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MR FEATURES Bringing Services Closer to Home:
In Cuba, ‘no es fácil’ is a daily utterance. Still, ‘it’s not easy’ is an understatement for the 1800 Cubans who depend on life-sustaining dialysis to do the work of their kidneys. While the developing world’s health systems struggle with underreporting of kidney disease and increased end-stage renal disease (ESRD) mortality rates, Cuba’s universal approach adds another concern: how to get dialysis to everyone who needs it. Imagine you live in the mountains, 125 miles from this life-saving service. To reach the dialysis center, you have to leave your house at four in the morning and take the bus into the nearest large city. Upon arrival, you wait for treatment, have your four hours with the machine and then get on the bus again, arriving home by midnight, if you’re lucky. This was the reality for hundreds of dialysis-dependent Cubans until 2003, when the Ministry of Health (MINSAP) launched a countrywide project to bring dialysis services closer to the people who need them. In order to achieve this, a study was undertaken by government and the national Institute of Nephrology to analyze who needs dialysis services and where they live, how many more artificial kidneys were needed and where they would best be placed. Buildings and equipment were rehabilitated, built or bought, and medical and biomedical technical staff were trained; meanwhile, new centers were outfitted and existing ones upgraded – including the national Institute of Nephrology - a multi-million dollar investment. Now, some two years later, Cuba has 47 dialysis centers – up from 31 – spread across the country in locations designed according to patient need. Shorter travel times, better equipment and an integrated, creative approach to dialysis treatment, has meant improved quality of life for those with chronic kidney disease (CKD) and lower ESRD-related mortality rates. Improving dialysis services and moving them closer to the patients who depend on them is one aspect of the Cuban health system’s strategy for managing renal diseases – reflecting the understanding that the island is not exempt from the international epidemic and its consequences. Indeed, the problem is on its way to worldwide crisis proportions: it is estimated that at least 60,000,000 people currently live with some degree of renal malfunction. Medical literature is unequivocal in its assessment of the alarming implications for health systems and the need for immediate action as regards prevention. Drs. Giuseppe Remuzzi and Jan Weening, leaders in the field, write: “Early detection of renal impairment, followed by preventive treatment, is…a global health priority….”[1]
In Cuba, three groundbreaking studies are in process, each designed to contribute to the formation and progressive implementation of comprehensive national strategies for prevention, early detection and continuous prevention-oriented treatment of renal disease. (See “Cuban Studies Aim for National CKD Prevention,” this issue). The urgency is also a product of rising life expectancy in Cuba, and the fact that people are living longer with such conditions as diabetes mellitus and hypertension. On the day MEDICC Review visited the new dialysis center at the Comandante Pinares General Hospital in San Cristóbal, (easternmost Pinar del Río Province), the ward was a blur of green surgical scrubs as nephrologists and a six-member team of specialized nursing staff worked to change a life: a kidney had just arrived in Havana, and the staff moved to get their patient – who had been on the waiting list for a year – to the transplant center in time for her surgery. Cuba currently performs 22 kidney transplants per million inhabitants, a figure health officials here are expecting to increase. After the transplant patient had been safely whisked off to Havana and the bustle subsided, MR sat down with Dr. Orosman Cuesta, specialist in Nephrology and also Family Medicine, to talk about the new dialysis service in San Cristóbal, a small municipality of 64,000 people located at the foothills of the Sierra del Rosario mountains. MEDICC Review(MR): Can you tell us a little about the history of this dialysis center? Dr Orosman Cuesta (OC): The Hemodialysis Center in San Cristóbal opened one year and nine months ago with the purpose of bringing the services as close as possible to the homes of patients here in the province. Before, these patients had to travel around 200 kilometers [125 miles] to receive this treatment…in hospitals [in either Pinar del Río or Havana, depending]. The country originally had 31 dialysis centers and now we have 47. These aren’t only in the provincial capitals, but reach all corners of the country, placed as close as possible to the population that needs them. An example of one of the farthest removed services from the provincial capital [to where patients had to travel previously for dialysis] is in Baracoa…in Guantánamo Province and in Sandino, here in Pinar del Río Province. When our own new service started, with cutting-edge technology, it substantially improved the quality of life for these patients in terms of their integration into their jobs, their family and society. The patients themselves are more satisfied because not only do they receive treatment using the latest technology, but we have also offered them the chance of living in their own homes again [before, many had moved closer to the city or had long hospital stays there]. Mortality rates have also improved.
MR: How many patients are served by this center and how many dialysis machines do you have? How about your staff? OC: This hospital extends dialysis services to patients from four municipalities (Palacios, San Cristóbal, Candelaria and Bahia Honda) throughout Pinar del Río, totalling 200,000 inhabitants. Right now we have 48 patients receiving dialysis here - 40 in hemodialysis and eight in peritoneal dialysis. We now have nine, quite modern artificial kidneys, and a state-of-the-art water treatment plant. We have 48 people on staff. Of these, three are nephrologists, three are biomedical equipment engineers, 25 are nurses, and the rest are service workers, janitorial, cooking staff, etc. Ours is also an interdisciplinary team, linking the work of psychologists, psychiatrists, geriatric specialists, internists, nutritionists, and a nephrologist, who are in charge of patient care, guarantee nutrition, and provide dialysis services. MR: How much does dialysis cost? Do patients have to pay? OC: The service is free to patients, like other health services in the country. For a patient receiving three treatments a week, this costs the health system approximately US$12,000 to US$15,000 per patient, per year. MR: Can you explain a typical treatment day for a dialysis patient before this center existed? OC: These patients had to leave their homes at 4:00am, the bus would pick them up, and they would get to the dialysis center around 7:00. Frequently, because they had to wait their turn for a dialysis machine, they wouldn’t get home until 10, or 11 at night. The quality of life for these patients was practically nil. Many patients couldn’t work, they lost ties with their family and were overwhelmed with the long distances they had to travel. After the remodelling, installing the new service, all of this changed. Not only has the treatment itself improved, but the program also guarantees adequate nutrition, with a daily protein quota. Furthermore, the transport brings them here at their appointed time for dialysis and takes them home when they finish. So the whole process, from when they leave home to when they get back, never takes more than six or seven hours. So in less than a workday, these patients are treated; they can go back to their lives and feel less of a burden. That’s why we are especially pleased with the new program - we see our patients enjoying fuller lives. MR: What happens if someone needing dialysis lives way up in the mountains and can’t commute to the center? OC: In spite of moving the services closer, there are still patients who live tucked away in the mountains or in areas that are difficult to reach, so we have casas de descanso [in San Cristóbal, this is a 16-bed facility where a handful of patients live during the week]. This guarantees them all the necessary comforts, with recreational activities, and staff that administers to them. And on weekends, they are given rides back to their homes. The house is also used for patients who don’t have support or resources – people who are alone, without family or who need extra help. So it makes treatment easier, more accessible and of a higher quality. The other objective of the house is to provide continuing education not only in nephrology, but also in other related specialties including cardiology, endocrinology, geriatrics and training in how to manage other chronic, non-communicable diseases. References
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