Cuba – A Global Health Miracle?

 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.