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Harvard Public Health Review/Summer 2002

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The Cuban Paradox

Perhaps best known for vintage cars, cigars, and communists, Cuba is also distinguished by something far more enticing to the students and staff of the Harvard School of Public Health--its health care system. The Cuban government assumes full fiscal and administrative responsibility for the health care needs of all its citizens, providing free preventive, curative, and rehabilitation services. This National Health System, as it's called, is an international success story and, for the last three years, a small group from the School has made its way down to this sunny island nation to learn more about what makes it tick. "It's good for people to see another system," says Richard Cash, senior lecturer in the School's Department of Population and International Health. "Seeing for yourself is far more important and to see what Cuba does with limited resources and to contrast it with our system and other systems is valuable. Everyone that has gone to Cuba has come away clearly educated by the process."

This March, Cash was joined in this educational experience by 12 MPH students. Roberta Gianfortoni, director for professional education at the School, has organized the trip since its inception and coordinated this year's excursion with Medical Education in Cooperation with Cuba (MEDICC), a non-profit organization that specializes in offering elective experiences in Cuba to US and Canadian students in the health and medical sciences. The School's contingent traveled under a special license granted to the MEDICC. Over an eight-day stay in the Cuban capital of Havana, the group visited institutions such as the Ministry of Public Health, maternity hospitals, schools of medicine and public health, AIDS sanatoria, and community health clinics. "The objective is to look at an alternative system," says Gianfortoni. "It's an interesting model to study. Our students are going to go to both developed and underdeveloped countries so it's interesting to consider how Cuba's concepts and methods can translate to other parts of the world."

Socio-economic development is typically measured by health indicators such as infant mortality and life expectancy at birth. However, in Cuba, a nation beset by severely limited resources and political tensions both internal and external, these health markers are essentially the same as those in the United States and other parts of the industrialized world. Cuba also boasts the highest rate of public health service in Latin America and has one of the highest physician-to-population ratios in the world. Alone remarkable for a developing country, these feats are even more extraordinary considering the context of a US embargo that's been in effect since 1961. Because its access to traditional sources of financing is seriously hindered by the sanctions, which until rec- ently included all food and medicine, Cuba has received little foreign and humanitarian aid to maintain the vitality of its national programs. And herein lies the paradox of Cuba's health care system: because Cuba has so few resources, prevention has become the only affordable means of keeping its population healthy.

"I find Cuba's system to be very inspiring because it is so public health focused," says Tracy Rabin, who has made the Cuba trip twice. She traveled the first time as a student in the Department of Immunology and Infectious Diseases; this year she participated as a research associate and program manager for the Program on Ethical Issues in International Health Research in the Department of Population and International Health. Her impressions are not an illusion: despite the economic difficulties of recent years, spending on public health in Cuba has increased steadily, which reflects the political will to maintain successes achieved in this area. An August 1960 law established the Ministry of Public Health as the highest authority responsible for health care. The same year, the Rural Social Medical Service was created, allowing Cuba to place doctors and nurses in the country's remotest areas to bring medical attention to inhabitants there.
Economic constraints have also forced the Cuban health system to get creative when it comes to solving health problems. Cuba does a lot of work with alternative and herbal medicines, which can be more accessible and affordable to a broader population. A testament to their resourcefulness: they recycle magnets from ballistic missiles for their electromagnetic therapy. Cuba is also internationally recognized for its innovative National Immuniza-tion Program, begun in the '60s, through which vaccination is integrated into primary care services and depends on active community participation. And the health care system is aggressive in terms of intervention. Since doctors live in the community, if patients skip appointments it's only a matter of hours before the doctor is knocking at their door. "There is a certain kind of caring there that we lose out on in the United States," observes Ella Oong, who just finished up her MPH.

"For me the Cuban system reinforces a commitment to community health," notes Rabin. "It's nice to see that a lot of these public health theories can work in a medical context--there isn't necessarily a division between medicine and public health; there's an effective way for the two to come together. The more that health professionals are educated about different systems the better the US system will be." Rabin, who plans to go to medical school and study emergency medicine, also hopes to integrate the two. "The emergency room is often the first place that people go for treatment for a wide range of health problems--everything from mental health to domestic violence to infectious diseases," she says. "I think that Cuba would be a prime place to visit for someone with a strong commitment to public health and to viewing patients as both individuals and members of a community and other groups."

A functional blend of public health and medicine, Cuba's commendable health care system is nevertheless a product of a socialist revolution--so whether its methods can be feasibly applied to the United States remains an open question. What does the School's contingent bring back to their homeland from its weeklong visit? "Well, the students salsa more," quips Cash, popping a Latin-music CD into his computer. "But seriously, it hits people differently. Some students are impressed by the use of traditional medicine; others are impressed with the immunization programs. And many are conflicted about the AIDS programs." One of the most controversial of Cuban health programs has been the sanatorium-based care for AIDS, which originally obligated all HIV-positive patients to live out the rest of their lives in these small clinic-based communities. Today, an outpatient option is offered to those who qualify, but many patients don't take advantage of it because they are often ensured better care in the sanatoria. "Really, what we have is a conflict of ideology--the conflict between personal freedom and public health," notes Cash. "What works for Cuba may not work for us."

But everyone on the trip wished that they had a little more time to find out. Ella Oong and Todd Reid, who is studying for his master's in epidemiology, said they wanted to stay a bit longer to conduct case studies and evaluate how the integration of various practices work. For example, the recent dengue outbreak and eradication campaign would have been perfect models to study Cuba's comprehensive health care system. Oong, who just graduated this year, won't return to Cuba with the School. Reid, however, will revisit next year. He is already learning Spanish in preparation for the trip, which will be extended to a three-week excursion. "There's nothing that replaces the actual experience of being in the midst of the population," says Reid. "You can read all you want, but I readily understood the importance of being immersed in a different culture. You get so much more just talking to people. You connect with them. You find out what you share."

Chelsea Merz

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