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Cuban Medicine Today by Dr. Hilda Molina Since I joined the health sector in 1968, the Cuban government has repeatedly asserted that "a central objective of the Revolution is the entitlement of free, quality medical care for everyone." The government systematically rejected the use of medicine as a means of making money. In 1989, Fidel Castro told me that he was "roundly opposed to charging for medical services," and that he "would even prefer that such services be given free of charge to foreigners who need them." But, beginning in 1989, 1 began to notice an unfortunate change of attitude. Cuban authorities have established mechanisms designed to turn the medical system into a profit-making enterprise for the government. I witnessed this firsthand at the International Center for Neurological Restoration, which I directed from 1990-1994. Beginning in 1989, Servimed (Servicios Médicos) of Cubanacán was strengthened to market "health tourism" and medical services to bring in additional foreign currency. Its representatives were toured worldwide to form relationships with international tour operators and doctors. These foreign associates were encouraged to recommend that their patients seek medical attention in Cuba, at a cost of roughly 10 to 20 percent of what it would cost in their own countries. Cuban hospital directors who had sufficient facilities to treat patients from other nations were urged to accept foreigners' applications for treatment. Though the government, not the hospital, received the foreign patients' medical payments, the hospital directors were encouraged to devote a specific percentage of their budget (normally between 30 and 60 percent, depending on the time of year) towards this end. II. Cuban Medical Services for Foreign Income There are several significant flaws in this new Cuban medical system. Foreign patients are routinely inadequately or falsely informed about their medical conditions to increase their medical bills or to hide the fact that Cuba often advertises medical services it is unable to provide. Patients are often forced to pay intermediaries fees in excess of the 10 to 20 percent benchmark established by the Cuban government. There is also a deficiency of medical attention for both foreign patients and Cubans. The lack of adequate professional qualifications, the absence of medical ethics, and the drive toward financial enrichment also characterize Cuba's medical system and often yield unfortunate results. At present, all the medical institutions that government leaders believe are minimally equipped to treat foreign patients have been informed that the government will no longer provide financial support. Instead, they are expected to support themselves by selling their services. With the exception of the International Center for Neurological Restoration, these hospitals have not yet raised enough resources to cover their costs. The driving force of this shift away from traditional primary healthcare goals towards making a profit has been Servimed's bureaucratic supervisors, who often have scant medical background and whose primary responsibility is soliciting foreign income. Servimed has associated itself with tour operators (some with questionable reputations) who also do not possess any medical qualifications. Fraudulent and corrupt relations exist between Servimed's authorities and their foreign correspondents, who are both illicitly enriched at the expense of sick people. Authorities are careful not to distinguish individual Cuban medical specialists, but instead keep everything anonymous ("The quality of Cuban medicine is in its totality an achievement of the Revolution"). This ensures that foreign patients are channeled through Servimed, rather than directly to the hospitals, and facilitates the Cuban government's collection of foreign currency while scoring propaganda points abroad. Foreign income earned from the sale of medical services goes directly to the Banco Interno de Cubanancón, a state agency. According to the Bank's director, this money is generally used to finance foreign trips by Castro and high-ranking functionaries. While in theory, the hospitals responsible for raising this money are authorized to draw between 30 to 60 percent of their contributions from the Bank, the reality is that the government often denies these financial transfers, demanding self-sufficiency. I OPPOSED THE EFFORTS OF DR. OBESO TO EXPORT FETAL TISSUE FOR EXPERIMENTAL USE. IN ORDER TO GET FETAL TISSUE, UNWITTING DONORS WERE DECEIVED INTO HAVING CESAREAN SECTIONS, AND THEN EMBRYO'S DESTINY WAS HIDDEN FORM THEM. The government's myth that Cuba is on healthcare's cutting edge attracts desperate patients whom Cuban hospitals are not actually in a position to help. It is common for Cuban hospitals to advertise services that they do not have the resources to perform. Moreover, they are incapable of guaranteeing results superior to what patients might expect in their own countries. As a result, patients are often inadequately or falsely informed about their condition and steered toward services they may not need. For example, all hospitals are under orders to prescribe Cuban-made drugs to patients, including PPG (the so-called Api-farmacos), and products manufactured by Labiofam and by the Center of Hemoderivados, even when they are not needed. Each hospital keeps scrupulous monthly sales records of these products and hospital directors are required to give an explanation when sales do not reach quotas. In hospitals that treat both Cubans and foreigners, there is an enormous disparity in the quality of healthcare services. Medical services are often immobilized by a lack of resources, so the government is sometimes forced to authorize budgetary allotments as rewards for hospitals that give priority to foreign patients over Cuban. The Orthopedic Hospital
"Frank País" Foreign patients are often pressured to have unnecessary operations and treatments to increase the hospital's earnings. In the drive for capital, doctors also feel obliged to perform surgical procedures that they have not fully mastered or that lack scientific backing, such as nerve transplants to the spinal medulla in patients with medullar lesions. Casts and numerous orthopedic devices manufactured at this hospital, and prescribed for foreign patients, are also often unnecessary and sold at excessively high prices. Dr. Rodrigo Alvarez Cambras, the hospital's director, claims to have developed the transposal of the Omentum Majus to the spinal medullary in patients with medullar lesions, though its originator was the American professor Harry Goldsmith, who introduced the technique into Cuba with me in 1987. Far more serious, Dr. Cambras carries out the procedure erroneously, due to a lack of knowledge of its underlying principles. The result? It does patients more harm than good. Unfortunately, Dr. Cambras's close friendship with the Minister of Public Health has allowed him to live in a state of near-total impunity in Cuba. The hospital has failed to be self-sufficient because of its excessive costs and mismanagement, and because initial investment and subsequent improvements were excessively costly. Costs have also been increased by administrative disorder and Cambra's habit of traveling abroad at government expense with members of his family. This institution is replete with large numbers of professionals and technicians who have limited qualifications, resulting in lack of attention to patients and inefficient rehabilitation. Paraplegia and quadriplegia cause enormous psychological problems in patients, many of whom become suicidal. Others lose all sense of control. Unfortunately, hospital authorities take advantage of these dire circumstances; these patients can be found consuming alcoholic beverages (boosting the government's profits on liquor sales) during the hours that they should be spending in physical therapy. In many hospitals, either with the indulgence (or ignorance) of hospital authorities, the following kinds of incidents often occur: Hospital workers demand extra payments from patients in exchange for better service. Hospital workers have sexual relations with patients (including the handicapped) and/or those traveling with them, in hopes of obtaining bribes and gifts. There is also prostitution on the part of both sexes. Hospital workers sexually abuse some patients. Patients are pressured to obtain permission and money for hospital workers to leave Cuba in exchange for low cost medical services in the patient's home country. Recently, hundreds of hospital personnel (nurses, rehabilitation specialists, doctors, service personnel) have successfully left Cuba this way. Often, their patients are then abandoned. Patients' and companions' money and personal effects are stolen. Patients are obliged to pay prearranged ranged fees, then fail to receive the services promised. Patients suffer avoidable complications such as dermatological infections or gastroenteritis (because of insufficient sanitary precautions in food preparation). Patients show no improvement after their treatment or even worsen because of misdiagnoses or incorrect treatment. In many hospitals, either with the indulgence (or ignorance) of hospital authorities, the following kinds of incidents often occur: Hospital workers demand extra payments from patients in exchange for better service.
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