When one thinks
of Cuba, if you’re like most Americans, a flood of preconceived notions of the
Cuban revolution, cigars, the missile crisis, classic cars, Fidel Castro and
socialism probably come to mind. For those of us who study global health,
another image comes of what is sometimes called the “Cuban health miracle.” This
image is bolstered by the fact that, despite its limited financial resources
(further constrained by the US embargo or “blockade” depending on which side you
are evaluating it from) Cuba has health statistics that are comparable, if not
superior, to the USA and other developed countries. Cubans live as long as
Americans, fewer of their babies die in their first year of life and they do it
all at a tiny fraction of what the US spends on health care. The big questions
is – how do they do it?
Since learning
about this phenomenon five years ago when I started studying global health, I
have been anxious to see firsthand what is actually going on in Cuba when it
comes to health care. Fortunately, when President Obama was elected he changed
the visitation regulations so that educational groups were allowed to go to Cuba,
so I was able to travel with a group of Furman students for two and a half
weeks as part of Furman’s Latin America Study Away program. On this trip,
unlike Africa, I was not directing but simply one of the “parachute professors”
teaching the students on campus in January and April and “parachuting in” to
join them in Cuba in March during their two months of travel around Latin
America (including Nicaragua, Guatemala and El Salvador).
To say I was
excited would be an understatement. We planned for months, attempting to
coordinate visits to all three “tiers” of the Cuban health care delivery system
including: consultarios (family doctors located in neighborhoods where they are
responsible for the all families in the area), polyclinics (the next level up
which includes some specialists) and hospitals (where people are referred to
from polyclinics if their cases are more complicated). We also scheduled a
visit to their medical school where they train doctors from all over the world (for
free) who are committed to returning to underserved areas to practice. We
learned about their medical internationalism program where they send doctors
all over the world to provide health care to those in need. In the end, we managed to
coordinate a rich academic program to help us better assess Cuban health care.  |
| Run down buildings |
Overall I’d
say, some of what I expected to see in Cuba I saw. I expected to see classic
cars, buildings from the colonial era, dancing in the street, mojitos, images
of Ernest Hemingway and the sounds of the Buena Vista Social Club. On the other
hand, there was much I didn’t expect. What I didn’t expect was the warm and
welcoming nature of the people in Cuba who, after asking us if we were Canadian
and finding out we were American, unilaterally stated that they liked Americans
but not our government policies (namely the embargo). I’ve traveled to lots of
places and have, at times, encountered hostilities towards Americans. I
expected it in Cuba, given the long history of political tensions, but didn’t
receive it. I also didn’t expect to see the run down nature of buildings
(Sherwin Williams could make a fortune down there as most buildings are in need
of a new coat of paint) or the ever present image of Che Guevara – young
charismatic revolutionary.
Even more interesting
was what we didn’t see – namely images of Fidel or Raul Castro. And academically,
what we weren’t allowed to see:
namely the inside of a hospital. While I requested a hospital and polyclinic
tour, we were denied access to both. We were offered a couple of explanations.
One was that, because of the opening of the borders to Americans they simply
were receiving too many requests (I don’t buy that one) or that two, they were
embarrassed to show us their deteriorating facilities and lack of resources.
The latter seems more likely.
So, what are
some of the key ingredients of Cuban health care that make it a success?
 |
| Close Neighborhood Surveillance |
1. A focus on primary care and prevention – With limited resources, the focus is on
preventing illness as opposed to treating it. All doctors are trained as
Primary Care Physicians first and the bulk of doctors in the country are not
specialists (like in the US) but family doctors who live and work in the local
community. By keeping their population healthy, they avoid the very expensive
costs of treating people who are seriously sick. Avoiding diabetes, high blood
pressure, high cholesterol or maintaining it within reasonable limits, is less
expensive then treating it once something disastrous happens.
2. Close surveillance and monitoring (perhaps
some coercion) – With family
doctors in each neighborhood responsible for the families in their area, there
is close monitoring and surveillance of potential health issues. Our
translator, for example, told us that when her sister turned 25 they received a
knock on their door from the family doctor reminding her that it was time for a
routine PAP smear. In the office of the family doctor we visited, there were
carefully up-to-date records of who in the neighborhood suffered from what
illnesses (# of case of diabetes, etc.). With this type of close monitoring, few
health problems go undetected or untreated.
3. Providing for basic needs -
By prioritizing education and health care (two things we know produce better
health outcomes) and providing basic food rations, Cuba has reduced the amount
of abject poverty which is good for overall health.
 |
| Food Ration Store |
4. Reducing Inequality – There is a huge body of academic
research that focuses on the relationship between inequality and health
outcomes. Basically, the more unequal a society is, the worse their health
outcomes; the more equal a society is, the better the health outcomes (some point
to Japan as evidence of this – a fairly equal society with the best health
outcomes in the world; other use this to at least partially explain why the US,
despite the fact that it spends more on health care than anyone else in the
world, does not have the best health outcomes). With the government control of
just about everything in Cuba, and a goal of producing a rather egalitarian
society, some point to the lack of inequality as a reason for better health
outcomes.
So, what’s the
down side?
1. Limited resources and supplies – When we were able to visit a doctor’s
office and a pharmacy the lack of supplies was very evident. Additionally, other researchers have documented a vibrant black market
that has arisen to fill this gap and a strong network of “socios” that provide
preferential service to their friends (although we did not have firsthand experience with this). Contributing to this lack of supplies,
of course, is the US embargo which, while it allows food stuffs to be exported
to Cuba because it would be inhumane not to, they have not made a similar exception
for medical supplies (for reasons that I don’t fully understand – why would you
allow food for humanitarian reasons but not medical supplies?).
2. Compromises to patient autonomy – One of the issues my students struggled
with the most were allegations of compromises to patient autonomy. While we saw
no evidence of this firsthand (we were not allowed to witness any doctor
patient relationships ) some of our readings for the program suggested
that patients are not always the final decision makers when it comes to their
health. Specifically, we read that a pregnant woman with a nonviable or fragile
fetus may be told by her doctor to have an abortion. On the one hand, if you
have limited resources and your goal is better infant mortality rates, this
makes complete sense. Fragile fetuses are quite expensive and often don’t have
good health outcomes. On the other hand, this doesn’t leave much control in the
hands of the patient.
So
are these allegations we read about true? We had mixed responses when we tried
to ask. Some doctors responded by saying very clearly that the patient always
made the final decision regarding their health. Others indicated that, “Of
course the doctor makes the final choice. The doctor knows best.” This
paternalism certainly rubbed our individualistic-focused American students a
bit wrong. I think the thing that is difficult to assess is how a patient, who
has lived their entire life in a society that values the community over the
individual, feels about this. Perhaps they don’t question it as much as we
would?
 |
| Veradero Beach |
In short, it
was an amazing trip to a beautiful island with breathtaking beaches, temperate
climate and warm friendly people. In terms of the question of if Cuban health
care is really a “miracle” – I would say in some ways yes. By focusing on
prevention and primary care, by perhaps stepping on people’s individual
freedoms a bit to produce better health outcomes, and by providing for many of
the basic needs that we know produce good health outcomes and reducing the
amount of poverty and inequality, I
think they have achieved miraculous health outcomes with very limited resources.
I think we could all learn a few lessons from our scrappy neighbor next store.
Prevention is cheaper than treatment. Closely administered primary care can
effectively manage disease. Providing for the basic needs of citizens reduces
abject poverty. Reducing abject poverty improves health. Investing in health
care and education, as basic human rights, produces long term positive outcomes
for the entire community.
