"THE CUBAN HEALTH SYSTEM AFTER HALF A CENTURY OF REVOLUTION"

By: Dr. Darsi Ferrer

Habana, may 8, 2009

The system of public health constitute one of the pillars that the cuban government uses to justify what they consider as a "social conquest" achieved in half a century of permanent power. Certain determined advances in the health coverage, and besides all, an effective propaganda which maintains the myth of the condition of Cuba as a world medical superpower, further from the concret results which overwhelm the population because of the insufficiencies and progressive deterioration of the medical services.

The end of the war for independence, in 1898, the country could not count on a basic infrastructure, practically no institution existed of public health and the population was being decimated by infectious diseases. Thousands of Cubans died due to the concecuences of hunger provoked by the devastation of the war, dysentery and contagious infections such as tuberculosis, malaria, typhoid fever and yellow fever, besides other things.

That situation of cero hygiene forced the american administration during the periods of occupation, 1899-1902, developed important actions in the public health section, as the creation of the medical institutions, the companies of hygiene in the cities and the struggle against contagious sicknesses.

With the instauration of the Republic, starting from 1902, prestigious physicians under the coordination of Dr. Charles J. finlay, continued the struggle to improve the health conditions of the population and the hygiene of the country. In little time the results where notorious; shrinking the mortality rate in infants by tetanus, yellow fever was irradicated and in 1909 the Secretary of health and welfare, which resulted in the first ministry of public health in the world.

During the following years the development of salubrity was being consolidated, supported in three systems: the system of national state health, the private and the mutual and associated clinics. An Act which elevated the health index of the nation helping to recognize it as advanced, and that the professionals an medic institutions and of the school of medicine would be at the most highest quality and enjoyed the great international prestige. By those years the health attention passed to officialy recognizing it as a right of the people.

Within the world raising contributions of the prestigious cuban physicians during the first half of the XX century stands out: the discovery by Dr. Charles J. Finlay the transmitting agent of the yellow fever and its preventive measures, besides formulating a new medical doctrine, the metaxenic theory of the spreading infectious deseases, which planted the basis for the development of the medical arboviralogy and medical artropodology; the introduction by Dr. Thomas Romay of the vacines in Cuba, who as an example inoculated his sons first; he invented it or modified more then 28 instruments destine to the exploration of urinal surgery by Dr. Joaquín Albarrán, also of other important personal discoveries related with urinary apparatuses; Dr. Agustín W. Castellanos was a canditade for the Nobel prize in medicine for his discovery of the angiocardiography, which facilitated the posterior development of the cardiovascular surgery, a process which rapidly was accepted by the World Organization of Health (OMS). They could mention many other advances in the field of medicine, but it would exceed the limits of the present work.

Especifically in the year 1958 Cuba exhited an index in health in many aspects similar to the countries of the first world and superior of that of Latin America. With a population of a little more than 6 million and a half of inhabitants it had in that era 6, 286 doctors, without adding the eye specialist, and 32,501 bed within the hospital services and benefits, for a total 1,076 inhabitants for each doctor and 237 inhabitants per bed; the life expectancy at birth was 58.8 a year and the infant mortality at 32.5 for each thousand born alive, estimates which maintain a decreasing tendency and which even after 20 years was not reached by countries of the continent; the brute rate of mortality of the population was of 6.4 for every 1,000 inhabitants.

To cite an example, at the start of the 80s the rate of infant mortality was of 70.6 for each one thousand born alive in Brazil, 53 in Mexico and 35.3 in Agentina, according to the annual stadistics of 1988.

Not everything was positive en the public health system of that era; the inadequate geographic distribution of its services created notable differences of coverture of health in the cities and the insufficiently recorded which existed in the rural zones, it also had some negative incidence of high level of corruption which digged deep into the structure system, besides other problems.

But, the deficiencies of the public health was compensated with services which offered at a modic cost the mutual system or cooperatives, which its sanitary institutions emerged in times of the colony, known as the fifth or the clinics, where the precursors of the HMO of the United States, which also, furthermore, accounted in the fifthties with approximatly a million and a half of associates, and offered an excellent profesional attention and mantained conditions of comfort and proper hygiene.

The associates of the mutual and cooperative services for a modic price of 2 dollars in their majority, and approximatly 10 dollars in the more expensive clinics (the two and 10 cuban dollars at that time was equivalent to that of the U.S. dollar), which guaranteed your right to medical consultations of all type of specialist, the use of laboratories and all classes of medical exams, medicines, surgeries, internment in a room for patients and their families, included where three meals and snacks for both, also they where able to enjoy the recreational activities and cultural which the center offered which belonged to these institutions.

The triumphal revolutionary process in 1959 produced in the nation a profound transformation of political sense, ideological, economical, social and cultural. Since their first start the socialistic path went laboring through the adoptive measures of popular characters, as it was in the atmosphere of the health in the implementation of the medical rural system, but besides all the social benefits it was based in the state runned properties of the bourgeoisie, through the confiscation of their goods, until they arrived in little time to the alienation of the individual properties of all the society.

Due to the consecuences of that situation a masive exodus during the month of september and october of 1960 was produced. In an abruptive form an important number of owners of assistantial units, actionist of mutual institutions or cooperatives, property owners of farmaceutical laboratories and druggerys, and many other health professionals. On the other hand the government decreeted august 1, 1961 the law No.959, which estipulated the rectory of the public ministry of health of all activities of health of the country, including the private and mutual units.

The consolidation of the national health system was a reality in 1970. by that time the revolutionary government had succeeded in submitting at its own control and dominance all the activities of social medical assistance, and of the production, distribution and commercialization of medicines and medical equipment. And private methods where eliminated and the independent, also the foreign enterprises, the national contractors, the churches, also where prohibited including the traditional organizations or independent societies of professional corporations, as in the case of the national medical college, which was disolved april 30, 1966 by official mandate.

The enormous subsidies from the Union of the Soviet Socialist Republic (URSS), permited that during the decades of the 70s and 80s the services where extended to the state health, even to give free coverage to all the cuban population, also they made possible the modernization and the enlargement of the web of medical institutions, the implementation of massive plans of formation of the professionals of health, the adquisition of technology and the modern medical equipments, the creation of institutes of investigation, also the design and the inmediate practice of important programs of health focused in the prevention, diagnostic, treatment and control of deseases.

Of this era constituted the benefits of the improvement of indicators as: the eradication of cases of poliomyelitis, the significant decrease at 9.4 of the mortality by infectious pathology and parasites in 1987, the important reduction of the number of death by tuberculosis. Also they can account for in succeeding in the increment of institutional parturition, the maintained reduction of the mortality maternal-infantile and the increment of hope for life.

It was in the year 1984 when the program of medical and the nurse of the family was introduced, which quickly passed to be the basis of the primary attention of the socialist medicine. In theory that model of medical attention is organized by geographic areas of health, constituted by polyclinic control and various consultancies, which function under the control of the functionaries of the health municipality, and assigns dertermined hospitals and institutes de investigations which guarantees the specialized services of the second level and third.

according to the defenders of the plan, the medicals approach and the family nurse in the community offers the possibility of developing procedures and services of promotions, prevention, cures and rehabilitations. Also, through the dispensaries of all patients permits the protection of specific populational groups and the realization of actions which intergrates the individual, the family and the in between.

In the 90s, after the fall of the socialist block, great quantities of recourses that came from the URSS desappeared, which provoked a profound crisis. In the atmosphere of health the lack of supplies caused a marked decline in the services, it was abandoned or restrained many of the existing programs, the population suffered the effects of retrodifferentiation an indicator key as in the decline in weight when born, the maternal mortality, an increase of malnutrition, the incidence in infectious deseases, and it was evidant the grave limitations in the structurals fitting of the "revolutionary" medical design.

In actuality the govenment and its apologistics seek to grasp in manipulating the medical reality. They substain the mith of advancement which do not exist while it results in a disaster the health care of the population, given the deplorable state of the institutions and the deterioration in the assistence services.

As in all the rest of the levels of the national life absorbed by the state, the system of health functions according to the political governmental interest, reason which transformed the essence of the medicine of its scientific sense and humanistic, and established an impersonal concept which makes doctors and patients comply within functions of the government. This submission of the system of state health created mechanisms which generate levels of unsubstantiated bureoucracy, corruption and inefficiency.

With the grave lack of material recourses the last years it can be added other factors which contribute in an important matter to the calamity of the health system. In a general form, the professionals of the sector are unmotivated professionaly, since they have to work for salaries without any real acquisitive power, which does not guarantee not even the slightist satisfaction of the most elemental necessities; take for example that a medical specialist receive a salary of about 23 dollars a month, according tho the official change of 24 pesos per dollar.

The very bad conditions of work also provokes a general level of frustration in the professionals, reinforced by the supression of the liberties and personal creativity, by not permitting the private initiatives neither the creation of associations or independent organizational corporations. Not less damaging are the results of the substituting of the selective plans of study which regulated the formation of doctors and other workers of the sector before 1959, to give way to the preparation of massive, and the emergence in many specialties, which does not take into account the capacity of does aspiring neither the professional vocation, which gives a sensible and systematic decrease in the quality of those recruited.

It is even greater the defficiencies in the professional field because the cubans can not depend on the possibilities of internet access in full era of the informatic age, united with the chronic deficit of the actual literature and a prohibition of travelling to international academic events. Only a small group of militants of the communist party, unconditional to the government, enjoy these privaleges.

The displeased market of the population with the health system is justified by the deplorable state of the centers where they receive medical assistance; the mayority of these instalations are found in ruines, lacking hygiene, also lacking elemental recourses. They do not exagerate those who consider a tragedy the necessity of being hospitilized. We can stop to point out that the patients should supply themselves by their families of the daily food, the cleaning implements to help decrease the filth of the inclosures, the bed sheets, pijamas, their personal hygiene, spuns, cups, canteens for water, including many have to resolve by the side their diagnostic results and medicines which are required for their treatment, without forgetting the presents which are given under the table for the professionals who are in charge of their medical attention.

For the shameful national medicine, every time is more significant in the island the number of sick without any solutions for their health conditions and who depend on the alternative of being helped by their exiled families, through the shipment of medicines, eye glasses with rectified lenses, orthopedic equipment, wheel chairs, positioning beds, nebulizers, dental prosthesis, equipment to measure high blood pressure, the levels of sugar, and other equipments of dire need.

Apart from other things the management deserve that the statistics be realized, the ones that are exclusive dominion of the government and which are not permited by the supervision of the specialist or other independent groups. This makes the statistic results that the country presents not trustworthy, well it is understood that its manipulated in benefit of maintaining a positive image for the State, or simply it is hidden as determined professional information and is classified as a government secret.

Example of the last which constituted statistics inaccesible of the number of suicides, abortions, the medical requirements of the doctors of classifying as virosis unspecified many of the sick with yellow fever so it can be less the number diagnost with that pathology, the joy for the decrease of VIH-AIDS in the country without questioning that in the last years the diagnostics of new cases in AIDs fase or in the late stage demonstrated an evident over registry, the values of hemoglobine established as normal are numbers inferior to the accepted by the World Organization of Health, the list which determines the correpondance of weight and the measure according to the year the child utilizes inferior values by those internationaly established, buy only mentioning a few.

The references of praise to the actual infant mortality, 5.3 for each 1,000 born alive, reached by the cuban medicine which omits that this indicator is supported by the backing of a political indiscrimanation of abortions. which is calcutated in more than 4 million during the period of the revolution. Besides all pregnancies the risk to the physicians are obligated in stimulating the abortion option, and in the factors of risk established are that the progenitor live in conditions of misery or suffer from some mental purturbation. A lot of mentally sick after giving birth are sterilized by surgical methods without the consent of them or their families. these legal procedures, including also the impunity in the cases of damages by medical iatrogenic, are defended in the judicial legislation by the services of the health system.

In chile it abortion is prohibited and, also, its rate of maternal mortality, 18 for each 100,000 pregnancies, is inferior to that of Cuba. This comparison indicates the interest of the cubans in the rate of infantil mortality, it is considered by the Organizations of United Nations as an indication of human development. The maternal death or the childs older than one year is of less strategic impact and, by all means, the authorities do not force themselfs in improving to the maximum these programs. Something which compares occures with the importance received by the hope of the population, 77.9 years in these moments, contrary to the non concern in which the list be approached in the indication of quality of life of the elderly.

Even though Cuba possess by comparison a mayor quantity of doctors per capital in the world, close to 70 thousand according to official rates, a significant percentage of offices and services of health which do not function due to the lack of personal, due to the result of massive exportation of professionals and medical recourses, send to the so called "international missions". Actualy about 36 thousand physicians and other technical specialists of health work in 68 countries of latinamerica and the african continent, in detriment to the cities of the national health, which motivates a marked displeasure and of increasing critics of the population.

The reason for such depredation of the medical system is not humanitarian, but political and economic. Keep in mind that the cooperation in the exterior annualy are injected into the government approximately one thousand million dollars in grosse profit. Also, in the receiving nations the soldiers of the army dressed in white help to spread the marxist ideology and that those governments consolidate their perpetual power. Any doubt you can consult the situation in Venezuela, where it is difficult to believe that today Chávez is still president, without the presence of the 20 thousand cuban doctors who offer their services of health to humble people of the mountains and the unreachable zones. The regime of Habana also receives in greatfulness for their "internacionalism" recognizing for the political process and lobbying in the different international sceneries of opposition to the sentence for the repeated violations of the rights and fundamental liberties of the country.

The deluded which sustain the fantasy that Cuba is a medical world power do not fool yourselfs. In the country functions a subsystem of differential health which offers medical services of excellence in instalations well conditioned, with professionals readily capacitated in all types of recourses. The peculiarity is that these exclusive destinations is for the medical foreign attention, members of the government elite and military of high rank. The rest of the population are prohibited the access to these centers of health, like what occures in Cira García Hospital, The Praderas, international Center of Neurological Restoration (CIREN), Center of Investigation of Surgical Medicine (CIMEQ), Koly Clinic, The best floors of the Hospital Almeijeiras, Hospital Frank País, besides others.

in the health circle it is undeniable the involution of Cuba as a balance of these last 50 years. the failed socialeconomic structure of the socialist model mantains sick the society because of its traumatic effects of the sustained stress, and as a consecuence the precarious conditions of the cubans.

The popupulation subsist in the middle of the desperate accumulative of vital necessities without hope of improving, reason which influences in the prevailing of high rates of suicides, violance, alchoholism, drug addiction, tobaco addiction, and pshychiatric deseases. Other fountains of deseases is the critical lack of Nutrition that, in 1991, spread a grave neuropathic epidemic, which reached the 30 thousand contaminated two years later. Also the decrease in the measure of the recent generations which is direct results of the food deficit.

The epidemic assault is favored by the chaotic hygiene conditions and environmental of the country, where the solid garbage deposits and liquid are a part of the public ornaments and increases the vector transmited deseases, also the portable water which is administered in a irregular mode, of bad quality due to the inadequate treatment and frecuent contaminated sewers because of the deterioration of the webs of distribution. Cuba was, in 1981, the first country of the american continent that suffered an epidemic of of hemorrhogic dengue, with more than 11 thousand of those effected, posteriously it was reported other grave epidemics in 1997, 2001 and 2006, even though every year there are epidemic breaks because of cases imported or endemic. Similar present significances of incidences of breaks of hepatites, hemorrhogic conjunctivities, tuberculosis, varicellas, leptospirosis, meningitis, virosis and diarhea deseases.

Who resist to believe that the cuban medicine is not a model to imitate if not all the contrary, have other arguments more solid in the decision to the high commanders of the country. The selected team of physicians which attended the initial stages of Mr. Fidel Castro, under direction of Dr. Zelma, committed the error which worsened the delicate state of health and, without time to lose, they seeked the help of a spanish doctor so that he could take charge of the case. The past vice minister of health, Abelardo Ramírez, was sent to be operated in France when it was dignosed a gastric cancer which later on caused his death. Even the neorosurgeon Domingo, a military of high qualification who worked as chief of docent of CIMEQ, visits every year a clinic in England where he maintains medical treatment. These are not the only characters who opt to sale to the national health, to grasp on to their power but prepare the luggage as soon as it appears the symtoms of a desease.

As a note it should be notified that in the country six doctors are imprisoned to long jail sentences, since march 2003, for defending the fundamental rights of the cubans, they are considered by international amnesty as prisoners of conscience. Other thousands of doctors are in conditions of hostage, without the right to travel freely. In the exterior lives thousands of doctors exiled by the government, who are prohibited to enter national territory.

Translator: Eduardo E. Rodríguez, boricua member of the PULC and collaborator of OCPI in Puerto Rico.