Healthcare in Cuba

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The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens.^[1] There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is José Ramón Balaguer.

An overall improvment in terms of disease and infant mortality rates was observed in the 1960s.^[2] AIDS is only one-sixth as common on a per-capita basis as in the United States.^[3] Like the rest of the Cuban economy, Cuban medical care suffered following the end of Soviet subsidies in 1991; the stepping up of the US embargo against Cuba at this time also had an effect.^[4] Cuba has one of the highest life expectancy rates in the region, with the average citizen living to 78.8 years old^[3] (in comparison to the United States' 78.1 years^[5]).

History

As was true of the other indigenous societies of the Americas, Cuban traditional medicine existed before the Spanish conquest. High-status traditional practitioners were called Bohiques. After colonization by the Spanish, Cuban medicine followed the Spanish tradition which was inherited from the Moors, who in turn drew upon classical Greek and Roman medical practices, which were inherited from the Ancient Egyptians, such as Imhotep. Chinese medicine has also been practiced in Cuba; its most famous practitioner was the 19th century doctor Cham Bom Biam or “El Medico Chino”.^[6]

The Hospital de San Felipe in Havana (in 1900), a healthcare educational facility built by the religious order San Juan de Dios in the mid-19th century

Modern Western medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th century and the first surgical clinic was established in 1823.^[7] Cuba has had many world class doctors, including Carlos Finlay, whose mosquito-based theory of yellow fever transmission was given its final proof under the direction of Walter Reed, James Carroll, and Aristides Agramonte.^[8] During the period of U.S presence (1898–1902) yellow fever was essentially eliminated due to the efforts of Clara Maass and surgeon Jesse W. Lazear.^[8][9]

By the 1950s, the island had some of the most positive health indices in the Americas, not far behind the United States and Canada. Cuba was one of the leaders in terms of life expectancy, and the number of doctors per thousand of the population ranked above Britain, France and Holland. In Latin America it ranked in third place after Uruguay and Argentina.^[10] There remained marked inequalities however. Most of Cuba's doctors were based in the relatively prosperous cities and regional towns, and conditions in rural areas, notably Oriente, were significantly worse.^[11] Only 8% of the rural population had access to healthcare.^[12] The mortality rate was the third lowest in the world.^[13] According to the World Health Organization, the island had the lowest infant mortality rate of Latin America.^[13]

Following the Revolution and the subsequent United States embargo against Cuba, an increase in disease and infant mortality worsened in the 1960s.^[2] The new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled On Revolutionary Medicine, stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices."^[14] These aims were hampered almost immediately by an exodus of almost half of Cuba’s physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in the University of Havana’s medical college.^[15] Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services.^[15]

In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states "Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations."^[16]

Cuba's doctor to patient ratio grew significantly in the latter half of the 20th century, from 9.2 doctors per 10,000 inhabitants in 1958, to 58.2 per 10,000 in 1999.^[17] In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox. Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care.^[17]

Post-Soviet Union

The loss of Soviet subsidies brought famine to Cuba in the early 1990s.

A Canadian Medical Association Journal paper states that "The famine in Cuba during the Special Period was caused by political and economic factors similar to the ones that caused a famine in North Korea in the mid-1990s. Both countries were run by authoritarian regimes that denied ordinary people the food to which they were entitled when the public food distribution collapsed; priority was given to the elite classes and the military."^[18] The regime did not accept donations of food, medicines and cash from the US until 1993.^[18]

Malnutrition created epidemics, but it had positive effects too. Manuel Franco describes the Special Period as "the first, and probably the only, natural experiment, born of unfortunate circumstances, where large effects on diabetes, cardiovascular disease and all-cause mortality have been related to sustained population-wide weight loss as a result of increased physical activity and reduced caloric intake".^[19]

In 2007, Cuba announced that it has undertaken computerizing and creating national networks in Blood Banks, Nephrology and Medical Images. Cuba is the second country in the world with such a product, only preceded by France. Cuba is preparing a Computerized Health Register, Hospital Management System, Primary Health Care, Academic Affairs, Medical Genetic Projects, Neurosciences, and Educational Software. The aim is to maintain quality health service free for the Cuban people, increase exchange among experts and boost research-development projects. An important link in wiring process is to guarantee access to Cuba's Data Transmission Network and Health Website (INFOMED) to all units and workers of the national health system. [8]

Present

WHO health statistics for Cuba
Source: WHO country page on Cuba

Life expectancy at birth m/f:	76.0/80.0 (years)
Healthy life expectancy at birth m/f:	67.1/69.5 (years)
Child mortality m/f:	8/7 (per 1000)
Adult mortality m/f:	131/85 (per 1000)
Total health expenditure per capita:	$251
Total health expenditure as % of GDP:	7.3

Rank	Countries surveyed		Statistic	Date of Information
125	167	HIV/AIDS adult prevalence rate	0.10%	2003 est.
162	175	Fertility rate	1.66 (children/woman)	2006.
153	224	Birth rate	11.89 (births/1,000 population)	2006 est.
168	226	Infant mortality rate	6.04 (deaths/1,000 live births)	2006.
129	224	Death rate	6.33 (deaths/1,000 population)	2005.
37	225	Life expectancy at birth	77.23 (years)	2006. est
17	99	Suicide rate	18.3 per 100,000 people per year	1996.*

All statistics from the World Factbook except * taken from World Health Organization figures.

Comparison of pre- and post-revolutionary indices

Life expectancy at birth in Cuba in 1955 was 63 years.^[20] In 1960 it was 63.9 years.^[21] To put these values in context, life expectancy at birth in some other regions and countries in 1960 were as follows (World Bank data):
World, 50.18 years;
Latin America and Caribbean, 56.21 years;
high-income OECD countries, 69.01 years;
United States, 69.77 years.^[22]

In 2007, the life expectancies at birth were as follows (World Bank data):
Cuba, 78.26 years;
World, 68.76 years;
Latin America and Caribbean, 73.13 years;
high income OECD countries, 79.66 years;
United States, 77.99 years.^[23]

The mortality rate for children under five years old was 54 per 1000 in Cuba in 1960 (World Bank).^[24] That year in Latin America and the Caribbean it was 154.66 per 1000; in the high-income OECD countries it was 43.11; in the United States, 30.2. No World datum is available for 1960, but for 1970 it was 145.67 per 1000 (all World Bank data).^[23]

The mortality rates for children under five in 2007 were as follows (World Bank):
Cuba, 6.5;
World, 68.01;
Latin America and Caribbean, 26.37;
high-income OECD, 5.71;
United States, 7.60.^[23]

Infant mortality was 32 per 1000 live births in Cuba in 1957.^[25] In 2000-2005 it was 6.1 per 1000 in Cuba; and, for comparison, 6.8 per 1000 in the United States.^[26] The 2007 infant mortality rates published by the World Health Organisation in 2009 were:
Cuba, 5;
World, 46;
High income countries, 6;
United States, 6.^[27]

The table below shows CEPAL (United nations) data spanning the pre- and post-revolutionary periods for three public health indicators. Health levels were better than the Latin American average before the revolution and showed continued steady improvement throughout the post-revilutionary period. The total mortality rate shown is the crude – i.e., not age-adjusted – rate, and therefore tends to rise as the proportion of elderly people in the population increases, which has been the case in Cuba because the birth rate is falling and life expectancy is rising.

Cuba: Public health 1950-2005

	Years
	1950-55	1955-60	1960-65	1965-70	1970-75	1975-80	1980-85	1985-90	1990-95	1995-00	2000-05
Life expectancy	59.5	62.4	65.4	68.6	71.0	73.1	74.3	74.6	74.8	76.2	77.1
Mortality rate	10.73	9.21	8.56	7.30	6.37	5.94	6.31	6.65	7.06	6.66	7.08
Under-5 mortality	112.4	93.9	75.9	58.6	43.6	27.0	21.2	19.3	18.7	11.8	7.72
Notes: Life expectancy is life expectancy at birth. Mortality rate is the crude mortality rate; i.e., annual number of deaths per 1,000 inhabitants. The under-5 mortality is the number of deaths of children up to age five, per 1,000 live births. Source: United Nations, Comisión Económica para América Latina y el Caribe (Economic Commission for Latin America and the Caribbean—CEPAL), Cepal Stat, Social Indicators and Statistics.

Cuba had 128 physicians and dentists per 100,000 people in 1957. This was comparable to the levels in many European countries and allegedly the highest in Latin America.^[28] In 2005, Cuba had 627 physicians and 94 dentists per 100,000 population. That year the United States had 225 physicians and 54 dentists per 100,000 population; there was no data for Latin America as a region, but the Central American isthmus had 123 physicians and 30 dentists per 100,000.^[29]

Health indicators and issues

Cuba began a food rationing program in 1962 to guarantee all citizens a low-priced basket of basic foods. As of 2007, the government was spending about $1 billion annually to subsidise the food ration. The ration would cost about $50 at an average grocery store in the United States, but the Cuban citizen pays only $1.20 for it. The ration includes rice, legumes , potatoes, bread, eggs, and a small amount of meat. It provides about 30 to 70 percent of the 3,300 kilocalories that the average Cuban consumes daily. The people obtain the rest of their food from government stores (Tiendas), free market stores and cooperatives, barter, their own gardens, and the black market.^[30]

According to the Pan American Health Organization, daily caloric intake per person in various places in 2003 were as follows (unit is kilocalories):
Cuba, 3,286;
America, 3,205;
Latin America and the Caribbean, 2,875;
Latin Caribbean countries, 2,593;
United States, 3,754.^[31]

Distribution of years of life lost by cause (%)

Place	Communicable	Non-communicable	Injuries
Cuba	9	75	16
World	51	34	14
High income countries	8	77	15
United States	9	73	18
Low income countries	68	21	10
Source: World Health Organisation. World Health Statistics 2009, Table 2, "Cause-specific mortality and morbidity".

The reasons people die in Cuba tend to be the same as in high-income, developed, countries. The table at right shows the relative seriousness of communicable diseases, non-communicable diseases (e.g., heart disease and cancer) and injuries, in various parts of the world. Data is from the World Health Organisation and is for year 2004.

Diseases of the circulatory system are the most common cause of death in Cuba, killing 306 people per 100,000 population in 2005. Neoplasms (cancer) are second, killing 173 per 100,000 population in 2005. The numbers killed by some other causes, in 2005 per 100,000 population, were: influenza and pneumonia 64, accidents 40, diabetes mellitus 18, intentional self-harm (suicide) 12, cirrhosis and other chronic liver diseases 10. Total mortality per 100,000 population was 754.

Like the rest of the Cuban economy, numerous reports have shown that Cuban medical care has long suffered from severe material shortages caused by the US embargo. The ending of Soviet subsidies in the early 1990s has also affected it.^[4]

Abortion rates, which are high in Cuba, increased dramatically during the 1980s, but had almost halved by 1999 and declined to near-1970s levels of 32.0 per 100 pregnancies. The rate is still among the highest in Latin America.^[17]

Among adults less than 49 years old, accidents are the leading cause of death, though occupational accidents have declined significantly in the last decade. The homicide rate is 7.0 per 100,000. The rate of suicide in the island is higher than average in Latin America and has been among the highest in the region and the world since the nineteenth century.^[32] Annual suicide deaths per 100,000 population (2003-2005 data) were: Cuba 13.6, Americas 7.7, Latin America and Caribbean 5.8, Latin Caribbean 8.7, United States 10.8.^[33] Among older adults heart disease and cancer predominate as causes of mortality. General mortality has been "characterized by a marked predominance of causes associated with chronic noncommunicable diseases", according to the Pan American Health Organization.^[34]

While preventive medical care, diagnostic tests and medication for hospitalized patients are free, some aspects of healthcare are paid for by the patient. Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. When a patient can obtain these items at state stores, prices tend to be low as these items are subsidized by the state. For patients on a low-income, these items are free of charge.^[35]

Sexual health

According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment.^[36]

In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world.^[37] The UNAIDS reported that HIV infection rates for Cuba were 0.1%, and for other countries in the Caribbean between 1 - 4%.^[38][39] Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education.

According to a 2005 report by UNAIDS and the World Health Organization, "Cuba’s epidemic remains by far the smallest in the Caribbean."^[39] They add however that,

... new HIV infections are on the rise, and Cuba’s preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cuba’s prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs.^[40]

In recent years because of the rise in prostitution due to tourism, STDs have increased.^[17]

Embargo

During the '90s the ongoing United States embargo against Cuba caused problems due to restrictions on the export of medicines from the US to Cuba.^[41][42] In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U.S. subsidiary trade, including trade in food and medicines, being prohibited.^[41] The legislation did not state that Cuba cannot purchase medicines from U.S. companies or their foreign subsidiaries; however, such license requests have been routinely denied.^[41] In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U.S. Government that such activities violate international law and has requested that the U.S. take immediate steps to exempt medicine from the embargo.^[43] The Lancet and the British Medical Journal also condemned the embargo in the 90s.^[44]

A 1997 report prepared by Oxfam America and the Washington Office on Latin America, Myths And Facts About The U.S. Embargo On Medicine And Medical Supplies, concluded that the embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U.S. firms or from non-U.S.sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba's medical system. It prohibited foreign subsidiaries of U.S. corporations from selling to Cuba, thus further limiting Cuba's access to medicine and equipment, and raising prices. In addition, the act forbids ships that dock in Cuban ports from docking in U.S. ports for six months. This drastically restricts shipping, and increases shipping costs some 30%.^[45]

However, in 2000 the Trade Sanctions Reform and Export Enhancement Act was passed, and the US is now Cuba's single largest source for imported food.^[46][47] The Cuban American National Foundation (CANF) states that should Cuba choose not to purchase from the U.S., it can purchase any medicine or medical equipment it needs from other countries.^[48] Such third-country transactions only cost an estimated 2%-3% more than purchases from the U.S. as a result of higher shipping costs.^[48] CANF also asserts the United States is the largest donor of humanitarian assistance to Cuba and much of this consists of medicines and medical equipment.^[48]

The US government states that since 1992, 36 out of 39 license requests from U.S. companies and their subsidiaries for sales of medical items to Cuba have been approved. The dollar amount of these sales is over $1,600,000. Furthermore, the U.S. government licensed more than $227 million in humanitarian donations of medicines and medical supplies to Cuba between 1993 and 1997. There are other factors beside the embargo explaining the lack of imports, in particular Cuba's lack of hard currency. Those with dollars can easily buy medicines and food in Cuba from Latin America and Canada. Cuba defaulted on its debt to Western banks in 1986 and lacks access to the international credit system in order to get foreign currency. In addition, the collapse of the Soviet Union caused the loss of several billions of dollars in yearly subsidies and overnight required hard currency for all imports. [9]

In a 2006 report to the U.N. Secretary-General, Cuba acknowledged the authorization of medicines, though stated that they were subject to severe restrictions and complicated procedures. Cuba is obliged to make payments in cash and in advance, and is precluded from obtaining credit funding, even from private sources. The sale and transportation of the goods require licenses to be obtained for each transaction. Cuba cannot use its own merchant fleet for transporting these goods, but has to make use of vessels from third countries, primarily the United States. Payments are made through banks in third countries, since direct banking relationships are prohibited. The Cuban delegation concluded that restrictions on importing medical products were "so extensive that they make such imports virtually impossible". The World Health organization/PAHO and UNFPA concurred that it was impossible for Cuba to purchase equipment, medicines and laboratory materials produced by the United States or covered by United States patents, even though those products were purchased through multilateral cooperation. Cuba was not able to purchase the isotope I-125 that is used to treat eye cancer in children. The companies manufacturing reagents and equipment are 70 per cent United States owned, which makes it difficult to purchase necessary medical equipment and other items^[49]

Medical staff

According to the World Health Organization, Cuba provides a doctor for every 170 residents,^[50] and has the second highest doctor-to-patient ratio in the world after Italy.^[51]

Medical professionals are not paid high salaries by international standards. In 2002 the mean monthly salary was 261 pesos, 1.5 times the national mean.^[52] A doctor’s salary in the late 1990s was equivalent to about US$15–20 per month in purchasing power. Therefore, some prefer to work in different occupations, for example in the lucrative tourist industry where earnings can be much higher.^[17]

The San Francisco Chronicle, the Washington Post, and National Public Radio have all reported on Cuban doctors defecting to other countries.^[53]

Black market healthcare

The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba's burgeoning black market economy, sometimes termed "sociolismo". According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, "The doctors in the hospitals are charging patients under the table for better or quicker service." Prices for out-of-surgery X-rays have been quoted at $50 to $60.^[54] Such "under-the-table payments" reportedly date back to the 1970s, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn known as the "Special Period" in the 1990s aggravated these payments. The advent of the "dollar economy", a temporary legalization of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans were able to obtain medications and health services that would not be available to them otherwise.^[55]

Cuba and international healthcare

Main article: Cuban medical internationalism

In the 1970s, the Cuban state initiated bilateral service contracts and various money-making strategies.^[56] Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA) and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies^[34] In the 1980s, Cuba's decision to withdrawal military assistance from the Marxist-Leninist regimes in Ethiopia and Angola was partly inrooted in their inability to meet payments.^[56] In 1986, Cuba had 219 doctors per 100,000 people (compared with 423.7 doctors in the Soviet Union, which had the most doctors among industrialized countries).^[57]

The supply of physicians came to exceed the domestic market. Moreover, Cuban doctors work on much lower salaries than local doctors. A Guatemalan doctor noted "No one's going to work in the mountains for a salary of $400," the salary on which Cuban doctors work.^[58] The $400 is 16 times the doctor's salary in Cuba - allowing Cuban doctors to buy refrigerators, stereos and other items that they couldn't afford in Cuba.^[58] Cuba's missions in 68 countries are manned by 25,000 Cuban doctors, and medical teams have worked in crisis such as the South Asian Tsunami and the 2005 Kashmir earthquake.^[59] Nearly 2,000 Cuban doctors are currently working in Africa in countries including South Africa, Gambia, Guinea Bissau and Mali.^[60] Since the Chernobyl nuclear plant exploded in 1986, more than 20,000 children from Ukraine, Belarus and Russia have traveled to Cuba for treatment of radiation sickness and psychologically based problems associated with the radiation disaster.^[61] In response to the 2005 Hurricane Katrina disaster, Castro offered to send a "brigade" of 1,500 doctors to the U.S. to provide humanitarian aid, but was never accepted.^[62]

Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil.^[63] Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: "Mission Into the Neighborhood") social welfare program established in Venezuela under current Venezuelan president Hugo Chávez.^[64] The program, which is popular among Venezuela's poor and is intended to bring doctors and other medical services to the most remote slums of Venezuela,^[65] has not been without its detractors. Operación Milagro (Operation Miracle) is a joint health program between Cuba and Venezuela, set up in 2005. The Venezuelan Medical Federation has criticized the appointment of Cuban doctors to high-ranking positions,^[66] and protests have taken place in the capital Caracas by Venezuelan medical staff who fear that the Cubans are a threat to Venezuelan jobs. Questions have also been raised by protesters about the level of Cuban medical qualifications, and there have been claims that the Cubans are "political agents" who have come to Venezuela to indoctrinate the workforce.^[65] Opposition supporters in Venezuela have called Cuban doctors "Fidel's ambassadors" and refused to go to their clinics.^[67] Two defected doctors have claimed that they were told their job was to keep Chavez in power,^[67] by asking patients to vote for Chávez in the 2004 recall referendum.^[67]

Human Rights Watch complains that the government "bars citizens engaged in authorized travel from taking their children with them overseas, essentially holding the children hostage to guarantee the parents' return. Given the widespread fear of forced family separation, these travel restrictions provide the Cuban government with a powerful tool for punishing defectors and silencing critics."^[68] Doctors are reported to be monitored by "minders" and subject to curfew. The Cuban government uses relatives as hostages to prevent doctors from defecting.^[69][70] According to a paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA", some via Colombia, where they have sought temporary asylum.^[69]

According to Luis Zuñiga, director of human rights for the Cuban American National Foundation, Cuban doctors are "slave workers" who labor for meager wages while bolstering Cuba's image as a donor nation and "the Cuban government exports these doctors as merchandise".^[71]

Cuban doctors have been part of a large-scale plan by the Cuban state to provide free medical aid and services to the international community (especially third world countries) following natural disasters.^[72] Currently dozens of American medical students are trained to assist in these donations at the Escuela Latino Americana de Medecina (ELAM) in Cuba.^[72]

Health tourism and pharmaceutics

Cuba attracts about 20,000^[73] paying health tourists, generating revenues of around $40 million a year for the Cuban economy. Cuba has been serving health tourists from around the world for more than 20 years. The country operates a special division of hospitals specifically for the treatment of foreigners and diplomats. Foreign patients travel to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinsons disease, cosmetic surgery, addictions treatment, retinitis pigmentosa and orthopaedics. Most patients are from Latin America, Europe and Canada, and a growing number of Americans also are coming. Cuba also successfully exports many medical products, such as vaccines.^[74] By 1998, according to the Economic Commission for Latin America and the Caribbean, the Cuban health sector had risen to occupy around 2 percent of total tourism. Some of these revenues are in turn transferred to health care for ordinary Cubans, although the size and importance of these transfers is both unknown and controversial. At one nationally prominent hospital/research institute, hard currency payments by foreigners have financed the construction of a new bathroom in the splanic surgery wing; anecdotal evidence suggests that this pattern is common in Cuban hospitals.^[75]

Alternative Healthcare

Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population^[1] In the 1990s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model.^[76] Examples of alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i.e. acupunctural anesthesia for surgery), natural dietary supplements, yoga, electromagnetic and laser devices.^[76] Children begin studying the multiple uses of medicinal plants in primary school, learning to grow and tend their own plots of aloe, chamomile, and mint, and later they conduct scientific studies about their uses. Radio and Television programs instruct people on how to relieve common stomach upset and headaches by pressing key points.^[77] Acupuncture is offered at all three levels of health care.^[78] Cuban biochemists have produced a number of new alternative medicines, including PPG (policosanol), a natural product derived from sugarcane wax that is effective at reducing total cholesterol and LDL levels, and Vimang a natural product derived from the bark of mango trees.^[76]

Medical research

The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine. Because the U.S. government restricts investments in Cuba by U.S. companies and their affiliates, Cuban institutions have been limited in their ability to enter into research and development partnerships, although exceptions have been made for significant drugs.

The Center of molecular immunology (CIM) developed nimotuzumab, a monoclonal antibody used to treat cancer. Nimotuzumab is an inhibitor of epidermal growth factor receptor (EGFR), which is over-expressed in many cancers. Nimotuzumab is now being developed with international partners.

In April 2007, the Cuba IPV Study Collaborative Group reported in the New England Journal of Medicine that inactivated (killed) poliovirus vaccine was effective in vaccinating children in tropical conditions. The Collaborative Group consisted of the Cuban Ministry of Public Health, Kourí Institute, U.S. Centers for Disease Control and Prevention, Pan American Health Organization, and the World Health Organization. This is important because countries with high incidence of polio are now using live oral poliovirus vaccine. When polio is eliminated in a country, they must stop using the live vaccine, because it has a slight risk of reverting to the dangerous form of polio. The collaborative group found that when polio is eliminated in a population, they could safely switch to killed vaccine and be protected from recurrent epidemics. Cuba has been free of polio since 1963, but continues with mass immunization campaigns.^[79]

In the 1980s, Cuban scientists developed a vaccine against a strain of bacterial meningitis B, which eliminated what had been a serious disease on the island. The Cuban vaccine is used throughout Latin America. After outbreaks of meningitis B in the United States, the U.S. Treasury Department granted a license in 1999 to an American subsidiary of the pharmaceutical company SmithKline Beecham to enter into a deal to develop the vaccine for use in the U.S. and elsewhere^[80]

Analysis

According to Katharine Hirschfeld, criticizing the government is a crime in Cuba, and penalties are severe.^[81] She noted that "Formally eliciting critical narratives about health care would be viewed as a criminal act both for me as a researcher, and for people who spoke openly with me".^[81] According to Hirschfeld the Cuban Ministry of Health (MINSAP) sets statistical targets that are viewed as production quotas. The most guarded is infant mortality rate. The doctor is pressured to abort the pregnancy whenever screening shows that quotas are in danger.^[81] Once a doctor decides to guard his quotas, patients have no right to refuse abortion.^[81]

According to previous research about other socialist countries such as the Soviet Union and the People's Republic of China, Marxist "revolutionary" efforts have included such practices as "deliberate manipulation of health statistics, aggressive political intrusion into health care, decision-making, criminalizing dissent, and other forms of authoritarian policing of the health sector designed to insure health changes reflect the (often utopian) predictions of Marxist theory".^[81] These practices are well documented for the former Soviet Union and China.^[81] Their existence was virtually unknown in the West during the Soviet era and Western social scientists cited favorable the health statistics supplied by the regimes in the USSR and China.^[81] Social scientists did not look critically at the ways they were created and maintained by state power.^[81]

Many Cubans complain about politics in medical treatment and health care decision-making. There is no right to privacy, patient's informed consent, or right to protest for malpractice. The patient has no right to refuse the treatment, including for religious or ethical reasons. For example, Jehovah's Witnesses cannot refuse blood transfusions and a Rastafarian cannot refuse an amputation on the grounds that it goes against Rastafari biblical teachings (Rastafari teaches that the body must be whole in order for it to resurrected on Judgement Day). As a result, the experience can be dehumanizing.^[81] After spending nine months in Cuban clinics, Katherine Hirschfeld asserted in her paper "My increased awareness of Cuba’s criminalization of dissent raised a very provocative question: to what extent is the favorable international image of the Cuban health care system maintained by the state’s practice of suppressing dissent and covertly intimidating or imprisoning would-be critics?"^[81]

In 2006, BBC flagship news programme Newsnight featured Cuba's Healthcare system as part of a series identifying "the world's best public services". The report noted that "Thanks chiefly to the American economic blockade, but partly also to the web of strange rules and regulations that constrict Cuban life, the economy is in a terrible mess: national income per head is minuscule, and resources are amazingly tight. Healthcare, however, is a top national priority" The report stated that life expectancy and infant mortality rates are nearly the same as the USA's. Its doctor-to-patient ratios stand comparison to any country in Western Europe. Its annual total health spend per head, however, comes in at $251; just over a tenth of the UK's. The report concluded that the population's admirable health is one of the key reasons why Castro is still in power.^[82] A 2006 poll carried out by the Gallup Organization's Costa Rican affiliate — Consultoría Interdisciplinaria en Desarrollo (CID) — found that about three-quarters of urban Cubans responded positively to the question "do you have confidence to your country's health care system".^[83]

In 2000, Secretary General of the United Nations Kofi Annan stated that "Cuba should be the envy of many other nations" adding that achievements in social development are impressive given the size of its gross domestic product per capita. "Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities - health, education, and literacy."^[84] The Kaiser Family Foundation, a non-governmental organization that evaluated Cuba’s healthcare system in 2000-1 described Cuba as "a shining example of the power of public health to transform the health of an entire country by a commitment to prevention and by careful management of its medical resources"^[85] President of the World Bank James Wolfensohn also praised Cuba's healthcare system in 2001, saying that "Cuba has done a great job on education and health", at the annual meeting of the Bank and the International Monetary Fund. Wayne Smith, former head of the US Interests Section in Havana identified "the incredible dedication" of Cubans to healthcare, adding that "Doctors in Cuba can make more driving cabs and working in hotels, but they don't. They're just very dedicated".^[86] Dr. Robert N. Butler, president of the International Longevity Center in New York and a Pulitzer Prize-winning author on aging, has traveled to Cuba to see firsthand how doctors are trained. He said a principal reason that some health standards in Cuba approach the high American level is that the Cuban system emphasizes early intervention. Clinic visits are free, and the focus is on preventing disease rather than treating it.^[87] Furthermore, London's The Guardian newspaper lauded Cuba's public healthcare system for what it viewed as its high quality in a Sept. 12, 2007 article.^[88]

In 2001, members of the UK House of Commons Health Select Committee travelled to Cuba and issued a report that paid tribute to "the success of the Cuban healthcare system", based on its "strong emphasis on disease prevention" and "commitment to the practice of medicine in a community".^[82]

The Parliament of the United Kingdom also drew up an analysis of the key features of Cuba's healthcare system, drawing comparisons with the state funded National Health Service (NHS). The overall conclusion was that many of the features identified would not have occurred had there not been an obvious commitment to health provision demonstrated by the protection and proportion of the budget given the health care. The study concluded the following.

• There appeared to be little evidence of a divide between the prevention/proactive response and the disease management/reactive response within Cuban healthcare.
• By far the biggest difference was the ratio of doctors per person. In Cuba it was one doctor per 175 people, in the UK the figure was one doctor per 600 people.
• There is a commitment in Cuba to the triple diagnosis (physical/psychological/social) at all levels.
• Extensive involvement of "patient" and the public in decision making at all levels.
• Integration of hospital/community/primary care via polyclinics.
• Team-work that works is much more evident both in the community and the hospital sector and the mental-health and care of the elderly sites visited were very well staffed and supported.

The study also pointed to problems within the system, these included;

• Low pay of doctors
• Poor facilities—buildings in poor state of repair and mostly outdated.
• Poor provision of equipment.
• Frequent absence of essential drugs.
• Concern regarding freedom of choice both for patient and doctor.^[89]

Complaints have arisen that foreign "health tourists" paying with dollars and senior Communist party officials receive a higher quality of care than Cuban citizens. Former leading Cuban neurosurgeon and dissident Dr Hilda Molina asserts that the central revolutionary objective of free, quality medical care for all has been eroded by Cuba's need for foreign currency. Molina says that following the economic collapse known in Cuba as the Special Period, the Cuban Government established mechanisms designed to turn the medical system into a profit-making enterprise. This creates an enormous disparity in the quality of healthcare services between foreigners and Cubans leading to a form of tourist apartheid. In 1998 she said that foreign patients were routinely inadequately or falsely informed about their medical conditions to increase their medical bills or to hide the fact that Cuba often advertises medical services it is unable to provide.^[90] Others makes similar claims, also stating that senior Communist party and military officials can access this higher quality system free of charge. [10] [11] In 2005, an account written by Cuban exile and critic of Fidel Castro, Carlos Wotzkow, appeared showing apparent unsanitary and unsafe conditions in the "Clínico Quirúrgico" of Havana;the article claims that health care for Cubans occurs in worse conditions in the rest of the country.^[91]

An article in Canadian newspaper National Post, based interviews of Cubans, finds that in reality even the most common pharmaceutical items, such as Aspirin and antibiotics are conspicuously absent or only available on the black market. Surgeons lack basic supplies and must re-use latex gloves. Patients must buy their own sutures on the black market and provide bedsheets and food for extended hospital stays. [12] The Cuban government blames the shortages on the embargo and states that those with more severe chronic diseases receive medicines. [13] However, other sources suggest that also those with such diseases lack medicines. It is also suggested that in some cases the local non-dollar stocks have been shipped abroad. [14] [15]

The U.S. State Department has argued that during the economic depression "the Cuban government made a deliberate decision to continue to spend money to maintain its military and internal security apparatus at the expense of other priorities – including healthcare." However, one study found that "the available data show that the fall in Cuba's medicine imports in the '90s didn't correspond to a significant lowering of the government's healthcare spending. Budgetary support for peso-denominated spending – i.e., labor costs of medical professionals, operational costs of hospitals and clinics – has remained strong. Attempts to blame medical shortages in Cuba on resource misallocation are thus misguided, or at least wrongly nuanced."^[92]

A recent ABC-TV 20/20 report on Healthcare, based on footage taken from within the island, criticized Michael Moore's portrayals of the Cuban Healthcare system in the movie Sicko. In that film, Moore took a number of Americans to a hospital in Havana where they bought affordable drugs, and were given treatments for free that they could not afford in America. The report highlights the dilapidated conditions of some hospitals that are accessible to regular Cubans by pointing to the bleak conditions of hospital rooms and the filthy conditions of the facilities. The report also addressed the quality of care available to Cubans by arguing that patient neglect was a common phenomenon. Finally, in discussing the infant mortality rate, the report highlights the government's alleged efforts to promote abortions of potentially infirm fetuses and other alleged government efforts to manipulate the rate.^[93]

See also

Cuba portal

• Carlos Finlay
• Cuban Center of molecular immunology
• Latin American School of Medicine (Cuba)
• Sicko

Sources

Data

The World Health Organisation, and its regional branch, the Pan American Health Organization, publish regular reports as well as making data available on the web.

World Health Organisation, World Health Statistics 2009 consists mostly of tables (.pdf format) of health indicators, for most countries, for selected years between 1990 and 2008.
World Health Organisation, National Accounts Series consists of statistics on the financing of health care in various countries. Cuba tables, covers years 1995-2007.

Pan American Health Organisation, Health situation in the Americas: Basic Indicators 2008. Table of health indicators for countries, one datum from a recent year (2000-2008) for each indicator.
Pan American Health Organisation, Health in the Americas 2007 is primarily a text report; also contains tables. First section is on the region as a whole, second section is reports on individual countries, including Cuba.

References

1. ^ ^{a b} Harvard Public Health Review/Summer 2002 The Cuban Paradox
2. ^ ^{a b} Dominguez, Jorge (1993), "Cuba since 1959", in Bethell, Leslie (ed., 1993), Cuba: a short history, Cambridge: Cambridge University Press
3. ^ ^{a b} CIA World FactBook - Cuba - 2009
4. ^ ^{a b} The effects of the U.S. embargo on medicines in Cuba have been studied in numerous reports.
   • R Garfield and S Santana. Columbia University, School of Nursing, New York; "The impact of the economic crisis and the US embargo on health in Cuba" "this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services"
   • American Association for World Health; Online. American Association for World Health Report. March 1997. Accessed 6 October 2006. Supplementary source : American Public Health Association website "After a year-long investigation, the American Association for World Health has determined that the U.S. embargo of Cuba has dramatically harmed the health and nutrition of large numbers of ordinary Cuban citizens."
   • Felipe Eduardo Sixto; An evaluation of Four decades of Cuban Healthcare.
   "The lack of supplies accompanied by a deterioration of basic infrastructure (potable water and sanitation) resulted in a setback of many of the previous accomplishments. The strengthening of the U.S. embargo contributed to these problems."
   • Pan American Health organization; Health Situation Analysis and Trends Summary [1] "The two determining factors underlying the crisis are well known. One is the dissolution of the Soviet Union and the socialist bloc, and the other is the economic embargo the Government of the United States."
   • Harvard Public Health; Review/Summer 2002 : The Cuban Paradox "Because its access to traditional sources of financing is seriously hindered by the sanctions, which until recently included all food and medicine, Cuba has received little foreign and humanitarian aid to maintain the vitality of its national programs"
   • The Lancet medical journal; Role of USA in shortage of food and medicine. "The resultant lack of food and medicines to Cuba contributed to the worst epidemic of neurological disease this century."
5. ^ CIA World FactBook - US - 2009
6. ^ El Médico Chino Professor Luis Enrique Ramos Guadalupe. Habana Radio
7. ^ Official site of the Finlay medical center
8. ^ ^{a b} The Philip S. Hench Walter Reed Yellow Fever On-line Collection [02954005]&query=james+carroll Online
9. ^ Clara Louise Maass
10. ^ Gott, R. (2004) Cuba: A New History (Yale : Yale University Press) p165. ISBN 0-300-10411-1
11. ^ Hugh Thomas, Cuba : The pursuit of Freedom. p968-970 "[since the revolution] The distribution of food has been erratic. Still, few die of malnutrition and, particularly in Oriente province, the very poor peasants must be fed better and more regularly than before the revolution" - "The revolution has in many ways improved everybody's health. The availability of medicines has been much more fairly distributed throughout the country. Preventative medicine has been much emphasized and many clinics have been established in rural areas."
12. ^ PBS - Views on Cuba
13. ^ ^{a b} "Cuba Before Fidel Castro". http://www.fiu.edu/~fcf/cubaprecastro21698.html. 
14. ^ On Revolutionary Medicine by Che Guevara Monthly review
15. ^ ^{a b} Cuban Healthcare: An analysis of a Community-based model Essam Farag online
16. ^ ° English translation of the 1976 Constitution of Cuba Wikisource
    1976 Constitution of Cuba 1976 (in Spanish)
17. ^ ^{a b c d e} An evaluation of four decades of Cuban healthcare. Filipe Eduardo Sixto, 2002.
18. ^ ^{a b} "Health consequences of Cuba's Special Period". Canadian Medical Association Journal. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2474886. 
19. ^ Carroll, Rory (27 September 2007). "Economic crisis boost to health of Cubans". London: The Guardian. http://www.guardian.co.uk/world/2007/sep/27/cuba.international. Retrieved 4 May 2010. 
20. ^ "Cuba facts issue 43". December 2008. http://ctp.iccas.miami.edu/FACTS_Web/Cuba%20Facts%20Issue%2043%20December.htm. 
21. ^ Life expectancy at birth, total (years); retrieved 2010-10-29.
22. ^ World Bank, Quick Query (op cit.), retrieved 2009. High income OECD (Organisation for Economic Cooperation and Development) countries were defined by the World Bank in 2009 as those with 2007 per capita GNI of at least $US 11,456 (notes to Quick Query).
23. ^ ^{a b c} World Bank, Quick Query, op cit., retrieved July 2009.
24. ^ Quick Query, op cit., retrieved July 2009
25. ^ Note: the source for this datum quotes data selectively and may not be a reliable source according to Wikipedia's standards. Kirby Smith and Hugo Llorens. "Renaissance and decay: A comparison of socioeconomic indicators in pre-Castro and current-day Cuba". http://lanic.utexas.edu/la/ca/cuba/asce/cuba8/30smith.pdf. 
26. ^ http://www.un.org/esa/population/publications/wpp2006/WPP2006_Highlights_rev.pdf
27. ^ These are the probability of dying between birth and age one, per 1000 live births. World Health Organisation, World Health Statistics 2009, Table 1, "Mortality and burden of disease." Retrieved July 2009.
28. ^ Note: this source quotes data selectively and may not be reliable. Kirby Smith and Hugo Llorens. "Renaissance and decay: A comparison of socioeconomic indicators in pre-Castro and current-day Cuba". http://lanic.utexas.edu/la/ca/cuba/asce/cuba8/30smith.pdf. 
29. ^ Pan American Health Organization, Health situation in the Americas: Basic Indicators 2008 [2] page 9, "resources, access & coverage indicators," retrieved July 2009.
    Also, World Health Organisation, 2005 [3], retrieved July 20, 2007, and 2007 [4], retrieved 1 August 2007.
30. ^ Snow, Anita (2 July 2007). "Living on Cuban Food Ration Isn't Easy". Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2007/07/02/AR2007070201103.html. Retrieved 4 May 2010. ;
    United States Department of Agriculture, "Cuba’s Food & Agriculture Situation Report". http://www.fas.usda.gov/itp/cuba/CubaSituation0308.pdf. . The Post article says that the government estimates that the ration meets about 1/3 of a person's food requirement; but the USDA Report (p 24 of the.pdf) says the ration meets roughly 2/3, although estimates vary.
31. ^ Pan American Health Organization, "Health situation in the Americas: Basic Indicators 2008"; retrieved July 2009.
32. ^ To Die in Cuba: Suicide and Society. By Louis A. Pérez, Jr. access online
33. ^ Pan American Health Organization, Health situation in the Americas: Basic Indicators 2009, op cit., p 6.
34. ^ ^{a b} "Cuba Demographic indicators". Pan American Health Organization. http://www.paho.org/english/sha/prflcub.htm. 
35. ^ Jerry M. Spiegel and Annalee Yassi "Lessons from the margins of globalization: appreciating the Cuban health paradox" in Journal of Public Health Policy, Volume 25, Number 1, 2004, pp. 85–110(26)online. "Patients pay for drugs, hearing, dental,and orthopedic prostheses, wheelchairs, crutches, and similar items but prices are low and subsidized by the state; and in the case of low-income patients, these items are offered free of charge"
36. ^ Approaches to the management of HIV/Aids in Cuba World Health Organization
37. ^ "High HIV-1 genetic diversity in Cuba AIDS 2002". Official Journal of the International AIDS society. http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200208160-00010.htm;jsessionid=Fsnp8F72GNT9Q12gng9rYChv85qJ0zyTGqsLXLbNPtVLQCGhJzGx!-910938601!-949856144!8091!-1#P22. 
38. ^ "Caribbean Statistics summary". http://www.avert.org/caribbean.htm. 
39. ^ ^{a b} "Cuba’s epidemic remains by far the smallest in the Caribbean". http://www.avert.org/aidslatinamerica.htm. 
40. ^ "Caribbean". UNAIDS/WHO AIDS epidemic update: December 2005. UNAIDS. http://www.unaids.org/epi/2005/doc/epiupdate2005_html_en/epi05_08_en.htm#TopOfPage. Retrieved 30 April 2011. 
41. ^ ^{a b c} The impact of the economic crisis and the US embargo on health in Cuba. American journal of public health. 1997 January. Accessed 6 October 2006.
42. ^ The Impact Of The US Embargo On The Health And Nutrition In Cuba. Online. American Association for World Health Report. March 1997. Accessed 6 October 2006. Supplementary source : American Public Health Association website
43. ^ Role of the USA in shortage of medicines in Cuba. Anthony F. Kirkpatrick. The Lancet. 2004. Accessed 6 October 2006.
44. ^ BMA must voice its opposition to Cuban embargo. British medical journal. 1998. Accessed 6 October 2006.
45. ^ Myths and Facts about the US embargo on medicines and supplies. Oxfam America and the Washington Office on Latin America.
46. ^ http://globalization.about.com/od/bigstories/a/cubaembargo.htm
47. ^ "U.S. Companies Flock To Cuba". CBS News. 24 September 2006. http://www.cbsnews.com/stories/2006/09/24/eveningnews/main2036729.shtml. 
48. ^ ^{a b c} "Health Care in Cuba: Myth Versus Reality - Cuba's Economic Choice: The Regime's Health Over the People's". The Cuban American National Foundation. http://www.canf.org/Issues/medicalapartheid.htm. 
49. ^ Report of the Secretary-General. 2006. "Necessity of ending the economic, commercial and financial embargo imposed by the United States of America against Cuba" (A/60/150) online
50. ^ Medical know-how boosts Cuba's wealth. BBC online.
51. ^ Commitment to health: resources, access and services United Nations Human Development report
52. ^ Economic crisis and access to care: Cuba's health care system since the collapse of the Soviet Union. Nayeri K, Lopez-Pardo CM. p.13 online
53. ^ [5], [6], [7]
54. ^ Miami Herald. August 04, 2006.
55. ^ Cuba's Health in Transition and the Central and Eastern European. Countries Experience. Antonio Maria de Gordon.
56. ^ ^{a b} Susan Eckstein. Back from the future. ISBN 0691034451. 
57. ^ Milton Irwin Roemer. National Health Systems of the World: The issues. 
58. ^ ^{a b} "Cuban doctors bring relief, but controversy mars work". http://www.latinamericanstudies.org/cuba/doctors-guatemala.htm. 
59. ^ Cuban Embassy opens in Islamabad Islamic News Agency
60. ^ Castro has stamped his mark on Africa's history Washington Post August 10, 2006
61. ^ 15,000 sick Ukrainian kids get treatment in Cuba San Francisco Chronicle
62. ^ Cuba to create doctors' brigade BBC News September 20, 2005
63. ^ Medical know-how boosts Cuba's wealth BBC News
64. ^ Hugo's Health Revolution Cuban Doctors in Venezuela. Yale Journal of public health
65. ^ ^{a b} Venezuela medics march over jobs BBC online.
66. ^ Appointment of Cuban doctors to managerial positions must be explained, says FMV El Universal.
67. ^ ^{a b c} "Cuban doctors defect, speak out - Two Cuban doctors who defected gave an inside account of the Cuban-Venezuelan health program.". The Miami Herald. August 15, 2006. http://www.flacso.org/hemisferio/al-eeuu/boletines/01/36/rel_07.pdf. 
68. ^ "Human Rights Watch World Report 2007 - Cuba". 11 January 2007. http://www.unhcr.org/refworld/publisher,HRW,,CUB,45aca29d20,0.html. 
69. ^ ^{a b} Cuban doctors working abroad defect to the USA. The Lancet, Volume 369, Issue 9569. 
70. ^ "Socialized medicine in Cuba part II: “Doctor diplomacy,” sex tourism, and medical apartheid". Surgical Neurology 62 (3). http://www.haciendapub.com/surgneuro10.html. 
71. ^ "Cuban doctors vanish in Zimbabwe". Miami Herald. 6 June 2000. http://www.cubanet.org/CNews/y00/jun00/06e4.htm. 
72. ^ ^{a b} Cusack, Carmen. "Healthcare in Cuba". Selected Works. http://works.bepress.com/carmen_cusack/1/. 
73. ^ Commentary: A Novel Tourism Concept Caribbean Net News
74. ^ Cuba sells its medical expertise BBC News
75. ^ [name=autogenerated1>http://lasa.international.pitt.edu/Lasa2001/DunningThad.pdf]
76. ^ ^{a b c} Cuba : A model for alternative healthcare National Foundation for Alternative medicine
77. ^ Alternative Health Care Flourishes in the Caribbean Barbara Jamison
78. ^ Acupuncture in a Cuban Hospital
79. ^ Cuba IPV Study Collaborative Group. Randomized, placebo-controlled trial of inactivated poliovirus vaccine in Cuba. N Engl J Med. 2007 Apr 12;356(15):1536-44. Free full text [PMID 17429085]
80. ^ Cuba vaccine deal breaks embargo, BBC, July 29, 1999
81. ^ ^{a b c d e f g h i j} Katherine Hirschfeld (July 2007). "Re-examining the Cuban Health Care System: Towards a Qualitative Critique". Cuban Affairs 2 (3). http://www.miscelaneasdecuba.net/media/pdf/Article-Hirschfeld-Press.pdf. 
82. ^ ^{a b} Keeping Cuba healthy BBC online. 1 August 2006
83. ^ Cubans Show Little Satisfaction with Opportunities and Individual Freedom World Public Opinion. 10 January 2007
84. ^ http://www.pbs.org/wgbh/amex/castro/sfeature/sf_views_uriarte.html "The Right Priorities: Health, Education, and Literacy. Views on Cuba.
85. ^ Student British Medical Journal
86. ^ Learn from Cuba, Says World Bank World History Archives. May 2001
87. ^ ‘Sicko,’ Castro and the ‘120 Years Club’ The New York Times. May 27, 2007
88. ^ Cuban Healthcare: First World Results on a Third World Budget The Guardian, London. Sept. 12, 2007
89. ^ CUBAN HEALTH CARE SYSTEMS AND ITS IMPLICATIONS FOR THE NHS PLAN. Select Committee on Health.
90. ^ Cuban Medicine Today by Dr Hilda Molina Center for a free Cuba - link fails 16.9.06
91. ^ El cuento de la Salud en Cuba, Publicado el 06.03.2005 11:32 Por Carlos Wotzkow, María Elena Morejón y Equipo Informativo de Gentiuno.com
92. ^ http://lasa.international.pitt.edu/Lasa2001/DunningThad.pdf
93. ^ Healthy in Cuba, Sick in America? John Stossel Takes on Michael Moore, Examines Government-Run Health Care By MELISSA SCOTT, Sept. 7, 2007.

External links

• Cubans Reap Health Rewards With Preventive Medicine Strategy - December 2010 Video Report by PBS Newshour
• Letter from Cuba Cuba: plenty of care, few condoms, no corruption. Hans Veeken, public health consultant, Medecins Sans Frontieres. BMJ 1995;311:935-937 (7 October)
• Cuba AIDS Project — HIV and AIDS in Cuba
• Apartheid in Cuba's Health system
• "Cuban Socialism Builds Model Health System" - Part I, II, III, IV, V by Workers World
• MEDICC Review An international journal of Cuban health and medicine