Everybody in Cuba has a family doctor. Really. A physician/nurse team cares for about 120 families or up to 1000 people in a specified geography. The doctor and his/her family often live above the simple medical clinic in housing provided by the State. Photos of two Havana family doctor’s offices are attached shown below. Usually they see patients in the mornings and make house calls in the afternoon. The team is required to make regular home visits for both clinical and social evaluations. They classify every person in their small catchment area as well, at risk, having a chronic condition, or disabled. They follow a set protocol for everyone in each category and update the classifications regularly. Every family doctor is required to complete an annual report about the health of the population in his/her care. They identify current and emerging conditions and lay out a plan or request for resources to address problems, for example an environmental condition that might be putting residents at risk. We were told these reports are reviewed carefully at the municipal, province and national level and serve as the basis for population heath planning. The family doctors also serve as local public health officers. For example when the government decided to fumigate every house to kill the mosquitoes that carry dengue and zika, the family doctors often persuaded residents to cooperate with the fumigation teams.

Each family doctor is affiliated with a group of specialists including a pediatrician, ob-gyn and internist based at a regional polyclinic. The specialists visit the family doctor’s offices regularly to support them and provide clinical consultation. The specialists see patients at the polyclinic by referral from family doctors. Family doctors can write prescriptions for virtually all essential medicines. Patients fill them at local pharmacies at very heavily subsidized prices, with provision to waive even that price if a person can’t afford to pay.(I walked into a neighborhood pharmacy and it seemed there were about 60 hand labeled boxes with prepacked generic drugs in them. About 60% of drugs and most vaccines are now manufactured in Cuba.)

It all sounds too good to be true, but every person I asked, from bus drivers to university professors told me they have a family doctor who makes occasional house calls.  They and the experts we talked to said there is a normal range of family doctors, from those who are dedicated for life to the area they serve and others who are filling an assigned slot without much commitment. Some people have such high confidence in their family doctor that they would never go directly to a specialist or hospital. Others go around them all the time directly to the polyclinic or hospital–which they can freely do.

Primary care—indeed most of Cuban medicine—is decidedly low technology. The family doctor’s office has an exam table, an autoclave to sterilize syringes and other simple diagnostic tools that are used repeatedly. The focus of medical training and practice is clinical examination and careful history. There is lots of listening in a typical encounter. Virtually all records are still on paper. They are often organized by family to enable the doctor to keep the full context in mind each time he sees a member of the family.

The family doctor/nurse team manage all care.  They have an array of social services they can utilize including maternity homes for high risk pregnancies and senior day care centers for frail elderly patients at risk of social isolation and inadequate nutrition. There is very little residential care for frail elderly.

The results are in the numbers. The infant mortality rate is lower than in the US and matches other first world countries. The average life expectancy is 79.

This is a picture of a local doctor’s office in a Havana neighborhood. It is probably the most fantastical doctor’s office you will ever see. An artist named Fuster started putting up enormous fantastical mosaics on his house about 50 years ago in homage to Goudi. Neighbors first thought he was crazy but eventually asked him to do their houses too, including the doctor’s office.  Now it is a major community project that provides training and jobs to lots of the people who live in this old fishing village and brings thousands of tourists every day.

Look carefully at the picture and you will see a hand written clinic schedule. We didn’t go in but we overheard a lively patient-doctor conversation underway when we took the picture. We also saw a more mundane family doctor’s office in old Havana. It had a handwritten note on the day saying that the doctor was off handling a pediatric emergency and would be back soon.