HAVANA TIMES – Cuba has 31,308 fewer health workers than in 2021. The figure includes a deficit of more than 12,000 doctors in 2022, according to official figures.
“There are no doctors here, nor laboratory technicians in the emergency room,” a doctor from eastern province of Holguín confessed on condition of anonymity, adding that “the bosses know this because it is a recurring theme in all end-of-shift reports.”
The neonatal ward of the Vladimir Ilich Lenin Hospital doesn’t have enough technicians to cover the night shifts. “So if a newborn is bleeding and you have to prescribe a haemoglobin test, or if a baby has fever and you need to conduct an erythrocyte sedimentation rate (ESR) to rule out infection in his body, you can’t,” said another health worker familiar with the situation. It is also not possible to perform blood tests to follow up patients in serious condition.
The danger of the lack of personnel, accompanied by the lack of supplies, medicines and hygiene in hospital institutions has already impacted in the most recent infant mortality rate of 7.5 per 1,000 live births, one of its causes being septicaemia -which is no other than the severe response of the body to chronic infections.
If such is the state of neglect in newborn care, that has plummeted the indicators of the Maternal and Child Program – and it has always been a priority for the country – what can be left for other areas of health care?
No one escapes the health crisis
“Right now, there is a crisis for nurses. In the Intensive Care Unit of the Lucia Iñiguez Landin Clinical Surgical Hospital, out of 13 beds, only six are functional due to a lack of personnel,” said a health worker.
From Ciego de Ávila, a surgeon complains that there are no sutures, gloves or surgical instruments. He’s not the only one. The situation has become common throughout the country. Even the doctors themselves depend on their relatives and friends abroad for medication or surgery because public health institutions cannot guarantee the most basic resources.
According to statements made to this website by several health professionals, doctors from different specialties have requested their “release” from the Ministry of Public Health (MINSAP) because they do not want to continue working under the current conditions and they may even be accused of medical iatrogenicity or negligence, because they have nothing to work with.
One of them said that in mid-2022, more than thirty specialists in neurosurgery, internal medicine, anaesthesiology and nephrology were summoned to the Municipal Public Health Directorate in Holguín to be advised that they would not be allowed to leave their medical posts because the “healthcare system is under pressure” due to the shortage of staff. Since then, the doctor has not been able to end terminate his contract, nor has he been allowed to leave the country because he is needed in the hospital.
While prescription for checks and diagnostic tests that determine surgical decisions and cancer treatments such as magnetic resonance imaging scans (MRI) and biopsies, as well as gastroscopy and colonoscopy procedures are postponed, patients go on endless waiting lists due to lack of reagents, supplies and personnel in several health institutions around the country.
The requests and demands of patients on social network and in the independent media also shows the chaos of the health system.
Stampede in official numbers
Data from the 2022 Statistical Yearbook of Cuba recently published by the Cuban National Statistics Office (ONEI) shows the considerable reduction of medical personnel (graduates from different specialties) in health care in Cuba. In the last year, it went from 312,406 to 281,098.
In the case of medical doctors from all grades and disciplines – whose presence in the public health system sustained an upward trend from 2018 (with 95,487) to 2021 (with 106,131) – only 94,066 were registered in 2022. That is, 1,421 medics less than five years ago, and 12,065 less than in 2021.
Of these, General Practitioners, who are community-based family doctors, show an increase of 1,136 in relation to the rest. The other health graduates that don’t have negative figures are pharmacists, with an increase of 503 workers in 2022.
Dentists also suffered reduction in their numbers, with a similar ascending pattern as that of doctors from 2019 to 2021. Of the 20,903 dentists that MINSAP had in their records in 2021, only 17,657 were registered in 2022. This amounts to a loss of 3,246 professionals of the specialty in just one year.
Of the remaining staff, the decrease in nurses stands out, from 86,983 in 2021 to 79,569 the following year, which means a reduction of 7,414 nursing workers.
Less technicians and technologists
Another group that has contracted alarmingly is that of graduates from technological careers, which include senior, medium, and basic technicians, as well as technologists and other holders of health bachelor’s degrees, whose presence in medical institutions has decreased from 92,950 in 2021 to 83,864 in 2022, for a drop of 9,086 workers.
So that their usefulness in the health infrastructure is understood, they assist in the execution of medical tests and procedures, the processing of samples in laboratories and performing scans, and x-rays, among many other responsibilities.
In total, Cuba currently has 31,308 fewer health workers than the previous year. Which, in theory, increases to 118 the number of inhabitants per doctor, to 627 people per dentist and to 139 citizens per nurse.
The provinces most devoid of doctors are Artemisa with 2,845, Mayabeque with 1,884 and Cienfuegos with the alarming figure of just 642 medics.
“But they still continue to send doctors abroad,” said a health professional, referring to the willingness of the Cuban authorities to rent Cuban professional services to other countries.
Likewise, the authorities insist on selling a sweetened image of public health in Cuba through propaganda at commercial events and on social networks to attract buyers of Cuban medical services and academic training.
According to an explanatory note from ONEI, the figures for “physicians and stomatologists correspond to the total registry of health workers. The rest of the personnel only includes the workers in the units of the National Health System (NHS)”.
The foregoing seems to indicate that the number of doctors and stomatologists includes those who work in State-owned private clinics and in State-run contracts abroad, known as “international missions” as part of Cuban Medical Brigades which at the beginning of the current year 2023 amounted to 23,792 Health “collaborators” in 56 countries, according to data from the Cuban Ministry of Foreign Affairs.
Due to the lack of transparency of the Cuban authorities and its institutions, it is unknown how many of those who work on state contracts abroad are actually medical graduates. The last time that the official discourse offered details of figures was in March 2020, when it reported that more than 28,000 Cuban medical workers were in 59 countries, of which 18,000 were doctors, cited a report by the NGO Cuba Archive.
For the same reasons nor can it be determined how many are on leave for personal reasons, so that a breakdown of how many doctors and nurses are currently working in public health in Cuba is not possible.
Therefore, the actual ratio of doctors per number of inhabitants, is necessarily much higher than what is portrayed by the propaganda. Especially considering that migrant status is disguised by permanent residence law. In other words, health workers that had fled the country in the past year will only be considered emigrants and, therefore, out of the NHS, two years after leaving Cuba.
Doctors, businesspeople or migrants?
“If while you are on the street you start to feel unwell and the hospital is far away, go to the nearest bar, cafeteria, restaurant or SMEs. There you will find a doctor or a nurse for sure… as well as a teacher or an intellectual”, the Santiago-born journalist Cuscó-Tarradell wrote on his Facebook page.
The remark alludes to the stampede of medical and qualified personnel to better-paid jobs in the private sector and responds to the population’s concern about the health crisis in Cuba. Now doctors have become waiters, restaurateurs, hairstylists to be able to feed themselves and their families, since their salaries as health care staff are among the lowest worldwide.
However, the dramatic deficit of doctors in the last year also indicates that the health care workers have chosen the arduous path of emigration as part of the nearly 233,000 Cubans who have arrived to the United States in the last fiscal year, according to official figures.
In this sense, doctors Manuel Guerra, Alexander Raul Pupo Casas and Alexander Jesús Figueredo Izaguirre stand out, as well as Noemia Rodriguez and dozens of other less known Cuban doctors who have also left the country.
Such is the case of more than 50% of the group of Holguin doctors who protested in August 2021 because of the lack of medicines and supplies during the COVID-19 pandemic, and in response to the Cuban Prime Minister Manuel Marrero Cruz, who accused doctors of poor patient care at times of the worst health crisis to date.
Some others are also likely to have entered the United States thanks to the Family Reunification Program or were among the more than 5,000 who arrived from illegal traffickers to Europe in recent months, according to an Interpol investigation. Likewise, they could have been beneficiaries of the new humanitarian parole, the express route par excellence for legal migration to the United States or they may have abandoned the Cuban Medical Brigades abroad.
How to stop the stampede?
For the Cuban authorities, the formula is simple: coercion and limitation of rights. For this reason, since 2015 MINSAP has maintained the “regulation” for all qualified personnel, especially consultants, by Decree-Law 306*.
By virtue of this legislation, the Ministry of Public Health prohibits specialists from different areas of medicine from leaving the country and, if necessary, any health worker, on the grounds that they are needed in the NHS. In fact, the Cuban health care staff are seen as the property of the state, which claims the right to violate their freedom of movement.
Calls have also been made for retired personnel to rejoin the NHS, despite the fact that the meagre salaries do not constitute an incentive, nor do they seem likely to improve.
And without a doubt this is one of the problems faced by the health sector in Cuba, where monthly salaries range from 3,110 Cuban pesos, in the case of a basic nurse, to 5,810 in the case of a specialist doctor (13.00 to 25.00 dollars), in a country with galloping inflation where the value of the dollar exceeds 225 Cuban pesos.
More recently, an indication from the MINSAP intends to force health workers who are at home to rejoin the SNS in the face of the personnel crisis.
The order is that “all doctors who have been with medical expertise for more than a year, undergo a new evaluation in the provincial medical commissions where the level of limitations of each one of them is defined and the level of activity that they can do”.
According to the written communication to which this website had access, signed on July 31 of this year by Dr. Reinol Delfin Garcia Moreiro, MINSAP vice-minister, it is intended to conclude with the re-evaluation no later than next October.
Causes of death in Cuba
Incredibly, and despite the loss of 10 percent of the health workforce that existed in 2021, the number of health centres remains practically unchanged in most cases, even gynaecological care services such as Maternity homes increased from 142 to 147.
Even more surprising, the endowment or allocation of beds in service units such as hospitals, polyclinics, care centres and others has increased from 62,625 to 62,884, while medical and dental consultations turned out to be 3,910 fewer than in 2021.
The 12 diseases that constitute the leading causes of death in Cuba miraculously decreased their incidence from 2021 to 2022, despite the chronic shortage of medicines and medical supplies (recognized even by the Cuban authorities).
This means that in 2022, 36,380 fewer people died than the previous year from heart, cancer, respiratory, circulatory, and liver diseases, and from suicide or, as ONEI calls it, “intentionally self-inflicted injuries.”
On the other hand, the incidence of notifiable diseases such as venereal diseases (blennorrhoea, syphilis and AIDS), acute respiratory diseases, different types of meningitis, acute diarrhoea and food poisoning, among others, skyrocketed in the last year.
Also striking is the increase in consultations of this type (both external and urgent) to 112,496 – an increase of more than 10,000 compared to 2020 – at a time when Cuba was going through its worst COVID-19 crisis and most of the services that were not directly related to the fight against the pandemic were paralyzed for months, leaving them completely neglected.
There is only a significant reduction in those that were opened for the isolation of patients with coronavirus, which does not count as representative data in post-pandemic times.
A devastating absence
This isn’t the first time that health care has seen its workforce shrink. During the 2008-2018 decade, a total of 98,000 MINSAP jobs disappeared as part of a restructuring process in the sector, according to an investigation by Diario de Cuba in 2018.
The question then is the same as it is now: Faced with such a deficit of health personnel, who cares for Cubans?
The decrease of 31,000 doctors, nurses and technicians in 2022, which is not explained by the ONEI report and does not correspond to an institutional strategy, represents almost a third of the number that the NHS lost within a period of 10 years.
Moreover, the sum of both figures amounts to the absence of 130,000 health care personnel from the MINSAP records in the last 15 years, which explains, in part, why it is impossible to disguise the debacle in medical care in Cuba nor hide the deterioration of the health and well-being of Cubans.
*Even though it was published in 2012 to amend Law 1312, the Migration Law, it was not until three years later that Decree-Law 306 which prohibit medical personnel from leaving the country came into effect.
(This text was translated and edited for publication in NoSomosDesertores by Annarella Grimal)