Healthcare In Cuba - Health Educator Salary

The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is Roberto Morales Ojeda.

Like the rest of the Cuban economy, Cuban medical care suffered following the end of Soviet subsidies in 1991; the stepping up of the US embargo against Cuba at this time also had an effect.

History

Modern Western medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th century and the first surgical clinic was established in 1823. Cuba has had many world class doctors, including Carlos Finlay, whose mosquito-based theory of yellow fever transmission was given its final proof under the direction of Walter Reed, James Carroll, and Aristides Agramonte. During the period of U.S presence (1898â€"1902) yellow fever was essentially eliminated due to the efforts of Clara Maass and surgeon Jesse William Lazear.

In the 1950s the number of doctors per thousand of the population ranked above Britain, France and the Netherlands. In Latin America it ranked in third place after Uruguay and Argentina. There remained marked inequalities however. Most of Cuba's doctors were based in the relatively prosperous cities and regional towns, and conditions in rural areas, notably Oriente, were significantly worse. The mortality rate was the third lowest in the world. According to the World Health Organization, the island had the lowest infant mortality rate of Latin America.

Following the Revolution and the subsequent United States embargo against Cuba, an increase in disease and infant mortality worsened in the 1960s. The new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled On Revolutionary Medicine, stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices." These aims were hampered almost immediately by an exodus of almost half of Cuba’s physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in the University of Havana’s medical college. Beginning in 1960, the Ministry of Public Health began a program of nation alization and regionalization of medical services.

In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states "Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations."

Cuba's doctor to patient ratio grew significantly in the latter half of the 20th century, from 9.2 doctors per 10,000 inhabitants in 1958, to 58.2 per 10,000 in 1999. In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox. Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care. As of 2012, infant mortality in Cuba had fallen to 4.83 deaths per 1,000 live births compared with 6.0 for the United States and just behind Canada with 4.8. Experts have however noted that these statistics may reflect heavy-handed treatment of pregnant patients or that the statistics may be falsified. One expert, for instance, notes that pregnant women may be forced to undergo abortions if fetal abnormalities ar e detected or forcibly placed under monitoring. Doctors also have incentives to falsify statistics, as a spike in infant mortality will cost them their jobs. Cuba does not allow for independent verification of its health data.

Chinese medicine has also been practiced in Cuba. Its most famous practitioner was the 19th century doctor Cham Bom Biam or “El Medico Chino”.

Post-Soviet Union

The loss of Soviet subsidies brought food shortages to Cuba in the early 1990s.

A Canadian Medical Association Journal paper states that "The famine in Cuba during the Special Period was caused by political and economic factors similar to the ones that caused a famine in North Korea in the mid-1990s. Both countries were run by authoritarian regimes that denied ordinary people the food to which they were entitled when the public food distribution collapsed; priority was given to the elite classes and the military." The regime did not accept donations of food, medicines and money from the US until 1993.

According to Johns Hopkins University epidemiologist Manuel Franco, malnutrition created epidemics, but it had positive effects too. Dr. Franco describes the Special Period as "the first, and probably the only, natural experiment, born of unfortunate circumstances, where large effects on diabetes, cardiovascular disease and all-cause mortality have been related to sustained population-wide weight loss as a result of increased physical activity and reduced caloric intake".

In 2007, Cuba announced that it has undertaken computerizing and creating national networks in Blood Banks, Nephrology and Medical Images. Cuba is the second country in the world with such a product, only preceded by France. Cuba is preparing a Computerized Health Register, Hospital Management System, Primary Health Care, Academic Affairs, Medical Genetic Projects, Neurosciences, and Educational Software. The aim is to maintain quality health service free for the Cuban people, increase exchange among experts and boost research-development projects. An important link in wiring process is to guarantee access to Cuba's Data Transmission Network and Health Website (INFOMED) to all units and workers of the national health system.

Present

Cuba had 128 physicians and dentists per 100,000 people in 1957. This was comparable to the levels in many European countries and allegedly the highest in Latin America. In 2005, Cuba had 627 physicians and 94 dentists per 100,000 population. That year the United States had 225 physicians and 54 dentists per 100,000 population; there was no data for Latin America as a region, but the Central American isthmus had 123 physicians and 30 dentists per 100,000.

Like the rest of the Cuban economy, numerous reports have shown that Cuban medical care has long suffered from severe material shortages caused by the US embargo. The ending of Soviet subsidies in the early 1990s has also affected it.

Abortion rates, which are high in Cuba, increased dramatically during the 1980s, but had almost halved by 1999 and declined to near-1970s levels of 32.0 per 1000 pregnancies. The rate is still among the highest in Latin America.

While preventive medical care, diagnostic tests and medication for hospitalized patients are free, some aspects of healthcare are paid for by the patient. Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. When a patient can obtain these items at state stores, prices tend to be low as these items are subsidized by the state. For patients on a low-income, these items are free of charge.

Sexual health

According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment.

In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world. The UNAIDS reported that HIV infection rates for Cuba were 0.1%, and for other countries in the Caribbean between 1 - 4%. Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education.

According to a 2005 report by UNAIDS and the World Health Organization, "Cuba’s epidemic remains by far the smallest in the Caribbean." They add however that,

... new HIV infections are on the rise, and Cuba’s preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cuba’s prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs.

In recent years because of the rise in prostitution due to tourism, STDs have increased.

Embargo

During the '90s the ongoing United States embargo against Cuba caused problems due to restrictions on the export of medicines from the US to Cuba. In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U.S. subsidiary trade, including trade in food and medicines, being prohibited. The legislation did not state that Cuba cannot purchase medicines from U.S. companies or their foreign subsidiaries; however, such license requests have been routinely denied. In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U.S. Government that such activities violate international law and has requested that the U.S. take immediate steps to exempt medicine from the embargo. The Lancet and the British Medical Journal also condemned the embargo in the 90s.

A 1997 report prepared by Oxfam America and the Washington Office on Latin America, Myths And Facts About The U.S. Embargo On Medicine And Medical Supplies, concluded that the embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U.S. firms or from non-U.S.sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba's medical system. It prohibited foreign subsidiaries of U.S. corporations from selling to Cuba, thus further limiting Cuba's access to medicine and equipment, and raising prices. In addition, the act forbids ships that dock in Cuban ports from docking in U.S. ports for six months. This drastically restricts shipping, and increases shipping costs some 30%.

However, in 2000 the Trade Sanctions Reform and Export Enhancement Act was passed, and the US is now Cuba's single largest source for imported food. The Cuban American National Foundation (CANF) states that should Cuba choose not to purchase from the U.S., it can purchase any medicine or medical equipment it needs from other countries. Such third-country transactions only cost an estimated 2%-3% more than purchases from the U.S. as a result of higher shipping costs. CANF also asserts the United States is the largest donor of humanitarian assistance to Cuba and much of this consists of medicines and medical equipment.

The US government states that since 1992, 36 out of 39 license requests from U.S. companies and their subsidiaries for sales of medical items to Cuba have been approved. The dollar amount of these sales is over $1,600,000. Furthermore, the U.S. government licensed more than $227 million in humanitarian donations of medicines and medical supplies to Cuba between 1993 and 1997. There are other factors beside the embargo explaining the lack of imports, in particular Cuba's lack of hard currency. Those with dollars can easily buy medicines and food in Cuba from Latin America and Canada. Cuba defaulted on its debt to Western banks in 1986 and lacks access to the international credit system in order to get foreign currency. In addition, the collapse of the Soviet Union caused the loss of several billions of dollars in yearly subsidies and overnight required hard currency for all imports.

In a 2006 report to the U.N. Secretary-General, Cuba acknowledged the authorization of medicines, though stated that they were subject to severe restrictions and complicated procedures. Cuba is obliged to make payments in cash and in advance, and is precluded from obtaining credit funding, even from private sources. The sale and transportation of the goods require licenses to be obtained for each transaction. Cuba cannot use its own merchant fleet for transporting these goods, but has to make use of vessels from third countries, primarily the United States. Payments are made through banks in third countries, since direct banking relationships are prohibited. The Cuban delegation concluded that restrictions on importing medical products were "so extensive that they make such imports virtually impossible". The World Health organization/PAHO and UNFPA concurred that it was impossible for Cuba to purchase equipment, medicines and laboratory materials produced by the United States or c overed by United States patents, even though those products were purchased through multilateral cooperation. Cuba was not able to purchase the isotope I-125 that is used to treat eye cancer in children. The companies manufacturing reagents and equipment are 70 per cent United States owned, which makes it difficult to purchase necessary medical equipment and other items.

Medical staff

According to the World Health Organization, Cuba provides a doctor for every 170 residents, and has the second highest doctor-to-patient ratio in the world after Italy.

Medical professionals are not paid high salaries by international standards. In 2002 the mean monthly salary was 261 pesos, 1.5 times the national mean. A doctor’s salary in the late 1990s was equivalent to about US$15â€"20 per month in purchasing power. Therefore, some prefer to work in different occupations, for example in the lucrative tourist industry where earnings can be much higher.

The San Francisco Chronicle, the Washington Post, and National Public Radio have all reported on Cuban doctors defecting to other countries.

Black market healthcare

The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba's burgeoning black market economy, sometimes termed "sociolismo". According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, "The doctors in the hospitals are charging patients under the table for better or quicker service." Prices for out-of-surgery X-rays have been quoted at $50 to $60. Such "under-the-table payments" reportedly date back to the 1970s, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn known as the "Special Period" in the 1990s aggravated these payments. The advent of the "dollar economy", a legalization of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans were able to obtain medications and health services that would not be available to them otherwise.

Cuba and international healthcare

Cuba provides more medical personnel to the developing world than all the G8 countries combined. In the 1970s, the Cuban state initiated bilateral service contracts and various money-making strategies. Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA) and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies In the 1980s, Cuba's decision to withdrawal military assistance from the Marxistâ€"Leninist regimes in Ethiopia and Angola was partly rooted in their inability to meet payments. In 1986, Cuba had 219 doctors per 100,000 people (compared with 423.7 doctors i n the Soviet Union, which had the most doctors among industrialized countries). As of 2005, Cuba became the world leader in the ratio of doctors to population with 67 doctors per 10,000 population as compared with 43 in the Russian Federation and 24 in the United States.

The supply of physicians came to exceed the domestic market. Moreover, Cuban doctors work on much lower salaries than local doctors. A Guatemalan doctor noted, "No one's going to work in the mountains for a salary of $400," the salary for which Cuban doctors work. The $400 is 16 times the doctor's salary in Cuba - allowing Cuban doctors to buy refrigerators, stereos and other items that they couldn't afford in Cuba. Cuba's missions in 68 countries are manned by 25,000 Cuban doctors, and medical teams have worked in crisis such as the South Asian Tsunami and the 2005 Kashmir earthquake. Nearly 2,000 Cuban doctors are currently working in Africa in countries including South Africa, Gambia, Guinea Bissau and Mali. Since the Chernobyl nuclear plant exploded in 1986, more than 20,000 children from Ukraine, Belarus and Russia have traveled to Cuba for treatment of radiation sickness and psychologically based problems associated with the radiation disaster. In response to the 2005 Hurric ane Katrina disaster, Castro offered to send a "brigade" of 1,500 doctors to the U.S. to provide humanitarian aid, but was never accepted.

Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil. Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: "Mission Into the Neighborhood") social welfare program established in Venezuela under former Venezuelan president Hugo Chávez. The program, which is popular among Venezuela's poor and is intended to bring doctors and other medical services to the most remote slums of Venezuela, has not been without its detractors. Operación Milagro (Operation Miracle) is a joint health program between Cuba and Venezuela, set up in 2005. The Venezuelan Medical Federation has criticized the appointment of Cuban doctors to high-ranking positions, and protests have taken place in the capital Caracas by Venezuelan medical staff who fear that the Cubans are a threat to Venezuelan jobs. Questions have also been raised by protesters about the level of Cuban medical qualifications, and there have been claims that the Cuba ns are "political agents" who have come to Venezuela to indoctrinate the workforce. Opposition supporters in Venezuela have called Cuban doctors "Fidel's ambassadors" and refused to go to their clinics. Two defected doctors have claimed that they were told their job was to keep Chavez in power, by asking patients to vote for Chávez in the 2004 recall referendum.

Human Rights Watch complains that the government "bars citizens engaged in authorized travel from taking their children with them overseas, essentially holding the children hostage to guarantee the parents' return. Given the widespread fear of forced family separation, these travel restrictions provide the Cuban government with a powerful tool for punishing defectors and silencing critics." Doctors are reported to be monitored by "minders" and subject to curfew. The Cuban government uses relatives as hostages to prevent doctors from defecting. According to a paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA", some via Colombia, where they have sought temporary asylum.

According to Luis Zuñiga, director of human rights for the Cuban American National Foundation, Cuban doctors are "slave workers" who labor for meager wages while bolstering Cuba's image as a donor nation and "the Cuban government exports these doctors as merchandise".

Cuban doctors have been part of a large-scale plan by the Cuban state to provide free medical aid and services to the international community (especially third world countries) following natural disasters. Currently dozens of American medical students are trained to assist in these donations at the Escuela Latino Americana de Medicina (ELAM) in Cuba.

Health tourism and pharmaceutics

Cuba attracts about 20,000 paying health tourists, generating revenues of around $40 million a year for the Cuban economy. Cuba has been serving health tourists from around the world for more than 20 years. The country operates a special division of hospitals specifically for the treatment of foreigners and diplomats. Foreign patients travel to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinson's disease, cosmetic surgery, addictions treatment, retinitis pigmentosa and orthopaedics. Most patients are from Latin America, Europe and Canada, and a growing number of Americans also are coming. Cuba also successfully exports many medical products, such as vaccines. By 1998, according to the Economic Commission for Latin America and the Caribbean, the Cuban health sector had risen to occupy around 2 percent of total tourism. Some of these revenues are in turn transferred to health care for ordinary Cubans, although t he size and importance of these transfers is both unknown and controversial. At one nationally prominent hospital/research institute, hard currency payments by foreigners have financed the construction of a new bathroom in the splenic surgery wing; anecdotal evidence suggests that this pattern is common in Cuban hospitals.

Alternative Healthcare

Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population In the 1990s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model. Examples of alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i.e. acupunctural anesthesia for surgery), natural dietary supplements, yoga, electromagnetic and laser devices. Children begin studying the multiple uses of medicinal plants in primary school, learning to grow and tend their own plots of aloe, chamomile, and mint, and later they conduct scientific studies about their uses. Radio and Television programs instruct people on how to relieve common stomach upset and headaches by pressing key points. Acupuncture is offered at all three levels of health care. Cuban biochemists have produced a number of new alternative medicines, including PPG (policosanol), a natural product derived from sugarcane wax that is effective at reducing total cholesterol and LDL levels, and Vimang, a natural product derived from the bark of mango trees.

Medical research

The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine. Because the U.S. government restricts investments in Cuba by U.S. companies and their affiliates, Cuban institutions have been limited in their ability to enter into research and development partnerships, although exceptions have been made for significant drugs.

The Center of molecular immunology (CIM) developed nimotuzumab, a monoclonal antibody used to treat cancer. Nimotuzumab is an inhibitor of epidermal growth factor receptor (EGFR), which is over-expressed in many cancers. Nimotuzumab is now being developed with international partners.

In April 2007, the Cuba IPV Study Collaborative Group reported in the New England Journal of Medicine that inactivated (killed) poliovirus vaccine was effective in vaccinating children in tropical conditions. The Collaborative Group consisted of the Cuban Ministry of Public Health, Kourí Institute, U.S. Centers for Disease Control and Prevention, Pan American Health Organization, and the World Health Organization. This is important because countries with high incidence of polio are now using live oral poliovirus vaccine. When polio is eliminated in a country, they must stop using the live vaccine, because it has a slight risk of reverting to the dangerous form of polio. The collaborative group found that when polio is eliminated in a population, they could safely switch to killed vaccine and be protected from recurrent epidemics. Cuba has been free of polio since 1963, but continues with mass immunization campaigns.

In the 1980s, Cuban scientists developed a vaccine against a strain of bacterial meningitis B, which eliminated what had been a serious disease on the island. The Cuban vaccine is used throughout Latin America. After outbreaks of meningitis B in the United States, the U.S. Treasury Department granted a license in 1999 to an American subsidiary of the pharmaceutical company SmithKline Beecham to enter into a deal to develop the vaccine for use in the U.S. and elsewhere

Contrasting views on Cuba's health system

As can be seen is this section, the issue of the effectiveness of the Cuban health system is politically polarized. Thus, as William Ventres put it in his review of five books about Cuba's medical system (including one by Katherine Hirschfeld; see below), it is "difficult to make sense of the reality of Cuban health care."

Praise

In 2006, BBC flagship news programme Newsnight featured Cuba's Healthcare system as part of a series identifying "the world's best public services". The report noted that "Thanks chiefly to the American economic blockade, but partly also to the web of strange rules and regulations that constrict Cuban life, the economy is in a terrible mess: national income per head is minuscule, and resources are amazingly tight. Healthcare, however, is a top national priority" The report stated that life expectancy and infant mortality rates are nearly the same as the USA's. Its doctor-to-patient ratios stand comparison to any country in Western Europe. Its annual total health spend per head, however, comes in at $251; just over a tenth of the UK's. The report concluded that the population's admirable health is one of the key reasons why Castro is still in power. A 2006 poll carried out by the Gallup Organization's Costa Rican affiliate â€" Consultoría Interdisciplinaria en Desarrollo (C ID) â€" found that about three-quarters of urban Cubans responded positively to the question "do you have confidence to your country's health care system".

In 2000, Secretary General of the United Nations Kofi Annan stated that "Cuba should be the envy of many other nations" adding that achievements in social development are impressive given the size of its gross domestic product per capita. "Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities - health, education, and literacy." The Kaiser Family Foundation, a non-governmental organization that evaluated Cuba’s healthcare system in 2000-1 described Cuba as "a shining example of the power of public health to transform the health of an entire country by a commitment to prevention and by careful management of its medical resources" President of the World Bank James Wolfensohn also praised Cuba's healthcare system in 2001, saying that "Cuba has done a great job on education and health", at the annual meeting of the Bank and the International Monetary Fund. Wayne Smith, former head of the US Interests Section in Havana identified "the incredible dedication" of Cubans to healthcare, adding that "Doctors in Cuba can make more driving cabs and working in hotels, but they don't. They're just very dedicated". Dr. Robert N. Butler, who was president of the International Longevity Center in New York and a Pulitzer Prize-winning author on aging, traveled to Cuba to see firsthand how doctors were trained. He said a principal reason that some health standards in Cuba approach the high American level is that the Cuban system emphasizes early intervention. Clinic visits are free, and the focus is on preventing disease rather than treating it. Furthermore, London's The Guardian newspaper lauded Cuba's public healthcare system for what it viewed as its high quality in a September 12, 2007 article.

In 2001, members of the UK House of Commons Health Select Committee travelled to Cuba and issued a report that paid tribute to "the success of the Cuban healthcare system", based on its "strong emphasis on disease prevention" and "commitment to the practice of medicine in a community".

The Parliament of the United Kingdom also drew up an analysis of the key features of Cuba's healthcare system, drawing comparisons with the state funded National Health Service (NHS). The overall conclusion was that many of the features identified would not have occurred had there not been an obvious commitment to health provision demonstrated by the protection and proportion of the budget given the health care. The study concluded the following.

• There appeared to be little evidence of a divide between the prevention/proactive response and the disease management/reactive response within Cuban healthcare.
• By far the biggest difference was the ratio of doctors per person. In Cuba it was one doctor per 175 people, in the UK the figure was one doctor per 600 people.
• There is a commitment in Cuba to the triple diagnosis (physical/psychological/social) at all levels.
• Extensive involvement of "patient" and the public in decision making at all levels.
• Integration of hospital/community/primary care via polyclinics.
• Team-work that works is much more evident both in the community and the hospital sector and the mental-health and care of the elderly sites visited were very well staffed and supported.

Criticism

The preceding study also pointed to problems within Cuba's health system, including:

• Low pay of doctors.
• Poor facilitiesâ€"buildings in poor state of repair and mostly outdated.
• Poor provision of equipment.
• Frequent absence of essential drugs.
• Concern regarding freedom of choice both for patient and doctor.

Katherine Hirschfeld, an anthropology professor at the University of Oklahoma, did her Ph.D. thesis on the Cuban health system, spending nine months conducting ethnographic work in Cuba in the late 1990s. According to Hirschfeld, "public criticism of the government is a crime in Cuba", which means that "formally eliciting critical narratives about health care would be viewed as a criminal act both for me as a researcher, and for people who spoke openly with me". Nevertheless, she was able to hear from many Cubans, including health professionals, "serious complaints about the intrusion of politics into medical treatment and health care decision-making". She points out that "there is no right to privacy in the physician-patient relationship in Cuba, no patients’ right of informed consent, no right to refuse treatment, and no right to protest or sue for malpractice". In her view medical care in Cuba can be dehumanizing.

Hirschfeld explains also that the Cuban Ministry of Health (MINSAP) sets statistical targets that are viewed as production quotas. The most guarded is infant mortality rate. To illustrate this, Hirschfeld describes a case where a doctor said that if the ultrasound examination revealed "some fetal abnormalities", the woman "would have an abortion", to avoid an increase in the infant mortality rate.

Hirschfeld referred to well-documented research about the Soviet Union and the People's Republic of China, showing that "revolutionary" efforts "can also include such practices as deliberate manipulation of health statistics, aggressive political intrusion into health care decision-making, criminalizing dissent, and other forms of authoritarian policing of the health sector designed to insure health changes reflect the (often utopian) predictions of Marxist theory". But, according to Hirshfeld, "the true extent of these practices was virtually unknown in the West", where "social scientists frequently cited favorable health statistics supplied by [these regimes], without critically looking at the ways these were created and maintained by state power".

Hirschfeld concludes that "Cuba’s health indicators are at least in some cases obtained by imposing significant costs on the Cuban population -- costs that Cuban citizens are powerless to articulate or protest, and foreign researchers unable to empirically investigate"

Complaints have also arisen that foreign "health tourists" paying with dollars and senior Communist party officials receive a higher quality of care than Cuban citizens. Former leading Cuban neurosurgeon and dissident Dr Hilda Molina asserts that the central revolutionary objective of free, quality medical care for all has been eroded by Cuba's need for foreign currency. Molina says that following the economic collapse known in Cuba as the Special Period, the Cuban Government established mechanisms designed to turn the medical system into a profit-making enterprise. This creates an enormous disparity in the quality of healthcare services between foreigners and Cubans leading to a form of tourist apartheid. In 1998 she said that foreign patients were 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. Others makes similar claims, also statin g that senior Communist party and military officials can access this higher quality system free of charge. In 2005, an account written by Cuban exile and critic of Fidel Castro, Carlos Wotzkow, appeared showing apparent unsanitary and unsafe conditions in the "Clínico Quirúrgico" of Havana; the article claims that health care for Cubans occurs in worse conditions in the rest of the country.

An article in Canadian newspaper National Post, based upon interviews of Cubans, finds that in reality even the most common pharmaceutical items, such as aspirin and antibiotics are conspicuously absent or only available on the black market. Surgeons lack basic supplies and must re-use latex gloves. Patients must buy their own sutures on the black market and provide bedsheets and food for extended hospital stays. The Cuban government blames the shortages on the embargo and states that those with more severe chronic diseases receive medicines. However, other sources suggest that those with such diseases lack medicines. It is also suggested that in some cases the local non-dollar stocks have been shipped abroad.

The U.S. State Department has argued that during the economic depression "the Cuban government made a deliberate decision to continue to spend money to maintain its military and internal security apparatus at the expense of other priorities â€" including healthcare." However, one study found that "the available data show that the fall in Cuba's medicine imports in the '90s didn't correspond to a significant lowering of the government's healthcare spending. Budgetary support for peso-denominated spending â€" i.e., labor costs of medical professionals, operational costs of hospitals and clinics â€" has remained strong. Attempts to blame medical shortages in Cuba on resource misallocation are thus misguided, or at least wrongly nuanced."

A recent ABC-TV 20/20 report on Healthcare, based on footage taken from within the island, criticized Michael Moore's portrayals of the Cuban Healthcare system in the movie Sicko. In that film, Moore took a number of Americans to a hospital in Havana where they bought affordable drugs, and were given treatments for free that they could not afford in America. The report highlights the dilapidated conditions of some hospitals that are accessible to regular Cubans by pointing to the bleak conditions of hospital rooms and the filthy conditions of the facilities. The report also addressed the quality of care available to Cubans by arguing that patient neglect was a common phenomenon. Finally, in discussing the infant mortality rate, the report highlights the government's alleged efforts to promote abortions of potentially infirm fetuses and other alleged government efforts to manipulate the rate.