HEALTH CARE OUTSIDE THE US
centers. We refer to such peer health workers as promotores in California. These outreach workers are collectively known as Committees to Defend the Revolution, but their primary role is overseeing the health of individuals within the neighborhoods they serve, as well as spreading information, preparing for natural disasters and serving as a community crime watch program. Privacy is less of an issue in Cuba than in the US – it appeared that everyone was involved in everyone else’s business in a way that reminded me of a small-town grapevine. This has its obvious plusses and minuses. Fifty such practices aggregate around a polyclinic, which has rudimentary laboratory, diagnostic imaging and treatment capabilities, and also serves as the educational center for the 50 practices. Specialists work either in the polyclinic or in hospital settings. The polyclinic also has a single computer with largely pirated and out-dated Microsoft Office software, and is used to manage populations of patients and profile physiciannurse teams. One half-day per week is spent meeting at the polyclinic to hold case conferences and morbidity and mortality reviews and to access mandatory CME. Each physician-nurse panel of 500 patients is divided and managed (dispensarization) into four groups according to risk: • Class I – Healthy: one office visit, one home visit • Class II – At risk: visits every six months office and home visits • Class III – Chronic condition: visits every three months office and home visits • Class IIII – Disabled: monthly office and home visits As the US approaches meaningful use, we can only aspire to manage the patients on our panels as comprehensively as do the Cuban physicians. The Cuban approach and results are made more impressive by the fact that when the USSR finally collapsed in 1993, cutting the Cuban Gross Domestic Product by 37 percent, there was no loss of quality in their health measures. Can you imagine what effect such a cut in the US economy would have on community clinics and poor people’s access to health care? The loss of Soviet support, coupled with the US
embargo, cut off access to most medications. The outpatient pharmacies have mostly empty shelves. Nevertheless, their chronic disease results match ours and their public health system is far more successful at reducing communicable disease than is ours. There are no cholera outbreaks in Cuba; HIV infection is exceedingly rare as well. How do they do so much with so little? The answers were right in front of us – lots of exercise simply getting around, no junk food and nobody homeless or starving or falling through the cracks of a system more interested in making money than in keeping the population healthy. Even medical students have a physical education requirement! No one is homeless, though housing is very crowded. No prescription drugs? Start producing herbal medicines as an alternative. No antiretrovirals for HIV/AIDS? Break the patent owned by the pharmaceutical industry and give out the life-saving drugs for free. In terms of the design of the medical system itself, they also employ a methodology well known to those who have participated in quality improvement efforts. The principal approach is as follows: • Build it from the bottom up • Register problem • Intervene • Evaluate • Follow-up We often refer to this approach as the “Model for Improvement,” and use “small tests of change” (or PlanDo-Study-Act cycles) as the basic methodology to find out what works on a small scale before spreading successful approaches widely. They use their weekly meetings to spread these ideas. The 17 years it takes a new evidence-based approach to become widely disseminated here US Hospice care is rare there. The government prides itself in doing whatever it takes to keep an individual alive, regardless of the probability of cure. There are obvious drawbacks to being a physician in Cuba, though we met a few American physicians who had moved to Cuba and were fully integrated into life there (and enjoying their professional and personal lives). There are also Cuba > 29 California Family Physician Spring 2011 21