Cuba’s Focus on Prevention
On a comparative health systems trip this past January, I was among a group of Mailman students who saw firsthand how reproductive, sexual, and LGBT health issues are structured in the Cuban healthcare system. In Cuba, every aspect of health is shaped by the interplay of what the state mandates, what the economy supplies, and what the culture expects.
In the field of reproductive health, virtually all women understand the benefits behind compulsory prenatal care. And since even the most specialized hospitals in Havana are undersupplied and unequipped to address many emergencies, there is extra emphasis on preventive care to reduce the need for scarce resources. On a visit to a polyclinic, a community-based medical hub with teams of doctors and nurses, we saw staff running around the building and posters with health messages in every hallway—but supply cabinets were almost empty.
Everywhere our group went, we heard the phrase “our focus is on health promotion and disease prevention” repeated like a mantra. At the National Center for the Prevention of STIs, a group of impassioned nurses lectured us on how their public health channels have a heavy focus on condoms. When multiple sources proudly told us that the majority of Cubans use condoms every time they have sex, we asked how that could be possible.
This is what they told us: Cenesex, a state-run National Center for Sexual Education, was founded by President Raul Castro’s daughter, Mariela, in 1989 to promote and coordinate the Cuban policy on sexual education. The center focuses on developing sexuality and sexual health education with a gender and human rights approach. The organization has been at the forefront of promoting LGBT health issues in Cuba.
“It’s difficult to explain if you are not Cuban,” a Cenesex representative told us. “It’s just a part of Cuban culture. Everyone receives health education so they know what could happen if you don’t use condoms.”
Policy in Practice
During a night out later that week, we saw a live example of what the Cenesex representative was talking about when our group unexpectedly heard a condom promotion campaign.
At Cabaret Las Vegas, a drag show in the Vedado neighborhood of Havana, the government’s influence over LGBT health was clear. In between performances of ‘Dreamgirls’ songs and gogo boys gyrating their hips, we were shown minute-long commercials aimed at raising HIV/AIDS awareness and promoting condoms. We later found out that in order for this club to stay open as a drag show, running health promotion messages is mandatory.
The club had existed previously as an underground spot for gay nightlife, but now received government support under the condition that they regularly play health promotion messages for patrons. Cenesex has worked to decrease stigma of LGBT people with Cabaret Las Vegas as part of that plan, and this struck many of us as a fascinating compromise. The transformation of an illicit venue into both a tool to fight stigma and create a safe space for health promotion was inspiring.
When our group met Dr. José Portilla, a representative from the Ministry of Health, he told us that when a woman becomes pregnant in Cuba, her family doctor is immediately notified and she is given a strict regimen of prenatal care. All expectant women are required to receive at least 12 visits with a physician throughout their pregnancy. This system only works because family doctors in Cuba are in charge of a catchment area of a community, where they must intimately know the health of each person in their assigned area. In the United States, prenatal care is often hindered by issues of access, something rare in a universal system like Cuba’s.
Our group was stunned and pressed the presenters with questions. Is the doctor always notified when a woman finds she is pregnant? How many women attend all 12 visits?
Everyone we asked had a similar response: the standard science-based health education at all levels, coupled with the community-based primary care system, creates a climate whereby it becomes intuitive for Cuban women to notify their family doctor when they become pregnant. Just as was the case with condoms, here was another example of everyone being educated about the benefits of a preventive health action, and choosing to take action.
This deep investment in healthy pregnancies, however, comes with a great burden on expectant mothers. We met many women with high-risk pregnancies who have to temporarily relocate to a maternal home in Cienfuegos, where nurses and midwives monitor their health until the babies are delivered.
“What if they don’t come?” we asked, skeptically.
The head physician jumped in to assure us, “They’ll come. If they don’t, we will frequently follow up to strongly encourage they do so.”
theory and practice
In the Core Curriculum at Mailman, we learned about how the Special Period in Cuba affected health, and how today, Cuba has some of the best health indicators compared to countries with similar gross domestic product. The country has one of the lowest rates of HIV/AIDS in the Western Hemisphere. Last year, they became the first country validated by the World Health Organization to eliminate vertical transmission of HIV and syphilis. The national infant mortality rate of Cuba rivals that of Canada, and is lower than the rate in the United States.
Beyond statistics, health education and promotion permeate all aspects of society in Cuba from policies to attitudes, but this is possible only through the steady involvement of the state.
After each day’s activities, my roommate and I would lay awake for hours unpacking everything we had learned and struggling to find clear answers. Cuba revealed the incredible possibilities of health promotion and education, but the United States has shown us the power of community empowerment, sustainable efforts, and major access to resources. We went back and forth discussing which system we’d rather work in and what our careers as public health professionals might look like if we had been born in Cuba. The systems in Cuba and the U.S. are profoundly different, especially with regards to sexual and reproductive health—but we have been inspired to strive for striking a balance between the two, using the best of what each has to offer.
Now that I have witnessed how extensively health systems can be wholly integrated into society, influencing even norms and attitudes, I want to use this knowledge to support and develop policies, programs, and efforts that encourage health promotion in a culture where it is not the norm. And it is up to us, future health workers in training and the field, to figure out how to make this happen.
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