training the 5-star doctor: medical education in cuba
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Training the 5-Star Doctor: Medical Education in Cuba. Richard Quint, MD, MPH Health Sciences Clinical Professor (Emeritus), UCSF Medical Education in Cooperation with Cuba (MEDICC). Brief Chronology. 1959: Bautista overthrown 1960: Land reform and health system changes - PowerPoint PPT PresentationTRANSCRIPT
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