Cuba is no Caribbean paradise. Even if one is willing to cast Fidel (now Raul) Castro’s government in a benevolent light, there are many observable problems plaguing this 40,000 square mile tropical island nation of 11 million. The economy is generally sluggish and wages are meager. Even lawyers and doctors are compelled to moonlight as taxi drivers or interpreters or chefs in their own home in order to supplement their salary. Despite government food rations allotted to each citizen, there is often not enough food on the family table.
Limited housing stock with (only recently) limited options to buy or sell has led to routine overcrowding with three and four generations living under one roof. New car purchases ended with the U.S. embargo and the subsequent break-up of the Soviet Union, causing most Cubans to endure packed buses and hours-long daily commutes. Ignoring for a moment the political restrictions on travel, the housing and financial challenges alone impede Cubans’ ability to relocate to another part of the country in search of better jobs or to leave Cuba altogether. A series of major lay-offs of government workers have led many Cubans to feel restless and declare the revolution passé, dysfunctional, or dead. Young people appear to be much less enchanted with La Revolución than their parents or grandparents, who experienced firsthand the transition from Batista’s corrupt regime to Castro’s communist manifesto.
Despite the daily challenges that many, if not most, Cubans encounter, there is genius afoot in Cuba. In 2010, I traveled to Havana on an officially sanctioned trip as a delegate of the American Public Health Association. (The last time an APHA delegation had visited Cuba was 1993.) The purpose of our trip was to explore the Cuban health system, and learn as much as we could in a week crammed with visits to clinics, hospitals, maternity home, research institutes, medical schools, and the like.
Cuba is a fascinating country! As a public health doctor on my first trip there, my goal was to discover which aspects of the health system might account for Cuba’s impressive “vital statistics.” The infant mortality rate, for example, is 4.8 deaths per 1,000 live births, while the rate in the U.S. is 6.3 deaths (31% higher). Life expectancy in Cuba is 78 years—a smidgeon better than the 77.9 years in the U.S. Comparing these statistics with the U.S. is impressive. But if one compares Cuba’s outcomes with those of its Caribbean neighbors, one finds a disparity that is considerably more impressive. Cuba’s health achievements in the context of the longstanding U.S. embargo suggest that there is something both unique and powerful about the Cuban experience, and I wanted to find out what that something might be.
I returned from my trip fired up about four priority principles that stood out during my time in Cuba:
- Humanity and Compassion
- Education and Empowerment
- Community and Intersectoriality, and
- Resourcefulness and Prevention.
The Principle of Humanity
The “social medicine” system of Cuba clearly places a priority focus on humanity, compassion, and the inherent value of sharing one’s skills and (typically scant) resources with those less fortunate. This principle is highly in evidence in the health system’s policies and domestic delivery of health care services. As a primary example, health care is provided free-of-charge. Let me say that again: all health care is provided free-of-charge to all Cubans (with a few exceptions, for instance, where a medication might be hard to come by and overly expensive).
Further, health care is delivered via an extraordinarily accessible system of policlinicos and consultarios in which a family doctor is charged with caring for all of the families living in his/her assigned neighborhood. This family doctor lives in the same building as his/her consultario (medical office) and provides services both on-site and in people’s homes. The provision of housing to family doctors serves as a powerful carrot to students considering a medical career. The most significant consequence of this model is that the doctor is wholly familiar with the health status and risk factors of each member of his/her assigned families.
The priority placed on humanity is also in evidence in the extensive medical care provided by 20,000 Cuban doctors to impoverished medically underserved people throughout Africa and Latin America. Medical students are required to spend a portion of their medical education in the “field” learning about serving the poor. In our visit to the Latin American Medical School (which has students enrolled from over 100 countries, including the U.S.), we were told that students are taught principles, values, and morality first and foremost. This precedence is admittedly imposed on the people from the top down, requiring them to do the right thing whether or not their personal motivations would lead them in this direction. But it is an admirable principle nonetheless, and one that is completely missing from our own medical education in the U.S. and that is, instead, overshadowed by both corporate profitability and government emphasis on insurance and cost containment.
The Principle of Education and Empowerment
Education has been highly valued in communist Cuba, starting with the massive and successful Literacy Campaign (La Alfabetizaticion) launched just after the revolution in 1959. According to the CIA (2010), Cuba has a 99.8% literacy rate—just above the 99.0% literacy rate reported for the U.S. More is revealed about our respective populations’ educational status if one considers that a 0.2% rate of illiteracy in Cuba translates into 22,000 Cubans, whereas the 1.0% rate of illiteracy in the U.S. translates into 3,000,000 Americans
Part of the miracle of the literacy campaign was the Federation of Cuban Women (Federación de Mujeres Cubanas or FMC) established in 1960 by Vilma Espín (an important figure in the revolution and Raul Castro’s wife). In addition to having educational goals, the FMC had a broad agenda of social, economic, and political goals that would ensure women’s empowerment, equality, and greater participation in society. The Family Code of 1975 mandated equal rights for women as well as equal responsibilities in the home for men and women, in order to overcome women’s barriers to employment. It is interesting to note that a communist regime classified by the U.S. government as a totalitarian regime was apparently not worried about the critical and independent thinking that such widespread education and profound empowerment of the Cuban citizenry would inevitably engender.
The Principle of Community and Intersectoriality
Following the overthrow of Batista, Fidel Castro established a national block-by-block infrastructure across the country called the Committees for the Defense of the Revolution (Comités de Defensa de la Revolución or CDR). The CDR slogan—“In every neighborhood, Revolution!”—captures the essence of community organizing, community empowerment, and community engagement or, alternatively, it presages government spying and the pressures of totalitarian oversight—depending on your point of view. For several years following the revolution, the CDRs’ primary purpose was to watch for and squelch counter-revolutionary activity.
Once the threat to the revolution waned, the CDRs were not disbanded as they might easily have been, but were instead preserved and transitioned into mechanisms for community-level outreach. The CDRs have since proven invaluable to both literacy education and health promotion—in particular, they have enabled Cuba to prevent an epidemic of HIV (Cuba’s rate of HIV infection is 0.03% vs. the 2.0% rate in many U.S. urban areas). This extraordinary community infrastructure (which I liken to the impregnable webbing of bamboo roots that grows just below the ground’s surface) facilitates an organic integration of public health, medicine, social support services, education, and community outreach.
The seasoned professionals we met with in Cuba were repeatedly confused by our questions about how public health topics are integrated into the medical school curriculum. For them, there is no separation. In addition, there is widespread “intersectoriality” (a concept I had never heard of before), i.e., the strategic coordination and collaboration between sectors. There appears to be a commonly held view that the inevitable interweaving of personal (or societal) issues requires an inclusive, coordinated delivery of a range of social and health services. Such an acknowledgement and rich and more immediate approach to solving a problem is drastically needed in America’s inner cities where poverty, unemployment, sub-standard housing, violence, and environmental hazards are clearly interwoven with health outcomes.
The Principle of Prevention
How much human suffering is avoided if disease and poor health are prevented? What amount of personal and societal resources is saved? A 99% literate populace along with CDR and FMC infrastructures in Cuba make it possible to implement continuous health promotion and prevention campaigns that encourage Cubans to modify health behaviors, participate in screenings and immunization campaigns, and avoid disease and premature mortality. Cuba has also invested hundreds of millions of dollars/pesos into the development of vaccines that are distributed domestically as well as sold abroad. Through this principle, Cuba has surmounted and avoided all sorts of health threats, including those posed by dengue fever, meningitis, and HIV. Historically, in the U.S., prevention and health promotion have been castigated as “soft” priorities by the medical establishment as compared with the greater “sophistication” of medical intervention and treatment. The volume of resources squandered on treating (instead of preventing) clearly preventable chronic or infectious diseases in the U.S. is massive.
The Cubans are a clever and resourceful people, doing whatever they can with the modest resources at hand. The U.S. embargo was mentioned repeatedly throughout our week in Cuba and is in evidence on streets filled with ancient cars and grocery stores with near-empty shelves. Still, in a short time, we observed numerous significant examples of the old English proverb, “Necessity is the mother of invention.”
Located in the tropics, Cuba is vulnerable to a number of vector-borne diseases. Since the early 1990s, however, Cuba has been unable to purchase either medicines or U.S. pharmaceutical company vaccines. Cuba’s response was to establish the Finlay Institute for Vaccine Development (named after Dr. Carlos Finlay, the Cuban physician credited with discovering the vector for yellow fever in the early 1900s). Cuba’s successful vaccine production (inspected annually by the United Nations) generates hundreds of millions of dollars in annual revenue through sales to countries throughout Africa and Latin America—revenue which is then fed back into the biotechnology and health sectors.
As another example, the famous Las Vegas-type show Tropicana founded in 1939 remains open despite its past affiliation with Cuban gamblers and American mobsters and arguably counter-revolutionary content because of its ability to lure tourists from around the world. Tourism is now Cuba’s leading revenue-producing industry. As perhaps a more quaint example, the streets of Cuba are overflowing with 1959 Chevys and Ford trucks—some held together by wire and glue, others somehow preserved in visibly stellar condition. Now fifty years after they left the plant in Detroit (and hundreds of thousands of miles later), the cars are still running despite their owners’ inability to purchase parts.
While many of the principles underlying Cuba’s positive health achievements might not be possible in a country that does not take kindly to socialism, let alone communism, I returned hopeful that at least some part of the genius of Cuba could be instituted in the impoverished urban communities across the United States that are sustaining dangerously high rates of morbidity and mortality. The genius of Cuba’s health system may be a residue of the revolution, but ironically, both Cuba’s flaws and strengths derive from a communist system that prioritizes the common good over individual rights, just as the flaws and strengths in the U.S. both derive from a capitalist democracy that prioritizes individual rights over the common good. Even if we in the U.S. don’t prioritize the common good, don’t we at least have an obligation to ensure the individual rights of everyone to health care, particularly those among us with no pocketbook or voice?
Musings & Commentary