Thursday, July 26, 2007

Health care myth and reality

Many blogs have commented on this essay (pdf, via Miscelaneas de Cuba) by Katherine Hirschfeld of the University of Oklahoma. It appears in the University of Miami’s journal, Cuban Affairs.

UM promotes the essay as a state-of-the-art critique of Cuba’s health care system, the perfect antidote to Michael Moore’s Sicko.

But if you read it, it’s pretty thin soup.

It has academic references out the wazoo, but considering that it’s based on nine months of research in Cuba, it contains little information. Mainly, it’s a warning to researchers not to accept the Cuban party line at face value, and to beware of measuring public opinion in a place where speech is limited. Fair enough. The essay’s main point is that foreign researchers often paint a rosier picture of Cuban health care than Cubans do, although this “is not to say that Cubans had nothing positive to say about their health care system.”

It says the research was done “in the late 1990’s;” a version of the same paper presented a year ago said it was 1996. It points out that the U.S. embargo “exacerbates material shortages on the island.” It describes the economic reforms of the 1990’s as “privatization,” which is quite a bit off the mark.

It makes the sweeping assertion that in one community, “no one used the formal health sector at all for commonplace medical complaints.” (The author keeps the name of this town a secret.) Which would mean that in that community, family doctors’ consultorios are either vacant or are mere social meeting places, that doctors don’t make house calls or otherwise have much to do.

Except, that is, to work in the black market, as illustrated in an example of a dentist who slowly gathered the wherewithal to operate on a wisdom tooth, and did so on a Saturday. There’s another example of a dental patient who got anesthesia only because she knew the nurse, and the nurse was looking out for her.

Surely, there are doctors that work on the side, and there is a black market in medical supplies and drugs, and it helps if patients know the right person inside the system.

But in Cuba one can see patients going to family doctors and clinics, and going to pharmacies to try to get prescriptions filled. The system is frayed, but it is not dysfunctional.

Then there’s another set of far-reaching claims: that there is no such thing as informed consent, Cubans have “no right to refuse treatment,” and doctors are sort of CDR’s in white coats, charged with “monitoring their neighborhoods for any sign of political dissent.”

On page 17, just when you’re ready for anecdotes and data from nine months of observation, the essay ends with a tentative conclusion. Hirschfeld poses a good question – whether Cuba’s political system distorts international perceptions of its health care system. But her intention, she says, was not “to answer this question so much as to argue for its relevance.”


Mambi_Watch said...

Nice post.

First of all, I think readers should know that ICCAS produces very good work, but I feel that their conclusions are very biased towards the view of the US government. Thus we should look the reports they publish with serious caution.

Hirschfeld's "qualitative critique" off the top seems flawed. Her premise that "[t]he vast majority of scholarly analyses of Cuba’s health care system have been positive" is based on THREE sources.

One (Weiner, 1998) is NOT a "scholarly" analysis, but an online column, and another (Limonta and Padron, 1991) is NOT a general analysis of Cuba's health care system. The Chomsky 2000 reference does seem to fit the bill, but note that neither of the three sources are from scholarly journals or peer-reviewed journals.

Hirschfeld is already on the wrong foot.

I've actually read very good critiques of Cuban healthcare in some scholarly journals, such as the Lancet and Annals of Internal Medicine. Seems that Hirschfeld missed these. Maybe because most of them blame the US embargo for the poor conditions of health facilities in Cuba.

Also, Hirschfeld states: "it became increasingly obvious that many
Cubans did not appear to have a very positive view of the health care system themselves."

Last year the Gallup Organization took a poll in Cuba (specifically Havana and Santiago) where they asked 1000 Cubans:

"Do you have confidence in your country's healthcare system?"
- 75% said Yes.

This is in comparison to the rest of Latin America (urban) who were asked the same question and responded at 57% in approval.

Also past polls in Cuba show that Cubans worry more about other things instead of health services. For many years, universal education and health are two subjects viewed very positively in Cuba.

Hirschfeld's study seems flawed to me from the start.

Charlie Bravo said...

The only difference is that in other countries of Latin America they don't have to fear government reprisals if they critique a government sponsored program. In Cuba, that's an offense.

Mambi_Watch said...

Actually, what seems prevalent in some Latin American countries is no better. Their voiced grievances are generally ignored while many of the affected live in desperate poverty.

And when they organize in order to address an issue they are viewed negatively. Take the Unionists in Colombia.

For many years, the health of women has been ignored in Latin America, especially in reproductive health.

The rate of clandestine abortions are high, but their governments refuse or hesitate to deal with the issue. Cuba deal with this issue long ago, and only adds to improving womens health in such important stages of life.

leftside said...

MW takes the high road, but I won't let Bravo's statement about supposed Cuban fear of (Gallup poll) repisals to go unaswered. I mean come on, Cubans with gripes give their opinions to any reporter every day. You think they are scared of telling the truth to a competently adminstered secret Gallup poll?

If criticizing a government sponspored program is an offense in Cuba, Raul is guilty, and just promoted even more law breaking with his speech today. He clearly called again for more questioning and debate and critiqued many failures of the State. There is not one case of reprisal in Cuba to anyone who answered a poll (or any other) question wrong. This is a cop-out to explain the many polls out of Cuba you don't like.

Charlie Bravo said...

Leftside, let's say that my assertion comes from my own experience of living there.