By Senator Bill Frist, M.D.
Jun 08 2015
June 8, 2015 | Forbes
When you think of Cuban exports, you might think of sugar, or perhaps its famously sought-after cigars. But one of the nation’s most profitable exports is actually its own healthcare professionals.
The Cuban government reportedly earns $8 billion a year in revenues from professional services carried out by its doctors and nurses, with some 37,000 Cuban nationals currently working in 77 countries. The socialist regime allows the government to collect a portion of the incomes earned by Cuban workers abroad.
For example, in 2013 Cuba inked a deal with the Brazilian Health Ministry to send 4,000 Cuban doctors to underserved regions of Brazil by the end of the year – worth as much as $270 million a year to the Castro government. By the end of 2014, Brazil’s Mais Medicos program, meaning “More Doctors,” had brought in 14,462 health professionals – 11,429 of which came from Cuba.
Over the past 50 years, Cuba consistently used the export of its doctors as a powerful and far-reaching tool of health diplomacy. The island nation has built good will and improved its global standing with emerging countries around the world during its years of isolation. It sent its first doctors overseas as far back as 1963, and to date has sent physicians to over 100 countries.
In my travels doing medical mission work to underserved regions in over a dozen African nations, the most common nonindigenous health personnel I run across are doctors and nurses from Cuba offering frontline primary and emergency care. They serve and cure, building trust in Cuba’s name globally.
Why is the medical expertise of this impoverished nation in demand? And why is it home to a population whose life expectancies rival those of much richer countries? Researchers have called this phenomenon the Cuban Health Paradox.
On two health-oriented trips to Cuba in the past year, what struck me was a systematically planned and organized primary care delivery system that captured the doctor-patient relationships of my father’s era of medical practice. Cuba treats healthcare as a human right, specifically stipulated in its constitution. Cuban nationals receive care for free, and have a neighborhood primary care physician who often knows them by name and sees them regularly.
The doctors are paid paltry amounts, many having second jobs. But in my conversations with them, they reflect love for their work and a palpable passion about caring for their patients. In turn, the patients trust and respect their conveniently-located and easy-to-reach doctor, go to them early in the course of an illness without financial barrier, and are likely to follow their recommendations.
Through easy accessibility of frontline doctors who can intervene early in a course of illness, Cuba has effectively implemented preventive medicine, something we as Americans are just now trying to incorporate into a new culture of health. Indeed, Cuba boasts some of the highest rates of childhood vaccinations, and its citizens are much more likely to die of cancer or heart disease than the communicable diseases associated with other poor countries. As I previously observed:
The [Cuban] system works well, and it’s easy to see why. An overweight or genetically-vulnerable 33-year-old may have early signs of hypertension and a creeping blood glucose level. In the U.S.—with lack of access to or emphasis on preventative primary care—this patient may not even begin seeing a physician regularly until he starts to feel overly fatigued at 42 or has his first heart attack at 49. At that point, the damage is well underway. He will start multiple blood pressure medications, a medication for diabetes, and may need procedures as well. But catching a pre-hypertensive blood pressure in the patient’s early 30s, initially trying weight loss followed by a single blood pressure agent and titration over the next decade will likely prevent that first heart attack. The patient may still go on to die from heart failure, but it might be at 85 instead of 65 and he may largely avoid many of the medical complications of his disease by catching and intervening early.
As we rapidly move toward normalization of relations with Cuba, we have much to learn from its effective primary care model successfully implemented under severely constrained financial resources. Part of Cuba’s success can be attributed to having the world’s largest number of physicians per capita. Physician office locations are centrally planned, with each physician team responsible for the health of the citizens within a geographic area.
But we must also look at the bigger picture when considering the Cuban Paradox. In addition to investing in accessible primary and family healthcare, the Cuban government has focused on providing access to education, housing, and nutrition—key non-medical or social determinants of health. Cuban citizens may be driving cars from the 1950s and have a meager average monthly wage of $20, but they boast “first world” population health status because of a combination of attention paid to social and environmental factors of health paired with planned, accessible primary care.
We also have the potential for the exchange of ideas and research in the biomedical field, in which the Cuban government has invested heavily. Shortly after President Obama’s administration announced the beginning of normalization of relations with Cuba, news reports of a Cuban-developed lung cancer vaccine were widely circulated. In April, Cuba’s Center for Molecular Immunology signed an agreement with the Roswell Park Cancer Institute in Buffalo, New York to import the cancer vaccine, known as CimaVax, to begin U.S. clinical trials.
Of course there is much we won’t emulate. I, for one, would not want to get seriously ill in Cuba. Cuba’s medical system lacks effective tertiary care, is sorely deficient in specialized care, and has only limited access to important drugs. Rationing of care and years of embargo means shortages of medicines and even aspirin and band aids require a prescription from a doctor. Hospitals can face acute shortages of everything from urinary catheters to the more effective second- and third-line antibiotics. Medical technological advances have either not reached the island nation or are beyond the government’s financial means.
But as the U.S. healthcare system struggles with cost, financial barriers to access, a shortage of primary care physicians, and too little attention paid to prevention, Cuba holds some fundamental lessons for us. Focusing on health outcomes will hopefully encourage a more holistic approach here at home that looks at all determinants of health – not just acute treatments provided in a doctor’s office.