A delegation of 51 American College of Surgeons (ACS) leaders visited Cuba this spring in an effort to strengthen ties with surgeons of the island nation. This article offers some general observations on Cuba and its health care system, followed by more detailed insights into what the delegation learned during meetings with leaders of the Cuban health care system. It also describes the needs of Cuban health care professionals and outlines ways the ACS can help.
Cuba is a study in contrasts—contrasts between expectations and the facts on the ground. Although it is a resource-rich environment, it can feel constrained, even austere.
The average salary is approximately 700 pesos per month, equal to about $30 U.S., although health care, education, and housing are provided by the Cuban government. Some Cubans clearly have more financial means than others, yet this society seems to be remarkably class free.
The iconic sights of the Cuban experience are most evident in Havana with the Malecón and old-world charm of a crumbling infrastructure that is kept together with baling wire and duct tape. The Cubans celebrate their people and their heritage, including the 1959 revolution—which they say improved the way of life for most Cubans—and its leader, Fidel Castro, as well as cultural touchstones such as vintage cars, rum, cigars, music, and Ernest Hemingway.
The Cuban people attribute any shortages of goods and services largely to the U.S. embargo that has been in effect for more than 50 years and makes trade with the U.S. impossible and the purchase of American-made innovations unaffordable. As a result, medical supplies and medications are often expensive and in limited supply, and many medical devices are old and outdated. Nonetheless, the Cubans have developed an efficient health care system that functions at a national level with apparently excellent results. Ensuring access to quality health care is a big part of the Cuban government’s commitment to its people.
However, a range of health care-related challenges face Cuban health care providers. Cancer is the leading cause of death in Cuba, and thus a priority area of research is cancer care augmented with radiation therapy equipment and positron emission tomography/computed tomography scanners. At present, these services are available only at a few centers. Medication for pediatric cancer care is unavailable, and due to a lack of staplers, anastomoses are done mostly with sutures. Lung transplantation is impossible because of the lack of access to organ preservation solutions. Notably, there is interest in developing robotic surgery.
Health care training also is an export commodity and part of the foreign policy of Cuba. Health care professionals from all over the world, including the U.S., train in Cuba. Many of these students come from low-income communities in their respective countries and are trained free of charge. Medical teams are sent to disaster areas gratis or as purchased services. The country’s international “medical brigades” travel around the world to provide relief services. For example, Cuba sent 85 physicians to West Africa in 2014 during the Ebola outbreak, two of whom died after contracting the disease. Surgeons also traveled to Haiti after the earthquake in 2010.
For the most part, health care starts in the community with a physician/nurse/health care technician primary care provider (PCP) triad, which provides the core of a tiered system of care. PCP triads are embedded in the community and the health care professionals who comprise it often live in the same housing complexes or neighborhoods as their patients. Each triad is responsible for the care (including preventive health) of approximately 1,500 residents. This structure is what is called “tier 1 care,” or the most basic care. Groups of 15 to 20 triads are linked to a community-based polyclinic, which offers specialty care and more sophisticated imaging and lab testing. The entire community-based polyclinic and its dependent triads provide what the Cuban health care system recognizes as “Level 1 care.”
Commodity surgical services, including acute care surgical services, are provided in district hospitals—known as tier 2 centers. Some more specialized services are offered regionally, as needed. High-level tertiary and quaternary specialized services, such as advanced minimally invasive surgery (MIS), trauma care, transplantation, and hepato-pancreatico-biliary surgery, are centralized in Havana at several tier 3 hospitals. Transfer of patients for higher levels of expertise is based on protocols and is at the discretion of local physicians and surgeons.
Patient records are paper-based due to the lack of computers in Cuba. Electronic health records (EHRs) are expected in the future but are not yet available. Decisions on physician- and nurse-training class size and clinic and hospital bed distribution are made centrally, based on input from experts at local sites across the 15 provinces of Cuba. Similarly, these educational and health care paradigms are replicated in each of these provinces.
The health care specialists with whom we interacted are proud of the system in which they work and their role in it. They seem supportive of the way it has been organized and staffed. They take their work seriously and care deeply about the quality of care they deliver. We heard of multiple levels of quality review and oversight, similar to North American systems.
Cuban Surgical Society
The first morning in Cuba, we met with leaders of the Cuban Surgery Society (CSS), including Manuel Cepero, MD, president; Simon Antonio Collera, MD, vice-president; and Armando Leal, MD, secretary. They provided us with a general overview of the organization and the Cuban health care system.
The CSS has 16 chapters, and more than 90 percent of Cuba’s 1,200 surgeons are members. Each chapter of the CSS has a focus area of work or research. MIS surgery is the most technologically advanced area, followed by transplant surgery. Examples of areas of research include hernia and breast surgery. Once the areas for development are identified, physicians are sent to international centers to learn techniques. The Cuban Ministry of Health has a relationship with more than 160 countries in Europe, Africa, and Asia.
Surgical training in Cuba
We gained insights into the surgical training process during our visit. Like all forms of education in Cuba, surgical training is free, given at a high level and at low cost to the government. It is financed by the Ministry of Public Health (Ministerio de Salud Publica). Surgical residents train across the country in the specialties identified by the ministry as having the greatest need.
After six years of medical school, surgeons undergo four years of general surgery training, which includes three core rotations: obstetrics/gynecology, pediatric surgery, and trauma. Residents are in the operating room (OR) from day one and given graduated responsibility under supervision. Each resident has a training tutor and a residency tutor and is expected to complete a set number of procedures annually. Achievement of these milestones is required to be eligible for annual exams that determine if a resident moves on to the next year.
At the completion of training, residents must present a thesis based on the needs or focus area of their parent hospital and district. Residents also must undergo an examination that is given at a center other than where they trained. After training and successful passage of the examination, surgeons may begin practice under supervision of a senior mentor.
Between 40 and 50 surgeons enter practice each year. At present, 14 percent of all surgeons are women, but certain specialties, such as plastic surgery, have more women in practice. Many Cuban surgeons are from one of the 160 South American, African, or European countries with which Cuba collaborates. Cumulatively, 145 U.S. surgeons have graduated from Cuban medical schools. Although initially all international medical students trained for free, with a requirement that graduates return to deliver services in their community, foreign students now must pay $15,000 to $20,000 per year or $180–$250 per week for shorter training periods. These fees are usually covered by the countries of origin but sometimes they are paid by individuals. At present, 85−90 foreign students are training in Cuba—10 on scholarships.
The leaders of the CSS expressed strong interest in pursuing the following opportunities:
- Collaborating with U.S. medical schools and with the ACS in training and research
- Finding U.S. residency positions for Cuban medical school graduates
- Gaining fair access to technology, pharmaceuticals, and equipment
- Reducing restrictive banking, credit, immigration, and international commercial regulations that they believe disproportionately disadvantage Cuba and the Cuban health care system
Next, the College delegation met with representatives of Instituto Cubano de Amistad con el Pueblo (ICAP), which was established in 1960. ICAP interacts with more than 150 countries and more than 2,000 organizations in supporting innovative approaches to trade and education, such as the Latin American School of Medicine, which has graduated more than 100 African students. This organization helps navigate investments, business transactions, legal issues/interpretations of laws, and donations to various programs.
ICAP representatives offered a plea for closer ties with diverse groups in the U.S., including the ACS. They provided more details about how the embargo affects Cuban commerce, particularly the health care system’s ability to offer advanced clinical care and to pursue research and educational opportunities. Our Cuban counterparts stressed that any differences they have with the U.S. are with the American government and not its citizens.
Cuban Ministry of Public Health
The ACS delegation’s second day in Cuba began with a meeting with representatives from the Cuban Ministry of Public Health, including Aldo Grandal, MD, Executive Director, International Relations, who provided us with a history of the Cuban health care system. Dr. Grandal explained that before the revolution in 1959, Cuba did not have a national health care system. Mr. Castro, the leader of the revolution, wrote of deplorable health care in Cuba in his book La Historia me Absolverá (History Will Absolve Me), which he wrote in 1953 while he was in prison. Under his leadership, the Cuban constitution includes an article that establishes health care as a right, and Law 41 specifies that health care for all Cubans without regard to social class is the responsibility of the government. Thus, medical care is free for all inhabitants. We also learned that pregnant women are cared for in a standardized and state-of-the-art way to reduce premature births and guard against the costs associated with providing neonatal intensive care.
Today, the overall life expectancy for a Cuban citizen is 79. Cuba has 13 medical schools, and 19 percent of its gross domestic product goes to health care. According to the physicians with whom we met, national efforts at organizing and coordinating systems of care have significantly improved the health of the public. In 2016, Cuba had 85,563 physicians providing care throughout the country. In a 50-year time span, the infant mortality rate dropped from 60/1,000 to 4.3 per 1,000. Today, infant mortality in Cuba is one of the lowest in the world.
National areas of health care focus include control of communicable and infectious diseases, rural health care, national health status information, and sanitation from a public health standpoint. Over the last 56 years, polio, small pox, rubella, diphtheria, and neonatal tetanus have been eliminated. Human immunodeficiency virus (HIV), meningococcemia, hepatitis B, and rabies are controlled thanks largely to a mandatory vaccination program. Special discussion was made of the Heberprot-P vaccine, a Cuban development with a 70–90 percent success rate in healing diabetic ulcers and reducing amputation.
With respect to safety and quality of inhospital care, the goal is to achieve international standards. To this end, systems and rule changes are being put in place and health care professionals who are noncompliant are subject to disciplinary measures.
The Ministry of Public Health has developed a financial model to support the Servicios Médicos Cubanos, through which physicians offer medical assistance to other low-resource countries. Volunteer surgeons go on medical services trips that can last up to three years. These are done in rotation. At present, 51,000 Cuban health care professionals are working in 67 other countries; 28,000 are physicians.
Hermanos Ameijeiras Hospital
During our meeting with the CSS described earlier, we learned more about the tiering systems for hospitals in Cuba. Stage 3 hospitals offer standard general surgery procedures. Stage 2 hospitals offer more specialized care but do not perform thoracic procedures. Stage 1 hospitals offer all types of surgical care, including cardiac and thoracic procedures, and transplantation. After the meeting with the Ministry of Health, we visited Hermanos Ameijeiras Hospital (Hospital Clínico Quirúrgico Hermanos Ameijeiras), a Stage 1 hospital in Havana, where we met with a general surgeon, an MIS surgeon, a thoracic surgeon, a cancer surgeon, the surgical intensive care unit and transplant coordinator, and the chief of transplant surgery.
The Hermanos Ameijeiras Hospital opened in 1982 and now has 42 different clinical service areas that are managed by protocols, similar to care maps or pathways. The hospital has the resources to offer CT and magnetic resonance imaging, digital subtraction angiography, and ultrasound services.
Surgeons perform more than 20,000 operations per year at this institution, which houses three intensive care units (ICUs)—burn, cardiac, and stroke. More than 1,000 patients receive care in the hospital’s clinics per day, and all services are available daily, except obstetrics, gynecology, and pediatrics, which are provided three times a week.
At present, 500 residents of all specialties train at the Hermanos Ameijeiras Hospital, and 50 percent of these residents are international medical school graduates. Surgical services at this facility include transplant surgery, hepato-pancreato-biliary, thoracic, gastrointestinal, and other procedures. This was the first hospital to offer MIS in Cuba.
In 1986, the first liver transplant at the hospital was performed after Jose Antonio Copo, MD, trained in Pittsburgh, PA, under the tutelage of Thomas Starzl, MD, PhD, FACS. Notably, Cuba has a national program for organ retrieval, including nascent living-related donor and pediatric transplant programs. Donor rates are 12 per 1 million population, and donor livers are in scarce supply. Nonetheless, technology is the principal limitation preventing expansion of the transplant program, particularly the lack of preservation solutions and coagulation/hemostatic tools.
In addition, surgeons at the Hermanos Ameijeiras Hospital perform 20 to 25 Whipple procedures annually, for a cumulative total of 179 in the past 10 years. More than 100 liver tumor resections are also performed at this hospital each year.
Wait times for elective surgery can be long—up to a year for a hip prosthesis. Surgical cases are only sent out of the country if no facility in Cuba has the necessary resources. These decisions are made by the Ministry of Health, since the ministry covers the costs of all health care services for the Cuban people, regardless of where they undergo treatment.
Plastic surgery covers a range of services, including burn care, microsurgical reconstruction, craniofacial surgery, and implants. The hospital has 13 faculty in plastic surgery, each responsible for a group of up to 10 residents. At present, plastic surgery has 40 residents; four are women, and only two are Cuban.
Quality is tracked by many mechanisms. We learned that 10 percent of surgical cases are audited for necessity. Procedure (care map) manuals are kept up-to-date, and health care professionals are expected to follow these protocols when delivering care. Pathology, infection control, trauma, and other committees track short-term outcomes using objective measures that are then discussed at a service chief’s meeting.
Centro Nacional de Cirugía de Mínimo Acceso
On day three, the ACS delegation toured Centro Nacional de Cirugía de Mínimo Acceso with our host, C. Julian F. Ruiz Torres, MD. This institution focuses on MIS operations, though some of these procedures are performed at 118 other sites in Cuba, including every hospital. The Centro Nacional, completed in 2016, is the only dedicated MIS center in Cuba, however.
Centro Nacional has four ORs and suites for performing procedures such as endoscopy. This facility also houses two dedicated gastrointestinal (GI) bleeding rooms, and two endoscopic retrograde cholangio-pancreatography (ERCP) rooms, a four-bed ICU area for complex postoperative care, and a total of 47 staff physicians. These surgeons perform 15–20 general surgery, otolaryngology, neurosurgery, and gynecology operations each day and 15 ERCP cases per week.
Advanced procedures include bariatric surgery, MIS pancreatectomy, adrenalectomy, total colectomy, low anterior resection, myotomy for achalasia, and anti-reflux procedures. A transmission electron microscope is available for specialized pathology.
Young surgeons from all over the country train at Centro Nacional, using animal models, and their skills are verified before they start providing clinical patient care.
The tour included Centro Nacional’s soon-to-open state-of-the-art training and simulation center. We observed what appeared to be technical proficiency and a high degree of skill in the surgeons, demonstrated via their leading edge audio-visual network. All four ORs are networked through a control room, with audio-visual signals forwarded to training conference rooms.
Universidad Ciencias Médicas de La Habana
Next, we visited the Havana Medical Sciences School, Universidad de Ciencias Médicas De La Habana, where we learned more about surgical education in Cuba. Oliver Peres, MD, president, scientific committee, and head of immunology, and Enrique Cabrera, MD, were our hosts.
After the revolution, Cuba was left with only slightly more than 300 physicians, most having left for the U.S. Consequently, the overall health care reform effort included a strong medical education component. Today, Cuba has 13 medical schools with more than 2,000 professors and more than 5,000 students in training, including students from abroad at the Latin American School of Medicine. These are open-entry schools with elimination testing. The curriculum focuses on integrating cognitive and skills, early interaction with patients, and preventive medicine. Each graduate must take licensing exams.
To expand the opportunities for medical education, the Cuban surgeons who we met would appreciate the opportunity to attend the ACS Clinical Congress and to participate in educational conferences and residency training.
Calixto García Hospital
As we learned during our meeting with the Ministry of Public Health, automobile collisions, accidents in the home, industrial accidents, falls, and other unintentional traumatic injuries are the fifth most common cause of death in Cuba. Hence, the third day of our trip also included a visit to the Calixto García Hospital (Hospital Universitario General Calixto García) traumatology services. We toured the emergency department (ED) and ICU. Our guides were the president of the trauma division, the first deputy director, and the training director. We met other members of the staff in charge of international relations, research, ED, the coordinator of trauma, the surgeon-in-chief, and the Advanced Trauma Life Support (ATLS®) program coordinator.
Founded in 1896, Calixto García Hospital is a top-tier facility, offering the full range of services. The hospital is responsible for a population of 483,000 in a district of Havana. The hospital complex covers 13 hectares, with each specialty having its own pavilion. Calixto García Hospital houses 23 ORs and offers care in 37 specialties, 28 of which are certified for teaching.
The hospital’s main focus is on trauma, surgery, and care of the seriously ill patient—in other words, acute care—offering training in 28 health care specialties. It is not the only trauma hospital in Cuba. In fact, trauma surgery and care are provided across the country at hospitals in each province.
Trauma patients may be transported by family or ambulance. Ambulances are staffed by nonmedical transport personnel who have limited capability to treat a trauma patient. On arrival at the hospital, trauma teams are led by a surgeon.
Calixto García Hospital is growing; in 2016, surgeons there performed 3,016 major operations, almost double the 1,528 operations carried out in 2011. Cardiac surgery is only performed on an emergency basis. A number of U.S. surgeons have helped with training and development of services, including ATLS training. Training and development relationships with Michigan State, East Lansing; Stanford, CA; and Albert Einstein College of Medicine, New York, NY, in various specialties were highlighted. The staff appreciate this support and look forward to expanding it to other institutions with the College’s help.
The ACS delegation’s last visit was to the University Polyclinic (Policlinico Universitario)—one of seven polyclinics in Havana. Our host was Marisol Pio, MD, director.
Polyclinics like this one are the backbone of the Cuban national health care paradigm, as they are where patients receive primary care and referrals. The cornerstones of the polyclinics are prevention and rehabilitation, public health research, and assessment of frequency and intensity of visits for at-risk populations.
The University Polyclinic was established in 1984 and encompasses the triad of health care professionals mentioned earlier in this article: a family physician, a nurse, and a hygiene technician/epidemiologist in a group practice setting (including a professor). The emphasis is on meeting the unique needs of the surrounding population, conducting screening visits, performing house calls, and providing in-home care. This is a family practice model with training in integrated medicine, which includes pediatrics, internal medicine, psychiatry, nutrition, and epidemiology.
All patients live within a two-block radius, and the clinic serves approximately 1,500 people. The health care professionals at the clinic have office hours and make house calls. The health care professionals at the clinic live in the community they serve, and they are viewed as extensions of the family for many of the inpatients. Specialists, such as obstetricians, gynecologists, and pediatricians, visit every two weeks.
Polyclinic patients may receive referrals for specialty care, including internal medicine, obstetrics-gynecology, pediatrics, psychiatry, dentistry, social work, and so on. A staff statistician manages the data critical to the national health system and epidemiologic data.
In addition, the clinic provides around-the-clock emergency care, including immediate life support, observation, nursing, radiology (X ray and ultrasound), laboratory, dentistry, endoscopy, and ophthalmology services. It also offers vaccination, family planning, geriatric, HIV counseling, and advanced screening services.
This global health care and wellness approach has resulted in a significant decrease in infant mortality, earlier detection of prostate and GI malignancy, and the introduction of innovative treatment for diabetic foot infections. Heberprot-P is a locally developed vaccine which, in early studies in Cuba, has decreased the limb amputation rate by 85.4 percent.
Summary and next steps
The U.S. can learn much from Cuba about preventive care, the provision of cost-effective services, coordinated care, and the organization and prioritization of services based on national needs. This system, however, has had some challenges, including overproduction of physicians, nurses, and other providers, who are then rented out to other low-income countries. It is worth noting that some tertiary outcomes are weak. For example, the mortality rate for Whipple operations is 11 percent.
So, what can the ACS do to help? Members of the College can encourage and facilitate enrollment of Cuban surgeons as Fellows of the ACS—starting with the leaders of the CSS and of the Calixto García Hospital. The establishment of a Cuba Chapter of the ACS and its participation in a regional collective is another way the ACS can support health care providers in this country. Perhaps College leaders can explore ways to provide some of our ACS educational materials, including ATLS manuals, at low or no cost, possibly through the ACS Foundation.
The leaders of the ACS are committed to building a closer relationship with surgeons in Cuba. This relationship would benefit patients both in the U.S .and in Cuba.
The photos in this article are courtesy of Mr. Riojas and Lawrence W. Way, MD, FACS.