Claudia Lopez, an intern, with outpatients at 5 de Septiembre Polyclinic, Havana. Photo by Gail Reed/World Health Organisation.

By Don Fitz

January 5, 2011-- Links International Journal of Socialist Renewal -- When Americans spend $100 on health care, is it possible that only $4 goes to keeping them well and $96 goes somewhere else? Single payer health care [government-funded universal health insurance] advocates compare US health care to that in Western Europe or Canada and come up with figures of 20–30% waste in the US.

But there is one country with very low level of economic activity yet with a level of health care equal to the West: Cuba.

Life expectancy of about 78 years of age in Cuba is equivalent to the US. Yet, in 2005, Cuba was spending US$193 per person on health care, only 4% of the $4540 being spent in the US. Where could the other 96% of US health care dollars be going?

1. A fragmented system

Explaining why health care is 16% of the US gross domestic product while it is less than half that in the UK, a 2008 article in Dollars and Sense pointed out that:

… the US has the most bureaucratic health care system in the world, including over 1500 different companies, each offering multiple plans, each with its own marketing program and enrollment procedures, its own paperwork and policies, its CEO salaries, sales commissions, and other non-clinical costs—and, of course, if it is a for-profit company, its profits.

An article widely cited during the debate on single payer health care calculated that administration eats up 31% of health-care costs. Insurance companies that compete in the market have duplicative claims-processing facilities and must keep track of a variety of approval and co-payment requirements.

Several Canadian physicians who peeked at US hospitals found that for-profit ones paid executive bonuses that were up to 20% higher, were more likely to up-code diagnoses in order to receive more reimbursement, and overwhelmingly had more lawsuits against them for performing unnecessary surgeries and billing for services not provided.

2. Over treatment

One of the most readable accounts of profit-motivated over treatment is Stan Cox’s Sick Planet (2008). He describes how the Parker Hughes Cancer Center in Roseville, Minnesota, went bankrupt after the Minneapolis Star Tribune reported that it “had been subjecting cancer patients to excessive testing and treating”.

When doctors install magnetic resonance imaging (MRI) machines in their office, they tend to use them 23% more than if they refer out for a scan. After the purchase price is covered by the first 2000–3000 scans, additional ones generate almost pure profit.

Are these a few bad apples, or do they reflect a broader trend? A study in Australia reported that if “100 patients are each subjected to 10 random diagnostic tests, around 40 of them will be ‘found’ to have a problem that really isn’t there”.

3. Expansion of illness

The pharmaceutical industry has become especially adept at transforming what can be a serious problem into an artificial sickness. It has redefined and expanded “a host of medical conditions—erectile dysfunction, female sexual dysfunction, restless legs, sleeplessness, bipolar disorder, attention deficit disorder, social anxiety disorder, and irritable bowel syndrome”.

Take the osteoporosis hype. It is a genuine medical issue. But the industry pressures women to have bone scans and take anti-osteoporosis drugs even though the scans do a poor job of predicting hip fracture, the major threat of fragile bones.

Between 1987 and 2007, the rate of problems classified as mental illness in the US more than doubled (from 1/184 to 1/76). In the same time period, the use of drugs like Ritalin for attention deficit hyperactivity disorder (ADHD) in children (mostly boys) shot up 30 fold.

4. Sickness looping

According to the Center for Disease Control (CDC), each year 2 million Americans get infectious diseases in hospitals. The massive over treatment endemic to health care in the United States increases costs in two ways: (1) the cost of the unnecessary treatment itself; and, (2) the cost of treating the sickness which results from the original treatment. We could say that “sickness looping” is when treatment loops back on itself and requires yet more treatment.

This is a major medical expense, responsible for about a third of all medical care. The second best-selling category is heartburn drugs known as proton pump inhibitors (PPI), which accounted for $14 billion in the US in 2008. But 60% of PPI prescriptions for hospitalized patients may be unnecessary. Since the drugs inhibit calcium absorption, those taking high-dose PPIs long-term are 2.65 times more likely to have hip fractures. They are twice as likely to develop pneumonia and almost three times as likely to get a potentially deadly infection. Most disturbing, they may cause heartburn and acid reflux, which they are supposedly treating.

Too much radiation can be very unhealthy. From 1980 to 2010, the average lifetime dose of non-therapeutic diagnostic radiation increased sevenfold, increasing the risk for cancer. As much as 2% of cancers could be due to CT scan radiation.

Did you think that the value of hormone therapy (HT) for menopausal women was thoroughly debunked? After all, it does not improve either memory or cognition. But it is associated with increased dementia, stroke, blood clots and heart attacks. After 50 million women stopped using HT, estrogen positive breast cancer dropped by 15%. So, when Martha Rosenberg saw a 2010 article describing industry’s efforts to began pushing it again, she thought it was like “seeing an article suggesting cigarettes may be good for you after all.”

5. Insurance looping

In addition to the 47 million uninsured Americans, there are over 60 million who are underinsured. We could say that “insurance looping” occurs when failure to provide treatment loops back into medical costs, making them higher rather than lower.

A Health Affairs article confirmed that the uninsured are more likely to be untreated, resulting in illnesses progressing and their treatments being more expensive. According to lead author Dr Andrew Wilper, “they’re not getting care that would prevent strokes, heart attacks, amputations and kidney failure.”

Those without adequate treatment also receive more hurried care when they do get it. They often have no alternative but use the emergency room, making the ER more crowded for everyone.

6. Doctors’ fees

The US has some of the highest paid doctors in the world. Even though there is no difference in patient survival rates for coronary bypass operations in the US and Canada, US heart surgeons bill at least twice as much.

The six- and seven-digit income figures for US physicians often stem from practices that are not particularly helpful to patients. A California study in the 1960s “showed that when physicians owned X-ray facilities, their patients ended up being X-rayed twice as often as patients whose physicians referred them to outside labs”. Illinois brought legal actions “against 20 MRI operators in the Chicago area for allegedly paying kickbacks to doctors who helped keep their machines supplied with patients”.

7. What needs to be researched?

Over half of the world’s spending on medical research is in the US. This has resulted in some amazing new techniques; but the increase in life expectancy gets smaller each decade. Focusing on increasingly rare disorders is likely to benefit the wealthiest half of families who spend 92% of US health care dollars.

The $3 billion Human Genome Project would supposedly revolutionise the treatment of most human diseases. But Stephen Hall writes in Scientific American that it is failing to produce medical miracles, largely because of its emphasis on genetic rather than environmental causes of disease. Many more people would be benefited by research on how to get already-known treatments to those who are not currently receiving them.

8. Costs not counted

Scrutinising dollar figures leaves out the unnecessary irritation, pain, suffering and death from profit-oriented health care. In 2008, reduced access to care resulting from lack of health insurance caused the death of 2200 veterans over the age of 65.

A review of pooled data from studies of 26,000 hospitals with 38,000,000 patients found that private for-profit ownership of hospitals is associated with a higher risk of death for patients. The authors noted that for-profit hospitals have extra costs which leads them to skimp on patient care, often by hiring fewer highly skilled personnel.

One study of health care plans concluded that “if all 23.7 million American women between ages 50 and 69 years were enrolled in investor-owned, rather than not-for-profit plans, an estimated 5925 additional breast cancer deaths would be expected”.

Another source of human suffering is prescription drug overdoses, which are now the second-leading cause of accidental deaths in the US. According to the CDC, they cause more overdose deaths than heroin and codeine combined.

As for-profit health care causes needless suffering, its cost feedback loops flow into each other, creating yet more illness and sending costs spiraling. The growth of the sickness industry reflects little growth in human wellbeing.

Revolutionary medicine in Cuba: health care as a human right

The Cuban approach to health care is so different that it cannot be described using the concepts that are so problematic in the US. It goes beyond taking profit out of medicine. Cuba stands alone in constructing an advanced health-care system with extremely limited resources.

What it has accomplished is remarkable. Life expectancy climbed from 58.8 years at the time of the 1959 revolution to 73.5 years by 1983, and 78 years currently. Cuba has eradicated polio, controlled malaria and dengue fever, and decreased infant, child and maternal mortality to be roughly equal to rates in the US. Cuban medicine is widely recognised by international health groups such as UNICEF as surpassing that of developing countries and being comparable to developed ones.

The foundation for the transformation is a commitment to health care as a human right. There is a strong connection between poverty and sickness. Better care is understood as interwoven with improvements in housing, education and employment.

One of the most revolutionary developments in Cuban medicine was the “idea that physicians are responsible for all those people living in a geographical area rather than just a number of patients”. What is now known as the primary health care (PHC) model in Cuba is based on targeting at-risk groups, including pregnant women, children and the elderly.

The 1989 fall of the Soviet Union and disappearance of most of its oil and markets for Cuban products dealt the economy a severe blow. By 1998-2000, 13% of Cubans were undernourished. Nevertheless, the new medical approach was so effective and had become so much a part of Cuban life that infant mortality continued to decline throughout the “special period” of exceptional hardship.

Consultorios

During a May 2010 visit to Cuba, I spoke with Ivan Angulo Torres, who was then finishing his final, sixth year of medical school. Though the PHC model has gone through several modifications, he outlined the form as it is practiced in Cuba today.

The most basic level of health care is the neighborhood consultorio, which provides coverage for 99% of Cubans. It is often a former home converted into a medical office on the first floor with the doctor and nurse each living on another floor, or nearby. Though the consultorio is often described as serving the surrounding area of about 150 families or 600 people, when I visited Consultorio No. 5 in Havana, Dr Alejandro Fradraga Fernandez explained that their team of three doctors and two nurses provided care to about 500 families or 1800 patients. As typical for a consultorio, it had posters listing docente, or staff of medical students from their first through sixth year who worked there.

Dr Fradraga works at the consultorio from 8 am until 2 pm and then does home visits from 2–4 pm. A healthy person is expected to visit the consultorio three times per year, if there are risk factors, four times per year. Family doctors are required to visit patients in their homes one to four times per year, depending on whether they are healthy, sick, at-risk or have special needs (i.e., an amputee or mentally ill).

While in a patient’s home, the doctor may see five or six people and get information that only a home observation can reveal. Physicians compile information into summary data for the neighborhood. Wall posters in Consultorio No. 5 report the number of residents who smoke, are overweight, have high cholesterol, are alcoholic, take drugs or have a lifestyle of sedentarismo—sedentary lifestyle. Sitting around doing nothing is as important to report as other risk factors.

Though the consultorio deals with health needs of everyone, much of the work is OB/GYN and pediatrics. Women are expected to visit the consultorio 12 times during pregnancy. Breast feeding is the norm in Cuba. Posters in Consultorio No. 5 describe the basics of breast feeding, explain how to overcome common problems and demonstrate how to nurse twins.

Polyclínicos

Cuba has 492 polyclinics (polyclínicos), with 83 in Havana. Each polyclinic develops programs for 30 to 40 consultorios. They have more specialised treatments than consultorios and are open when family doctors are off work. They are critical in the coordination of teaching, research and community preventive health programs.

For example, polyclinics help control dengue fever, a mosquito-borne illness that frequently breaks out in Cuba. Polyclinics arrange for teams of medical students to go door-to-door to take samples of standing water and tell people to drain them.

This illustrates a critical connection between health care, poverty and housing. Health-care campaigns work in Cuba because health workers can find people at home, neighbourhoods are stable, and people do not show the high mobility patterns of many low income communities in the US.

Polyclinics are thoroughly integrated into Cuban communities, in part, because they blend Western techniques with “natural and traditional medicine” of Caribbean culture. When Teresa Frías took me on a tour of Havana’s Polyclínico Universitario, I saw rooms for admission, observation, autoclaves, laboratory, vaccination, X-ray, optometry, ophthalmology, OB/GYN, family planning, ultrasound, menstrual regulation (largely for teenagers), mouth diseases, podiatry, psychology, social work, bone specialties, speech therapy, physical therapy, adult gym, children’s gym, acupuncture, massage therapy, heat therapy, reflex therapy, electromagnetic therapy and mud therapy. Cuban doctors often try low-tech traditional medicine that patients may be more comfortable with before using a more expensive high-tech option. Of course, the US embargo ensures that many high-tech machines are in short supply.

The Cuban medical system aims to deal with 80% of problems at the level of consultorios and polyclinics and only 20% at the higher levels of hospitals, specialty hospitals and long-term care facilities such as nursing homes. In fact, 74% of all outpatient consultations are with family doctors. According to some estimates, 97% of medical care in Cuba is from family doctors.

The most striking difference about Cuban hospitals is their lack of luxury. Cuban hospitals remind me of the US in the 1950s—they are clean, very plain and are not full of TV sets and electronic gadgets.

Two visions of health care

Cuba shows that a quality health-care system does not have to be based on unending expansion of expensive medical technology. Removing profit from medical care lowers administrative costs, reduces over treatment, tempers the expansion of diagnoses, stops making people sicker by denying them preventive treatment, controls exorbitant incomes of doctors and helps focus research in needed areas.

In Primary Health Care in Cuba (2008), Linda Whitehead and Laurence Branch describe how a Cuban shocked a visiting Canadian doctor by saying that virtually none of his patients with hypertension were on medication. While corporate medicine uses “diet and exercise” as a catchy phrase, in Cuba it is the way that medicine is actually practiced.

The hallmark of Cuban medicine has been designing and putting into effect a system of primary and preventive health care which is little more than sloganeering in other countries. Only 2–3% of US health-care expenditures are for preventive care.

After World War II, the myth arose in the US that better health was associated with more specialists. But Cuba realised that successful health care is closely linked to the prevalence of family doctors. While a majority of Cuban doctors are family physicians, this is the case for only 11% of those in the US. Additionally, Cuba has a higher rate of doctors in the population: one doctor per 180 inhabitants while the ratio is one doctor per 480 inhabitants in the US.

This is one reason why Cuba has virtually no difference in health care indicators among sectors of society. The US, in contrast, has enormous disparities in measures such as infant mortality among ethnic and geographic groups. The lack of commitment to ending inequality in the United States is demonstrated by the parades of empty rhetoric with little to no lasting effect, which are known in the US as “educational campaigns”. In contrast, Cuba has “mobilisation campaigns” that use the enthusiasm of medical students, Committees for the Defence of the Revolution and the general population to combat illiteracy, polio, dengue fever and infant mortality.

When talking with family doctor Alejandro Fragadas, I told him, “Please do not laugh when I ask you this; but when your patients come to see you, how do they get to your office, and, when you make home visits, how do you get to them?”

Looking at me as if I were from another world, he said, “They walk to see me and I walk to see them.” How many Americans walk to their family doctor, if they even have one? The same drive that deprives people of physical activity so necessary to good health simultaneously pours pollutants into the lungs of everyone along the way. This is just one of the infinitely expanding sickness cost loops that spiral into each other in Western culture.

Stark contrasts

It is not possible to create good medicine separately from everything else in society that makes people sick. Revamping the US medical system would be far more valuable than demanding a universal right to bad health care controlled by insurance companies.

The US is one of the worst perpetrators of medical “brain drain”, or wooing doctors, with vastly higher salaries, from India, Africa and Latin America. This leaves some of the most desperate communities on Earth with even fewer doctors. The medical brain drain is so bad in Ghana that the country is left with one doctor for every 45,000 residents.

Cuba, on the other hand, sends a massive number of doctors to other countries. At the same time that the US had 550 medical personnel in Haiti following the 2010 earthquake, there were 1500 from Cuba. Almost a quarter of Cuba’s 70,000 doctors are now working abroad.

In addition, Cuba brings thousands of students from 100 countries to study medicine at the Latin American School of Medicine (ELAM) at no cost. After six years of training at ELAM, graduating doctors bring the model of primary and preventive health care to distressed communities that need it the most. They help turn the “brain drain” into a “brain gain”.

[Don Fitz is editor of Synthesis/Regeneration: A Magazine of Green Social Thought, which is published for members of the Greens/Green Party USA. He continues to listen to stories, contemplate over treatment and peek into hospital rooms to try to find where 96% of US health-care costs are squandered. If you know where he might look, contact him at fitzdon@aol.com.]