Author’s note 1
In 1999, the World Health Organization (WHO) developed a measure to assess the ability of a National Health System (NHS) to translate expenditures into health outcomes called the “index of performance or efficiency on the level of health” (IELH). Health expenses per capita, disability-adjusted life expectancy (DALE), effectiveness of the NHS, and education are the components of such measure. In that year, the U.S. ranked 72nd in the world, while Cuba ranked much higher at 36th. 2 In July 9, 2001, the LA Times wrote “Old-fashioned doctoring keeps Cubans healthy. The nation may be one of the poorest in the world, but reports health indices that rival those of rich countries such as the U.S.; Cubans are absolute best at doing something with nothing.” Later, DALE was refined into health-adjusted life expectancy (HALE). 3 Experts found that for 1970–2009, the U.S. had the fastest deceleration in world health-efficiency among high-income nations, without any valuable gain or reduction in cost for wellbeing or health. 4 U.S. policy makers want to adopt policies of welfare states and even some of Cuba’s to make U.S. NHS the best. 5 Despite Cuba’s higher IELH world rank compared to the U.S., its oppressed, impoverished, and despaired people in the period of 1959– 2016 kept leaving the island mainly to the U.S., Cuba’s supposed enemy and apparent the least healthy nation of the developed world. What health dimensions are the DALE, IELH, and HALE not measuring that have created such a paradox between the Cuban and U.S. NHS from 1990 to 2016? The objectives of this study were to find any similarities, differences, and efficiencies’ behaviors and causes between the Cuban and U.S. NHS and suggest the most human efficient policies to hasten their NHS development.
Design of Matrix of NHS Cases and Data
Historical facts and statistics for the periods 1900–1958/1964 and 1959/1964–2016, before and after the Cuban socialist revolution, 6 were collected and described. System analysis of the Cuban and U.S. life and health sectors’ inputs, processes, and outputs, as well as cross section international and cohort intra-national comparisons of 190 variables for both NHS were made. Pan American Health Organization/WHO and other United Nations (UN) agencies’ databases at their Havana Offices were consulted. Also consulted were university libraries in Havana, Glasgow, Edinburgh, Pennsylvania, Connecticut, and Miami directly and through the internet while living at Havana 1998–2009 and Miami 2010–2017. 7 The author estimated missing data and made adjustments of conflicting Cuban data (based on his first-hand experiences as practicing physician and biostatistician) using Maddison’s econometric methods. 8 The references in this paper summarize hundreds of other sources consulted. 9
Operational Definitions and Classification
- A NHS’s real human efficiency on levels of health is considered when it reflects all the physical, mental, and social dimensions of the WHO health 10
- A NHS model is not equivalent to central planning; every nation has a NHS as legitimate as its national economic system.
- Since 1900, the Cuban NHS was reformed to mimic the US-style NHS of democratic-capitalism, and since 1959, the Soviet-style NHS of totalitarian-socialism; 11 the U.S. NHS was reformed in the style of a Swiss social-democracy system since 1965.
- Every NHS has two closely related industrial sectors: (a) a health care internal sector (NHS coresub system); and (b) a life support external multi-sector (NHS biophysical-socioeconomic environmental conditions or super system). 12
- Between 1917 and 1991, no reform policies in the socialist Soviet bloc nations showed transparently their inhuman effects on the morbid-mortality and average life expectancy (ALE) of their citizens. To understand the Soviet method of governmental data manipulation and biases, requires mining all public and secret data, facts, and conflicting policies, classifying health and life policies according to ethics and human efficiency. 13
Efficiency Behavior of Cuban and U.S. NHS, 1800 through 2015
Figure 1 shows Cuba’s apparently high NHS efficiency results from 1959 to 2015, accentuated by disastrous periods in 1966–1974 and 1991–1999 for all life and health sectors. Cuba’s slow rise and less publicized falls of ALE at birth occurred while the island auto-suppressed human rights and auto-depressed gross domestic product (GDP) per capita and other standards of living.
Figure 2 shows an apparent drop in U.S. NHS efficiency since 1945. U.S. and Western scientific-technological growth enhanced patient biophysical medicine and public health. In 1965, the start of the Medicaid and Medicare federal-state health insurance programs for the poor and elder in the U.S. accentuated the fall. This apparent decline in efficiency occurred while all standards of living, including human rights and education, consistently rose.
Cuban and U.S. NHS–Similarities and Differences, 1900 through 2016
Tables 1–4 compare the Cuban and U.S. NHS with respect to inputs, processes, and outputs for 1900– 1958/1964 and 1959/1965–2016. Similar progress in Cuban and U.S. life and health sectors are observed in 1900–1958/1964, while the main differences are observed in 1959/1965–2016.
Cuban and U.S. NHS Efficiency Behaviors, 1900 to 1958/1964
Until 1958/1964, the Cuban and U.S. NHS be haved as the best in developing and developed nations, with respect to life and health sectors. What were their main policies?
- Cuban NHS life support sectors’ policies 1900– 1958. Ethical & efficient: Tradition of access to top U.S., French, and world standards of living by most urban and rural poor, and application of their scientific-technological platforms by most professionals. Ethical & inefficient: In 1940– 1958 workers’ unions and government began implementing an excessive number of subsidies that started to bring about bad working habits and fostered carelessness, indigence, and dependency by the poor. Unethical & efficient: None. Unethical & inefficient: Costly goods and services were obtained often by politicking. During this period, mostly Europeans migrated to Cuba.
- Cuban NHS healthcare sector’s policies 1900– 1958. Ethical & efficient: Tradition of access of most poor to top governmental, private, mutual, and charitable standards of healthcare, and of U.S., French, and world biomedical, pharmaceutical, vaccine, and public health applied scientific-technological platforms by most doctors. Ethical & inefficient: None. Unethical & efficient: None. Unethical & inefficient: Costly teaching hospital beds were obtained often by politicking.
- U.S. NHS life support sectors’ policies 1900– 1964. Ethical & efficient: Tradition of access to top U.K., French, German, and world standards of living of most urban and rural poor, and basic and applied scientific-technological platforms by most professionals. They invented and innovated goods and services at world class standards. Ethical & inefficient: In 1949–1964 unions and public agencies provided too many benefits that began to give rise to bad work habits, and fostered carelessness, indigence, and dependency by the poor. Unethical & efficient: None. Unethical & inefficient: Costly goods and services were sometimes obtained by public permanent bureaucracy connections. In this period, migration into the U.S. was mainly of educated Europeans.
- S. NHS healthcare sector’s policies 1900– 1964. Ethical & efficient: Tradition of access to top public, private, mutual, and charitable standards of healthcare and outreach programs by most poor, and to top U.K., French, German, and world biomedical, pharmaceutical, vaccine, equipment, public health basic and applied scientific-technological platforms by most doctors. They invented and innovated the most comprehensive and active hospital biomedical care at top world standards, rising patient protection from disease, and bio-environment friendliness. Ethical & inefficient: None. Unethical & efficient: None. Unethical & inefficient: Costly research hospital beds were sometimes gotten by public permanent bureaucracy relations.
Cuban and U.S. NHS Efficiency Behaviors, 1959/ 1965 through 2016
In 2016, Cuba showed worse conditions in its life and health sectors, paradoxically with very good biophysical health, but covert socio-mental health outcomes that lagged most developing nations. Meanwhile, the U.S. showed the best performance regarding world life sectors and outcomes, with most powerful health sector apparently bad organized, and best biosociomental health outcomes in all developed nations. What were their key policies?
- Cuban NHS life support sectors’ policies 1959– 2016. Ethical & efficient: None. Ethical & inefficient: None. Unethical & efficient: The elite group covertly enjoys top U.S. standards of living, while the rest of the population suffers needlessly bottom North Korean ones. Cuban intelligence accesses U.S. applied scientifictechnological platforms through its allies (Russia, China, North Korea, Iran), breaking the U.S. embargo. Professionals of the elite secretly own civil-military cyber technology, neuropsychiatric-technology and biotechnology firms abroad, as well as ghost companies to launder money, conduct drug-trafficking, and defraud the U.S. Medicare program. The elite misinforms the world, reporting achievements on egalitarianism and public health, as it covers up its most profound social inequities whereby the elite has access to goods and services to which the common people do not. Unethical & inefficient: One-party/ government bureaucracy monopolizes all Cuban businesses. The people lack water, food, housing, arms, phones, transportation, electricity, dignity, and hope of humanizing their socioeconomic condition. They suffer from oppression, impoverishment, forced labor, compulsory marches, and queues for everything. The elite demoralizes and robotizes the common people through public indoctrination and corruption. The elite manipulates GDP per capita, growth performance by sectors, and all other statistics. The elite lies to the UN Assemblies, blaming the U.S. embargo for its disastrous economic performance. Costly goods and services are often available through bureaucratic politicking and corruption. Immigration into the island ended; massive emigration of talent, in all sectors, started.
- Cuban NHS’ healthcare sector’s policies 1959– Ethical & efficient: Exaggerated Swedishstyle 9-month monitoring and early detection and evaluation of biogenetic and socio-mental fetal viability; newborns receive a 12-month follow-up. Ethical & inefficient: None. Unethical & efficient: None. Unethical & inefficient: Cuba controls data related to all births, diseases, and deaths, in addition to all decisions including the doctor-patient relationship. If a woman’s pregnancy may result in the infant’s death, then the gestation is forcibly terminated, regardless of its term, and the woman sterilized if needed, to avoid adversely affecting Cuba’s ALE and HALE. Cuban intelligence and its allies provide elite research doctors with U.S. bioinfomedical, pharmaceuticals, neuropsychiatric-equipment, genetic-engineering/biotech products, immunovaccines, and public health applied scientifictechnological platforms otherwise banned by the U.S. embargo. Most common people have access to a level of partial and expectant medical care similar to that of the 1950s. Lack of transportation forces most people to go to Soviet-style polyclinics instead than to hospitals. There is very limited hospital care available to adults, but worst to the elder and dying patients, as a result of under-testing/diagnosis and therapy/procedures, mismanagement, and under-supplied elderly asylums. There are unpublicized clinics in Havana (and abroad) that provide the elite and foreigners who travel to the island with near Cleveland or Mayo Clinics’ comprehensive and active-style medical care, and luxury elder care homes. There is an excess of doctors graduated in 13 Community Polyclinic-Medical Schools, after receiving inferior quality education than in the Latin American School of Medicine. The elite has banned private medical practice and forced doctors to live as indigents with the lowest wages in the world. Most missions abroad are operated by physicians who give away Cuba’s medicines to foreign people trying to gain favor with pro-socialist leaders in those countries, while Cubans suffer shortages of physicians and medicines to buy. Misleading disease and death rates of fetuses, infants, mothers, persons suffering from malnutrition, stunting, HIV/AIDS and sanitation/vaccine-eradicated epidemics, chronic diseases, homicides, ALE, and HALE, are manipulated to advertise the Cuban NHS. Beds in luxury elite and tourist clinics are usually available by politicking and corruption.
- S. NHS life support sectors’ policies 1965– 2016. Ethical & efficient: Increased traditional access to top world standards of living of most population, and of basic and applied scientifictechnological platforms of most professionals. They invented and innovated goods and services at top world standards. Ethical & inefficient: Federal-state-local excessive subsidies for the poor weaken their will to work for a living. An increase in regulations and taxes on industries slowed production and middle class growth in the U.S. Unethical & efficient: None. Unethical & inefficient: Costly goods and services were often gotten by public permanent bureaucracy connections. Immigration to U.S. was predominantly less educated Asians and Latin Americans.
- 1. U. NHS healthcare sector’s policies 1965– 2016. Ethical & efficient: Increased traditional access to top public, private, HMO, charitable healthcare and outreach programs for most of the population; also to world-leading bioinfomedical, pharmaceuticals, equipment, geneticengineering/biotech, immunology-vaccine, and public health basic-applied scientific-technological platforms by most doctors. They invented and innovated the most comprehensive and active bioinfomedical hospital and general care at top world standards. These have increased patient risk protection of disease and survival-free of suffering-disability, and bio-social environment friendliness. Top world standard licenses for medical schools, hospitals, pharmacies, physicians, and safety and effectiveness’ regulations for Food and Drug Administration’s approval of new products, caused adoption of large, prolonged, costly, but most trustable randomized clinical trials. Ethical & inefficient: Increased subsidies to Medicaid up to 100% and Medicare 80% for people over 64 years old. This stimulates illness and disability, and fosters fraudulent claims and irresponsible self-healthcare in most people. Consequent, there is over-testing/diagnosis and therapy/procedure of diseases, over-demand of mismanagement, and over-payments. Public overregulation of the health insurance industry encourages patient irresponsibility towards his health. Unethical & efficient: None. Unethical & inefficient: Expensive research hospital beds got often by public permanent bureaucracy relations.
In 1791, Menuret during the French revolution dreamt of ending private individual medicine and hospital care, with a state-police absolutely controlling all human life, epidemic medicine, physicians, and home care. 14 Marx’s economic ideology of class struggle encouraged a reform in Germany in 1883, and a revolution in Russia in 1917. These focused on government trying to equalize access to income and health care for the poor, forgetting the individual freedom to choose between life and health goods and services, inherent to his socio-mental health. From 1920 forward, Gramsci modified Marxism, as a cultural ideology, to remove U.S. libertarian values. It created and implanted “false memories and perceptions of the world’s life realities” in Western academia and media, which have had a confusing mission rather than a clarifying one. 15
What Current WHO National Level of Health Indices Do Not Measure
ALE and HALE assess 19,000 lethal diseases and injuries. HALE also assesses disabilities of 292 biophysical diseases-injuries, 8 substance abuse conditions, and 15 mental disorders. But it places most biophysical and socio-mental wellbeing, ability, and positive health of the humane WHO definition of health, 16 in a large residual category not classified yet. HALE does not assess patient-people social environmentcaused mental disorders, suffering, and disabilities attributable to totalitarian oppression. The WHO IELH substitutes 10 UN standards of living measures putting in their place the education and health expenses per head indices by analogy with the UN human development index. 17 Thus, HALE and IELH, exclude most socio-mental suffering, disability, wellbeing, ability, and all tridimensional positive levels of health of every nation measured.
Hidden Causes of Supposed High Cuban NHS Efficiency 1959–2016
Since 1959, Cuban life and health sectors gradually collapsed from high baselines that placed Cuba ahead of Hong Kong and Singapore. The elite credited the apparent good health outcomes in the 2000s to the family physician plan. My family and I experienced it, and I worked to improve it. So, what truly occurred?
- In the life sector: (1) Appalling and slowly improving living conditions were achieved through terror, censure, captivity, and misinformation, degrading Cuba from 1959 to 1990 to a poor Soviet central Asia (2) The wealthy U.S. was “demonized” as the enemy, and blamed its commercial embargo as the source of all of Cuba’s hardships. (3) The island in 1991–1999 unnecessarily became like a Nazi “concentration camp” suffering epidemic optic and peripheral neuritis from forced hunger, physical work, beriberi, toxic cigarettes, and homemade liquors. The suicide rate rose to the highest world ranks. However, atherosclerosis, diabetes, and some cancer death rates fell. (In 1946, a similar “chronic disease cleaning” was noted in necropsies of Jews who had faced forced hunger and energy spending during the Holocaust). (4) In 2000–2016, Cuba resembled devastated Germany after World War II—where hundreds of new hotels for foreign tourists and the covert elite contrasted with the collapsing homes of the common people.
- In the health sector: (1) Most medical supplies and medicines were missing. There was mainly the consoling action of an excess number of doctors working (often as nurses and sanitation workers), most of them suffering from Stockholm’s syndrome. (2) Communal leaders forced doctors to appease psycho-ideologically and prescribe herbs and psycho-pharmaceutics to the patients, to avoid rebellions against the repressive state. They had to validate the ill environment and patients as healthy to keep up Cuba’s NHS prestige. (3) Conditions at most medical schools, clinics, and hospitals were abysmal. (4) Compared to doctors’ bad conditions, the condition of patients were even worse. (5) The slow rise of ALE and HALE did not reflect these oppressioncaused socio-mental sufferings and disabilities. So much atrocity was hidden thanks to Cuba’s elite success in avoiding censure in the UN and WHO classification of its auto-caused human rights abuses and social disasters such as epidemic plagues. 18
Unfounded Causes of Apparent Decline in U.S. NHS Efficiency 1965–2016
During 1990–2016, the U.S. NHS appears absurdly with lower IELH results than Cuba. Experts explain this simply due to Cubans more accessible primary care of doctors, similar slow rise in ALE and HALE in both countries and faster U.S. rise of GDP and health expenditures per capita than in Cuba. Actually, this is the effect of a hyper-complex web of interactions of U.S. freedom and Cuba’s coercion in their respective life and health sectors, policies, and statistics. No health index is yet able to capture the real biophysical and socio-mental quantity, quality, and true equality of population global health dynamics of the wealthy progression of the U.S. compared with Cuba’s ruinous regression. Since 1945, U.S. and Western biomedical research programs have created the highest world standards of comprehensive and active hospitals and general care of patients, but more impersonal and costly. Since 1965, excessive financed social support programs encouraged the reporting of illnesses and disabilities, augmented by misdiagnosis and fraud, and fostered patient inconsistent self-healthcare. Since 1966, the U.S. family medicine was strengthened with bioinfomedical systems. But, the clinical method of patient primary care remains restricted to assess-diagnose-treat-prevent better biophysical-mental diseases and risks. It cares less about socio-mental disorders, risks, wellbeing, ability, and positive health. It leaves a hard job to the impersonal public health promotion of the patient.
A Patient Global Health Index Can Help Rise NHS Health Efficiency
The U.S. must urgently fuse the biosociomental health comprehensive observation and measurement clinical methods of Hippocrates and Euryphon. This fused method can assess, diagnose, and care for all patient and environment health indicators, encompassing a patient-centered life complete health. It shall balance negative health effects (suffering, disease symptoms-risks, disability, pathogenic parameters, senescence, dying, and death) with positive ones (wellbeing-ability, health manifestations-enhancers, healthgenic parameters, gestation, birth, and growth). Patient global health is the complex most probable inter-working of many quantitative and qualitative degrees of negative and positive biosociomental health, rather than a simpler least likely “all or nothing” absence of illness or presence of wellness. 19 Physicians must bridge clinically and epidemiologically the patients’ negative and positive health matrices of biosociomental variables. Health shall be enhanced as patients become more informed and educated, are able to take on responsibility and delay the onset of chronic disorders. Patient’s global health and enhancer causes can raise the statistical power of clinical trials. The author works on the medical algebra of the patient negative and positive global health equation. 20
Usual NHS analyses exclude life and health gains of persons covered or costs of suppressed human rights, other than the right to healthcare. Human rights-adjusted NHS analysis shows the U.S. and Swiss systems competing for top human efficiency, while the Cuban and North Korean NHS compete for the bottom. Policies of democratic-autocratic Cuba in 1900–1958 showed higher human life and health efficient outcomes than totalitarian Cuba in 1959– 2016, despite efforts of this government to hide unacceptable unethical and inhumane policies. Totalitarian Cuba has only first-class human life and health for the foreign tourists overtly and the elite covertly. Cuba’s NHS shall improve with human rights observation, privatization and mutualism competition again.
From 1945 to 2016, the U.S. life, health, industry, education, and research systems have expanded and diffused the most essential package of scientific-technological inventions and innovations to reach its entire population, imperceptibly improving human life and health quantity, quality, and equality in the whole planet too –incredibly without proper recognition of the UN and U.S. experts. The U.S. model challenges the Marxist logic of reform, resulting in an induced and free diffusion of the patient not well measured but enhanced positive and global health, besides the well-measured partial negative health.
Physicians have a big potential for discoveries in the scientific areas of patient biosociomental wellbeing, positive health outcomes, causes, and methods. Research in bioinfomedical paradigm/programs with primary mobile health care, shall gradually result in an optimum quantity, quality, and equality of population health, and reduce all preventable costs for young and mature patients. The U.S. should invest more on bio-behavioral primary care medical research of the patient, creating math-cyber-informatic tools to assess, diffuse, educate, support decisionmaking, and enhance patient health in near real time.
Patient health magnitude and enhancer factors can facilitate the trials of greatly needed new clinical scientific-technologies. Composing a living patient global health index will allow building better human population health levels and bottom-up efficiency indices.
- I thank Pierre Mansourian, ex-Director WHO HQ Research, Louis Currat, ex-CEO Global Forum for Health Research, Mary Eisenhower, President, People to People International, and Richard Dickey, Wake Forest University, for encouraging me to study national-global health systems; Kent Bream’s UPenn students for discussion of a prior paper in February 2017; María Espinosa for content synthesis; and Santiago deValle for redaction revision.
- WHO. The World Health Report 2000. Health Systems: Improving Performance. Geneva: WHO, 2000. IELH is the difference of observed and theoretical DALEs in absence of a functioning-NHS, education-adjusted, divided by the difference of the maximum possible DALE achieved for the observed health expenses per capita, and DALE in the absence of a functioning NHS.
- HALE is a form of health expectancy that applies disability weights to health states to compute equivalent years of life expected to be lived in full health. Global Health Observatory. http://www.who.int/gho/mortality_burden_disease/life_tables/hale_text/en; GBD 2015 DALYs, HALE Collaborators. Global, regional and national disability-adjusted life-years (DALYs) for 315 diseases, injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis. Lancet. 2016; 388(10053):1603–58.
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