Continuing the Dialogue on Health: Insights From the 2010 APHA Delegation to Cuba

THE RELATIONSHIP BETWEEN the United States and Cuba has been marked by its tumultuous political history.¹ Yet despite a complicated past, Cuba has long garnered attention from the United States for its approach to health. Numerous health leaders, including legislators and researchers, have engaged in lengthy dialogue and exchange regarding the health system in Cuba. More recently, in November 2010, a delegation composed of members of the American Public Health Association (APHA) traveled to Havana to witness how the Cuban health care system operates.²

Cuba is the largest island in the Caribbean, approximately the size of Pennsylvania, and is considered a developing nation. The country has been operating under a strict US-imposed trade embargo since 1992. In 2008, Cuba’s gross domestic product (GDP) was $60.81 billion and its per capita gross national income (GNI) was $5460,^3,4 whereas in the United States the GDP was $14.22 trillion and the per capita GNI was $47 890.^3,4 Despite these economic differences, several health indicators in Cuba are comparable to, if not better than, those in the United States. According to the 2011 Pan American Health Organization’s report on basic indicators, Cuba’s life expectancy in 2011 was 79.2 years, compared with 78.6 years for the United States.⁵ Similarly, the infant mortality rate in Cuba was 4.5 per 1000 live births in 2010, compared with 6.6 per 1000 live births in the United States in 2008; the AIDS incidence rate in 2009 was 5.5 per 100 000 population in Cuba and 11.2 per 100 000 population in the United States.⁵ These health statistics, despite limited resources, have motivated several health leaders in the United States to investigate the Cuban health care system. More specifically, health leaders have sought to explore which components may be most helpful in obtaining favorable health outcomes.

The 2010 APHA delegation to Cuba was led by Carmen Nevarez, MD, MPH, who was then the president of APHA. The 70 delegates included physicians, nurses, counselors, community organizers, and researchers.² Over the course of five days, delegates learned about health promotion efforts (1) at the national and international level, including the Cuban public health system and health policy as well as international medical teams; (2) at the grassroots level, including community-based projects through UNICEF and community-based health facilities (policlinicos); and (3) for special populations, including the aging population, child victims of the Chernobyl nuclear disaster, and mothers and children. Among the sites the delegation visited were the National School of Public Health, the Latin American Medical School, the National Center for Medical Sciences Information, the Center for the Prevention of Sexually Transmitted Infections and HIV/AIDS, the National Oncology Institute, a vaccine research and development facility, and an ophthalmological hospital. During their visit, delegates identified two main components of the Cuban health care system.

PREVENTION-BASED APPROACH

The first component was a prevention-based approach that influenced health insurance, medical training, and health services. In the United States, with a fragmented health care system facing national reform, lack of insurance and underinsurance remain as huge obstacles to accessing health care. Therefore, health insurance is often a popular topic among US health professionals, and even more so when discussing countries such as Cuba where there is universal health care.^6,7 Tiffany Tate, MHS, a public health consultant in Maryland, indicated that after returning from the delegation’s trip to Cuba, she called her new physician to make an appointment. The first question the receptionist asked Tate was what kind of insurance she had, rather than the need for her visit. Tate indicated that this exchange “could be interpreted as our health care system placing a greater emphasis on reimbursement than patient care,” adding, “I came back a really big advocate of [universal health care] because health care is a right, and we don’t have that in [the United States].” Tate went on to say that through universal health care, “People feel valued as individuals” because “questions about coverage don’t exist, so a patient’s interaction with the health care system mainly consists of discussing their health and receiving care.” She believes the United States should improve the health insurance system.

Following the Cuban revolution in 1959, there was a need to replace the health professional work force, particularly physicians that fled the island.^6–8 Currently, medical school training integrates public health and medicine.¹ Tate recalled that when members of the delegation visited the National School of Public Health and Latin American Medical School in Havana, some delegates attempted to understand medical training in Cuba on the basis of the model they were familiar with in the United States. Once at the Latin American Medical School, Tate recalled, some delegates asked, “When do you teach people public health?” After much discussion, she said, faculty at the school of medicine responded, “We teach them every step of the way.” Tate felt this was a “common-sense approach,” adding that it was “intuitive” given the way the health system is structured in Cuba.

In addition, Cuba’s medical training has been discussed at the global level as Cuba has trained and continues to train physicians from Africa and Latin America at no cost to the students or their countries of origin.^6–12 ¡Salud!, a documentary distributed by Medical Education Cooperation With Cuba, highlights Cuba’s global health role through the medical students trained on the island.¹³ This global health focus was also discussed by Sheila Palevsky, MD, MPH, of New York after touring Tarara, a clinic established to provide aid to child and adolescent victims of the Chernobyl nuclear disaster—care that might otherwise not be available to them. Palevsky said,

This is a demonstration of their [Cuba’s] internationalism. They’re providing care for people from overseas and this meshes with their training of physicians from other communities where there’s that need.

Palevsky also mentioned that these types of initiatives were strategic in helping Cuba raise its visibility, particularly as Cuba is often unable to provide direct international financial aid.^6,10

COMMUNITY-BASED APPROACH

The most discussed component was a community-based approach to health, where prevention efforts are applied and most clearly seen. In terms of maternal and child health, women with high-risk pregnancies are identified by their primary care provider and then provided with comprehensive prenatal care within a local or regional maternity home.¹ Women live in these homes beginning when they are 20 weeks pregnant and are provided with nutritious meals, dental care, ultrasound screenings, and education. Additional services aimed at improving maternal and child health, such as smoking cessation and stress management, are also offered. The maternity homes are run mainly by nurses, with a physician making daily rounds. Women deliver their babies at a maternity hospital and are referred to the hospital before delivery if they develop any acute problems.

The delegation visited one of the maternity homes in Havana. Debra Jones, MD, a maternal–fetal specialist in Florida, said the women in these maternity homes received medical care that was equivalent to what they would receive on an outpatient basis in the United States. “They’re not shortcutting the basic screening tests that we would do [in the United States], they do the key laboratory work that I do,” Jones said, adding, “They have an advantage that they get their patients into their system very early and provide them access to not only prenatal care but to health promotion and psychosocial support.” Jones was very enthusiastic about the maternity homes and felt more efforts in the United States should be focused at the beginning of the life cycle.

Another example of a community-based approach is the policlinicos, which are outpatient structures. One of the delegates, Debora Kerr, MA, chief operating officer for the Florida Public Health Institute in Lake Worth, said, “There was a physician imbedded into the community,” referring to the practice of having doctors and other health providers residing in the same neighborhoods as the patients they serve.¹ Kerr commented that each physician had intimate knowledge of the community, allowing for a “personal touch.” Delegates felt these health providers have a greater understanding of widespread needs such as nutrition support and environmental hazards.

Several delegates identified the importance of working at the community level and the application of this model in Cuba. Norge W. Jerome, PhD, professor emeritus at the Department of Preventive Medicine and Public Health of the University of Kansas Medical School, discussed her perspective as a nutritional anthropologist with extensive experience as a cross-cultural ethnographer:

You treat the individual, but with respect to the community context because the individual lives in the community that has more needs than is being expressed by that one patient.

Monica Peek, MD, MPH, is an assistant professor of medicine at the University of Chicago and a primary care physician. In recounting her visits to clinics and other health facilities in Havana, she said, “I think that the Cuban health system does a really good job at thinking about population health at the community level.” Recalling her experiences in the United States, Peek said that

the people who come see me in the office might not be the people who most need to see me. I’m seeing the people who are most motivated to see me, who have the insurance, support and savvy to navigate the health system. Other people without such resources may be more in need, with worse health, but don’t manage to find their way into the doctor’s office.

She added, “The most medically vulnerable people are often the ones who don’t come through our doors.”

Overall, the visit to Cuba was enlightening for the delegates as they were able to identify key components of the Cuban health care system that appeared to have a direct impact on an individual’s access to health care. However, several questions remained that delegates did not have the opportunity to explore. For example, the delegates recognized that the perspective they were given was that of Cuban health professionals rather than Cuban community members, which affected the level of information they were provided with. Similarly, although limitations within the Cuban health care system have previously been identified, such as patient privacy, lack of technology, shortage of basic equipment and supplies, and minimal physician salaries,⁷ the delegates were not able to delve into these topics.

Many of the initiatives in Cuba, although not standard, have been applied to some extent in the United States. For example, Massachusetts and San Francisco have shifted toward universal health care models,¹⁴ and there has been increased value placed on community-based programs, such as those that incorporate community health workers or promotores (members of the communities they serve who often act as liaisons between the health care system and marginalized communities).¹⁵ The visit to Cuba in 2010 allowed the delegates to reflect on key practices that are aligned with public health values, and it also served to establish an ongoing relationship with Cuba. A second delegation visited Cuba in May 2011 and a third went in December 2012. This APHA-structured dialogue between health professionals in the United States and Cuba may not come as a surprise, as APHA first invited Cuba to join the association in 1889, when the country was still under Spanish colonial rule.¹⁶

More than a century later, APHA remains committed to bringing together a diverse array of health professionals from all over the world.