Thursday, May 25, 2006

Cuba: A Clean Bill of Health

Cuba: A Clean Bill of Health

For almost half a century now Cuba, the unapologetically communist nation led by Fidel Castro, has endured crippling economic and trade sanctions imposed by its next-door neighbour, the United States. But not only has this tiny Caribbean country survived, it's achieved close to the unthinkable. Over the years of its isolation, Cuba has made major medical breakthroughs and now has a health system that's the envy of most of its neighbours, including the mighty US. Here's Ginny Stein.

GINNY STEIN: In Cuba, appearances can be deceiving. This crumbling nation, one of the world's last outposts of communism, has struggled under economic sanctions for almost half a century, but while it may be one of the poorest countries in the Caribbean, its medical report card is now the envy of most of its neighbours.

DR JEANNIE ELLIS, PUBLIC HEALTH SPECIALIST: :Infant mortality rate, under-five mortality, maternal morbidity and mortality rate, life expectancy - all of these health care indicators are far better than any other country in the region. You know, this crazy situation - how has Cuba done it? How has Cuba achieved that? How have they managed, with such severe sanctions against them, to achieve that?

In Cuba, armed with little more than the absolute basics, even a facelift is possible - and it's free.

DR OSCAR, (Translation): Not in that direction. Let's go up.

DR VIVIAN, (Translation): Not in that direction..

DR OSCAR, (Translation): You see the wound is like this. Then you cut it here and here.

Today Maria Elena Yena is having plastic surgery to remove a scar from her neck. But this is not an operation for the faint-hearted patient - Maria is wide awake. In more affluent nations such a procedure would be done under a general anaesthetic. The only pain relief here is administered locally.

DR OSCAR, (Translation): Your nasal lines are already gone. Before that you had a hole and now its gone.

Three hours after the operation began, and as other patients have come and gone, this procedure is coming to an end.

DR OSCAR, (Translation): You will feel a little bit dizzy now. You will feel first some pain in the left side. Because that is the side we operated on first. Patient: Of course.

Maria is just moments from going home.

DR OSCAR, (Translation): Let's sit you up. Hold onto this with your hand. When I tell you please open your mouth. Open it now. It's possible that this will feel very tight at night.

MARIA ELENA YENA, (Translation): This is where it feels tight.

She's pleased to have taken the first step in removing the scar from her neck.

MARIA ELENA YENA, (Translation): I am very happy. Before when I got dressed, and at the place I worked I need to look good. We work with foreign conductors and everybody should like nice, but the scar was very ugly.

General surgeon Dr Vivian Revilla Rodriguez says the surgery's success goes to show that a lot can be done with a little.

DR VIVIAN REVILLA RODRIGUEZ, GENERAL SURGEON (Translation): I think, there is no doubt that high tech plays a very big role but I think that this kind of medicine that we practice which is not that high tech helps us to use more traditional procedures and train us better. And after getting the experience in this low-tech environment when you find yourself in a high tech world you can cope better, you're very well prepared. Maybe this sort of primitive way of work helps I would say.

Despite the impact of sanctions, something appears to be working here, for it's not just its poor neighbours that Cuba has managed to surpass, in terms of basic health indicators. According to UNICEF, Cuba's infant mortality rate in 2005 was lower than the United States', and life expectancy rivals most developed nations.

DANIEL PURCALLAS, WORLD HEALTH ORGANISATION, HAVANA (Translation): Cuba has been preparing for this for decades. Cuba has more doctors per capita than any other country in Latin America, by a long shot, followed by Uruguay. I can't remember the exact figure right now, but it's around one doctor per 200 inhabitants. This is a terrific ratio in comparison with the rest of the continent....

Dr Jeannie Ellis is an Australian public health specialist who has lived and worked in Cuba.

DR JEANNIE ELLIS: Having worked in other countries, I don't know any other country where everyone in the community can walk to their local doctor. If they can't walk to the doctor the doctor will do a home visit because the doctor can walk to the house. I mean, that is amazing. I mean, not even in first-world countries is there - can I think of another system where that exists.

Dr Yamirka Estevez is one of Cuba's tens of thousands of doctors working at the country's first line of medical defence - as a neighbourhood family doctor. Right now she's on her way to see an elderly patient too sick and frail to make it to her clinic.

DR YAMIRKA ESTEVEZ, (Translation): Good afternoon, good afternoon.

A typical afternoon is spent making home visits, a pattern of health care carried out by family doctors across the country, even in rural areas.

DR YAMIRKA ESTEVEZ, (Translation): Can you please help her sit up, here in the bed so I can check her? You are sitting up. Perfect. How beautiful.

Fransisco Mena Cartaya, or Pancho as he likes to be called, has been caring for his wife with the help of their son since she became ill with diabetes.

FRANSISCO RODRIGUEZ MENA CARTAYA, (Translation): I called her this morning and now you see they are here. They always come very fast. There is no delay. They give the best attention. I cannot complain.

He's a loyal cadre, or 'historico', as the elder generation of Cubans who were alive at the time of Cuba's revolution, are called.

FRANSISCO RODRIGUEZ MENA CARTAYA, (Translation): Money? Money? No. No. Even medicine, that is free in Cuba. No everything is free. Who said that it cost money?

He's full of enthusiasm for his country's health care system.

FRANSISCO RODRIGUEZ MENA CARTAYA, (Translation): I believe according to what I know, the health system like we have in Cuba, there is no place in the world with such a system. I can guarantee that. I have been in the United States. My mother was there and she died there. And I saw things there I did not like. I did not like them. When you go to a hospital if you don't have money you will die.

In Cuba, free access to health care is more than just an expectation - it's considered a birthright. Dr Yamirka is optimistic her patient will recover.

DR YAMIRKA ESTEVEZ, (Translation): I have recommended what we call home care, which is given to those patients who need to be followed up in their treatment. The proper treatment has been set out and she should recover fine.

She's proud of her profession, but in a country where Cuban doctors are paid as little as $10 a week, this was one question she was not comfortable answering as government minders stood by.

REPORTER, (Translation): Does it matter to you that you don't make that much money?

DR YAMIRKA ESTEVEZ, (Translation): It's better I don't answer that question.

When Fidel Castro seized power in Cuba in 1959, half of the country's doctors fled overseas, but the nation's health system and its level of education have since become much-flagged cornerstones of the Cuban revolution. President Castro once decreed that if Cuba ever surpassed the United States in public health it would be Cuba's historical revenge for decades of hostility and sanctions, which target medicines, medical technology and medical information. In Cuba, the cold war is alive and well.

SPEAKER AT RALLY, (Translation): Bush keeps saying “I am a war time President” to justify increasing his control.

Today the 79-year-old leader is once again trading punches with his archenemy, the United States, this time in retaliation against moves to adorn its mission with electronic tickertape relaying news from the outside world into this highly censored state, a move that's earned the US's newly-arrived envoy a nickname.

REPORTER: You've been labelled 'the little gangster' by the President. It's obviously a term that doesn't particularly concern you? Is it what you expected?

MICHAEL PARMLY, US SPECIAL INTEREST OFFICER, HAVANA: Oh, I think at this point I've come to expect almost anything from this regime. I'm not surprised by anything from this regime.

These flags are being raised in what was once the car park of the US mission to block the messages from public view and to honour victims of what it considers US-sponsored violence against Cuba. The United States is standing firm by its policy of imposing wide-ranging economic sanctions, which also target the health sector.

MICHAEL PARMLY: The aim is to not provide resources to a totalitarian regime - it's that simple. In a country where the economy is 95-98% state-controlled, state-owned, any money that comes into the country is going to go - 95, 98% of it - to the state apparatus, it's not going to go to the Cuban people.

The United States remains the world's largest medical market. All major pharmaceutical companies vie for business there and to deal with Cuba could be costly. So, unable to import medicines, Cuba started to make its own for use at home and to sell overseas. Using more than US$1 billion in state funding, Cuban scientists' biggest success so far has been its hepatitis B vaccine.

REPORTER: How many countries are you selling that to?

DR MANUAL RAICES PEREZ-CASTANEDA, CENTRE FOR GENETIC ENGINEERING AND BIOTECHNOLOGY: We are commercialising hepatitis B to many countries, more than 44 countries, in fact.

Last year biotech exports doubled to US$300 million - a major boost to Cuba's health budget. Manuel Raices Perez-Castaneda is a research scientist turned business executive at one of Cuba's largest biotechnology institutes.

DR MANUAL RAICES PEREZ-CASTANEDA: We receive an investment of US$1,000 million in the '90s, and with all the product we have generated we have paid back already all this investment and we are working right now in positive cash flow.

DR JEANNIE ELLIS: I guess, as the saying goes, adversity is the mother of creativity and it's true - Cuba has had to, in the face of adversity, invest heavily in biotechnology to develop their own vaccines. Cuba develops its own vaccines and then sells those vaccines to other, poorer countries for a cheaper price than they would have to buy vaccines on the international market that are produced by big pharmaceutical companies from the United States.

There's no doubt that Cuba's medical achievements have won it kudos at home and abroad, but it's the training of thousands of international medical students for free that's marking Cuba's stamp on the region.

DR JUAN CARRIZO ESTEVEZ,LATIN AMERICAN MEDICAL SCHOOL DIRECTOR,(Translation): This project is totally free. This is a gesture of solidarity on behalf of Cuba that follows the ethics set down from the start of the Revolution. In Cuba, education is free and it's the same with those countries we have training agreements with. In this school nobody pays anything. Everything is paid for by the Cuban government.

The Pan American Medical School is the brainchild of President Castro. More than 12,000 students are currently studying here. They come from as far a field as East Timor. A 6-year, all expenses paid study program aimed at mass producing doctors for the developing world. The first class graduated last year and have now returned home to work, a condition of the course.

DR JUAN CARRIZO ESTEVEZ, (Translation): I think it is remarkable how far this project, the Latin American Medical School will reach in the future, In ten years from now we will have trained between 100,000 and 150,000 students.....

This is medical diplomacy at work, though it's not something the school's director will admit.

DR JUAN CARRIZO ESTEVEZ, (Translation): We don't use that term. I think that Cuba in a very humble way in the name of solidarity contributes to the world by sharing what we have and not just what we have leftover.

Nakita Thomas is a second year medical student. She's one of a group of 70 from the United States.

NAKITA THOMAS, THIRD YEAR MEDICAL STUDENT: The majority of people that are here are from immigrant parents and from cities that are under-represented you know, on the poorer end of the class system, I guess you can say, so on that level we are majority, minorities in the States - of colour, Latinos, African Americans, Caribbean Americans.

It may be illegal for American citizens to visit Cuba but there's a legal loophole when it comes to studying for free. But it's not just medical knowledge she'll be taking home.

NAKITA THOMAS: The thing that I am actually very, very pleased about is the lessons that I am learning outside of the classroom, actually. I mean, I come from such a place that is so filled with consumption and individuality and to come to a country where it's more about me, my brother, my sister, helping - not more of just me, mine and what I can get - and learning that a lot of the things that we have in the States is really not necessary. Here I am doing without and I am fine.

Cuba itself currently has one of the best doctor to patient ratios in the world and its own training programs are producing surplus doctors. Like most of the students here, Denet Fontane Alvarez is set to graduate in a few years time and her first posting will probably be overseas.

DENET FONTANE, FIRST YEAR MEDICAL STUDENT,(Translation): I like to help the needy, not only from Cuba but from other countries. It is a beautiful career, a very human one, a selfless career which aids anyone who needs help. First you have to like medicine, it is a career that demands a lot of effort and sacrifice and dedication. And I said you need to like medicine. In Cuba we have the opportunity that anyone who likes medicine has the door open to them.

The United States sees the export of Cuba's medical missionaries in a different light.

MICHAEL PARMLY: The trade-off being - OK, we will send doctors to your country, we will take patients from your country but we expect your support on UN votes, we expect your support on economic issues around the world, and that's the payment that's made.

Cuba's overseas medical corps now numbers more than 27,000. It has dispatched doctors across Latin America, with Venezuela being the largest recipient. Cuba's deal with Venezuela swaps doctors for oil. Cuba gets 90,000 barrels of oil a day for the next 15 years - a cut-price deal on oil reported to be worth up to a billion dollars. In return, Venezuela gets more than 22,000 Cuban doctors.

DR JUAN TRAINA, CENTRE OF STUDY ON THE CUBAN ECONOMY, (Translation): The agreement with Venezuela, or at least the public agreement with Venezuela, is that Cuba supplies services to Venezuela and not only medical services. A common account has been established in which it compensates Cuban imports with Venezuelan services. I don't have an exact figure of how much money does Cuba make out its doctors in Venezuela, but a part of this money is used to pay for the oil. But I sustain that the most important thing here is the stability of supplies of oil from Venezuela to Cuba.

There is no doubt that medicine in Cuba is now big business. Revenues raised across the health sector now rival those generated from tourism. Cuban authorities are reluctant to release official figures, but government economist Dr Juan Traina says figures released last year give an indication of the worth of the health sector.

DR JUAN TRAINA: Around 2 billion, 2.5 billion, maybe.

REPORTER: And the tourism sector?

DR JUAN TRAINA: It is the same figures.

And now Cuba has combined its health and tourism sectors, profiting from medical tourism. Scores of Venezuelans are lining up for free eye surgery in Havana as part of the two nations' medical care-for-oil deal.

DR ALBERTO BARRIENTOS, EYE SURGEON,(Translation): Be careful. Don't lean on this. Move closer.

REPORTER: Where is he from?


Not all patients get this for free. Medical tourism has become a nice little earner for Cuba at this state-run hospital for foreigners.

ELIZABETH RAMOS SANCHEZ, COMMERCIAL DIRECTOR, CAMILO CIENFUEGOS (Translation): The clinic has 62 rooms. It's running at full capacity. Having lots of our patients under day care is part of our strategy. We also have patients in hotels. That's the reason why we ask patients to send their records in advance. The clinic is now totally packed.

Matthias Cuno is following the lead of his uncle in coming to Cuba from Germany to seek treatment for retinitis pigmentosa, or tunnel vision.

MATTHIAS CUNO, INTERNATIONAL PATIENT, GERMAN (Translation): My uncle also had the disease. Its genetic. My uncle came to Cuba for the treatment. We found out about this clinic through the television and from other sources. After he received the treatment I decided to come here. I came last year for my first operation. And now this is my second trip to follow it up.

The United States - a nation where medicine is very much big business - has responded by accusing and condemning Cuba for attempting to do the same.

REPORTER: Why is health and medicine targeted?

MICHAEL PARMLY: Because medicine has a humanitarian aspect and it has a business aspect and so what we are targeting is the business aspect, and so much of what Cuban medicine is, is a business. It has nothing to do with the humanitarian side - you know, the Hippocratic oath and curing someone who is sick. It's about business and it's about cold, hard business.

Cuba's health system has evolved out of necessity. The battle to beat the sanctions is a constant in everyone's lives, but there is also hope that if the US ever eased or dismantled its economic blockade, increased prosperity would flow to all.

DR JUAN TRAINA, (Translation): And I am convinced that if the United States were to lift its sanctions against Cuba many Americans would come to Cuba to get treatment and to solve their health problems because they are not covered by medical insurance. And Cuba would become a cheaper option, offering even better than what is available to them in the US.