Cuban Health Care. Don Fitz
the countries most ravaged by Mitch, Fidel and his medical advisers decided that Cuba should bring students from across the world to study medicine in a central location. This was the origin of the Latin American School of Medicine (ELAM, for its Spanish acronym) which chapters 7 and 8 explore. Chapter 7, “ELAM: The Latin American School of Medicine,” tells how it had enrolled 21,018 medical students from over one hundred countries by 2010. The school’s curriculum was carefully designed to help students serve their countries’ most needy populations when they returned. ELAM drew on Cuba’s vast experience working abroad and became a unifying force for future medical missions. Since so many people around the world rely on traditional and natural healers, the Cuban model of Comprehensive General Medicine (MGI, Medicina General Integral) teaches students to be listeners and healers as much as doctors. The ELAM curriculum differs according to whether students have sufficient pre-med background, whether they are from Cuba, Latin America, or a non-Latin culture, and whether they are fluent in Spanish. The chapter describes the culture of medical school in Havana, the base curriculum, and the interests of students coming from a variety of countries. Chapter 8, “Thirteen Faces of ELAM,” looks more closely at international students attending the school.
Cuba is remaking medicine in a range of contexts: from Latin America and the Caribbean to Africa, Asia, and the Pacific Islands. Impossible to replicate in an exact fashion, the Cuban model must be adapted wherever it goes. Chapter 9, “Cuba: The New Global Medicine,” features three in-depth accounts of ELAM students participating in community projects and international crisis relief. Following the 2007 earthquake in Peru, Cuban doctors faced multiple obstacles as they established consultorios and a policlínico in that country based on the Cuban model. In Haiti, relief efforts following the 2010 earthquake led to Haitian patients developing very different relationships with Cuban doctors than those they established with U.S. doctors. This chapter also looks at how a group of African and African-American medical students in Havana worked to blend Cuban medical approaches with traditional Ghanaian healing practices.
Chapter 10, “Challenges of the Twenty-First Century,” looks at three important challenges Cuba has faced in recent times, then outlines some of the key lessons to be learned from the Cuban health model. The first part of the chapter, which relies on Steve Brouwer’s Revolutionary Doctors: How Venezeula and Cuba Are Changing the World’s Conception of Health Care, examines Venezuela’s unique effort to reproduce the entire Cuban health system via the Barrio Adentro I through IV programs. It shows how a system, once developed, can be implemented elsewhere with structural changes introduced in the opposite order of their original appearance (though the Family Doctor/Nurse Program was the last step in the unfolding of the Cuban system, it was the first step in Venezuela). The second part of the chapter is based on my participation in Cuba’s celebration of the 2012 March Against Homophobia. Any country with a homophobic history, including Cuba, must have mass participation in efforts to transform its culture if it is to remove barriers to effective health care. The third part of the chapter describes how Cuba worked to control dengue fever by actively involving the population. That approach reflects the country’s history of mass mobilizations and is a model for poor countries needing a low-cost method for controlling mosquito-borne illnesses. The chapter also presents key lessons learned from the Cuban experience of health care reform.
Chapter 11, “Cuba’s Medical Mission,” takes stock of the country’s health care endeavors during the second decade of this century. It describes Cuba’s response to the Ebola virus panic of 2014; the medical services Cuba has provided to remote regions; the West’s calculated underreporting and baseless critiques of Cuba’s accomplishments; and the contrast between Cuban internationalism and the “disaster tourism” more characteristic of U.S. medical missions abroad. The chapter also contrasts corporate use of biotechnology in the service of agroindustry giants such as Bayer/Monsanto to Cuban biotechnology research that aims to improve medicine in underserved countries.
Chapter 12 concerns the current structure of medical care inside Cuba and contrasts it with the U.S. system, whose bloated nature goes far beyond the powers of insurance companies. It covers the fragmented nature of health care reimbursement that employs a small army of gatekeepers. It also examines undertreatment, overtreatment of real and non-real illnesses, sickness “looping,” pharmaceutical “looping,” over-diagnosing, pharmaceutical overpricing, intentional pharmaceutical waste and profiteering in what could be called the “sickness industry.”
Though the U.S. system is often criticized by contrasting it to other rich countries, it should also be compared to the Cuban health care system, which is more sustainable and holistic. Chapter 12 also examines the non-financial aspects of corporate medicine, including unnecessary pain and avoidable deaths. Can the problems with U.S. health care be resolved by “Medicare-for-All,” which follows the European model? Cuban medicine was born in the context of a complete reconceptualization of society. Its success shows that medicine must be a critical component in a bigger picture of overcoming multiple forms of oppression.
ACKNOWLEDGMENTS
Completing this book was not a solitary project. It was only possible due to the assistance of dozens of people. Before referring to them, I want to recognize the works that helped me form a broad view of the Cuban medical project. Ross Danielson’s Cuban Medicine (1979) chronicles the various medical revolutions in Cuba, from the earliest known times through the development of polyclinics. Two works by Piero Gleijeses, Conflicting Missions: Havana, Washington, and Africa, 1959–1976 (2002) and Visions of Freedom: Havana, Washington, Pretoria, and the Struggle for Southern Africa, 1976–1991 (2013), thoroughly document Cuba’s role in Africa. Cuba, Revolución Social y Salud Pública: 1959–1984 (2008) by José R. Ruíz Hernández, often read by Cuban students, is the official history of the health system from the first days of the revolution through the development of family medicine.
Breaking the decades of silence that Cuba maintained on its medical missions in Africa, the 2005 publication of Hedelberto López Blanch’s Historias Secretas de Médicos Cubanos collects oral histories of doctors’ experiences in Algeria in 1963 through the 1975 battles in Angola. Linda M. Whiteford and Lawrence G. Branch’s Primary Health Care in Cuba: The Other Revolution (2008) is one of the most readable short books that captures the essentials of Cuban health care. By contrast, Stan Cox’s Sick Planet: Corporate Food and Medicine (2008) succinctly documents the effects of medicine as a business in the United States. Two books by John M. Kirk, Cuban Medical Internationalism: Origins, Evolution and Goals (2009), coauthored by Michael H. Erisman, and Health Care without Borders: Understanding Cuban Medical Internationalism (2015), constitute the definitive accounts of the work of Cuban doctors overseas. Anyone wishing to understand the story of two countries working in close partnership to change medicine to benefit the world’s poor should read Steve Brouwer’s Revolutionary Doctors: How Venezuela and Cuba Are Changing the World’s Conceptualization of Health Care (2011).
My research depends heavily on interviews and oral histories, and I wish to thank the many people who shared their experiences with me. Dr. Ezno Dueñas Gómez and Dr. Felipe Cárdenas Gonzáles recounted the changes they witnessed while living through the revolution. Along with Dr. María Luísa Lima, they told me of the development of Cuba’s first polyclinics. Dr. Justo Piñeiro described his experiences as a Cuban doctor in Tanzania from September 1966 to November 1967. I received firsthand accounts of the medical mission in Angola from Dr. Jorge Luís Martínez, Dr. Carlos Suárez Monteagudo, and Dr. Oscar Mena Hector.
I am also grateful to the ELAM students who granted me interviews, including those from the United States (Cassandra