Los Angeles Times
July 9, 2001
By Sarah Lunday,
Special to The Times
HAVANA -- In the office of Dr. Alex Carreras near downtown Havana, water drips
from a patched ceiling, a window is missing glass and a broken machine for
sterilizing instruments lies idle. The phone rings constantly as Carreras
explains that his only nurse is out for the week. Carreras and the nurse care
for 120 families in the neighborhood.
Living and working in the community is essential to understanding patients'
needs, he said. Recently, after a patient said he had stopped smoking,
Carreras was suspicious and went to the patient's house. "I could see the
cigarettes on the table," he said with a shrug.
Carreras keeps track of the community's health with handwritten charts, noting
basic indicators such as who has high cholesterol, who has diabetes and who
has a drinking problem. "You know everything," he says.
While Cuban doctors might not actually know everything about their patients,
they come closer than their counterparts in many areas of the world, including
the United States. Their ability to track patients' histories, ensuring that
children get their immunizations and that older patients stay active in the
community, has made this country a model for primary medical care for other
impoverished countries and even areas of the United States.
The Cuban system involves an extensive network of family doctors scattered
throughout its countryside and cities. Primary care doctors become very
familiar with the neighborhoods they live in and generally have no more than
500 patients. (By comparison, some U.S. doctors might have several times that
number of patients in their care.) If patients need more than basic care, the
doctors refer them to rural and neighborhood hospitals.
To be sure, the system has its drawbacks: frequent shortages of medical
supplies and long waits for complicated procedures that require
hospitalization. Yet basic health care for all of Cuba's 11.2 million
residents is provided, unlike in the United States, where an estimated 40
million Americans lack health insurance.
"Everybody is in the system. They do a lot better in teaching preventive
care than most countries," said Dr. Stephen A. Schendel, chief of plastic
and reconstructive surgery at Stanford University Medical Center. Schendel has
made many trips to Cuba in the last five years to perform reconstructive
plastic surgery on children and to train Cuban physicians in advanced
techniques.
Cuban physicians, such as Carreras, say what the country lacks in up-to-date
technology and journals, it makes up for through its extensive network of
family doctors. The country has 58.2 doctors for every 10,000 people, as
contrasted with 27.9 doctors per 10,000 in the United States, according to the
Pan American Health Organization.
Cuban doctors' closer relationships with their patients also allow them to
diagnose diseases early, decrease smoking and deliver healthier babies,
according to Bob Schwartz, executive director of Disarm Education Fund, a
nonprofit medical assistance program based in New York. The country may be one
of the poorest nations in the world, but its inhabitants report health
indicators that rival those of rich countries, such as the United States. For
example, the average American's life expectancy is 77 years, while in Cuba it
is 76. Cuba reports infant mortality rates of 6.4 deaths per 1,000 births,
compared with a U.S. rate of 7.3 deaths per 1,000 in 1999. Immunization rates
for children older than 1 are roughly equal in the two countries, at about
95%.
Cuba's system is the product of significant investment in national health
reform that Fidel Castro began after taking power in 1959. Today, the Cuban
health system serves as an international model for rural health care. Poor
communities throughout Latin America and Africa have been influenced by Cuba's
health system, according to the Center for Cuban Studies in New York.
The country has sent thousands of physicians abroad to live and work,
providing free medical care in countries including Nicaragua, El Salvador,
Honduras and South Africa.
In the early 1980s, Cuba's health-care system influenced the development of
rural health-care programs for Native Americans in California, said Mario
Gutierrez, who was executive director of the California Rural Health Board for
five years. Under his term, health clinics in rural areas became more like
community centers than outpatient facilities.
The centers established community health representatives who are still a
feature of the programs today. The representatives know every family in the
area near the clinic. They drive people to and from doctors' offices, make
home visits after surgeries and ensure that children receive all
immunizations, said Gutierrez, who is now director of strategic programs at
the California Endowment in Sacramento.
Dr. Debra Johnson, a plastic and reconstructive surgeon in Sacramento, has
visited Cuba three times and says she learns something during every visit.
"It's sort of a duct tape and bailing wire kind of medicine," said
Johnson, who is married to Gutierrez. "The Cubans are the absolute best
at doing something with nothing."
Dr. Henry Vazquez cares for about 480 people in and around the mountain
village of Boquerones. He has no computer or X-ray machine. He sometimes
fashions home remedies from an herb garden when medicines are unavailable.
Once, when no car or truck was available, he rode a village mule to transport
a sick patient to the nearby rural hospital four miles away.
When the 27-year-old family doctor walks through this tiny village of
tin-roofed row homes, mango trees and chickens pecking the dirt, young men
stop to greet him and women wave from their doorways. He fondly pats them on
the back and talks about their past illnesses.
Vazquez can rattle off statistics about this community without hesitation:
There are 45 patients older than 60. Eight patients are younger than 1. About
20 babies are born annually. There are no cases of HIV or AIDS.
The doctor says he likes primary care and believes he is prepared to take care
of any emergency health problems at his small office in the village. However,
in a few years, he may ask the government to move him to a more exciting post.
Maybe even emergency medicine in the city.
"If I choose to move," he said, "I'll feel like I've left my
mark."
Sarah Lunday is a freelance writer in Atlanta who recently traveled to Cuba
as part of the Kaiser Media Fellowship program.