Cuba is often cited as having one of the world's best health-care systems, with a life-expectancy level with the U.S. and a growth industry in health tourism in spite of years of tough trade sanctions limiting supplies. Complementary and Alternative medicine is commonly cited as one of the drivers of this impressive performance. But how much of this picture is real, and how much is myth? Do the millions of "alternative" pills being exported to other nations really work? And why are Big Pharm moving in?

Assessing Cuba's Health

The health system is one of the major talking points of Castro's Cuba. To understand why, we simply need to look at the W.H.O. indicators of the health of the island nations roughly 11m inhabitants [1].

On paper then, Cuba manages to achieve basically the same health outcomes as the United States, for 96% less money, while also providing universal free health care. Indeed, the U.S.A and Cuba are ranked 37th and 39th in world health statistics respectively [2]. Of course, [smug] medical care in the United States is mediocre and over-priced by British or European standards [/smug], but this is still an amazing achievement in a poor nation that has been under trade embargoes for half a century.

The obvious question to ask then: what is the reality on the ground, and how is it being achieved?

Michael Moore's "Sicko" appears to have raised a debate over in America about Cuban vs. American health care, with Moore and the left presenting the Cuban system as some kind of holy grail to aspire to [3], while right-wingers point out the inadequacies of country with little money or access to common drugs such as painkillers or antibiotics [4]. The reality (as usual in these debates) is a bit more subtle.

Really, the debate ends as soon as you actually look impartially at the numbers. The simple fact is that Cuba's health isn't particularly good in absolute terms, but outstrips virtually every nation on the planet when it comes to efficiency and value-for-money. The American system meanwhile appears to haemorrhage cash, even in comparison with Britain's NHS - health in the United States is poor by European standards, and barely any better than Cuba's [2]. There are also more complex issues to be taken into account - while Cuba's health outcomes are relatively consistant in all sections of the population, there are vast inequalities in the U.S. - infant mortality is 13.9 per 1000 live births for African Americans, while for whites just 6.4 per 1000 [5].

It's also important to realize that health tourists from the West may get a different impression to locals. Westerners paying cash are greeted with rich hospital-hotels equipped with minibars, gyms, cable television and stylish receptionists, but these hospitals are purely for making profit from tourists - standards elsewhere are somewhat lower.

Prevention is Better Than Cure
It's this oustanding efficiency and self-reliance that is worth looking at. As Spiegel and Yassi commented in 2004: "Cuba’s experience presents nothing less than a fundamental paradox or challenge to the assumption that generating wealth is the fundamental precondition for improving health." However "there has been remarkably little scholarship evaluating how Cuba’s successes have been achieved, let alone sustained during a period of extreme economic difficulty."

There is one obvious reason for Cuba's relative performance - the fitness of its population. In a nation without a heavy reliance on cars, Cubans walk several miles a day, making them considerably fitter than their Western counterparts to begin with, and therefore less prone to various diseases - obesity-related illnesses for example [7].

This complements Cuba's main strategy - prevention. As the Guardian notes: "From promoting exercise, hygiene and regular check-ups, the system is geared towards averting illnesses and treating them before they become advanced and costly." [7] Cuba's system isn't about treating the sick, it's about preventing sickness in the first place, which is far cheaper. A propaganda war has been waged by Castro's administration: "Posters... cast disease prevention as a patriotic duty. Just as George Bush is made to look sinister in posters with hooded eyes, microbes are depicted as mini-ogres seeking to undermine the revolution."

This strategy is supported on the ground by a comprehensive network of community doctors and "polyclinics". GPs or "consultarios" are based in communities with roughly one for every 600 people, the best ratio in the world [8]. "A Cuban family physician typically spends the morning seeing patients in the clinic adjoining his or her house and spends the afternoon making home visits to patients in the community immediately surrounding that clinic" [9]. These doctors are embedded into the community, and able to build up relationships with their patients, allowing them to both give advice and keep a close eye on their charges.

The next step up is one of 440 "policlinicos", "consisting of interdisciplinary teams, policlinicos offer specialty care in a variety of areas, usually including pediatrics, internal medicine, nursing, social work, dentistry, and physical therapy, and sometimes including cardiology, pulmonology, ophthalmology, neurology, endocrinology, dermatology, and psychiatry." Each serves 30 to 40 consultorios, and family doctors "spend a half-day per week joining their patients for specialist visits", providing continuity, support and education [9]. Far cheaper to run than hospitals, they can nonetheless deal with a wide range of outpatient issues.

Alternative Medicine...
So Cuba has an impressive basic infrastructure and prevention strategy. What it lacks is treatments. "Much of what is called complementary and alternative medicine in the United States is designated “natural and traditional medicine” in Cuba and is increasingly available throughout the country" [9].

The reason for this is neatly explained in a 1999 Washington Post article: "The collapse of Cuba's Soviet patron, coupled with the protracted U.S. trade embargo, have helped create dire shortages of drugs, hospital supplies and equipment in this island nation of 11 million people. In many of Cuba's 273 hospitals, medical equipment sits unused for lack of spare parts. Even aspirin is scare." As a government faced with prescribing a) nothing or b) quack medicine, which would you choose?

So it's not suprise to hear Serge F. Kovalesk's observations in the Post: "Swaying awkwardly to traditional Chinese music, an elderly woman practices the age-old art of tai chi -- in her case, to treat the neurological disorder known as Parkinson's disease. Down the hall at the Clinic of Traditional and Natural Medicine, patients with circulatory problems place their hands and bare feet on large blocks of cobalt, a metallic element with supposedly curative properties. On another floor, a man receives acupuncture treatment, which -- along with doses of pumpkin seed extract -- is intended to shrink a tumor in his prostate. Elsewhere in the clinic, doctors extol the virtues of passion flower as a treatment for high blood pressure, basil and garlic for diabetes and music therapy for digestive problems."

This appreciation for alternative.. sorry, traditional medicine is instilled in children at a young age, as Barbara Jamison of CareMark relates: "So pervasive has alternative medicine become that children begin studying the multiple uses of medicinal plants as early as elementary school. First, they learn to grow and tend their own plots of aloe, chamomile, and mint, and later they conduct scientific studies about their uses. Acupressure has entered Cuba's everyday vocabulary, with radio and TV programs instructing people on how to relieve common stomach upset and headaches by pressing key points."

The fact that CareMark - a mail-order pharmaceutical company - has this kind of report on their website is indicative of another trend - the use of Cuba's model as "evidence" by those lobbying for the adoption of Complementary and Alternative Medicine in the U.S. and elsewhere. These reports are noticably uncritical. Claims are repeated that operations have been conducted using acupuncture instead of anaesthetic due to the shortage of supplies, but scientific studies have failed to support this [13].

As in my article about Iraq last week, there are certain trends here that stand out regarding the placebo effect. We have government and medical support for alternative therapies, education (that some might call brainwashing) about them in schools, and then the "evidence" of a healthy population. These three factors are bound to reinforce any placebo effect that these treatments engender.

...and Alternative Drugs
Cuba is a poor country, and its medical resources are a major source of revenue. Trained doctors are sent to Venezuela in return for tens of thousands of barrels of oil per day and health tourists flock to the island for treatment [7]. Since the 1990s though, spurred on by the demand on the island for cheap generic equivalents of drugs that had become unavailable since the fall of the Soviet Union, a pharmaceutical industry grew that now supplies drugs and expertise to some 50 other nations. Wired notes that "development experts estimate that by the early '90s the business was worth more than $700 million a year" - no small potatoes for a regime struggling for cash [14].

A lot of this is legitimate, and high quality stuff, and seems to be part of an extraordinarily astute strategy on Castro's part. It began when "in 1981, half a dozen Cuban scientists went to Finland to learn to synthesize the virus-fighting protein interferon".

After the collapse of the U.S.S.R. and "faced with economic calamity, Castro did something remarkable: He poured hundreds of millions of dollars into pharmaceuticals" [7]. One scientist at a vaccine lab in Havana tells the story:"I remember one day telling Fidel that we needed a new ultracentrifuge, which costs about $70,000," Campa says. "After five minutes of listening he said, 'No. You'll need 10.'". Whether or not this particular anecdote is true, Castro took a high-risk gamble on creating generic equivalents to Big Pharm, and it paid off.

However, understanding they "whys" of the Cuban Pharm Industry reveals some worrying problems. "The industry is government run, regulated by the government, and is set up with the aim of making money for the government, and prociding "something" to the Cuban population. "Each institute has its own production facility and conducts clinical trials through the state-run hospital system" [7].

It's a system wide open to abuse, even more so that Big Pharm in the west. Vaccines are essential for the preventative strategies used by the government in treating its citizens, and seem to be of high quality, but other drugs and pills marketed abroad may or may not work. I wrote an article about Policosanol yesterday that showed that the only evidence supporting the drugs efficacy came from Research funded by the same government that sells it. Independent foreign assessments tell a different story.

Complicating this issue still further is the fact that Western companies like our favourite GSK are sniffing around - if you can't beat them, join them seems to be the strategy. "Havana's Carlos J. Finlay Institute has entered into a deal that allows major drug multinational GlaxoSmithKline to license its discovery in order to facilitate the first entry of a Cuban medical product into the more lucrative Western market." [15]

I should balance the above by saying that Cuba's research system is world-class. Indeed, this quality combined with their access to emerging markets is what seems to be attracting Western pharmaceutical companies to build relations with and plough investment into Cuban laboratories [15]. There is, however, a seedy underbelly, and one wonders what will happen when Big Pharm and the Cuban Gray Medical Economy meet.

Summary:
Cuba's health system is impressive because of its ability to match the health outcomes of countries with far greater wealth. Regime propaganda, a focus on prevention rather than more expensive cure, and the placing of community doctors on every corner are three of the major reasons for this apparent paradox.

However, alternative medicine plays a part. Of course pumpkin seed extract and sugar cane pills probably aren't having a clinical effect, but with CAM rebranded by the government as traditional medicine, the Revolution is practising what could arguably be described as a benevolent deceit, the net result being the systematic use of the placebo effect to bolster a population without regular access to many needed drugs. It's easy to criticize this from our perspective, and many do [10,11], but I again ask the question I posed at the end of my essay on medicine in Iraq - where quality medical help simply isn't an option, is quack medicine actually doing good for now? The answer isn't a simple one.

More worrying is the approach of the Cuban government, research establishment and pharmaceutical industry - which in the case of Cuba are essentially the same thing. Cuba wants to bring valuable dollars into its coffers by monetizing its pills and medical expertise. This is perfectly reasonable, but what isn't okay is the use of Big Pharm tactics and junk science to do so. In many ways this problem is even worse in Cuba than with companies like GSK because it is institutionalized - big pharm in Cuba is the government - so basically unregulated.

Here is where peer review in journals and better inspection from international bodies is needed. One also wonders if Cuba's short term gains from this approach may be damaging in the long run. Cuba's monetary gains from medicine depend on the nation's reputation for producing good doctors and good science. If their medical researchers begin to get a reputation for publishing misleading studies, then the image will be tainted, and the revenue may fall.

At any rate, Cuba's health care system looks set to attract a lot of study in the years to come.

[1] Cuba Health Profile (WHO).
[2] 2000 Health Rankings (WHO)
[3] "Sicko" (Official Site)
[4] "Sicko" Presents False View of Cuba's Health System (National Policy Analysis).
[5] Gutierrez S.M., Mizota T., Rakue Y., 2003. Comparison of four health systems: Cuba, China, Japan and the USA, an approach to reality. Southeast Asian J Trop Med Public Health; 34:937– 46.
[6] Spiegel J.M., Yassi A., 2004. Lessons from the margins of globalization: appreciating the Cuban health paradox. J Public Health Policy; 25:85–110.
[7] First world results on a third world budget (Guardian).
[8] Sanchez L., 1999. Introduccion a la Medicina General Integral. Seleccion de temas literatura basica. La Habana, Cuba: Editorial Ciencias Medicas 105–10.
[9] Dresang, L.T., et al, 2005. Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine. J Am Board Fam Pract 18:297–303.
[10] Green Medicine Event Concludes in Cuba (Quackfiles).
[11] Cuba Demonstrates Its (un)Scientific Expertise in Natural Medicine
[12] With Drugs Scarce, Cuba Tries Natural Cures (Washington Post).
[13] Lee, H., and Ernstb, E., 2005. Acupuncture analgesia during surgery: a systematic review. Pain, 114:511-517.
[14] The Cuban Biotech Revolution (Wired).
[15]Cuba Ailing? (The Straits Times).