Lessons from Cuba: Integrating Community Involvement and Public Health
by Dr. Davida Flattery, DO
“We Cubans live like the poor and die like the rich” said our translator proudly as we stepped onto the chipped, yet exquisitely tiled courtyard of the neighborhood “consultorio”. During a seven day research tour in Cuba, our group of health professionals from Oakland, CA explored how an economically isolated nation has developed an exemplary health care delivery system.
Organized by Medical Education Cooperation with Cuba, a nonprofit organization based in Oakland, our tour is part of collaboration between the Alameda County Public Health Department, Oakland’s Ethnic Health Institute, Alameda County Medical Center and a community clinic called La Clinica de La Raza. During the next three years, our collaboration will develop a community health project inspired by what we observed in Cuba and focused on improving chronic disease outcomes here in Oakland.
Prior to the revolution in 1959, significant health related inequalities existed within Cuban society. Today, 100% of Cubans have access to primary medical care. There are 59 physicians per 10,000 Cubans as compared to 3 physicians per 10,000 people in Cuba’s Caribbean neighbor Haiti and 26 per 10,000 people in the United States. In Cuba, as in the United States, the average life expectancy is 78 years, as compared to 61 years in Haiti.
Paradoxically, Cuba’s per capita gross domestic product is far below that of the developed countries whose health outcome statistics it rivals. The Cuban national government considers health a basic human right. The provision of free, universal and equitable health care is considered to be the responsibility of the state. The health care system is explicitly oriented towards primary care and preventative medicine. In fact, 82% of Cuba’s health care dollars are spent on public health, as compared to 45% in the United States.
The “consultorio,” which comprises the foundation of the Cuban health delivery system, is a neighborhood-based micro-clinic staffed by a family doctor and nurse team. We met with Dr. Maria Diaz, who explained that she is responsible for safeguarding the health of the 100 families who live within one kilometer of her consultorio. She lives, as do most Cuban family doctors, within the neighborhood that she serves.
In addition to addressing acute complaints, Dr. Diaz makes a global assessment of the health of each of her patients using a biopsychosocial model. She does this by evaluating each household with a focus on the non-medical determinants of health: the physical condition of the home, the availability of clean water, the level of education and occupation of family members, the presence of substance abuse or domestic violence, and the existence of fall risks for the elderly. She also looks at how well a family is coping with illness. For example, if a diabetic patient’s diet is inappropriate, her plan of care would involve a family member attending a cooking class. Medical charts are organized by household, instead of by individual patient. In this way, clinical medicine and public health are integrated at the primary care level. Before her hospitalized patients can be discharged home, she must sign off on the discharge plan. This ensures coordination between outpatient and inpatient care.
Community involvement in health promotion is impressive in Cuba; we visited a junior high school where teens considered to be at high risk because of social problems in their homes were training to become community health educators themselves. Upon completion of a three-year curriculum, these teens will be equipped to share accurate information with their peers about such critical issues as HIV, teen pregnancy, substance abuse, and proper nutrition. This program simultaneously provides these teens with extra attention from stable adults that may help them succeed, equips them with the information they need to safeguard their own health, and empowers them to be leaders among their peers.
Additionally, we visited the “Older Adult University”, a government response to the data indicating higher mortality rates for elders whose families had institutionalized them, as opposed to those who were cared for at home. This “university” offers classes such as “what to expect from your body as you age” and “sexuality and aging.” As appropriate for their level of functioning, elders are also engaged in child care, community decision-making and teaching classes for one another in their areas of expertise. In this way, health education, community involvement and service are integrated.
Sitting atop a dilapidated roof overlooking Old Havana, watching a 76 year-old Cuban grandmother demonstrate how to dance the rumba, I reflected that despite caring deeply for our patients and our communities, utilizing staggering advances in medical science and technology, and spending massive amounts of money, we as American physicians are shamefully unable to meet the basic health needs of our population. What Cuba has that we lack is comprehensive public policy mandating affordable, universal and equitable health care for all people. I am confident that if our federal government were to enact such policy, we too could develop a health system that would allow us to consistently provide the quality of care that our patients deserve and urgently need.