‘Revolutionary medicine’

HAVANA—Cuba’s healthcare system, with its free and universal coverage as well as excellent health outcomes, has earned a reputation for being one of the world’s best. Despite its troubled, sanction-crippled economy, Cuba has a life expectancy at par with the United States (79 years) and the most number of doctors per capita in the world (1 per 175 people).

President Duterte himself seems to be an admirer of the Cuban model, which is why he sent Secretary Paulyn Ubial to Cuba in the early days of his presidency.

Che Guevara, the doctor and guerrilla leader, was one of the architects of the system, established after the Communist revolution in 1959. Some of the reforms included free medical education—and a lot of slots for those who wanted to study medicine. His “revolutionary medicine” prioritized primary healthcare, involved the community in decision-making, and focused on prevention (e.g., education, mandatory vaccinations) as much as cure.

Another is the establishment of a state-run pharmaceutical and biotech industry.

Cuba actually manufactures its own medicines—and even exports vaccines developed from its own research efforts. In 2011, Cuba announced the release of the world’s first vaccine for lung cancer, CimaVax, which today continues to show promising results and is the subject of further research.

Finally, there is Cuba’s “medical internationalism,” which sees the country “exporting” doctors both to respond to calamities and to provide long-term care in various parts of the world, generating goodwill and revenue in the process. Taken together, Cuba’s health outcomes and outputs have not just boosted the government’s domestic legitimacy, it has also buttressed Cuba’s political capital on the global stage.

The collapse of the Soviet Union in 1990, however, undermined the healthcare system, as Cuba lost subsidies and markets that allowed it to survive despite US sanctions. Nowadays, ask any Cuban about the healthcare system, and they will instinctively say “it is good” (until recently it was a crime to criticize the government). But a deeper conversation will reveal problems.

For one, medicines are usually unavailable in the official pharmacies. “It is impossible to get even an aspirin,” Paula, a student from the University of Havana, told me. People turn to the “bolsa negra” (black market) to procure medicines, or else they use folk remedies. Only when the illness is really serious do they go to the hospitals, many of which suffer from equipment shortage and aging infrastructure.

Human resources are also a challenge. Cuba may have a lot of doctors, but many of them prefer to work abroad where they can earn $800 per month—a huge sum compared to the $30 back home. Thus, many of the doctors who do stay in Cuba pursue more rewarding jobs, like being a tour guide or a taxi driver.

Meanwhile, those who actually work in hospitals expect “regalitos” (little gifts) to make their stay worthwhile. This leads us to a broader problem: Healthcare may be nominally “free,” but to get faster and better service, one has to “reward” the underpaid medical staff.

The Cuban healthcare system may not be as rosy as it seems, but it still offers lessons for health reform. The enduring success of primary healthcare and prevention-centered medicine should motivate countries to adopt a similar approach, empower “gatekeepers” (e.g., nurses, midwives, family physicians), and strengthen referral networks.

Moreover, Cuba’s experience in making medical education accessible should inspire similar efforts, mindful that the prohibitive cost of medical training is one of the drivers of expensive healthcare.

Finally, the Cuban example underscores the importance of making health “people-centered”—that is, taking into account people’s values, knowledge and preferences in medical practice and health policy. As Che Guevara said, “We should go with an inquiring mind and a humble spirit to learn at that great source of wisdom that is the people.” Such a mindset, if applied by healthcare professionals around the world, would be truly revolutionary.

Follow @gideonlasco on Twitter. Send feedback to mail@gideonlasco.com