Family Medicine
in Cuba
Lee T. Dresang, MD
Assistant Professor, University of Wisconsin Medical School
Faculty, St. Luke’s Family Practice Residency
Milwaukee, WI
Laurie Brebrick, FNP
Sixteenth Street Community Health Center
Milwaukee, WI
Danielle Murray, MD
Fellow, Meharry Obstetrical Fellowship
Nashville, TN
Ann Shallue, DO
Resident, St. Luke’s Family Practice Residency
Milwaukee, WI
Lisa Sullivan-Vedder, MD
Assistant Professor, University of Wisconsin Medical School
Faculty, St. Luke’s Family Practice Residency
Milwaukee, WI
Corresponding Author:
Lee T. Dresang, MD
3289 S. Illinois Avenue
Milwaukee, WI 53207
Phone: 414-294-0588
Fax: 414-384-5578
Email: ldresang@fammed.wisc.edu
Date of submission: February 22, 2004
Word count (excluding abstract, table and references): 2708
Key words: CUBA, FAMILY PRACTICE, PUBLIC HEALTH,
COMPLEMENTARY THERAPIES
ABSTRACT
Despite a poor economy, Cuba has achieved health outcomes similar to those of the
United States. Family medicine is a foundation of the health system in both countries.
The authors of this paper traveled to Cuba to explore differences between family
medicine in the two countries. In this paper, we analyze differences in the proportion and
distribution of family physicians, their involvement in public health and their use of
complementary medicine. These differences may provide US family physicians with
ideas for change or further research.
INTRODUCTION
In March of 2003, the authors of this paper traveled to Cuba through the Medical
Education Cooperation with Cuba (MEDICC) organization to gain firsthand insight into
the role of family physicians in Cuba. As a family physician, three family practice
residents and a family nurse practitioner, we were interested in comparing and
contrasting family medicine in Cuba and the US.
We chose to focus on Cuba because of the excellent health outcomes which it achieves.
Cuba spends much less on health care than the US but has similar health outcomes. Cuba
spends just 7.4% of its Gross National Product on health care, compared with the 13.6%
spent in the US.1 Cuba’s GNP per capita is one of the lowest in the Western hemisphere
(Table 1). Nonetheless, Cuba, unlike most Latin American countries, has achieved health
outcomes at levels almost equal with the US (Table 1).
Table 1: Comparison of Health Statistics and Gross National Product
Cuba vs. US and other Latin American Countries2
Country
Life Expectancy
at Birth
Maternal
Infant Mortality
Mortality
(per 1,000 live
(per 100,000
births)
live births)
Cuba
76.3
34.1
7.2
US
77.2
7.1
7.2
Haiti
54.6
523.0
80.3
Guatemala
65.3
111.1
49.0
Source: Pan American Health Organization
Year: 2001
Gross
National
Product per
Capita (US$)
11703
31,910
1470
3630
With our trip to Cuba, we saw a unique opportunity to visit a developing country with the
purpose of learning rather than teaching.
METHODS
We traveled legally to Cuba through MEDICC, an organization which administers
medical rotations in Cuba. Information on how to participate in pre-planned MEDICC
electives and how to organize “short course” rotations can be found at www.medicc.org.
We prepared for our trip with a literature search, reading and discussions. In Cuba, we
met with family physicians, nurses, public health officials, medical educators, and
complementary medicine providers as we toured seventeen health care facilities in
Camaguey, Nuevitas and Havana.
RESULTS/DISCUSSION
While we wish to highlight differences between family practice in the US and Cuba, it is
worth briefly summarizing similarities.
Similarities between family medicine in Cuba and the US
The philosophy and practice of family medicine is similar in the US and Cuba. Family
physicians in both countries provide preventive care, continuity of care, diagnosis and
treatment of acute and chronic health conditions, and care for entire families and the
communities where they live.
In both countries, family physicians are responsible for the majority of health care in
rural and other traditionally underserved areas. In Cuba, physicians serve two years in
clinics, often located in rural and other traditionally underserved areas, as part of their
family medicine residency. After their training, family physicians are strategically located
to be accessible to all.
Similarly, family physicians are responsible for most of the care in rural and underserved
areas of the US. The US government defines a Primary Care Health Personnel Shortage
Areas (PCHPSAs) as one with a patient per primary care physician ratio of less than 1 per
3,500. In 1995, 784 of the 3,082 counties in the US were designated as PCHPSAs. Of
the 2298 non-PCHPSAs, 1132 would become PCHPSAs without family physicians. This
contrasts with only 45 of 2298 non-PCHPSAs which would become PCHPSAs without
internists, 11 without pediatricians and 9 without obstetricians.4
Selected differences between family medicine in Cuba and the US
While similarities abound between family medicine in Cuba and the US, three striking
differences are the proportion and distribution of family physicians, their involvement in
public health and their use of complementary medicine.
The proportion and distribution of family physicians
Whereas Cuba has the highest family physician to population ratio in Latin America5 and
family physicians are evenly distributed around the country, the US has a shortage of
family physicians in many areas and is currently dealing with a decline in residency
applicants.
Cuba’s health care system is family practice dominated; in contrast, the US health system
is specialist dominated. In Cuba, every physician must complete a three-year family
practice residency after their six years of medical school. Only thirty percent specialize
further.6 In the United States, only about one third of physicians are primary care
physicians – family practice, internal medicine and pediatric physicians.7 Cuba has a
family physician per patient ratio of approximately 1:600 or about 1 per 150 families.6 In
the US, the average family physician per population ratio is approximately 1:3200.8 Two
studies suggest that the ideal ratio is 1:1500.9,10 The growth of managed care, which
emphasizes the role of the generalist, has led to recommendations that “50% of all US
physicians and residency positions should be in the primary care disciplines.” 7
Despite recommendations for more family physicians in the US, applications to family
practice residencies have been dropping in recent years. The number of family practice
residency slots filled in the match has dropped steadily from a maximum of 2,905 in 1997
to 2,239 in 2003.11 This has been attributed to: “student perceptions of the demands,
rewards, and prestige of the specialty; market changes; lifestyle priorities; and the
influence of faculty and resident role models.”11
Cuba differs from the US not only in the proportion, but also in the distribution of family
physicians. The US is the only developed country in the world without a national health
system. The lack of a centrally organized health system is one reason for a
maldistribution of health services, with shortages in some areas and duplication of
services in other areas. Cuba, in contrast, has a national health system with a clinic
(consultorio) (Figures 1 and 2) in each community and specialty clinics (policlinicos),
hospitals and institutions strategically located for referrals.
In Cuba, the location of consultorios -- clinics with adjoining housing units for a family
physician and a nurse – is centrally planned to achieve an even population-based
distribution. Each family physician and nurse team is responsible for approximately 600
individuals or 150 families in a designated geographic area surrounding their
consultorio.12 Family physicians typically spend half of their day in their consultorio and
the other half making home visits. Notably, family physicians often have a half-day per
week to join their patients visiting specialists in policlinicos. This provides continuity for
patients, builds collegial relationships between family physicians and specialists, and
offers education for all parties involved.
The system of consultorios evolved in response to challenges similar to those faced in the
US today: an emphasis on curative rather than preventive services, a lack of collaboration
between the levels of health care resulting in fragmented care, patient discontent related
to the inconsistent quality of care, and an excessive use of emergency rooms.13 When
Cuban physicians finish their family medicine residency, they choose from a list of
clinics with openings. This system helps maintain an even distribution of family
physicians.
In contrast, the US has evident health shortages, especially in rural areas. The greatest
shortage of health care providers is in rural communities of fewer than 10,000 people that
are not adjacent to metropolitan areas.14 More than 20 million people in the US live in
non-metropolitan areas with a shortage of primary care physicians. People living in nonmetropolitan areas are approximately four times more likely to live in an HPSA than
people in metropolitan areas.15
The US already has programs such as the National Health Service Corps that recruit
family physicians to HPSAs. However, the US could improve the distribution of family
physicians by training more family physicians. According to the Counsel on Graduate
Medical Education (CGME), “specialty choice is the most powerful predictor of rural
practice location; family physicians are much more likely than any other specialty to
settle in rural areas and comprise almost half of the entire physician population in rural
areas. The relatively small number of family physicians educated has contributed to the
shortage of rural physicians.”14
The abundant supply of family physicians in Cuba allows for family physicians to take on
roles outside of the consultorios within Cuba and in developing countries throughout the
world. In 1999, in addition to the 17,335 family physicians working in consultorios, 1454
worked in schools, 799 in daycares, 1347 in workplaces, 2124 in management and 670 in
teaching.12 In addition, Cuba is able to send as many as 1500 family physicians to work
in other countries.16 Funding for family physicians in Cuba is from the government;
funding abroad is by host countries in exchange for their services. Cuba demonstrates that
there is little risk of training too many family physicians. In addition to working in
current HPSAs, family physicians in the US can play increasing roles in daycare,
workplaces and abroad.
Epidemiologic surveillance by family physicians
In Cuba, family physicians “regularly assess the health situation of their communities in
epidemiological terms, using this information to help them ferret out health problems and
the individuals that might be at risk.”12 Epidemiologists meet with family physicians on a
regular basis to monitor for trends and aberrations (Figure 3). “Data concerning acute and
chronic illnesses pass sequentially from family physicians to the municipal, provincial
and national levels of the Ministry of Public Health.”16 Computerized surveillance of
chronic problems like diabetes as well as acute illnesses like influenza has been
implemented at all provincial levels and is being extended to municipalities and rural
health centers.16 Using uniform forms and collecting data on a national level give power
to epidemiological studies.
Coordinated efforts of Cuban family physicians and public health officials have impacted
not only individual practices, but also the country as a whole. For example, a 1981
outbreak of dengue fever which resulted in 344,203 reported cases and 158 deaths, was
quickly identified and the disease was eliminated within four months through spraying of
insecticide and an intense public education campaign to eliminate mosquito breeding
grounds.17 Similarly, an epidemic of peripheral and optic neuropathy which resulted in
50,862 reported cases between 1991 and 1994 was identified, researched and eliminated
through vitamin distribution.17
Family physicians in the US also assess the needs of their patients and communities and
make individual and larger scale interventions, but the infrastructure for doing so differs
from the centrally organized Cuban system. Community-oriented primary care (COPC) is
a “systematic approach to health care based on principles derived from epidemiology,
primary care, preventive medicine, and health promotion that has been shown to have
positive health benefits for communities in the United States and worldwide.”18 In the
United States, “because of lack of predictable reimbursement for COPC services and
difficulties encountered incorporating COPC in medical and residency curricula,
widespread application of COPC has not occurred.”18 Care Management is promoted
within many health systems as a method for monitoring and improving how certain
health problems are addressed, but only within that proprietary system. The lack of a
national system means that certain organizations actively participate in health
surveillance while others are less active.
Unlike Cuba, the US does not have an all-encompassing national databank for family
physicians to access. A few national databanks exist in the US. For example, the Center
for Disease Control (CDC) monitors certain health conditions, such as STDs. The CDC
and local health departments are available for voluntary reporting of public health
concerns. However, often data is collected by individual health systems or researchers
and is not available at a national level or the method of data collection is not compatible
with the methods used by others who are researching the same problem. Having a
national databank would be helpful for analyzing regional practice differences such as
variations in use of epidurals in labor or opiod use for chronic pain. Regional differences
in infectious disease rates detected through a national databank would allow family
physicians to adjust their preventive and curative strategies accordingly.
Critics of a national databank raise concerns of privacy protection and misuse of patient
information. Health data would need to be protected as it is currently protected within
individual health systems.
Epidemiologic surveillance strategies employed in Cuba “may prove instructive for
countries, including the US, that lack efficient data gathering and reporting systems for
preventive services and efforts in community-oriented primary care.”16
Recommendations from the Association of Family Practice Residency Directors and
others are available for family medicine educators wanting to teach COPC to medical
students and family practice residents.18 In addition, the US has the technology to
standardize data collection at a national level. This would prove useful for research and
timely given current concerns of bioterrorism.19
Complementary and alternative medicine (CAM) by family physicians
Family medicine has achieved “integrative medicine” to a greater extent in Cuba than in
the US. “Complementary medicine” is non-allopathic medicine used alongside
conventional allopathic medicine. “Alternative medicine” is non-allopathic medicine
used instead of conventional medicine. “‘Integrative medicine’ results from the
thoughtful incorporation of concepts, values and practices from alternative,
complementary and conventional medicines.”20
In Cuba, family physicians learn the science of CAM in medical school. Students spend
two hundred hours in the first two years of medical school on CAM rotations (Figure 4).
In addition, it is integrated into physiology, anatomy and clinical courses. Examples of
CAM taught to Cuban physicians include acupuncture, herbal medicine, trigger point
injections (Figure 5), massage, heat therapy, TENS, magnetic therapy, pyramid therapy,
moxycombustion, fangotherapy (mud), cupping, laser/photo therapy, floral/essence
therapy, homeopathy, yoga, meditation exercise training and music and art therapy. Most
family physicians in Cuba practice at least herbal medicine, also known as “green
medicine.” A national formulary and educational materials on green medicine are
distributed to all practitioners by the Cuban Ministry of Public Health.16 One example of
herbal medicine used in the western part of Cuba, the bark of sassafras tree macerated in
alcohol is applied topically to treat arthralgias.21 A family physician we met practiced his
own acupuncture. For therapies which they do not perform themselves, family physicians
refer to natural medicine clinics.
In contrast, in the United States, CAM is “not taught extensively at US medical schools
or generally provided at US hospitals.”22 In a survey of family medicine department
chairs and residency directors, 29 percent indicated they are currently teaching, 6 percent
starting to teach, and 6 percent considering teaching some form of CAM. Seventy-two
percent of this teaching is elective.23 An increasing number of US medical schools are
teaching CAM. From 1996 to 2000, the number of medical schools reporting CAM as
part of a required course increased from 46 to 82 of the 125 US medical scools.24
Although most family physicians in the US are not being trained in CAM, CAM is
widely used by those living in the US. In 1997, the total out-of-pocket expenditures for
CAM in the US was conservatively estimated to be $27.0 billion.25 CAM use is more
common in recent years: “approximately 3 of every 10 respondents in the pre-baby boom
cohort, 5 of 10 in the baby boom cohort, and 7 of 10 in the post-baby boom cohort
reported using some type of CAM therapy by age 33.”26 In the US, “patients say that
physicians whom they have ordinarily found to be caring, thoughtful and understanding
become angry, defensive and dismissive when the possibility of using alternative
medicine is mentioned.”27 Perhaps because of this, less than 40 percent of patients
discuss their use of CAM with their primary care physician.25
The extensive use of CAM by family physicians in Cuba may be due, in part, to the
current embargo and paucity of allopathic medicines. However, even in the US with its
abundance of allopathic medicines, a need for greater familiarity with CAM by family
physicians in the US may be indicated if for no other reason than to integrate what their
patients are already doing outside the health care system into their current traditional
care. A step in this direction, the Society for the Teachers of Family Medicine (STFM)
has developed curriculum guidelines for “programs wishing to include formal training in
complementary and alternative medicine in residency training.”28 Although more studies
will be useful, there no longer is a need to wait for better studies before teaching CAM:
the Cochrane database already includes over 5,000 randomized, controlled trails
involving CAM.24
CONCLUSIONS
Despite political differences, Cuba and the United States share a passion for baseball, the
use of the US dollar as an official national currency, and family medicine as a foundation
of their health system. Cuba, however, trains every physician as a family physicians with
only thirty percent specializing further, distributes them more evenly, integrates them
more into the public health system and better trains and supports their use of
complementary medicine. The excellent health outcomes which Cuba achieves with so
few resources attest to the effectiveness of their health care model. Family physicians in
the US may want to draw from the experience of family physicians in Cuba as family
medicine enters the 21st century.
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Figure 1: Consultorio
Figure 2: Consultorio
Figure 3: Epidemiologic data on wall of consultorio
Figure 4: Instruments used for complementary medicine techniques at
Carlos Finley Institute in Camaguey
Figure 5: Trigger point injection