Through A Public Health Lens
We hailed from countries in East and South Asia, Europe, Latin America, and North America, and included professionals in law, psychology, social work, nursing and medicine. For all of us on the Harvard School of Public Health (HSPH) Study Tour this March, Cuba stood out as a notable example of impressive health outcomes in spite of minimal economic resources. We wanted to find out how this was possible, and honestly, we really didn’t know what to expect.
On the first day, Ministry of Health representatives welcomed us with an overview of the health status of the Cuban people and a description of the health infrastructure. They then sent us off on the beginning of what seemed like a whirlwind tour. The visits to the various institutions had been arranged in response to the different interests of our group. Everywhere, we enjoyed a sense of goodwill and respect and the sharing of a common passion for health care, as well as learning a lot in the process.
The Cuban health system is free to all. It is centrally driven but decentralized in its implementation, with rigorous monitoring at all levels. There is a strict adherence to the ideals of public health: prevention, a community-orientation, and equitable access to health care. Because Cuba has always made health a priority, it spends a large percentage of its small national budget on health. As a result, its infant and maternal mortality rates, life expectancy, immunization coverage, and doctor/population ratio are similar to – or better than – most developed countries.
Primary Care: Cornerstone of Success
A high point for all of us was our visits to some family physicians in Havana. In each neighborhood, a resident physician-nurse team, responsible for approximately 175 families, keeps track of each community member. If a patient misses an appointment, he or she can expect a home visit. Health statistics are reported regularly.
The next level of care is the polyclinic. Here, physicians, typically with specialist qualifications, take care of the patients referred by the primary care team. This interdisciplinary secondary care includes emergency care, obstetrics, and mental health. Specialized hospitals treat more complicated problems. Our group visited obstetric, pediatric and oncology hospitals, in addition to the internationally recognized Institutes of Tropical Medicine and Neurologic Rehabilitation.
The goal of the health system appears to be universally applied high quality care. We were told that “any clear knowledge discovered in any part of the world, the Cuban health system must incorporate with great rapidity.” Committees of specialists are responsible for incorporating new knowledge into appropriate standard management regimens for national application. And although medical technology is clearly limited in Cuba because of the US trade embargo, much of what is needed is produced domestically. Nevertheless, problems were evident in the pharmacies, where shelves were distressingly bare. With a policy of self-reliance, Cuba has successfully concentrated its research efforts on vaccine development and medical genetics. The government also promotes alternative medical practices.
Cuba’s population faces health problems similar to most industrialized nations. Cardiovascular diseases are a priority, but since 1985 the number of heart surgeries has been reduced because of the lack of equipment and anesthetics. Lack of medications most severely affects treatment of cancer, the second leading cause of death. The painful process of rationing arouses strong feelings about the perceived cause of the problem. One Ministry of Health doctor told us:
I am not an epidemiologist of luxury, but of war. This is a blockade, not an embargo. What happens to the people during war. The people die. Why? Because they are in the middle of a war,dialysis is very difficult because of the blockade,in 1995 we had 1094 patients with chronic renal insufficiency, and because we lacked this equipment, we could not treat them.
The Management of AIDS in Cuba
When Americans hear about Cuban health care, they often express indignation that there is a place specifically set aside for people with HIV/AIDS; the sanatorium is perceived as a place of quarantine. This is decried as a violation of human rights. In fact, initially it was mandatory for HIV positive Cubans to live there. However, it soon became optional, and remains so, although it is highly recommended to all newly diagnosed patients at least for an initial period of care and education.
As visitors to the AIDS sanatorium near Havana, we were permitted free access to the grounds, although guided by physicians and staff, including the director of the sanatorium, Dr. Jorge Perez, a former short-term visitor to Harvard’s David Rockefeller Center for Latin American Studies. He introduced us to many of the patients and clearly knew each one very well. We saw sturdy housing, a park-like setting, clean public areas, and plenty of nutritious food. They have opportunities for work, social events, well-integrated medical and mental health care, social acceptance, and a sense of community. Many of the Cubans with HIV/AIDS live here, and care of this community is a priority, both for treatment and for quality of life. It costs the Cuban government over 1% of its total budget, one hundred times as much per capita as the rest of the population.
It is clear that Cubans are quite conscious of the international “political capital” of managing this disease well, and are proud of their success in doing so. Current emphases are on education, condom promotion and screening in order to limit transmission. Pregnant women are offered screening for HIV. This is supposedly non-mandatory, but few women refuse to be tested. Those testing positive often go to the sanatorium for education and potential relocation, but many end up returning to their homes after the education period.
Individual versus Community Rights
The practice of public health always entails a tension between the rights of the individual and those of the community. It also involves judgements about the extent that government or a community should interfere in the life of an individual in the interest of his or her own health. Cuba’s health system is community-oriented and interventionist in its approach. This results in model infectious disease control programs. Family physicians have considerable discretion in how socially invasive they can be to guarantee the health of their patients. For example, they can go to a person’s place of work to monitor an addiction or to his home to follow up on suspicions of child abuse. Many of us with our North American need for privacy felt uncomfortable with such an approach. On the other hand we were very impressed with the commitment and integrity of the health professionals that had the task of implementing such policies. One family physician, who makes the equivalent of $20 a month, explained what drives this commitment: “You have to have love; that’s the bottom line. You have to love the people.”
Our experience in Cuba led us to reconsider our definitions of “freedom”. As signatories of the Universal Declaration of Human Rights, both Cuba and the United States have agreed to uphold not only the civil and political rights, but also the economic and social rights of their peoples. In the United States, civil and political rights are the most valued. Freedom of speech, freedom of expression, and freedom from intervention are the backbone of the libertarian philosophies that founded this country. In Cuba, economic and social rights are valued more highly for society and therefore for the individual. Thus, an individual’s civil and political rights may be limited, but education and health care for each person is guaranteed.
Inevitably, we wondered how much of the Cuban experience could be applied elsewhere. The lesson we learned was the importance of the connection between politics and health, most of all that the two cannot be separated. It is interesting to consider how the health care systems of both the US and Cuba are each a reflection and an extension of its political and revolutionary history. As stated by one of the Cuban family doctors: “there is no way to bring the advances in health made in Cuba to other countries because you cannot underestimate the years of struggle, of imperialism, and of hard work that have made us what we are.”
We also came to realize while in Cuba how much the politics and policies of our own country have had an impact on the health and daily lives of every Cuban. In the absence of utopia, each society has to make its own trade between different sets of freedoms and rights. Many of us came to believe that the US is violating the human rights of Cubans by maintaining a trade embargo that continues to block shipments of pharmaceuticals, medical supplies and food to Cuba.
We all felt very fortunate to experience Cuba firsthand. This essay reflects a sampling of some of the intense experiences we had over the course of one short week. And we all learned to look at things differently in the process. As stated by the Japanese pediatrician who came on the trip:
If you don’t want to forget your significant experience, I’d recommend you to wear your wristwatch upside-down. It will remind you of the ideas and feelings of being in Cuba whenever you notice your watch. You may feel some difficulty when you look at it from the opposite direction, which suggests that it is difficult to see from the other side sometimes. In addition, whenever someone asks you what time it is or why you wear it in that way, you can talk about your transforming experience in Cuba and explain the importance of alternative perspectives,and recommend to them to do the same.
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