Cuba may lack health care resources, but the nation’s emphasis on preventive care holds lessons for more developed nations. (Photo: Getty Images)
Next April, 20 future doctors currently studying at Michigan State University will head to Havana, Cuba — and be the first students from the United States to participate in a clinical experience that will enable them to enter hospitals in the Cuban capital. Their mission: To learn more about the island nation’s medical system and its focus on primary care and public health.
“Cuba has always had scarce resources but they started out with the foundation that everyone has a right to basic, necessary health care,” William Cunningham, assistant dean for the College of Osteopathic Medicine in West Michigan and interim director of Michigan State University’s Institute of International Health, tells Yahoo Health.
Cuba sorely lacks the resources and the advances in medical technology that exist in the U.S., but the nation’s emphasis on preventive care and public health holds important lessons for the U.S., Cunningham believes — lessons that can perhaps help shape future cadres of medical professionals in this country and even influence the U.S. health care system going forward.
On paper, the numbers look extremely favorable: Cuba boasts one of the lowest infant mortality rates in the Western hemisphere, according to the CIA’s World Fact Book, averaging 4.7 deaths per 1,000 live births compared to 6.17 in the U.S. in 2014. American health experts like Cunningham attribute this and other favorable health indicators largely to Cuba’s focus on preventive medicine. But Katherine Hirschfeld, associate professor of anthropology at the University of Oklahoma, who did her doctoral research in Cuba, advises caution when it comes to the numbers. Cuba, after all, is a dictatorship where official figures are engineered by the state to its advantage, she tells Yahoo Health. And with no outside agencies allowed to conduct independent analyses, it’s difficult to verify their accuracy and even harder to get a sense of just how successful or important prevention has been as a health care strategy.
Still, now that Cuba and the U.S. have entered a period of détente and more medical professionals will have the opportunity to visit the island, Hirschfeld believes there are important lessons that can be learned from Cuba — notably how its Family Doctor program, a primary care initiative developed by by the government and managed by the military to decrease the geographic barriers to health care, works. “The program’s goal was to place family doctors in urban neighborhoods and the original plan called for doctors to live in apartments above their clinics,” she explains.
The community perspective aimed to enhance preventive medicine with a particular focus on maternal and child health, early cancer detection, and the detection and early treatment of chronic illnesses, says Marcia Garcia, a general surgeon in Cuba and an adjunct professor in Michigan State University’s Institute of International Health. The program also includes a substantial public education component.
The family doctor is the first port of call for all Cubans and the program would be more successful, in Hirschfeld’s view, if the clinics had been appropriately staffed and funded. Nevertheless, the model in and of itself is a draw for numerous doctors in the U.S.
For Paul Erwin Campbell, MD, DrPh, the head of the Department of Public Health at the University of Tennessee in Knoxville, who visited Cuba in February of this year, the doctor-patient ratio of one to roughly 1,500 is definitely a positive, and is reflective of the emphasis on primary care at the community level.
“This is the foundation of the Cuban health care system that gets carried through the physician-nurse team, who have responsibility for the health of an entire community,” Erwin tells Yahoo Health. “The physician-nurse team are the first level of care and their focus is largely on prevention by seeing every person in the community through a combination of people coming to their clinics and by making home visits, which the system requires them to do. I believe that things really work because the physician and the nurse actually live in the community that they serve and have a responsibility toward it.”
Physicians are required to see every person in their community at least once a year and they are not only responsible for care at the individual level, but also at the community level, Erwin says. Furthermore, the community can provide feedback to the health system “so that if they are dissatisfied with their physician-nurse team, they can ask for a new team.”
Focusing on prevention as the first port of call is also, of course, a consequence of Cuba’s isolation from the rest of the world (the U.S. embargo aside, the country also suffered tremendously after the collapse of the Soviet Union, it’s main financier, in the early 1990s) and a lack of sufficient medicines, medical equipment, and technology. So being able to nip illnesses, minor as well as more serious, in the bud is as much an economic motivation as it is a health matter, Erwin says. In response to the shortage of dialysis machines following the drying up of Soviet funding, for example, “Cuba developed a national kidney disease prevention program based on the idea that if you don’t have enough technology to deal with the end result of the disease, you push it further upstream,” he says.
“I believe that the Cuban model has been so successful because they have been able to achieve good health outcomes by spending relatively little, in part because of their focus on primary care and preventive medicine,” says Paul Drain, MD, assistant professor of global health at the University of Washington Seattle’s Department of Global Health, who first visited Cuba in 2008 and has been back twice since. “That’s the opposite of the U.S., where we rely on specialists for everything, where we start out with the family doctor but then one patient can be managed by four or five different specialists and things get complicated and expensive.”
For Drain, one of the hallmarks of Cuba’s focus on prevention is its highly developed vaccine program. For several decades, Cuba has been researching and formulating vaccines for the prevention and cure of a number of serious illnesses, including some cancers. There are many more mandatory vaccinations in Cuba than there are in the U.S.
The vaccination program has successfully eradicated illnesses like measles, Garcia says. Mandatory vaccinations are administered against illnesses such as dengue (a mosquito-borne virus) and cholera (a water-borne bacterial illness that causes severe diarrhea and dehydration), as well as chronic hepatitis B, a serious liver disease of which there are about 200,000 cases a year in the U.S., according to the Mayo Clinic. Several countries around the world are interested in the hepatitis B vaccine, Garcia says, and Cuba continues to research possible vaccines for diabetes, rheumatoid arthritis, multiple sclerosis, severe psoriasis, and various cancers, including melanoma, lymphoma, pancreatic, and cervical cancer.
Granted, the Cuban population has no choice when it comes to vaccinations, since they are required by law to have them, Drain concedes. “But the Cubans have really pioneered a lot of vaccine research and they have been working recently on vaccines for stage-4 cancers, one of which is currently being evaluated in several different countries, including Venezuela,” he says. “It will be interesting to see what the results show, but given that Cuba has such a small research budget compared to ours, if the Cubans can develop a vaccine that can work for cancer, it will put things into perspective and make the U.S. medical system feel embarrassed.”
With relations between the two countries easing up, though, the U.S. may soon be able to tap into Cuban vaccine know-how. Earlier this year, the Roswell Park Cancer Institute in Buffalo, NY, inked a deal with Cuba’s Centro de Imunologia Molecular, or Center of Molecular Immunology, to research a vaccine for the prevention and treatment of lung cancer that is already being used on the island. Pending federal government approval, the vaccine could soon be subject to clinical trials here in the U.S.
But as much as the Cuban experience may offer some key insights into medical care, the country has a long way to go before it can truly join the international community as a health leader. Many of the challenges are basic, Hirschfeld says, and include improving sanitation in hospitals and requiring doctors to work with gloves, not reuse syringes, and ensure proper trash collection. Cuba needs to allow external agencies to conduct “honest, unrestricted health surveys of the population,” she says, “because how can effective health plans be created if the true health status of the population is unknown?”
Most importantly, medicine in Cuba should be allowed to function as an “autonomous profession” instead of “as an arm of the state,” says Hirschfeld. In her view, “the Cuban health system will have no international credibility if it remains complicit in the state’s ongoing human rights abuses.” That requires also implementing standard informed consent protocols for all medical procedures — tests, medical research, and surgeries – and giving Cubans the right to refuse treatment, sue for malpractice, and the right to know all the risks that come with experimental drugs or vaccines, she says.
Medical supplies and equipment — from the basic to the more sophisticated — are also in very short supply in Cuba, and not having these poses a real impediment to advances in health sciences, Erwin says. Just as important is the lack of Internet access that prevents Cuban medical professionals from accessing scholarly journals in public health and medicine.
Still, Erwin says, “given what they have accomplished relative to the resources available to them, I believe we all have something to learn.”