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Learning from the Cuban Health Care Paradox

by Mercedes Rubio, ASA Minority Fellowship Program

Why does Cuba, a third-world country, exhibit some health statistics on a par with those of the United States as opposed to those characteristic of other third-world countries? For example, in 2000 the infant mortality rate in the United States was 6.9 deaths compared to Cuba's 7.2 deaths (per 1,000 live births). What explains this paradox (a poor country with at least one such admirable health index)? This October, thanks to generous support from the W.K. Kellogg Foundation, I had a rare opportunity to attend the Family Medicine Conference in La Habana, Cuba, and as a health disparity scholar, I welcomed the chance to learn first hand about this paradox.

During the weeklong conference, we attended lectures at the Ministry of Public Health and visited medical schools, poli-clinics, specialized clinics, and private doctors' offices, in urban and rural areas. By midweek, I began to appreciate the reasons for Cubans' health status.

First, there is a commitment by the state to keep its population healthy. For example, Cuba has a universal health care policy that guarantees its population access to medical services, subsidized medicine, and specialized care for the aged and at-risk populations. But because of economic hardship stemming from collapse of the former Soviet Union, the execution of this policy is not as comprehensive and universal as conceptualized. Since the 1990s Cuba lags in the use of new health technology or pharmaceuticals. The lack of high-tech equipment and medicine is critical for those in need of transplants and cutting-edge treatment, but figures on the percentage of the population requiring more specialized and high-tech care are elusive.

Further, the U.S. bondage to acute care contrasts fundamentally with Cuba's health care system in that Cuban policymakers better recognize and implement policies tapping the economic efficiency of health prevention and promotion. The Cuban population is encouraged to seek preventive care, and a high literacy rate aids health promotion efforts that help individuals remain healthy through mechanisms of healthy living. Additionally, health professionals receive unique training. Health professionals are trained to view the patient as a person embedded in a community. Typically, a family doctor lives in the community, providing patients with easy access to health care. Family doctors' professional socialization includes providing health care within a four-block radius and to provide service to these residents across their life course. The family doctor keeps track of the health of the community via check-ups, follow-ups, and other medical needs, and house visits are common.

Often family doctors are called upon to be sociologists, social epidemiologists, and social workers. Professional ideology includes an appreciation that health problems are often rooted in social context and patient experiences. As sociologist and social epidemiologist, family doctors survey the neighborhood in which they reside and incorporate neighborhood contextual factors that are potential health hazards such as the location of trash, and pollutants, as well as habitats for mosquitoes that may pose a health hazard. They also visit homes to observe risk factors such as household composition and family dynamics. Venezuelan President Hugo Chavez has recently emulated the Cuban approach by recruiting Cuban health professionals to set up similar community-based health care for the poor in Caracas.

While infant mortality is an indicative statistic of a nation's health, Cuba's health care system is not at U.S. standards. In spite of this, the average U.S. and Cuban life expectancy at birth in 2001 are both at 76.9 years, according to the World Health Organization. Interestingly, while U.S. health expenditures constitute 13.3 percent of Gross Domestic Product, Cuba's is only 6.8 percent. As poor as Cuba is, its health system is controlled by a political ideology that affects state policies and social institutions that positively affect health.