Castrocare in Crisis

Cuba is a Third World country that aspires to First World medicine and health. Its health-care system is not only a national public good but also a vital export commodity. Under the Castro brothers' rule, Cubans' average life expectancy has increased from 58 years (in 1950) to 77 years (in 2009), giving Cuba the world's 55th-highest life expectancy ranking, only six places behind the United States. According to the World Health Organization (WHO), Cuba has the second-lowest child mortality rate in the Americas (the United States places third) and the lowest per capita HIV/AIDS prevalence. Fifty years ago, the major causes of disease and death in Cuba were tropical and mosquito-borne microbes. Today, Cuba's major health challenges mirror those of the United States: cancer, cardiovascular disease, obesity, diabetes, and other chronic ailments related to aging, tobacco use, and excessive fat consumption.

By any measure, these achievements are laudable. But they have come at tremendous financial and
social cost. The Cuban government's 2008 budget of $46.2 billion allotted $7.2 billion (about 16 percent) to direct health-care spending. Only Cuba's expenditures for education exceeded those for health, and Cuba's health costs are soaring as its aging population requires increasingly expensive chronic care.

Cuba's economic situation has been dire since 1989, when the country lost its Soviet benefactors and its economy experienced a 35 percent contraction. Today, Cuba's major industries -- tourism, nickel mining, tobacco and rum production, and health care -- are fragile. Cubans blame the long-standing U.S. trade embargo for some of these strains and are wildly optimistic about the transformations that will come once the embargo is lifted.

Overlooked in these dreamy discussions of lifestyle improvements, however, is that Cuba's health-care industry will likely be radically affected by any serious easing in trade and travel restrictions between the United States and Cuba. If policymakers on both sides of the Florida Straits do not take great care, the tiny Caribbean nation could swiftly be robbed of its greatest triumph. First, its public health network could be devastated by an exodus of thousands of well-trained Cuban physicians and nurses. Second, for-profit U.S. companies could transform the remaining health-care system into a prime destination for medical tourism from abroad. The very strategies that the Cuban government has employed to develop its system into a major success story have rendered it ripe for the plucking by the U.S. medical industry and by foreigners eager for affordable, elective surgeries in a sunny climate. In short, although the U.S. embargo strains Cuba's health-care system and its overall economy, it may be the better of two bad options.

MEDICAL HELP WANTED

After half a century of socialist rule, there remain clearly distinct social classes in Cuba. The most obvious difference is between those households that regularly receive money from relatives in the United States and those that have no outside source of hard currency. A mere $20 a month from a cousin in Miami can lift a family out of poverty and provide it with a tolerable lifestyle. Elegant living is found in Havana's Miramar area, where architectural masterpieces of the nineteenth and early twentieth centuries have been restored and painted in pastels and are inhabited by diplomats or Cubans of mysteriously ample means.

When they take ill (or need liposuction), the more privileged residents of Miramar go to Havana's Clínica Central Cira García, a well-appointed clinic that is run by the government-owned tourism conglomerate the Cubanacán Group and that primarily serves foreigners. (The doctors, technicians, and nurses who staff the Cubanacán Group's health facilities all work for the Cuban Ministry of Public Health. Cubanacán's medical operations include a retinal surgery center, a dermatology clinic that specializes in skin treatments with human placental preparations, and abortion services.) Aside from the posters of Che Guevara and Fidel Castro, Cira García feels like a top European or North American clinic, as the thousands of patients who arrive every year from more than 70 nations could attest. Private suites and a variety of elective procedures are provided at modest prices. Sixty full-time physicians, 40 specialist adjuncts from neighboring public health hospitals, and many nurses work at Cira García. All of the clinic's equipment appears to work, the pharmaceutical supplies are plentiful, the daily patient loads are small, and the doctors feel as though they have the tools and the time to do what they have long trained to do. On average, the physicians at Cira García have 20 years of experience, including at least two years in another developing country.

The clinic's Canadian clients favor family package deals that allow children to play on local beaches while their parents get a new knee ($6,850) or a titanium implant to correct a herniated vertebral disk ($4,863). Spaniards and Italians tend to visit Cira García for thigh liposuctions ($1,090) and face lifts ($2,540). Some Latin Americans from countries with strict antiabortion laws travel to Cira García for the procedure ($600). The clinic is so popular that its administrators are assessing how to find space in the crowded neighborhood to build a new wing with 50 more beds.

But a lot may change if the United States alters its policies toward Cuba. In 2009, a group of 30 physicians from Florida toured Cira García and concluded that once the U.S. embargo is lifted, the facility will be overwhelmed by its foreign patients. It takes little imagination to envision chains of private clinics, located near five-star hotels and beach resorts, catering to the elective needs of North Americans and Europeans. Such a trend might bode well for Canadians seeking to avoid queues in Ottawa for hip replacements or for U.S. health insurance companies looking to cut costs on cataract surgery and pacemakers. But providing health care to wealthy foreigners would drain physicians, technicians, and nurses from Cuba's public system.

And any such brain drain within Cuba might be dwarfed by a brain drain out into the rest of the world, as Cuban doctors and nurses leave the country to seek incomes that cannot be matched at home. Countries facing gross deficits in skilled medical talent are already scrambling to lure doctors, nurses, lab technicians, dentists, pharmacists, and health administrators from other nations. In 2006, the WHO estimated that the global deficit of medical professionals was roughly 4.3 million, and the figure can only have grown since then. As the world's population ages and average life expectancies rise from the United States to China, millions more patients will need complex, labor-intensive medical attention. And in countries with falling life expectancies and high rates of HIV/AIDS, donor resources aimed at combating the disease often have the unintended consequence of further straining meager supplies of human medical resources by drawing talent away from less well-funded areas of medicine, such as basic children's health care.

According to the American College of Physicians, the United States currently has approximately one doctor for every 2,500 patients and a critical shortage of nearly 17,000 doctors. The American Medical Association estimates that there is an especially grave deficit of primary-care physicians, with only 304,000 licensed -- about 30,000 fewer than needed. And the recently enacted federal health-care reform law will put more than 30 million more Americans on insurance or public rolls, thereby dramatically increasing the need for physicians.

Primary-care physicians are the worst-paid doctors in the United States. Their average salaries have grown by less than four percent per year since 2000, compared with roughly ten percent per year for the salaries of surgeons and specialists, according to the American College of Physicians. Last year, primary-care doctors in the United States earned about $173,000 on average, compared with $344,000 for anesthesiologists and $481,000 for orthopedic surgeons. With most U.S. doctors incurring debts of $200,000 to complete their schooling, there is little hope that the acute primary-care deficit can be filled anytime soon by talent trained in the United States. Already, U.S. and Canadian medical institutions are trying to fill their human-resource gaps through recruitment from Africa, Asia, eastern Europe, and Latin America.

REVOLUTIONARY MEDICINE

The two keys to Cuba's medical and public health achievements are training provided by the
state and a community-based approach that requires physicians to live in the neighborhoods they serve and be on call 24 hours a day. In the wake of the 1959 Cuban Revolution, more than one-third of Cuba's doctors fled, mostly to the United States, leaving the country with just 6,300 physicians and a doctor-patient ratio of 9.2 per 10,000, according to the Cuban Ministry of Public Health. In response, Fidel Castro declared public health and doctor training to be paramount tasks for the new socialist state.

By the early 1980s, Cuba led the socialist world -- including its patron, the Soviet Union -- in all health indicators. Between 1959 and 1989, Cuba's doctor-patient ratio more than tripled, soaring to 33 per 10,000, and health-care expenditures rose by 162 percent. Cuba today has the highest doctor-patient ratio in the entire world, with 59 physicians per 10,000 people -- more than twice the ratio of the United States. Cuba is the world's only poor country that can rightly say that basic health is no longer an existential problem for its people. Its achievement in this respect is unparalleled.

Cuba now boasts more than 73,000 practicing doctors (half of whom work in primary care), 107,761 nurses, and a total health-care work force of 566,365, according to government figures. About 12 percent of Cuba's adult population is employed by the state in the health-care sector. Because of economic exigencies that have limited Cuba's access to advanced technology for diagnosing and curing ailments, the Cuban health system has focused -- successfully -- on prevention. Between 1959 and 2000, Cuba reduced its infant mortality by 90 percent, and the number of mothers who died from pregnancy-related complications dropped from 125 per 100,000 live births to 55 per 100,000.

Now, with its rapidly aging population, Cuba faces different challenges. In 1959, about half of Cuba's population was under 40 years of age; today, less than one-quarter is that young, and Cuba is the second-oldest country in the Americas. The government estimates that by 2018, one in every five Cubans will be over 60 years old. Handling this situation will be difficult for Cuba, since shifting resources from the prevention of dysentery and malaria, for example, to the treatment of diabetes and age-related cardiovascular disease is proving costly in every country, rich and poor alike.

Cuba faces the additional challenge of trying to make that transformation even as its economy has not yet fully recovered from the contraction it suffered after the Soviet Union's demise. The recent global economic crisis has further dampened Cuba's trade and tourism, forcing the Cuban government to cut its forecast of 2009 GDP growth from six percent to 1.7 percent. The country's trade deficit soared by 65 percent in 2008, with imports totaling $14.2 billion and exports just $3.7 billion.

Today, more than 80 percent of Cuba's food is imported, largely due to gross inefficiencies in the agricultural sector. About 75 percent of Cuba's arable land lies fallow, farm production fell by 7.3 percent in 2009, and meat production dropped 14 percent. And although the government has tried in recent years to boost agricultural productivity by giving 100,000 Cubans new rights to farm state land, output remains low.

In a second effort to increase agricultural productivity, the regime now allows farmers to sell some meat and produce in urban markets through third-party dealers. Goods sold in this so-called flea-market economy go for high prices relative to average earnings. And transactions are executed in Cuban convertible pesos (also called convertible units of currency, or CUC), which are pegged to the U.S. dollar. But most Cubans have few CUC: they are paid in Cuban pesos, which have no international value and are traded domestically at a rate of 25 to one against the CUC. CUC-bearing Cubans are often connected to an elaborate network of relatives overseas, particularly in Florida.

Cubans without foreign connections and access to remittances barely survive on an old Soviet-style food-rationing system that provides each household with coupons redeemable for basic foods and sundries. Worse, the government is now scaling back elements of its rationing programs, limiting the range of staples and cleaning products that it subsidizes. President Raúl Castro, who realizes that the Cuban economy is unsustainable in its current form, favors eliminating other government programs, including some that provide make-work jobs -- in which Cubans are paid for unproductive labor to provide them with some wages and to keep the unemployment figures low.

Officially, unemployment in 2008 hovered at around three percent. But the actual unemployment rate has reportedly been as high as 25 percent in recent years. (At the peak of the hardship caused by the collapse of the Soviet Union, in 1993, unemployment was at 35 percent, according to the UN Economic Commission for Latin America and the Caribbean.) "I'm always surprised by how many Cubans don't work but receive salaries," a top United Nations official told me in Havana in November 2009. "It is a right to have a post, so everybody has one. Maybe they work every other day, maybe not at all. It costs a lot to the country." But even for those with jobs, their salaries rarely cover their food costs. Cubans therefore hustle in the flea-market economy, which "isn't illegal; it's a-legal," one foreign resident explained.

These changes in employment, the affordability of food, and agricultural productivity have had two profound implications for the health of Cubans. First, although Cubans' average caloric intake is very high, the nutritional value of their diets is very low. According to one recent Cuban government survey, Cubans consume 3,250 calories a day on average, most of it in the form of starch and fatty pork. Obesity and diabetes are the fastest-growing causes of patient visits to government clinics and hospitals. And UNICEF has found that vitamin and mineral deficiencies, which stunt growth and contribute to learning deficiencies, are widespread among Cuban children.

The second profound effect that changes in basic living conditions in Cuba have had on health
relates to the medical profession. Like all Cubans, health-care professionals are eager to obtain CUC, but they are paid in the worthless domestic peso, receiving an average equivalent of $25 per month. These low wages give doctors a strong incentive to participate in international missions that earn them convertible currency. Of the 73,000 physicians licensed to practice in Cuba, 37,266 are now working overseas, under special bilateral agreements between the Cuban government and the governments of 77 other countries. Since 1963, Cuba has sent 126,321 health-care workers to 103 countries, according to the Cuban Ministry of Public Health. This overseas deployment of health-care workers benefits the Cuban state, as two-thirds of the doctors' overseas income goes to the state and only one-third goes to the individual.

The Castro government's largest and most extensive bilateral effort is with Hugo Chávez's leftist government in Venezuela. Under an "oil-for-doctors" program initiated in 2000, Venezuela provides 100,000 barrels of petroleum products to Cuba per day in exchange for three things: 31,000 Cuban doctors and dentists, training by Cuban doctors for 40,000 Venezuelan physicians, and Operation Miracle, an initiative funded by Venezuela under which Cuban doctors provide eye surgery, in Cuba, to thousands of poor Latin Americans annually.

The Cuban government benefits politically from this medical diplomacy, including by demonstrating the wisdom of its approach to public health. It is widely believed that health-care workers have become a top, if not the top, trade commodity for Cuba. Based on oil prices in February 2010, the Venezuelan oil exchange alone would have had a value of $7.5 million per day, or nearly $3 billion per year. Whatever the exact benefits of these exchanges, however, Cuba's medical diplomacy is taking a toll on the homeland.

MOUNTING STRAINS

For years, Cuban hospital patients have needed to provide their own syringes, bed sheets, and towels. Some say they fear getting infections while visiting clinics because of shortages of soap, disinfectants, and sterile equipment. A preventable form of cancer, cervical carcinoma, now ranks as the fourth leading cause of death for Cuban women. In most of the world, cervical cancer is on the decline thanks to annual gynecological screenings (with the Pap test) and the use of the human papillomavirus vaccine. In Cuba, however, the number of routine Pap tests performed has fallen by more than 30 percent and the number of diagnosed cervical cancer cases has doubled since 1985, according to the country's 2008 Annual Health Statistics report. Cervical cancer is the number one malignancy for Cuban women aged 15-44. Some women told me last November that they no longer undergo routine gynecological exams and prevent their young daughters from doing so because they fear infection from unhygienic equipment and practices.

Another problem in Cuba's health picture is maternal mortality. Because the country's birthrate is low and its population is aging, the state has placed great emphasis on infant care and survival. But this effort has meant paying insufficient attention to postpartum maternal care. "If a child coughs, they go to the doctor," one senior doctor at the University of Havana told me, yet mothers often are forgotten after childbirth. Most deaths occur during delivery or within the next 48 hours and are caused by uterine hemorrhage or postpartum sepsis. Cuba also has unusually high rates of death among women with histories of induced abortion, a very common procedure there.

Cuba's doctors are increasingly strained. Physicians return from years abroad because they must, both contractually and to avoid repercussions for their relatives in Cuba. They then must accept whatever assignments the government gives them, including sometimes years of service in a remote village, a Havana slum, or a sparsely populated tobacco-growing area. Many doctors and nurses leave the health-care system altogether, taking jobs as taxi drivers or in hotels, where they can earn CUCs. In February 2010, seven Cuban doctors sued the Cuban and Venezuelan governments, charging that the mandatory service they had performed in Venezuela in exchange for oil shipments to the Cuban government constituted "modern slavery" and "conditions of servilism for debt." Large numbers of defections among doctors, meanwhile, have caused the Cuban regime to cut back on physician placements to some countries, such as South Africa.

EXODUS FEARS

According to Steven Ullmann of the University of Miami's Cuba Transition Project, if Washington lifts its embargo, Cuba can expect a mass exodus of health-care workers and then the creation of a domestic health system with two tiers, one private and one public. The system's lower, public tier would be at risk of complete collapse. Ullmann therefore suggests "fostering this [public] system through partnerships and enhanced compensation of personnel." He also argues that officials in both governments should "limit out-migration of scientific brainpower from the country." Properly handled, the transition could leave Cuba with a mixed health-care economy -- part public, part locally owned and private, and part outsourced and private -- that could compensate Cuban physicians, nurses, and other health-care workers enough to keep them in the country and working at least part time in the public sector.

The only U.S. policy currently in place, however, encourages Cuban physicians to immigrate to the United States. In 2006, the U.S. Department of Homeland Security created a special parole program under which health-care workers who defect from Cuba are granted legal residence in the United States while they prepare for U.S. medical licensing examinations. An estimated 2,000 physicians have taken advantage of the program. Although few have managed to gain accreditation as U.S. doctors, largely due to their poor English-language skills and the stark differences between Cuban and U.S. medical training, many now work as nurses in Florida hospitals.

The Castro government, meanwhile, is in a seemingly untenable position. The two greatest
achievements of the Cuban Revolution -- 100 percent literacy and quality universal health care -- depend on huge streams of government spending. If Washington does eventually start to normalize relations, plugging just a few holes in the embargo wall would require vast additional spending by the Cuban government. The government would have to pay higher salaries to teachers, doctors, nurses, and technicians; strengthen the country's deteriorating infrastructure; and improve working conditions for common workers. To bolster its health-care infrastructure and create incentives for Cuban doctors to stay in the system, Cuba will have to find external support from donors, such as the United Nations and the U.S. Agency for International Development. But few
sources will support Havana with funding as long as the regime restricts the travel of its citizens.

In the long run, Cuba will need to develop a taxable economic base to generate government revenues -- which would mean inviting foreign investment and generating serious employment opportunities. The onus is on the Castro government to demonstrate how the regime could adapt to the easing or lifting of the U.S. embargo. Certainly, Cuban leaders already know that their health triumphs would be at risk.

The United States, too, has tough responsibilities. How the U.S. government handles its side of the post-embargo transition will have profound ramifications for the people of Cuba. The United States could allow the marketplace to dictate events, resulting in thousands of talented professionals leaving Cuba and dozens of U.S. companies building a vast offshore for-profit empire of medical centers along Cuba's beaches. But it could and should temper the market's forces by enacting regulations and creating incentives that would bring a rational balance to the situation.

For clues about what might constitute a reasonable approach that could benefit all parties,
including the U.S. medical industry, Washington should study the 2003 Commonwealth Code of Practice for the International Recruitment of Health Workers. The health ministers of the Commonwealth of Nations forged this agreement after the revelation that the United Kingdom's National Health Service had hired third-party recruiters to lure to the country hundreds of
doctors and nurses from poor African, Asian, and Caribbean countries of the Commonwealth, including those ravaged by HIV/AIDS and tuberculosis. In some cases, the recruiters managed to persuade as many as 300 health-care workers to leave every day. Although the agreement is imperfect, it has reduced abuses and compensated those countries whose personnel were poached.

Cuba's five decades of public achievement in the health-care sector have resulted in a unique
cradle-to-grave community-based approach to preventing illness, disease, and death. No other socialist society has ever equaled Cuba in improving the health of its people. Moreover, Cuba has exported health care to poor nations the world over. In its purest form, Cuba offers an inspiring, standard-setting vision of government responsibility for the health of its people. It would be a shame if the normalization of relations between the United States and Cuba killed that vision.