infant mortality rates are pretty much the same as the USA's. Its doctor-to-patient ratios stand comparison to any country in Western Europe. Its annual total health spend per head, however, comes in at $251; just over a tenth of the UK's. The report concluded that the population's admirable health is one of the key reasons why Castro is still in power. In fact, a recent poll carried out by the Gallup Organization's Costa Rican affiliate  Consultoria Interdisciplinaria en Desarrollo (CID)  found that about three-quarters of Cuban citizens are positive about their country's education and healthcare systems.
In 2000, Secretary General of the United Nations Kofi Annan stated that "Cuba should be the envy of many other nations" adding that achievements in social development are impressive given the size of its gross domestic product per capita. "Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities - health, education, and literacy." The Kaiser Family Foundation, a non-governmental organization that evaluated Cubas healthcare system in 2000-1 described Cuba as "a shining example of the power of public health to transform the health of an entire country by a commitment to prevention and by careful management of its medical resources" President of the World Bank James Wolfensohn also praised Cuba's healthcare system in 2001, saying that "Cuba has done a great job on education and health", at the annual meeting of the Bank and the International Monetary Fund. Wayne Smith, former head of the US Interests Section in Havana identified  "the incredible dedication" of Cubans to healthcare, adding that "Doctors in Cuba can make more driving cabs and working in hotels, but they don't. They're just very dedicated". Dr. Robert N. Butler, president of the International Longevity Center in New York and a Pulitzer Prize-winning author on aging, has traveled to Cuba to see firsthand how doctors are trained. He said a principal reason that some health standards in Cuba approach the high American level is that the Cuban system emphasizes early intervention. Clinic visits are free, and the focus is on preventing disease rather than treating it. 
  Furthermore, London's The Guardian newspaper lauded Cuba's public healthcare system for what it viewed as its high quality in a Sept. 12, 2007 article.  

## Studies of the Cuban health system in the United Kingdom
In 2001, members of the UK House of Commons Health Select Committee traveled to Cuba and issued a report that paid tribute to "the success of the Cuban healthcare system", based on its "strong emphasis on disease prevention" and "commitment to the practice of medicine in a community".
The Parliament of the United Kingdom also drew up an analysis of the key features of Cuba's healthcare system, drawing comparisons with the state funded National Health Service (NHS). The overall conclusion was that many of the features identified would not have occurred had there not been an obvious commitment to health provision demonstrated by the protection and proportion of the budget given the health care. The study concluded the following.
- There appeared to be little evidence of a divide between the prevention/proactive response and the disease management/reactive response within Cuban healthcare.
- By far the biggest difference was the ratio of doctors per person. In Cuba it was one doctor per 175 people, in the UK the figure was one doctor per 600 people.
- There is a commitment in Cuba to the triple diagnosis (physical/psychological/social) at all levels.
- Extensive involvement of "patient" and the public in decision making at all levels.
- Integration of hospital/community/primary care via polyclinics.
- Team-work that works is much more evident both in the community and the hospital sector and the mental-health and care of the elderly sites visited were very well staffed and supported.
The study also pointed to problems within the system, these included;
- Low pay of doctors
- Poor facilitiesbuildings in poor state of repair and mostly outdated.
- Poor provision of equipment.
- Frequent absence of essential drugs.
- Concern regarding freedom of choice both for patient and doctor.

# Criticisms
The US State Department, citing many independent sources, states that Cuba's infant mortality rate in 1957 was the lowest in Latin America and the 13th lowest in the world, according to UN data. Cuba ranked ahead of France, Belgium, West Germany, Israel, Japan, Austria, Italy, and Spain, all of which would eventually pass Cuba in this indicator during the following decades. Cubas comparative world ranking has fallen from 13th to last out of the 25 countries examined. Also missing from the conventional analysis of Cuba's infant mortality rates is its very high abortion rate, which, because of selective termination of "high-risk" pregnancies, yields lower numbers for infant mortality. Cuba's abortion rate was the 3rd highest out of the 60 countries studied. In terms of physicians and dentists per capita, Cuba in 1957 ranked third in Latin America, behind only Uruguay and Argentina -- both of which exceeded the United States in this measure. Cuba's physicians and dentists in 1957 was the same as the Netherlands, and ahead of the United Kingdom and Finland. The report states "Unfortunately, the UN statistical yearbook no longer publishes these statistics, so more recent comparisons are not possible, but it is completely erroneous to characterize pre-Revolutionary Cuba as backward in terms of healthcare."
Complaints have arisen that foreign "health tourists" paying with dollars and senior Communist party officials receive a higher quality of care than Cuban citizens. Former leading Cuban neurosurgeon and dissident Dr Hilda Molina asserts that the central revolutionary objective of free, quality medical care for all has been eroded by Cuba's need for foreign currency. Molina says that following the economic collapse known in Cuba as the Special Period, the Cuban Government established mechanisms designed to turn the medical system into a profit-making enterprise. This creates an enormous disparity in the quality of healthcare services between foreigners and Cubans leading to a form of tourist apartheid. In 1998 she said that foreign patients were routinely inadequately or falsely informed about their medical conditions to increase their medical bills or to hide the fact that Cuba often advertises medical services it is unable to provide. Others makes similar claims, also stating that senior Communist party and military officials can access this higher quality system free of charge. In 2005, an account written by Cuban exile and critic of Fidel Castro, Carlos Wotzkow, appeared showing apparent unsanitary and unsafe conditions in the "Clinico Quirurgico" of Havana;the article claims that health care for Cubans occurs in worse conditions in the rest of the country.
An article in Canadian newspaper National Post, based interviews of Cubans, finds that in reality even the most common pharmaceutical items, such as Aspirin and antibiotics are conspicuously absent or only available on the black market. Surgeons lack basic supplies and must re-use latex gloves. Patients must buy their own sutures on the black market and provide bedsheets and food for extended hospital stays. The Cuban government blames the shortages on the embargo and states that those with more severe chronic diseases receive medicines. However, other sources suggest that also those with such diseases lack medicines. It is also suggested that in some cases the local non-dollar stocks have been shipped abroad.
An article in The Boston Globe, partially based on interviews with Cubans, argues that the massive export of doctors and other medical personal to Venezuela in exchange for oil has caused shortages in Cuba. Regarding Operacion Milagro, "It's all the Venezuelans who need cataracts surgery first, and then the Cubans if there's any time left", said Georgina, 60, a retired Havana clerk.
A recent ABC-TV 20/20 report on Healthcare, based on footage taken from within the island, criticized Michael Moore's portrayals of the Cuban Healthcare system. The report highlights the dilapitated conditions of the hospitals that are accessible to regular Cubans by pointing to the bleak conditions of hospital rooms and the filthy conditions of the facilities. The report also addressed the quality of care available to Cubans by arguing that patient neglect was a common phenomenon. Finally, in discussing the infant mortality rate, the report highlights the government's efforts to promote abortions of potentially infirm fetuses and other government efforts to manipulate the rate.