1. Erwin, Paul Campbell MD, DrPH
  2. Bialek, Ron MPP

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Let us begin with a clear acknowledgement: we are not experts on the Cuban health system. In February 2015, we were part of a small group of US-based editors of medical and public health journals who spent a week in Cuba through the auspices of the Medical Education Cooperation with Cuba (MEDICC).1 A nonprofit organization established in 1997, MEDICC's mission is to "[promote] cooperation among the U.S., Cuban, and global health communities to improve health outcomes and equity, offering the Cuban experience to inform global debate, policies, and practice." In its early years, MEDICC sponsored visits to Cuba by US medical students, medical residents, nursing students, and public health students; following President Bush's narrowing of groups eligible to travel to Cuba in the early 2000s, MEDICC began sponsoring visits to Cuba for groups of medical and public health professionals, such as our group. Among other current activities, MEDICC provides the MEDICC Review (, the only English-language journal published in the United States with a particular focus on Cuba, publishing medical and population health research principally authored by Cubans.


The primary purpose of our February visit was to gain a better understanding of the current landscape of health-related research publications in Cuba, including the challenges of submitting manuscripts to US-based journals and accessing published information. The week included visits to all levels of the Cuban health system-from the family medicine physician/nurse teams at the community level to the polyclinic to the tertiary care centers in Havana. We also visited ELAM-The Latin American Medical School-where, among others, we had the opportunity to meet and talk with a dozen very dedicated US citizens who are enrolled in ELAM.


As much as we learned about the Cuban health system, what we have kept coming back to are the questions that many of our Cuban colleagues did not seem to understand about the US health "system." It was not from a lack of clarity in the translation; rather, these questions arose because Cubans simply do not experience the same realities we face. In this commentary, we highlight 3 questions Cubans had for us, concerning what they do not understand about health in the United States, juxtaposed with the Cuban experience.


1. Why is there a measles outbreak in the United States, and why is the US childhood immunization rate so low?


The most recent data on childhood (19-35 months) vaccination rates in the United States show that only 70% of children have been fully vaccinated with all recommended vaccines.2 It is not just the fact of the Cuban rate being at more than 99%, nor about the process and mechanisms involved at the level of the family medicine physician/nurse team-who do home visits to ensure that children are up-to-date-but rather the communitarian sensibilities practiced and experienced by Cubans that led them to raise this question. As our translator made note about her own child, "I am obligated to do this for the good of the community." How stark the contrast to the recent outbreak of measles in California, where herd immunity was compromised not only by families refusing vaccination for their children but also where the exact opposite of communitarian concern was expressed: "I don't want my child to be vaccinated, but I want you to vaccinate your child so mine will be protected."3


2. Why does the United States distinguish between medical care and public health?


For decades, there has been talk in the United States about the need for better integration of medical care and public health, propelled most recently by the Patient Protection and Affordable Care Act. Split into deeply divided siloes, the language about primary medical care and public health dances around cooperation, integration, and ultimately synergy-and it stands to reason: when 2 entities are separated by culture, history, philosophy, and goals, the talk must focus on how to bring the two closer together. One element of the Cuban health system may best serve to explain why this question is not understood in Cuba: the Ministry of Public Health is in charge of the family medicine physician/nurse teams, polyclinics, and hospitals and is also in charge of the curriculum for medical, nursing, and dental schools, as well as the national school of public health. As Bill Keck, MD (Editor-in-Chief of MEDICC Review), has recently written,


When we think of "integration," we think of collaboration among two siloed disciplines. In Cuba, those silos do not exist. Cubans and many others call the Cuban National Health System a "public health system." In that context, teaching one to use condoms is a public health service and cardiac surgery is a public health service. (personal communication, February 25, 2015)


The epidemiologist and the biostatistician at the polyclinic analyze data from the family medicine physician/nurse teams and provide reports back to them as well as to the central surveillance system. The health educator may work alongside the traditional medicine provider at the polyclinic, explaining methods for growing plants used for traditional remedies. Again, Bill Keck notes, "There are no local public health departments in Cuba so the thought that 'public health workers' would work in one context and 'clinical workers' would operate in another is completely and refreshingly foreign." When a system is a unified whole to begin with, the language of integration is indeed foreign.


3. Why are there such large health inequities in the United States?


In the United States, we have come to understand the impact of the social determinants of health on health inequities: education and employment, and their association with income, health insurance and access to care, and opportunity. In Cuba, there are no direct costs to people for education-from primary school to graduate school-and no direct costs for medical care-from the family medicine physician/nurse team visits to referrals to the polyclinic for specialty care or even to the tertiary care centers for organ transplantation. Thus, 2 of the primary drivers of health inequities with which we are familiar in the United States simply do not exist in Cuba. And it is not just access to care that is different: the family medicine physician/nurse team are responsible for the health of their entire community and are accountable to the community for achieving optimal personal and population health status. This accountability is then most evident through the focus on prevention-primary, secondary, as well as tertiary-at all levels of the Cuban health system. In the United States, where the greatest proximal causes of morbidity and mortality are preventable (tobacco use, physical inactivity, poor nutrition), and where such health behaviors are significantly correlated with income in a dose-response fashion, health equity remains beyond the horizon. When health and education are based on equity, and when justice is the bioethical concept listed first, as it was in our discussions with a Cuban bioethicist-in contrast to how we in the United States order them (with patient autonomy first and justice last)-the question Cubans have about US health inequities becomes more understandable.


These questions Cubans had for us brought to mind several more questions we could ask of ourselves, for example:


* Why is there personal bankruptcy due to medical costs in the United States? (cf, free medical care in Cuba)


* Why is there the push for high-paying medical specialties because of huge student loan debt? (cf, free medical education in Cuba)


* What is the reason for the on-call system physicians' use? (cf, being always available because the family medicine/nurse teams live in the communities they serve)



Why do these questions matter? Because, in short, Cuba has managed to achieve remarkable health outcomes relative to the resources available to them, as noted on MEDICC's Web site:


* Cuba is among the top 20 countries in progress toward the UN Millennium Development Goals.4


* Save the Children ranks Cuba as the number 1 country in Latin America to be a mother.5


* Cuba has the lowest HIV rate in the Americas.6


* The doctor-to-patient ratio in Cuba is among the world's highest; 61% of physicians are women.7



To these we would add:


* 100% of pregnant women have more than 4 prenatal visits compared with 97% in the United States.8


* Cuba's infant mortality rate in 2013 was 4.70/1000 compared with 6.17 for the United States.9


* Life expectancy in Cuba is 79 years, equal to that in the United States.8,10



We are not so naive to believe that the Cuban health system, or even the manner in which Cuban society is structured and functions, is without fault, challenges, or shortcomings. Among other limitations, resources of many types and at all levels are often inadequate, including technology (eg, Internet connectivity) and the latest in medical equipment (eg, for genetic testing and sequencing)-these limitations are significant obstacles that Cubans themselves acknowledge. Such barriers-and many related ones (eg, pharmaceuticals)-are a direct result of the long-standing US embargo: it is well past time to end what has only hurt the Cuban people without changing the Cuban political structure. The value to us of our visit to Cuba is what it has meant to our understanding of our own context and system, made clearer when viewed from the perspective of a different set of realities. Let us take the time to understand these perspectives from Cubans and embrace the opportunity for us to learn from one another, given the recent change in the US-Cuban relationship. Learning and viewing reality from different perspectives are critical steps to improving-for both of our systems.




1. Medical Education Cooperation with Cuba. Accessed March 3, 2015. [Context Link]


2. Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, state, and selected local area vaccination coverage among children aged 19-35 months-United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(34):741-748. [Context Link]


3. National Public Radio. The psychology behind why some kids go unvaccinated. Published 2015. Accessed March 3, 2015. [Context Link]


4. Overseas Development Institute. Millennium development goals report card: learning from progress. Published 2010. Accessed March 3, 2015. [Context Link]


5. Save the Children. State of the World's Mother's Report, 2014. Published 2014. Accessed March 3, 2015. [Context Link]


6. UNAIDS. Global report. Published 2013. Accessed March 3, 2015. [Context Link]


7. Global Health Workforce Alliance and World Health Organization. A universal truth: no health without a workforce. Published 2013. Accessed March 3, 2015. [Context Link]


8. World Health Organization. Global Health Observatory (GHO) data. Published 2015. Accessed March 3, 2015. [Context Link]


9. Central Intelligence Agency. World fact book. Published 2014. Accessed March 3, 2015. [Context Link]


10. National Center for Health Statistics, Centers for Disease Control and Prevention. Deaths: final data for 2013. Accessed March 18, 2015. [Context Link]