A study of Cuba’s health system shows that the extraordinary can be achieved if systems focus on social health, rather than markets and private medicine, argues William Alderson
Robert Huish, Where No Doctor Has Gone Before: Cuba’s place in the global health landscape, (Wilfrid Laurier University Press 2013), 180pp.
I defy anyone who cares about health to read the first page of the preface of this book without wanting to read the rest. The experience described by Robert Huish led him to find out more, and what he found out is a lesson for us all. A Canadian on holiday in Cuba, he was seriously injured by a violent sea. Two local people immediately took him to the hospital, where he was treated and discharged within 25 minutes. He did not need to go back for a check-up because two days later a nurse came round to his hotel to find out how he was. His treatment was completely free.
This is a country where there is one doctor for every 179 people (p.10), and where people complain about waiting thirty minutes when they just walk into a policlinico to see a doctor because they are used to being seen immediately (p.45). It is a country which provides full medical training free to thousands of students from other countries, and that includes not only all tuition, but ‘all services, books, accommodation, food and necessities’ for six years and more (p.80). After the collapse of the Soviet Union, the country lost 87% of its exports, and food imports were cut by half, but ‘this event led to the enhancement of a sustainable primary care system, a global health workforce, and advancements in accessibility to medicine’ (p.40). This is a country where healthcare is seen as a human right, not a social burden.
To most of us this seems like a dream health service, but it exists, and in a country under economic pressure. The US embargo prohibits the sale of medicine and food to Cuba, and ‘a Canadian exporter served four years in a Federal prison in the United States for selling water purifiers to Cuban hospitals’ (p.158). When US students took up Cuban medical scholarships, the Bush administration in 2002 took harsh action: ‘The US Department of State and the US Treasury Department sent warnings to students stating that they could face jail sentences and fines upwards of $40,000 for pursuing a medical education that contravened the Trading with the Enemy Act’ (p.108). Meanwhile the US Department of Homeland Security created a $10 million scheme ‘to intentionally recruit Cuban and Cuban-trained doctors working in other countries’ (p.69).
Despite all this, Cuba offered medical relief to victims of hurricane Katrina in the USA in 2005. When the offer was rejected, the emergency response brigade was redirected to South America and then Pakistan, where over a thousand Cuban personnel were involved over thirteen months (p.158). Huish carefully discusses not just the facts of Cuba’s international medical work, but also the motives behind it. He also devotes a chapter to the specific problems facing Cuban-trained doctors returning to Ecuador, and the conflict they faced between their training, which rejects exploitation of medical treatment for personal profit, and a system which did not recognise their priorities. In 2007 these graduates formed a group ‘with a goal to lobby the Ecuadorian government to find ways to accept their skills within the public sector’ (p.153).
Central to the Cuban ethos of healthcare as a human right is the delivery of sustainable medical services to those who have little or no access to it. For this to be sustainable, doctors need to address the causes of illness and not simply patch up the consequences. ‘They visit worksites and houses to identify potential health risks from poor environmental and living conditions to social determinants of health. This allows doctors to build better understanding of community-level health patterns in order to develop strategies of disease prevention and health promotion’ (p.100).
At the same time, doctors need to be able to work without technology. As one Cuban-trained Gambian put it: ‘The facilities for sophisticated diagnostic equipment often don’t exist, for example. But if we can make a diagnosis based on a detailed clinical history and a thorough clinical examination – which is true for 85 percent of cases – then we even have an edge over students trained in Western Europe or the States’ (p.92). This also means that doctors have a much broader training when it comes to treatment: ‘Instruction in biomedical sciences continues throughout the program’ (p.97), but ‘the core curriculum also dedicates time and attention to traditional and natural medicine’, (p.95) such as homeopathy, acupuncture and herbal medicine (p.101). ‘Rather than reject alternative medicines, Cuban medical education embraces them’ (p.96). One effect of this is that Cuba has found ways of innovating medicines to get around the embargo. ‘In the 1980s, the Finlay Institute made breakthroughs with forward innovation of a vaccine against Group B Neisseria Meningitides. More recently, Labiofam, a Cuban commercial pharmaceutical operation has begun preparing to release a homeotherapeutic cancer drug to the international market’ (p.10).
This book gathers together many more gems of information, some truly uplifting and some appalling. Perhaps the worst is the leaked memo from Lawrence Summers, the former Chief Economist of the World Bank, seriously recommending moving ‘dirty industries’ to poor countries because they are going to die young anyway. Huish then quotes from the furious response of the Brazilian Secretary of the Environment, before revealing that he was fired, whilst Summers ‘went on to become Secretary of the US Treasury, President of Harvard University, and, recently, Director of the National Economic Council for the Obama administration’ (p.118).
Against such a background, whatever questions and disagreements there may be about the nature of the political system in Cuba, it does at least value people higher than the World Bank, Harvard and the US government. Furthermore, this book makes it brilliantly clear that Cuba offers us a radically different vision of healthcare from that of the government of any major country. Since charging for prescriptions, dental services and spectacles began in 1952, every British government has fostered competition between the NHS and private medicine, and within the NHS, and continually eroded the idea of healthcare as a right. Meanwhile, in Cuba ‘they have demonstrated one of the greatest advancements in medicine: universal access through cooperation, not competition’ (p.72). This book reveals that in medicine, at least, another world is possible.
 In her review for Counterfire of Samuel Farber's Cuba since the Revolution of 1959 (Haymarket 2011), Jacqueline Mulhallen noted that; ‘The health system itself was a massive achievement. However, it is now suffering from poorly maintained, dirty hospitals and a shortage of doctors since the Cuban trained doctors are in demand overseas (pp.74-75).’ Robert Huish reports that the decline in doctors was actually from 1 per 149 people to 1 per 179 people, still a massively better ratio than any other country. He also rejects the claim about dirty hospitals.