Third-World Economy, First-World Health
Think of a country where the population is older and living longer than ever before, with an average life expectancy at birth of 79 years; a country where the leading causes of death are cardiovascular diseases and cancer—rather than communicable diseases such as tuberculosis and malaria.Are you thinking of the United States or the United Kingdom? Think again. I'm describing Cuba, known more widely among Americans for its communist politics, poor human rights record, and dire economy, rather than its strong public health record. Despite its third-world economy, Cuba has achieved first-world health indicators—with impressive statistics comparable to the U.S. in infant mortality, vertical HIV transmission, and infectious disease control.
As a student trained in epidemiology, I immediately wondered what is driving these trends and successes in health and what, if anything, the U.S. can take away from Cuba. This January, 11 fellow MPH students and I traveled to Cuba to learn just that, and better understand the strengths and challenges of Cuba’s universal health care system.
Through our meetings with the Ministry of Public Health and visits to national health centers, local clinics, and community programs, I found that it is Cuba’s culture of public health, born out political ideology, economic necessity, and social responsibility, that mandates and sustains health for all of its people.
Public health as a human right, responsibility, and necessity
Following the Cuban Revolution that drove out U.S.-backed dictator President Fulgencio Batista in 1959, Fidel Castro assumed leadership as Prime Minister of the Republic of Cuba and transformed the country into a revolutionary socialist state. Among the major tenets of the new state was the principle that health is a basic human right.
In fact, immediately following the revolution, Cuba adopted The Constitution of 1976, which stipulates that each citizen has a right to free, universally accessible health services and declares it the duty of the State to promote and protect the health of all individuals.
In addition to this national mandate for public health, the Cuban Revolution inspired a fervent nationalistic spirit that has only deepened with the drastic economic and social isolation caused by the longstanding U.S. trade embargo over the last five decades. Such isolation has made Cuba more self-reliant than ever. Born out of a necessity for survival, Cuba's ability to take care of its people autonomously is a source of national pride.
As a result of the U.S. embargo, Cuba’s access to foreign funding, technology, resources, and information has been limited. It has, therefore, been imperative for Cuba to succeed in health promotion and disease prevention, since it lacks many of the sophisticated medical treatment and technologies available in more developed countries. Simply put, poor public health is a luxury that Cuba cannot afford.
The Cuban centerpiece: polyclinics for community-based healthcareCuba is a primary care-focused health system that operates as a network of polyclinics, hubs of 40-60 teams of nurses and doctors servicing a total of 30,000 - 60,000 patients. Although people still have ability to go to hospital directly, this is a different model.
Family doctors in each community serve about 1,500 residents and conduct basic physical exams, education services, and ongoing therapy and patient care management. The clinic offices are centrally located with 24-hour access, since the doctor typically lives above the office and is on call all the time.
These family doctors are then rolled up into polyclinics and are able to perform robust laboratory tests, treatments, emergency services, and educational services. The polyclinic is equipped with the technology and trained staff required to perform most care services, with specialist doctors also visiting the clinics routinely.
Aside from the polyclinics, Cuba offers an array of specialty hospitals including maternal, pediatric, surgical, and psychiatric hospitals. Although Cubans are able to access hospitals freely without referrals, the country does not have a robust ambulance service, so if a person wants to go to a hospital directly, they must find their own way to get there. Once a patient is stabilized at a polyclinic, if they still require hospital services, the ambulance serves solely to transport patients to and from the polyclinic. However, the system is designed so that 80 percent of patients can be serviced completely through the polyclinic.
Health promotion and disease prevention as the cornerstones of the Cuban health system
The secret recipe to Cuba’s successes in health is not a secret at all. In all of our discussions with local health professionals, the resounding message was that the cornerstone of the Cuban healthcare system is health promotion and disease prevention, with the primary goal to prevent or control health issues before they progress into deadly, costly, or otherwise unmanageable conditions.
To promulgate messages around good health and disease prevention, Cuba employs a community-based approach using a train-the-trainer method. Health professionals, community leaders, and other volunteers receive training on specific programs and practices, and then become the go-to in their local communities. The newly trained community leaders then help to spread awareness or troubleshoot health issues as they arise, especially cases of sexual and mental health problems.
In addition, Committees for the Defense of the Revolution, Cuba’s mass neighborhood watch organization charged with looking out for counter-revolutionary activity and promoting social welfare, also serve as foot soldiers for public health. Aside from their Big Brother-esque duties, CDR members, which make up over 75 percent of the Cuban population, operate as on-the-ground health promoters who fulfill a range of functions, including hosting educational talks, promoting vaccinations and other public health measures. They even partner with the Ministry of Public Health to implement public health campaigns locally.
What can the USA takeaway from Cuba’s health system?
With limited political power and frequent public and Industry resistance, the greatest lesson America can take away from the Cuba is the value of a culture of public health. In addition to isolated programs and services, it would serve us well to repair and fortify the social fabric of our society by strengthening family and community ties, for the benefit of health. If more Americans could confidently say they knew, cared for, and trusted their neighbors, there might be a greater drive for social responsibility for health—an individual responsibility for the community and a community responsibility for the individual. Such local social investment would enable a leaner, more effective community-based network for health promotion and disease prevention. Trusted associates, rather than a perceived intrusive government, could act as champions of public health, where political power is lacking.
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