Healthcare to Envy

Cuba’s Cure: Why is Cuba exporting its health care miracle to the world’s poor?
by Sarah van Gelder

Cubans say they offer health care to the world’s poor because they have big hearts. But what do they get in return?

They live longer than almost anyone in Latin America. Far fewer babies die. Almost everyone has been vaccinated, and such scourges of the poor as parasites, TB, malaria, even HIV/AIDS are rare or non-existent. Anyone can see a doctor, at low cost, right in the neighborhood.

The Cuban health care system is producing a population that is as healthy as those of the world’s wealthiest countries at a fraction of the cost. And now Cuba has begun exporting its system to under-served communities around the world—including the United States.

The story of Cuba’s health care ambitions is largely hidden from the people of the United States, where politics left over from the Cold War maintain an embargo on information and understanding. But it is increasingly well-known in the poorest communities of Latin America, the Caribbean, and parts of Africa where Cuban and Cuban-trained doctors are practicing.

In the words of Dr. Paul Farmer, Cuba is showing that “you can introduce the notion of a right to health care and wipe out the diseases of poverty.”

Health Care for All Cubans

Many elements of the health care system Cuba is exporting around the world are common-sense practices. Everyone has access to doctors, nurses, specialists, and medications. There is a doctor and nurse team in every neighborhood, although somewhat fewer now, with 29,000 medical professionals serving out of the country—a fact that is causing some complaints. If someone doesn’t like their neighborhood doctor, they can choose another one.

House calls are routine, in part because it’s the responsibility of the doctor and nurse team to understand you and your health issues in the context of your family, home, and neighborhood. This is key to the system. By catching diseases and health hazards before they get big, the Cuban medical system can spend a little on prevention rather than a lot later on to cure diseases, stop outbreaks, or cope with long-term disabilities. When a health hazard like dengue fever or malaria is identified, there is a coordinated nationwide effort to eradicate it. Cubans no longer suffer from diphtheria, rubella, polio, or measles and they have the lowest AIDS rate in the Americas, and the highest rate of treatment and control of hypertension.

For health issues beyond the capacity of the neighborhood doctor, polyclinics provide specialists, outpatient operations, physical therapy, rehabilitation, and labs. Those who need inpatient treatment can go to hospitals; at the end of their stay, their neighborhood medical team helps make the transition home. Doctors at all levels are trained to administer acupuncture, herbal cures, or other complementary practices that Cuban labs have found effective. And Cuban researchers develop their own vaccinations and treatments when medications aren’t available due to the blockade, or when they don’t exist.

Exporting Health Care

For decades, Cuba has sent doctors abroad and trained international students at its medical schools. But things ramped up beginning in 1998 when Hurricanes George and Mitch hammered Central America and the Caribbean. As they had often done, Cuban doctors rushed to the disaster zone to help those suffering the aftermath. But when it was time to go home, it was clear to the Cuban teams that the medical needs extended far beyond emergency care. So Cuba made a commitment to post doctors in several of these countries and to train local people in medicine so they could pick up where the Cuban doctors left off. ELAM, the Havana-based Latin American School of Medicine, was born, and with it the offer of 10,000 scholarships for free medical training.

Today the program has grown to 22,000 students from Latin America, the Caribbean, Africa, Asia, and the United States who attend ELAM and 28 other medical schools across Cuba. The students represent dozens of ethnic groups, 51 percent are women, and they come from more than 30 countries. What they have in common is that they would otherwise be unable to get a medical education. When a slum dweller in Port au Prince, a young indigenous person from Bolivia, the son or daughter of a farmer in Honduras, or a street vendor in the Gambia wants to become a doctor, they turn to Cuba. In some cases, Venezuela pays the bill. But most of the time, Cuba covers tuition, living expenses, books, and medical care. In return, the students agree that, upon completion of their studies, they will return to their own under-served communities to practice medicine.

The curriculum at ELAM begins, for most students, with up to a year of “bridging” courses, allowing them to catch up on basic math, science, and Spanish skills. The students are treated for the ailments many bring with them.

At the end of their training, which can take up to eight years, most students return home for residencies. Although they all make a verbal commitment to serve the poor, a few students quietly admit that they don’t see this as a permanent commitment.

One challenge of the Cuban approach is making sure their investment in medical education benefits those who need it most. Doctors from poor areas routinely move to wealthier areas or out of the country altogether. Cuba trains doctors in an ethic of serving the poor. They learn to see medical care as a right, not as a commodity, and to see their own role as one of service. Stories of Cuban doctors who practice abroad suggest these lessons stick. They are known for taking money out of their own pockets to buy medicine for patients who can’t afford to fill a prescription, and for touching and even embracing patients.

Cuba plans with the help of Venezuela to take their medical training to a massive scale and graduate 100,000 doctors over the next 15 years, according to Dr. Juan Ceballos, advisor to the vice minister of public health. To do so, Cuba has been building new medical schools around the country and abroad, at a rapid clip.

But the scale of the effort required to address current and projected needs for doctors requires breaking out of the box. The new approach is medical schools without walls. Students meet their teachers in clinics and hospitals, in Cuba and abroad, practicing alongside their mentors. Videotaped lectures and training software mean students can study anywhere there are Cuban doctors. The lower training costs make possible a scale of medical education that could end the scarcity of doctors.

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