IN OAKLAND, CALIF., schools and other nontraditional sites host health clinics that provide both primary care and preventive health services for area residents, many of whom are uninsured.
In south Los Angeles, mental health professionals have created programs based on nutrition and group exercise, along with peer-to-peer education about the transmission of HIV/AIDS. Community groups, faith-based organizations, schools, and health providers are coming together in Albuquerque, N.M., to enroll hundreds of children in Medicaid and start neighborhood walking groups—part of an effort to break down walls between health-care providers and their patients
The U.S. health-care system is known for treating advanced-stage illnesses with expensive therapies that are often not accessible to those without health insurance. So if these low-cost, preventative programs in Oakland, LA, and Albuquerque don’t sound like the typical U.S. approach to health, you’re right: These and other community-based efforts trace their inspiration to the remarkably successful health system built by the nation of Cuba.
That inspiration, and the U.S. initiatives that have followed, have been nurtured by the California-based nonprofit Medical Education Cooperation with Cuba, known as MEDICC. Through guided trips to directly observe Cuba’s health system, MEDICC aims to help those working in underserved communities in the U.S. learn about the Cuban model, where quite limited health-care expenditures in a decidedly low-income population manage to provide universal care and health outcomes that rival those in the U.S.
A recent grant from the Robert Wood Johnson Foundation is supporting expansion of the program. “Cuba has not reinvented the wheel when it comes to health care, but they approach the challenge in a way that we can learn so much from,” says Diane Applebaum, a family nurse practitioner who directs MEDICC’s U.S.-Cuba Community Partnerships for Health Equity program.
A constitutional right
The Cuban approach to health has yielded some enviable results. Despite spending a fraction of the cost on health care we incur here in the U.S.—$603 per person annually in Cuba compared to the $9,145 per person in the United States—life expectancy in Cuba is virtually the same as in the U.S. The State of the Mother report by the organization Save the Children ranks Cuba as the number one country in Latin America to be a mother, and Cuba has one of the lowest HIV rates in the Americas. Cuba’s doctor-patient ratio is one of the best in the world, with almost three times as many physicians per capita than in the U.S. Cuba approaches 100 percent coverage in vaccination of children and providing prenatal care for pregnant women.
These outcomes are produced by a national system that relentlessly prioritizes preventive health services and universal access to primary care. Physician-nurse teams live and work in each Cuban community, including rural communities, where they provide free care for all through neighborhood clinics called consultorios. Each consultorio cares for about 500 families, and they are considered guardians of their patients’ health, not just a response team when community members fall ill. That means the providers regularly leave their offices to conduct home visits that include review of their patients’ food and water supplies and environmental living conditions.
The next level of care in the Cuban system, polyclinics, address more specialized needs along with dentistry and laboratory testing services, also in a community-based setting. Cuba has earned global goodwill by sending tens of thousands of its health-care professionals to provide care in some of the poorest countries in the world. U.S. clinical and public health professionals shepherded to Cuba by MEDICC have marveled at the vigorous embrace of community-wide preventive strategies. “What we learned from the Cuban model is the importance of focusing on the social determinants of health,” says Francisco Ronquillo, an Albuquerque-based health extension officer with the University of New Mexico. “We saw people actually blocking the streets to do group exercises.”
Free government-provided health care is a right enshrined in the Cuban constitution, and it is a right that is enforced with vigor. “This is quite a distinction from the way we approach health in the U.S.,” says C. William Keck, a physician and former president of the American Public Health Association, who has researched and published articles on the Cuban model. “In the U.S., our real health policy agendas are too often about power and money, rather than improving health. But even in our market economy, local communities can find valuable ideas from Cuba that we can apply here.”
Keck is not the only health professional urging that the U.S. and others take a close look at the Cuban example. In 2006, U.S. and Cuban physicians wrote an article for the International Journal of Epidemiology outlining the Cuban public health success story and questioning why the model was not widely studied and emulated. The “undisputed priority in public health from a global perspective is the need to rescue the populations of poor countries from disease we have been able to prevent or cure for many decades,” wrote Richard Cooper, Joan Kennelly, and Pedro Orduñez-Garcia. They concluded, “Why have we ignored what works?”
Engaging the community
But this Cuban secret may not be ignored much longer. In December, President Obama and Cuban President Raul Castro announced the resumption of diplomatic relations that had been severed since 1961. Although the U.S. trade embargo with Cuba will remain until there is congressional action to remove it, U.S. residents can now more freely travel to Cuba, and U.S. banks and companies have more ability to engage in the Cuban economy. Combined with the 2010 Affordable Care Act, which includes substantial funding for preventive services, expanded access to primary health care, and the forging of partnerships between clinical care providers and public health programs, the U.S. has laid the foundation to begin implementing the health strategy that has worked so well for our neighbors to the south.
These principles boosted by the Affordable Care Act are already being embraced in California’s Alameda County. Between 2008 and 2010, health officials and providers from the county, which encompasses the city of Oakland, made multiple trips to observe the Cuban methods.
For Wright Lassiter, then-CEO of the Alameda County Medical Center, it was an experience that reoriented his lifelong perception of health systems. “It was one of the most exciting experiences of my career, and one of the most unsettling experiences of my career,” he told a Bay Area forum shortly after returning from Cuba. “They were doing so much better at something I was supposed to be doing, and that is running a health system.”
Following the Cuban model, the county expanded its existing network of school-based clinics, where students receive primary care along with instruction in the importance of exercise, good nutrition, and use of contraception. The Alameda Health System created the Hope Center, which provides wrap-around health and social services to patients who are coming off a period of multiple hospitalizations. And the county added efforts such as a mobile van that serves the health needs of the homeless.
Kimi Watkins-Tartt, deputy director of the Alameda County Public Health Department, says many of these “health portals” in the area embrace preventive services and operate in the spirit of the consultorios she observed in Cuba. “If your whole delivery system is based on waiting for people to come who are sick and have money or insurance, that is unsustainable,” Watkins-Tartt says.
Albuquerque health providers and advocates have gleaned similar insights from visits to observe the Cuban system, along with a series of presentations provided in the community by a Cuban physician. The provider-patient walking group and the campaign to enroll area children in Medicaid, along with classes on health education, leadership training, and parenting skills, are the product of determined efforts to connect health-care providers with the faith-based organizations and schools where people in the area have naturally coalesced.
“Cuba showed us how we could go beyond the walls of the clinic to engage the community,” says University of New Mexico’s Ronquillo. “Here in the U.S., we focus so much of our resources on the very ill. If we can do what Cuba does and put energy behind promoting good health at much earlier stages, we can keep people healthy and have less need for the high-cost level of care.”
Designed to serve
Of course, there are components of the Cuban approach that are difficult if not impossible to replicate in the U.S., such as Cuba’s enviable physician-patient ratio, a product of a fully socialized system where physician salaries are much lower than in market-based health systems. And the U.S.’s continued avoidance of the universal health coverage provided in Cuba and virtually every developed nation—the Affordable Care Act explicitly excludes millions, most notably undocumented immigrants—poses a barrier for full replication. U.S. clinics serving the poor shoulder the financial burden of providing uncompensated care, while Cuban clinics are funded on a model designed to serve all in need.
And there are certainly aspects of the Cuban system that are not to be envied. Compared to the U.S., medical records technology and the availability of some advanced treatments are lacking. It’s also hard to imagine more-individualistic Americans welcoming aggressive government health intervention, such as unrequested home visits, any more than they would welcome replication of Cuba’s less democratic political system and restricted private economy.
But we don’t have to adopt the Cuban system wholesale in order to learn from it. There is enough money in the U.S. health system now to provide far better outcomes for underserved communities, if those investments are directed more toward community health than toward profits. Cuba’s success teaches us that a nationwide focus on prevention strategies and access to primary care can lay the foundation for a much healthier country.
Got something to say about what you're reading? We value your feedback!