By David Blumenthal, M.D. President, The Commonwealth Fund
Twitter: @commonwealthfnd
Fidel Castro’s passing on November 25 is a vivid reminder of the outsized role that he and Cuba have played in the history and imagination of the United States. Over nearly 60 years, U.S. governments of both parties have repeatedly tried to assassinate Castro, and have invaded, sanctioned, and embargoed Cuba.
Yet, by objective standards, this island nation would hardly seem worth the trouble. Its population of 11.2 million is smaller than Ohio’s, its land mass about the size of Pennsylvania. Its gross domestic product (GDP) per capita ranks 137th in the world, behind Mongolia and Albania. On average, Cubans earn about $20 per month.
Why should a country this small and poor have so obsessed Americans for so long? The answer lies partly in Florida’s 29 electoral votes. That state’s fervently anti-Castro Cuban exiles and their offspring can make or break presidential campaigns. But the answer rests also in Castro’s personal charisma, cunning, tenacity, and longevity, which he used to fashion a socialist counterexample to the huge, fiercely capitalistic neighbor 90 miles to Cuba’s north.
There are many deplorable aspects to this counterexample. Cuba is a one-party state that imprisons dissidents and controls its population’s access to outside ideas. Castro’s stewardship of the Cuban economy has been rigid and dysfunctional in its opposition to private enterprise, and partially accounts for the island’s poverty.
But there are also some much more positive sides to the Cuban experience. One of these—its health care system—was on display when I visited the country in mid-November with a delegation of American health care experts led by Michael Leavitt, the former Republican governor of Utah and secretary of health and human services under President George W. Bush. When it comes to health care, Cuba is a success story with few parallels.
Since its 1959 revolution, Cuba’s infant mortality rate has fallen from 37.3 to 4.3 per 1000 live births—a rate equivalent to Australia’s and lower than the United States’ (5.8). From 1970 to 2016 life expectancy increased from 70.04 to 78.7 years, approaching expectancy in the United States (79.8). Cuba’s leading health care problems—non-communicable diseases such as heart disease, cancer, and stroke—are typical of much more wealthy countries.
Cuba achieved these successes despite the trials of what it euphemistically calls its “special period” (lasting much of the 1990s) when its GDP dropped precipitously by a depression-equivalent of 35 percent. This downturn resulted from the collapse of the Soviet Union and Cuba’s loss of its economic subsidies. The average Cuban shed 25 to 35 pounds because of food and fuel shortages during the special period. Cuba has also had to contend with the crippling U.S. embargo that restricts access to many drugs and medical devices.
By almost all accounts, Cuba’s health care achievements directly reflect the decisions of Fidel Castro. The Cubans we met consistently reported that Castro personally prioritized two services: education and health care. While these reports may reflect the Cuban party line, there is objective evidence reflecting these investments. Cuba’s literacy rate is 99.8 percent (some health care personnel actually complained, tongue-in-cheek, of how knowledgeable and demanding their patients are). The nation’s commitments to health care are also widely apparent.
Cuba spends about 10 percent of its GDP on health care. Services are free and funded by the state. Its delivery system prioritizes primary care and public health, and extends into virtually all the island’s communities. The system operates at three levels. At its base is a network of almost 13,000 local family practices and 451 polyclinics that offer general and specialty care. Family practices consist of a physician and a nurse who live in the communities they serve. Each practice is responsible for between 1,000 and 1,500 patients, and physicians are required to visit every patient in their home at least yearly (or more often if indicated). For specialty services family practitioners send patients to the polyclinics, which also organize public health services.
The next level of service is the island’s 151 community hospitals that dispense secondary services. A third level of service consists of 12 institutes that offer highly specialized care, and participate in teaching and research.
Cuba’s investments in health care go beyond direct services and reflect Castro’s evident belief in health and biomedical science as long-term mainstays of the Cuban economy. Cuba has trained a surplus of physicians in its 13 medical schools, and sends 50,000 health professionals, including 25,000 physicians, abroad annually to provide care in developing countries. Recently, it has begun charging for these services, making health care an export equivalent and a source of scarce foreign exchange.
Cuba has also invested in biomedical research. We visited research centers specializing in biotechnology, genetics, and cancer immunology that have patented new treatments for diabetic foot ulcers and lung cancer, among others. While not large or sophisticated by first world standards, Cuba’s research investments are unusual for a nation of its modest wealth, and have produced pharmaceutical exports that are another source of foreign currency. According to Cuba’s ministry of foreign trade, medical products and services, including physicians practicing abroad, pharmaceuticals, and medical tourism, account for 70 percent of Cuba’s export revenues.
Now that Fidel Castro has passed on, history will long debate his complex legacy. From a health care standpoint, however, Cuba has demonstrated that a poor country can dramatically improve the health of its population through long-term, consistent investments in primary care and public health. Even if those investments depended on the authoritarian rule of a long-reigning communist dictator who made many other errors, Cuba’s example shows what very basic health care services can accomplish when the political will to apply them exists.
This article was originally published on The Commonwealth Fund Blog.