Training the 5-Star Doctor: Medical Education in Cuba

Richard Quint, MD, MPHHealth Sciences Clinical Professor (Emeritus), UCSF

Medical Education in Cooperation with Cuba (MEDICC)

Brief Chronology

• 1959: Bautista overthrown• 1960: Land reform and health

system changes • 1961: Literacy campaign; Playa

Giron invasion (Bay of Pigs); U.S. initiates trade embargo

• 1989: Soviet bloc dissolves• 1989-1995: The “special period”;

Tightening of the embargo• 2000: The Elian Gonzalez affair• 2005: Travel restrictions tightened• 2009: What will Pres. Obama do?

Health in Cuba Pre-1959

• Infant mortality > 50/1000 live births• Maternal mortality 125/100,000• Life expectancy (1960): 65.1 years• Private medicine: urban centers• Poor nutrition• Clean water available to 35% of population

Gilpin, 1991

Health Care After 1959: Operational Principles

• People’s right and a responsibility of the state

• Integration of preventative and curative services

• Universal: accessible and free• Coordination of health care,

social services, and socioeconomic development

• Popular participation is fundamental

Ministry of Public Health (MINSAP)

Conceptual Model of the Influences on Health in Cuba

Non-Medical Determinants Education Housing Sanitation Clean air Nutrition Employment

Health Service Determinants Accessibility Universality Comprehensive Quality Horizontal integration Focus on primary care Health promotion focus

Social Mediators Social cohesion Income disparities

HEALTHOUTCOMES

J. Public Health Policy, 2004

Basic Health Expenditures (2008)

Country % GDP Per Capita ($US)

Canada 9.6 3,500

Cuba 7.5 322

Mexico 6.1 379

USA 15.6 >7,000

WHO, 2008

Life Expectancy

1970 2000 2006

Canada 77 79 81

Cuba 74 78 78

Mexico 70 73 74

USA 75 77 78

WHO, 2008

Cuban Child Mortality Rates*

Year Neonatal Infant 1-4 years

1974 ------ 38.7 1.31980 11.0 19.6 1.01990 4.6 10.7 0.7 1994 4.0 9.9 0.61998 2.8 7.1 0.52006 2.1 5.0 0.4

*= per thousandMINSAP, 2008

Infant Mortality Comparisons

1990 2000 2006

Canada 7 5 5

Cuba 11 6 5.8

Mexico 42 32 29

USA 10 7 7

WHO, 2008

Immunization Levels (2006)

Percent immunizedCountry BCG DPT3 Pol3 Meas HepB3 HiB3

Brazil 99 99 99 99 97 99

Cuba 99 99 99 96 89 97

Haiti 75 53 52 58 NA NA

Mexico 98 98 98 96 98 98

USA --- 96 92 93 92 94

UNICEF, 2008

Maternal Mortality (2005)

Canada 7Cuba 30.2 (2007)Mexico 60USA 11

WHO, 2008; MINSAP, 2008

HIV Prevalence (>15 y.o./100,000)

2005

Canada 222

Cuba 52

Mexico 244

USA 508

WHO, 2008

Developing the Infrastructure: 1960-1969

• Price reductions, nationalization of private facilities, hospital and clinic construction, increase and improve water supply

• Rural medical service• Polyclinics: preventative and comprehensive

services• Professional training: the Soviet model• Community education: the CDR and FMC

Gilpin, 1991

Health Care in Cuba: 1970-1979

• Dissatisfaction with hospital-based training

• 1974: Medicine in the community, a promotion of health maintenance and improvement concepts

• Polyclinics as teaching sites

• Hospital construction: general and specialty centers

• Production of medicines and vaccines

Gilpin, 1991

Toward Comprehensive Care: The Family Medicine Program

1980-1989

• Primary care emphasis

• New curriculum development• Community-based primary care team: MD and RN• Continuing medical education for older MDs

• Secondary and tertiary care development

• Expansion of number of medical schools: 25 in 2009

Gilpin, 1991

A New Kind of Family Doctor

• RN-MD team in 95% of neighborhoods

• 120-150 families per locale

• Clustered around polyclinics

• Postings in factories, schools, day care centers, senior homes

MEDICC Review Vol 10 No 4, 2008

The Family Physician as a 5-Star Doctor

Caregiver: physical, mental, social

Decision-maker Communicator Manager Community leader

Boelen, M, WHO

Educating the New Family Doctor:1990- present

• Problem identification at local levels• Introduction of problem-based learning• Earlier introduction to clinical skills training• Teaching aimed at service learning• Family medicine departments in all medical schools• Practical exams

Morales, IR et. al., MEDICC Review, Vol 10, No 4, 2008

Educating the New Family M.D.: Advantages

• Training in multidisciplinary teams

• Integration of clinical medicine with population health

• Earlier contact with patients

• More Family M.D.s trained (44% of total)

MEDICC Review Vol 10 No 4, 2008

Educating the New Family M.D.: Shortcomings

• Generalist approach taught largely by specialists

• Hospital-based clinical training predominated

• Bias against family medicine skills and capabilities

MEDICC Review, Vol 10, No 4, 2008

Scaling Up for the 21st Century:Cuba and the Developing World

• 2004-2005: 75% of medical training focused in polyclinics

• 20,000-30,000 M.D.’s needed ASAP for home and abroad

• Educating foreign medical students (ELAM)• 2008: introduction of new curriculum –

“morphophysiology”

MEDICC Review, Vol 10, No 4, 2008

Human Resource Development in Health:Foreign Graduates From Cuban Medical Schools1966-2003

Human Resource Development in Health:Foreign Graduates From Cuban Medical Schools1966-2003

Region Countries Medicine Dentistry Nursing Total

Americas 35 1316 120 0 1436

Africa/Mideast

44 1813 196 4 2013

Asia ? 133 16 0 149

Europe ? 50 16 0 66

TOTAL 3312 348 4 3664

Source: Vice Ministry for Medical Education, Ministry of Public Health, Havana

Latin American Medical School: Physicians for Developing CountriesLatin American Medical School: Physicians for Developing Countries

• 26 countries

• 9,679 students

• 101 ethnic groups

• 51% women

Different from Previous Scholarships: Aiming for SustainabilityDifferent from Previous Scholarships: Aiming for Sustainability

• Student selection: poor, indigenous, marginalized

• Training geared to country of origin

• Looking for commitment to underserved

• Eventually replace Cuban doctors in-country

FIN

Turning the Corner: Cuba’s Family Doctor ProgramTurning the Corner: Cuba’s Family Doctor Program

Family medicine put to the test: Healthy people in a resource-scarce environment

Evolution of community-based models:Maximizing lessons for other developing countries

Top Priority:Human Resource Deployment and DevelopmentTop Priority:Human Resource Deployment and Development

Nationally: 68,017 physicians in 2004, 1 X 165 inh380,576 health workers

Internationally: 67,609 health professionals served abroad, of these 50,707 doctors

Context: 156,300 Cuban professionals served in 160 countries (1960-2001)

40,000 foreign graduates from Cuban schools(1960-2001), 16,472 of these university-level

Examples of Cuban International Disaster Relief1960-2000Examples of Cuban International Disaster Relief1960-2000

1960 Chile Earthquake, 5,000 dead Medical team

1970 Peru Earthquake, 60,000 dead Medical team, 6 rural hospitals,106,000 blood donations

1972 Nicaragua Earthquake, 5,000 dead Medical team, food, medicines

1974 Honduras Hurricane Fifi, 2,000 dead Medical team

1990 Soviet Union Chernobyl disaster program 17,733 children treated in Cubathrough October, 2004

Date Brazil Radiation poisoning 52 patients treated in Cuba

1998 Central America Hurricane Mitch, 30,000 dead and disappeared

Medical teams

1998 Haiti Hurricane Georges Medical team

1999 Venezuela Torrential rains, mudslides, 9,000 dead

Medical team

2000 El Salvador Dengue epidemic, 10,000 cases over 16 wks.

Medical team, advisors andequipment

Cuban International Medical Cooperation1963-2002Cuban International Medical Cooperation1963-2002

Source: International Cooperation Unit, Ministry of Public Health, Havana

Region Countries

Africa 32

Americas 36

Europe 9

Asia/Mideast 14

TOTAL 91

Some Basic Indicators (2006)

Country GNI*(US$) Percapita hlth. exp. (US$)Canada 36,280 2754Cuba 1170 322

Mexico 12,000 217USA 44,000 3074

NB: health expenditures are for public programs* = per capita

WHO, 2008

Challenges

• Quality assurance of the teaching process

• Adapting new models to countries with fewer resources

• M.D. opposition to training on such a large scale

Access to Water and Sanitation (2007)(% of Population)

Water Sanitation

Country Total Urban Rural Total Urban RuralBrazil 90 96 57 75 83 37Chile 96 100 59 92 96 64Cuba 91 95 78 98 99 95Haiti 54 52 56 30 57 14Mexico 97 100 87 79 91 41USA 100 100 100 100 100 100

UNICEF, 2008

Responding to the Special Period: 1990s and Beyond

• Soviet bloc collapses, US embargo tightened• Economy shrinks by 35%• Available hard currency down by 70%• Daily caloric intake drops by 33%• Optic neuropathy epidemic of 1992-93• Impact of primary care system on health• Refurbishing of polyclinics and construction of new

centers of excellence• Infant mortality rate continues to improve

MEDICC 2008