Training the 5-Star Doctor: Medical Education in Cuba

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Training the 5-Star Doctor Medical Education in
Cuba

• Richard Quint, MD, MPH
• Health Sciences Clinical Professor (Emeritus),
  UCSF
• Medical Education in Cooperation with Cuba
  (MEDICC)

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Brief Chronology

• 1959 Bautista overthrown
• 1960 Land reform and health system changes
• 1961 Literacy campaign Playa Giron invasion
  (Bay of Pigs) U.S. initiates trade embargo
• 1989 Soviet bloc dissolves
• 1989-1995 The special period Tightening of
  the embargo
• 2000 The Elian Gonzalez affair
• 2005 Travel restrictions tightened
• 2009 What will Pres. Obama do?

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Health in Cuba Pre-1959

• Infant mortality gt 50/1000 live births
• Maternal mortality 125/100,000
• Life expectancy (1960) 65.1 years
• Private medicine urban centers
• Poor nutrition
• Clean water available to 35 of population
• Gilpin, 1991

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Health Care After 1959 Operational Principles

• Peoples right and a responsibility of the state
• Integration of preventative and curative services
• Universal accessible and free
• Coordination of health care, social services, and
  socioeconomic development
• Popular participation is fundamental
• Ministry of Public Health (MINSAP)

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Conceptual Model of the Influences on Health in
Cuba
Health Service Determinants Accessibility
Universality Comprehensive Quality
Horizontal integration Focus on primary care
Health promotion focus
Non-Medical Determinants Education Housing
Sanitation Clean air Nutrition Employment
HEALTH OUTCOMES
Social Mediators Social cohesion Income
disparities
J. Public Health Policy, 2004
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Basic Health Expenditures (2008)

• Country GDP Per Capita (US)
• Canada 9.6 3,500
• Cuba 7.5 322
• Mexico 6.1 379
• USA 15.6 gt7,000

WHO, 2008
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Life Expectancy

• 1970 2000 2006
• Canada 77 79 81
• Cuba 74 78 78
• Mexico 70 73 74
• USA 75 77 78

WHO, 2008
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Cuban Child Mortality Rates

• Year Neonatal Infant 1-4 years
• 1974 ------ 38.7 1.3
• 11.0 19.6 1.0
• 1990 4.6 10.7 0.7
• 1994 4.0 9.9 0.6
• 1998 2.8 7.1 0.5
• 2006 2.1 5.0 0.4
• per thousand
• MINSAP, 2008

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Infant Mortality Comparisons

• 1990 2000 2006
• Canada 7 5 5
• Cuba 11 6 5.8
• Mexico 42 32 29
• USA 10 7 7

WHO, 2008
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Immunization Levels (2006)

• Percent immunized
• Country BCG DPT3 Pol3
  Meas HepB3 HiB3
• Brazil 99 99 99
  99 97 99
• Cuba 99 99 99
  96 89 97
• Haiti 75 53 52
  58 NA NA
• Mexico 98 98 98
  96 98 98
• USA --- 96 92
  93 92 94
• UNICEF, 2008

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Maternal Mortality (2005)
Canada 7 Cuba 30.2 (2007) Mexico
60 USA 11
WHO, 2008 MINSAP, 2008
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HIV Prevalence (gt15 y.o./100,000)

• 2005
• Canada 222
• Cuba 52
• Mexico 244
• USA 508

WHO, 2008
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Developing the Infrastructure 1960-1969

• Price reductions, nationalization of private
  facilities, hospital and clinic construction,
  increase and improve water supply
• Rural medical service
• Polyclinics preventative and comprehensive
  services
• Professional training the Soviet model
• Community education the CDR and FMC

Gilpin, 1991
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Health Care in Cuba 1970-1979

• Dissatisfaction with hospital-based training
• 1974 Medicine in the community, a promotion of
  health maintenance and improvement concepts
• Polyclinics as teaching sites
• Hospital construction general and specialty
  centers
• Production of medicines and vaccines
• Gilpin, 1991

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Toward Comprehensive Care The Family Medicine
Program1980-1989

• Primary care emphasis
• New curriculum development
• Community-based primary care team MD and RN
• Continuing medical education for older MDs
• Secondary and tertiary care development
• Expansion of number of medical schools 25 in
  2009
• Gilpin, 1991

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A New Kind of Family Doctor

• RN-MD team in 95 of neighborhoods
• 120-150 families per locale
• Clustered around polyclinics
• Postings in factories, schools, day care centers,
  senior homes

MEDICC Review Vol 10 No 4, 2008
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The Family Physician as a 5-Star Doctor

• Caregiver physical, mental, social
• Decision-maker
• Communicator
• Manager
• Community leader

Boelen, M, WHO
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Educating the New Family Doctor1990- present

• Problem identification at local levels
• Introduction of problem-based learning
• Earlier introduction to clinical skills training
• Teaching aimed at service learning
• Family medicine departments in all medical
  schools
• Practical exams

Morales, IR et. al., MEDICC Review, Vol 10, No 4,
2008
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Educating the New Family M.D. Advantages

• Training in multidisciplinary teams
• Integration of clinical medicine with population
  health
• Earlier contact with patients
• More Family M.D.s trained (44 of total)

MEDICC Review Vol 10 No 4, 2008
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Educating the New Family M.D. Shortcomings

• Generalist approach taught largely by specialists
• Hospital-based clinical training predominated
• Bias against family medicine skills and
  capabilities

MEDICC Review, Vol 10, No 4, 2008
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Scaling Up for the 21st CenturyCuba and the
Developing World

• 2004-2005 75 of medical training focused in
  polyclinics
• 20,000-30,000 M.D.s needed ASAP for home and
  abroad
• Educating foreign medical students (ELAM)
• 2008 introduction of new curriculum
  morphophysiology

MEDICC Review, Vol 10, No 4, 2008
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Human Resource Development in Health Foreign
Graduates From Cuban Medical Schools1966-2003
Region Countries Medicine Dentistry Nursing Total
Americas 35 1316 120 0 1436
Africa/Mideast 44 1813 196 4 2013
Asia ? 133 16 0 149
Europe ? 50 16 0 66
TOTAL 3312 348 4 3664
Source Vice Ministry for Medical Education,
Ministry of Public Health, Havana
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Latin American Medical School Physicians
for Developing Countries

• 26 countries
• 9,679 students
• 101 ethnic groups
• 51 women

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Different from Previous Scholarships
Aiming for Sustainability

• Student selection poor, indigenous,
  marginalized
• Training geared to country of origin
• Looking for commitment to underserved
• Eventually replace Cuban doctors
  in-country

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FIN