Cuban Health Care

BY ALEX TILSON

The graph was jaw dropping. The majority of the different country data points showed a fairly consistent relationship: as per-capita health care expenditures rose, life expectancy rose – dramatically at first, then with a lower but still important upward slope. But there were also some anomalous points - perhaps most notably, the U.S. and Cuba. To someone who has spent the majority of his career in the health care industry, this was worth exploring further, and I knew that an in-country visit would be the best way to do it.

The U.S. struggles with a healthcare system that is a world-leader in cost (with a consistently increasing percentage of GDP – now approaching 20% (6)), but delivers marginal efficiency. We abandon healthcare obligations to a portion of the population (virtually unique in this regard amongst developed countries (2)), we burden our population with exorbitant bills that they can not understand, much less pay for (medical bills are the biggest causes of U.S. bankruptcies (3)). We pay unimaginable amounts for new drugs, with ever-escalating prices (4), while the biggest government purchaser, Medicare, is, absurdly, and again uniquely amongst developed countries, barred by law from negotiating prices (5).

The mere word ‘Cuba’ elicits all sorts of (often irrational) emotions for Americans, and I claim, it has made it difficult for us to learn from our neighbor. But if Americans took the time and approached the subject with an open mind, they would find a country that has, despite enormous obstacles, managed to become a world-leader in the delivery of cost-effective medical care. Amazingly, their citizens have longevity comparable to that of the U.S. (7), but with a mere fraction of the per-capita cost. 

To a healthcare professional (I have been in the medical device industry, as both an engineer and as an entrepreneur, for twenty years), this was worth understanding in more detail. We designed a trip that would enable a significant amount of our time investigating this question in more detail. We took a refreshingly creative approach to data collection:  We travelled amongst and across the country at a uniquely personal level, with a heavy work schedule, collecting a wide range of data from a wide cross-section of society. Our research included datasets from both urban and rural areas.  We met with both health care consumers and providers. We were able to vacuum in all sorts of insights that you would not be able to find through more traditional research. This was all enabled uniquely through bicycle touring. Bicycle touring delivers wide swaths of the country at a very human level and pace. It creates the ability to have a constant stream of personal interactions, across a fantastic slice of Cuban life. What follows is a discussion of our learnings: exactly how and why does Cuba achieve more for less? Some of the learnings are from books and articles, but the real insights grew from our time in Cuba. 

Note that some of this report’s analysis is from Cuban government statistics that have been called into question (8). It is clear that monolithic sources of information – endemic to communist countries – are often indeed distorted. Such was clearly that case with the USSR, it is the case with North Korea, and China certainly fudges its data constantly. And so, it is argued, the Cuban data sources are not reliable.

Close to home, we have seen these dangers for ourselves, as the forces of Colin Powell, ably assisted by others including Condi Rice, created hyped-up data to bring the US to war, a war that eventually led to massive (ongoing) chaos and 500,000 deaths (9) (lets stop talking about the U.S.-only-tallied deaths and start thinking more about the total human deaths) and a total bill of nearly three trillion dollars (10) - $9,000 for every man, woman, and child in the U.S.  Clearly, there are gross dangers and a history of mis-representation from information that is singly sourced. So, while I agree that there are probably some elements of bending to some of the Cuban data, I suggest that the energy spent arguing about that would better be spent back home, focused internally, aimed towards our own government and the deaths, bills, and chaos that its distortions have created.

What are the elements that enable Cuba’s great longevity at such a low cost?

1) Clear government priority, enshrined in constitution.

One of the founding principles of the modern Cuban state was the importance of healthcare. Cuba views healthcare as a human right, not a privilege, and has enshrined it as such within their constitution. Article 50 of the Cuban Constitution states:

Everybody 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 and preventive and specialist 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 of the population cooperates in these activities and plans through the social and mass organizations (11).

2) Many of the health benefits, paradoxically, are fringe benefits of the country’s economic failings: Food consumption, diet and restaurants.

We typically ate one or two meals a day at the Casa Particular. The food was never anything that we would consider fancy, and it was always a challenge to get enough calories.

Meat is a luxury. When we did find it, it was fresh, never preserved with the wealth of chemical found in American processed meats. We did not see a single feed lot. Since the fall of the Soviet Union and the end of their support, chemical contamination of the food supply (pesticides and antibiotics) has become low-to-non-existent. Essentially, all Cuban food is organic.

Also note that Cuba boasts of a very clean environment, ranking tops in world indices (though some of this is due to the lack of development/economic failings, as much as for deliberate policy choices) (12). 

By comparison, biking equivalent mileage through the U.S., we would have seen several hundred fast food restaurants, with a wall of billboards leading us into town, and massive signs along the main street. Cuba certainly has no McDonalds supersize meals and no overflowing bucket of KFC fried chicken with gravy, biscuits and slaw. No Taco Bell fried donut tacos. It has no Starbuck’s and no double mocha frappuccino with double whip. There is nothing comparable in Cuba.  We saw no fast food advertisements on TV. If U.S. fast food is largely unhealthy, fatty, processed, and with oversized portions, Cuba has none of that.

Summary:  Cuban food is difficult to procure, created in modest portions, with few restaurants (virtually all of them marginal), virtually no fast-food, and virtually no processed food. But if one wanted to be positive, they could say that one of the end effects of this is that they are healthier because they eat food that is earthy, simple, and healthy. 

3) Cuba gains longevity by constructing a society that drastically reduces the three biggest causes of accidental death in the US: guns, cars, and opioids.

A) Guns

American citizens own guns at a per-capita rate 44x that of Cubans. American citizens are 20x more likely to die of gun violence than citizens of other countries. It is well-documented that America’s fascination with guns leads to drastically heightened suicides (14, 15), accidents, and murders (16). I am sure that this discussion will prompt many gun-nuts to proclaim that our freedoms originate from our pervasive guns (and that therefore Cubans are the worse off because they don't have their guns), but there is an indisputable cost and violence that results from American guns. Guns make the U.S. less-safe and lower our longevity, particularly amongst certain demographic groups (17).

During our stay there, we did not see any recreational gun use - unlike our travels across the US, where guns are common and, are, we would say kindly ‘part of the cultural fabric’.

As America sees police violence spilling over with killings in Ferguson and Baltimore, and tallies approximately 2000 police gun deaths a year (compared to approximately two a year in England! (18)), we contrast that with a Cuba in which a police gun presence was minimal.  In 2013, 33,000 Americans were killed by guns (19), giving us a rate of 10.6 deaths per 100,000 people. Cuba had a total gun death of 103, giving them the rate of a mere 0.93 per 100,000 (20). Our neighboring city of Oakland has approximately 100 homicides per year (virtually all gun-related). Cuba’s total was almost identical, but with a population of 11M, 35x greater (21).

Gun violence in Cuba is rare.  A quote from a surgeon working in an emergency room in Cuba: “Violence is not very common.  And when I see it, the case is usually not very serious. It is very rare to see a gunshot wound. It is very, very rare.  I am not telling you that it never happens, but it is rare.  I have seen two cases of gunshot wounds in my career, and both of them were the results of accidents.” (22)

Americans need to more honestly understand what their fascination with guns buys them – they are wayyyy out there on the violence scale compared to other countries: “Americans are far more likely to die by gunfire than people in any other rich country. In 2013, 21,175 people killed themselves with guns and 11,208 were killed by others. Mass shootings are more common too. Jaclyn Schildkraut and Jaymit Elsass, two criminologists, have counted 133 such events (such as the Charleston massacre) in the U.S. between 2000 and 2014 (excluding gang violence or terrorism). In England, they counted one (23).

B) Cars

Americans love their cars, and cars have consistently been engineered to be safer, but accidents remain common and deadly. Cubans own cars at a rate 1/20th of Americans (24).  Moreover, the average car velocity is markedly lower, and people rarely seem to be in a hurry. Ownership rules are a mess, there is a minimal used car market, a poor supply of parts, and car prices are very high. As there is effectively no internet and cell phone use is minimal, there is little of the ‘texting while driving’ danger that you find in the U.S. This lack of cars creates a population that has poor mobility, and poor use of time – people are always waiting by the side of the road, trying to hitch a ride, or when they are lucky, passing by jam-packed into the flatbed of a farm trailer - but it also creates one that reduces car deaths and in which exercise is pervasive (see below). The U.S. sees almost 36,000 car fatalities per year (25). Cuban car fatalities, while far higher per person-mile, are nevertheless about 1/3 less, per capita (25).

Suspiciously, driving in Cuba does not appear safe for dissidents (26).

C) Opioids and Drug Use
The U.S. has the highest rate of opioid use in the world (27). Their use - not just illegal drugs, but also the abuse of prescription opioids - has risen to become a major killer in the U.S.

In Cuba, we were surprised how little drug abuse we saw. While we have been frequently approached with opportunities to buy drugs on all of our U.S. and Canadian trips (what is it that makes a bike tourist so approachable for an illegal drug solicitation?), we were never approached in Cuba.

As you tour across America, at what is a very human-event observational speed, and as your navigate all sorts of environments, you typically witness an abundance of shady drug behavior. In Cuba we saw none. The most we saw was cigars.

4) Cuba invests to create a world-leading per-capita rate of doctors.

Cuba has invested an enormous amount in their healthcare system. Their healthcare as a percentage of GDP ratio is above virtually all countries, but still well below that of the U.S.

One of the things that they purchase with those expenditures is a lot of doctors.  Cuba has 6.7 physicians per 1000 people. By comparison, the U.S. has 2.4 per 1000. Cuba’s rate is one of the highest in the world (29). Seeing a doctor in Cuba is easy: their ‘polyclinic’ model effectively distributes access (see section below).

5) Doctors are paid less. A lot less.

Certainly, one way that Cuba spends less on healthcare is that it simply pays its healthcare workers less. Typically salaries are around $60 per month (30)!  The numbers do not compare directly, because many things in Cuba are subsidized or are free, but it is nevertheless a paltry sum. Contrast this with U.S. wages (which I am not arguing should be lower) of between $170k and $400k (31).

How do they get away with this?  85% of the employees in Cuba are on government payrolls, and all government wages are set low, so there are not a lot of other options. Certainly, a health care worker has prestige that others would not have, even if they don't have more money. Surely, some get paid on the side. But it is a real problem. The main route to wealth in Cuba is tourism, a job in which wages can rise by 10x, or even 100x. Again and again, we saw that this created real and unfortunate distortions, in which top young talent does not participate in medicine, law, engineering, or new business ventures, but simply covets a job that allows them to interact with tourists and their dollars:  it is not the best use of top Cuban minds.

Also note that Cuba sends a large number of its doctors overseas (50,000!) to help those with whom the government is philosophically aligned (including most prominently, Venezuela), and in exchange for oil.  

6) One payer systems do not waste money on billing and insurance-related activities.

“Billing and insurance-related activities cost the U.S. health care system $471 billion each year. Most amazing is that 80 percent of these costs would vanish if the U.S. switched to a single payer system like Medicare or the Canadian system, according to the results of a system-wide analysis. The savings offered by a simplified, single payer system add up to $375 billion annually. That's enough to insure all the uninsured and to upgrade the coverage of those who are currently underinsured. Money spent on such unnecessary bureaucratic tasks is money that could and should be spent on patient care. Such a system would enjoy powerful economies of scale, sharply reduce the burdens of claims processing, and [eliminate] the need for marketing, advertising and underwriting expenses. Our nation's patients, our physicians, and the U.S. economy all stand to gain from such a shift,” he added (32).

Single payer systems – like Cuba’s – eliminate a shocking amount of waste that can currently be found in the U.S. healthcare system.

7) Vast differences in the area of (expensive) prescription drugs.

The United States spends almost $1,000 per person per year on pharmaceuticals. That is around 40% more than the next highest spender, Canada, and more than twice as much spent by countries like France and Germany (34).

At nearly 10% of total US healthcare spending, prescription drugs are a significant percentage of the total spending (35).

Western drug companies are some of the most profitable companies on the planet. In business school, as we studied Michael Porter’s Five Forces, the drug industry was considered the paragon of structurally attractive, (i.e., consistently profitable).

The drug industry has done a phenomenal job raising prices. The drug industry has done a phenomenal job introducing new drugs at demonstrably higher prices, even when they are not of demonstrably higher efficacy (36).

Amazingly, the drug industry has been shielded from price negotiations with its largest customer, Medicare: “In 2003, Congress and President Bush enacted the "Medicare Prescription Drug, Improvement and Modernization Act," which established a prescription drug program for Medicare. That legislation expressly prohibited Medicare from negotiating drug prices with pharmaceutical companies. The United States is unique among industrialized countries because it is the only country that fails to protect its citizens from discriminatory pricing of prescription drugs. Canada, France, Italy, Germany, Japan and the United Kingdom all negotiate on behalf of their citizens to obtain lower prices for brand name drugs.  As a result, purchasers in these countries pay significantly less for prescription drugs than uninsured citizens in the United States (36.5).

While American drug manufacturers talk about their vast R&D expenditures, they typically spend more on sales and marketing. 

8) People are more active, largely by necessity.

At our children’s school, we are on the only ones who bike to school. The percentage of children to walk to school has plummeted. SUVs are the norm. Cuba is poor, cars are scarce, and the weather is quite accommodating, so people either walk or bike everywhere. The result is a European-type model of health, in which people are slimmer not necessarily because of deliberately ‘working out’, as Americans tend to do, but just through moving throughout the tasks of daily life. 

Cuba makes a concerted effort in sports. At the local level (‘see below, a commonly found mantra: “Sports are a right of the village”), sports fields, and kids playing in them, were a constant.

At the international level, Cuba fights above its weight in sports, with a clear goal of using sports to develop national pride (similar to efforts by the Soviets, Eastern Bloc countries, and the Chinese).

The end result of all of these elements is a population that burns more calories, and when coupled with their already meager caloric intake, people are slim and in healthy movement. 

As one studies populations that have uniquely high average lifespans, (for example, certain communities in Japan, Sicily and San Diego), a recurring key element is social engagement. I’ve travelled to over forty countries, and I’ve never seen anything as social as Cuba. Doors are open and people engage each other, constantly. Events happen in the town square at every hour of every day. Generations mix. It was a joy to see and it undoubtedly has longevity benefits. 

9) There is a strong emphasis placed on community care (‘polyclinics’).

The polyclinics are strongly associated with Cuba, and are a foundation of the country’s medical success. Polyclinics are geared towards the localized, community-based delivery of preventive services, public health, and primary care.  While receiving medical care in the U.S. is a fairly formal process – and often painfully expensive - Cuba’s system is very different. Polyclinics are small, local, and widely distributed. They are free. Access is easy.

On top of this structure is a network of regional centers with more specific skills and more advanced equipment. Often the doctors in the polyclinics have local knowledge that would be impossible for them to have in the U.S., particularly now that health care privacy has been taken to the next level (HIPPA). The example typically given is that a doctor living in the community – they are all embedded locally – would proactively suggest a polyclinic visit for an aging neighbor who they see is having trouble.  If they saw a young neighbor suddenly dating, they would proactively suggest a visit to discuss birth control. This degree of action works well in Cuban society, but would rarely be physician-led in the U.S.

“Currently, there are 498 polyclinics, which each serve an average of 22,000 rostered patients. Cuba also has 14,078 family doctors' offices that work under the auspices of the polyclinics. Over-all, this provides for 1 physician per 159 people and 1 nurse per 79.5 people (7).

The role of the polyclinic is far more extensive than that of the typical Canadian medical clinic. The polyclinic's staff is multidisciplinary and includes a wide range of professionals. Currently, the average polyclinic offers 22 services, such as rehabilitation, radiography, ultrasonography, endoscopy, thrombolysis, emergency services, traumatology, clinical laboratory, family planning, emergency dentistry, immunization, dermatology, cardiology, family and internal medicine, pediatrics, and obstetrics and gynecology (8). Polyclinics also provide mental health care, maternal and child care, and care for diabetic and elderly patients (8). All of the staff at polyclinics are familiar with and responsible for every individual in the community. They focus on prevention and universal screening initiatives, and they encourage immunization through house calls, home visits and semiannual checkups. During the subcommittee's visit, we were told that diabetes can often be diagnosed long before the patient is aware of a problem. Similarly, staff at polyclinics work closely with early child development, preschool and elementary teachers so that the moment a problem is spotted in a child, he or she can be referred to the appropriate specialist.

The polyclinic is also a hub for medical and educational training. Students in medicine and nursing receive part of their training at a polyclinic, which is often where they will work after graduation. Polyclinics are also resources for data collection and scientific research, and they are conduits for scientific advances. The data collected are used by health authorities to evaluate the effectiveness of the polyclinic programs. Scientists are frequently appointed to polyclinics, where they undertake academic research and facilitate the transfer of knowledge to and from front-line staff (41).”

During our visits we saw facilities and equipment that could best be described as ‘modest’, even bordering on ‘meager'. Nevertheless, the polyclinics were notably available, local, distributed, free, and universally accessible – all words that rarely apply to American care. 

10) Cuba invests a large percentage of its healthcare funding in areas with the highest returns, including contraceptives, maternal care, and vaccines, bug/disease vector control, and with a very strong emphasis on preventative care.

Clearly acknowledging budgetary limitations, Cuban Healthcare has prioritized elements with the highest returns.

A) Contraceptives
Birth control in the U.S. continues to be an endless political battleground, but Cuba takes a much more pragmatic approach. Every adult we talked to made it clear that birth control was universally available, and that it was either free or virtually free (41).

Contrast this with the U.S., where female contraceptives were only recently federally mandated for insurance plans (42), and are not provided for those who are not on such plans. Where contraceptives has been more broadly available (see Colorado study, largely financed by the Susan Buffet Foundation (43)), there has been a profound drop in teen pregnancies, indicating a clear need that is not being met by the healthcare system.

Vasectomies are sometimes covered by insurance in the U.S. (but are not covered by the changes of Obamacare, many plans, and obviously for those without insurance). Costs can range up to several thousand dollars (44). Vasectomies are free in Cuba.

B) Disease Vector Control
Despite being surrounded by water, and featuring warm weather and significant wetlands, we had no problems with mosquitos.  Amazingly, mosquitos never waked us – and most of the homes we stayed in did not even have glass windows or screens (merely wooden slats).

Cuba takes very seriously the challenges of tropical diseases. “Recognized worldwide as an effective epidemic-controlling strategy, the Cuban dengue model recently incorporated more aggressive preventative measures since the ongoing drought and abnormally high temperatures on the island promote multiplication of the mosquito that carries the disease. Monthly door-to-door visits by specialized health workers to kill mosquito larvae have been augmented to every twelve days in some Havana neighborhoods and to every week where the illness focus has been identified. Cuban health authorities recently instituted a series of stepped-up preventative measures including aerial spraying over coastal areas, more frequent fumigation of houses with weapons of mass mosquito destruction known locally as ‘bazookas’ for their resemblance to those big guns, and community education programs about the dengue vector (45).”

C) Vaccines

Americans are currently confused about vaccinations, with many opting out and falling for a host of ill-founded McCarthy-esque ideas (Jenny McCarthy). Vaccines are modern medical miracles and have saved untold lives. With few exceptions, getting immunized should be recognized as a civic duty. Vaccinations are effective due to “herd immunity:” to fully protect against a disease, a certain percentage of the population must be immunized. The fewer who are vaccinated, the greater the risk to everyone (46).

            American drug companies have increased their vaccine prices at an amazing rate:  22x over the last 30 years (47).

Since the revolution, Cuba has instituted a rigorous, universal, free, mandatory vaccination policy with some of the world’s highest adherence rates. They have effectively eliminated a wide range of diseases: 

Sources:

1) https://www.e-education.psu.edu/geog438w/node/322

2) http://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/

3) http://www.cnbc.com/id/100840148

4) http://www.wsj.com/articles/high-prices-for-drugs-attacked-at-meeting-1433119411

5) http://healthaffairs.org/blog/2013/05/28/strengthen-medicare-end-drug-company-price-setting/

6) http://mercatus.org/publication/us-health-care-spending-more-twice-average-developed-countries

7) CIA Factbook Life Expectancy:

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html

Cuba: (55th) 78.2.  United Status :(42nd) 79.5

Economist World Factbook, 2015.   page 80.  Cuba: 79.2.  United States: 78.9

8) http://freebeacon.com/issues/cuba-manipulating-health-care-statistics/

9) https://en.wikipedia.org/wiki/Casualties_of_the_Iraq_War

10) http://www.reuters.com/article/2013/03/14/us-iraq-war-anniversary-idUSBRE92D0PG20130314   Estimates vary, but the long-term costs to care are real, so we have adopted a mid-line figure of $3T.

11) http://www.servat.unibe.ch/icl/cu00000_.html

12) http://zeenews.india.com/news/eco-news/cuba-only-country-with-sustainable-dvlpment-wwf_331619.html

http://www.alternet.org/environment/12-ecologically-sustainable-countries-and-why-they-should-be-admired

13) https://triviahappy.com/articles/fast-food-geography-discover-cuba-through-el-rapido

14) The Economist, Jan 31, 2015, ‘An Awful Hole’

15) ‘America’s Biggest Gun Problem is the One We Never Talk About’, by Dylan Matthews and Estelle Caswell, Aug 11, 2015.  www.vox.com

16) The True Cost of Gun Violence, May-Jun 2015, Mother Jones magazine

17) http://www.futureswithoutviolence.org/go/guns-and-domestic-violence-facts/?lp-variation-id=0&gclid=Cj0KEQjw-tSrBRCk8bzDiO__gbwBEiQAk-D31f4_fd_dhb7yONHftoDmoIkcxzZ51r0NouEX2zylIgsaAolM8P8HAQ

http://www.gunpolicy.org/firearms/region/cuba

In the US, it is 88, which is more than twice that of all but three countries in the world. 

http://en.wikipedia.org/wiki/Number_of_guns_per_capita_by_country

http://en.wikipedia.org/wiki/List_of_countries_by_firearm-related_death_rate

The US is roughly 20x more likely to die of gun violence than that of other countries.

http://www.politifact.com/punditfact/statements/2014/jan/17/lisa-bloom/americans-are-20-times-likely-die-gun-violence-cit/

18) http://www.theguardian.com/us-news/2015/jun/09/the-counted-police-killings-us-vs-other-countries

19) http://www.gunpolicy.org/firearms/region/united-states

20) http://www.gunpolicy.org/firearms/region/cuba  

21) http://en.wikipedia.org/wiki/Oakland,_California

http://www.insidebayarea.com/breaking-news/ci_22070183/recent-surge-killings-has-oakland-at-115-homicides

22): Caring for Them From Birth to Death, The Practice of Community-Based Cuban Medicine, by Christina Perez.  Published by Lexington Books, 2008.  Pg 219

23) The Economist, June 27 – July 3, 2015.  Page 22.

24) http://www.lubrita.com/news/45/671/Interesting-statistic-list-of-countries-by-vehicles-per-capita/ 

US: 812 per 1000.  Cuba 38 per 1000. 

25) http://en.wikipedia.org/wiki/List_of_motor_vehicle_deaths_in_U.S._by_year

https://en.wikipedia.org/wiki/List_of_countries_by_traffic-related_death_rate

26) http://www.huffingtonpost.com/2012/07/23/oswaldo-paya-dead-cuba_n_1694886.html

27) Time Magazine, June 15, 2015, ‘They are the Most Powerful Painkillers Ever Invented.  And They’re Creating The Worst Addiction Crisis America Has Ever Seen’

28) http://takingnote.tcf.org/2011/07/graph-of-the-day-americans-pay-more-get-less-for-healthcare.html

29) http://data.worldbank.org/indicator/SH.MED.PHYS.ZS

30) http://www.foxnews.com/world/2014/03/21/cuba-hikes-salaries-for-doctors-nurses-to-as-much-as-67-month/

http://www.aljazeera.com/indepth/features/2012/06/201265115527622647.html

31) http://www.businessinsider.com/how-much-salary-does-a-doctor-make-2014-4

32 http://www.thedoctorwillseeyounow.com/content/healthcare/art4572.html

http://www.pnhp.org/news/2015/january/375-billion-wasted-on-billing-and-health-insurance-related-paperwork-annually-stud

33) http://healthaffairs.org/blog/2013/05/28/strengthen-medicare-end-drug-company-price-setting/

34) http://www.pbs.org/newshour/updates/americans-spend-much-pharmaceuticals/

http://healthaffairs.org/blog/2013/05/28/strengthen-medicare-end-drug-company-price-setting/

35) http://www.cdc.gov/nchs/fastats/health-expenditures.htm

36) http://www.wsj.com/articles/high-prices-for-drugs-attacked-at-meeting-1433119411

36.5) http://healthaffairs.org/blog/2013/05/28/strengthen-medicare-end-drug-company-price-setting/

37) http://www.washingtonpost.com/blogs/wonkblog/wp/2015/02/11/big-pharmaceutical-companies-are-spending-far-more-on-marketing-than-research/

38) http://blog.ihs.com/revolutionary-medicine%3A-eye-on-cuba’s-pharma-industry-development-following-plans-to-normalise-us-cuba-diplomatic-relations

http://www.globalresearch.ca/cuba-develops-four-cancer-vaccines-ignored-by-the-media/5390303

39) Caring for Them From Birth to Death, The Practice of Community-Based Cuban Medicine, by Christina Perez.  Published by Lexington Books, 2008.

40) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2630353/

41) The Economist Pocket World in Figures, 2015.  Page 17.  In the US, 70.4% of women use modern contraception (ranked 22).  Cuba it is 73.2% (ranked 14th).

42) http://www.nwlc.org/resource/contraceptive-coverage-health-care-law-frequently-asked-questions

43) http://www.chicagotribune.com/lifestyles/health/ct-warren-buffett-secret-birth-control-revolution-20150801-story.html

44) http://clearhealthcosts.com/blog/2013/01/how-much-does-a-vasectomy-cost-oh-and-is-it-covered/

45) http://www.medicc.org/publications/medicc_review/0705/headlines-in-cuban-health.html

46) http://www.everydayhealth.com/columns/health-answers/why-unethical-opt-out-measles-vaccination-your-child/

47) http://www.nytimes.com/2014/07/03/health/Vaccine-Costs-Soaring-Paying-Till-It-Hurts.html

48) http://www.medicc.org/publications/medicc_review/1004/pages/spotlight.html