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The Cuban Paradox

How can Cuba with so little, do so much for the healthcare of its citizens? The answer lies in a focus on universal preventive primary care.

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The country of Cuba has a GDP per capita of about 12,000 US Dollars (USD), coming in at 120th place in the world; an order of magnitude below developed nations such as Singapore (130000 USD, 2nd) and the United States (76000 USD, 8th). However, the average life expectancy of a Cuban resident tells a very different story, going toe to toe with venerable nations like Singapore and even outpacing the United States.

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Cuba, Singapore and the US on Life Expectancy and GDP - Our World In Data

That is the Cuban Paradox, how can a country with so little do so much for the healthcare of its citizens? Indeed if you look at healthcare spending per capita, Cuba spends nearly half as much as Singapore, and 5 times less than the United States.

With the 1959 overthrow of the Batista Regime, the fledgling Cuban government immediately stated that universal healthcare would become a priority of state planning. This was accelerated by the subsequent embargoes from the United States on essential medical supplies, which drove an increase in disease and infant mortality. Then, in 1960, the revolutionary Che Guevera wrote the goals for the future of Cuban Healthcare in the essay titled, On Revolutionary Medicine:

The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices.

Cuba’s focus on universal access to prevention-based primary care was far ahead of its time, it was almost a decade until the World Health Organization (WHO) caught up with the Declaration of Alma-Alta in 1978. This declaration identified Primary Health Care as the key to the attainment of “Health for All”. An excerpt from the declaration reads:

The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

Within the next decade, the Cuban Ministry of Health unveiled a master stroke with its Family Doctor and Nurse program. This program provided individuals and communities with a team of medical practitioners to coordinate medical care and health promotion efforts in their region. Each family doctor-and-nurse office takes care of 20-40 families and forms the first line of defence for community health.

Today, there are over 13000 family physicians, with an impressive physician-individual ratio of 1:2500. The doctor-and-nurse teams live in ministry-provided family medicine offices, and are available around the clock.

These teams monitor different parameters of community and individual health such as environment, medical history, and current health. They even make annual home visits to families for holistic health diagnoses. Through these evaluations, the doctor-and-nurse teams can identify, target and eliminate community health risks.

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The Cuban Ministry of Health acknowledges and actively addresses the Social Determinants of Health through a unique policy of holistic healthcare. The hands-on approach to community well-being achieved robust clinical preventive services and some of the highest vaccination rates in the world.

This philosophy of healthcare does not need to be technology-light. Although Cuba is a resource-starved nation, it has held onto its 20th-century healthcare principles and adapted them for 21st-century technology. In 2006, the first national meeting of Genética Communitaria (Community Genetics) was held with over 600 medical and scientific personnel in attendance.

The Cuban approach to 21st-century genomics draws parallels to their family medicine system in the 1980s: 184 regional genetic centres were spread through all the Cuban municipalities to create “a national programme for the diagnosis, management and prevention of genetic diseases and congenital malformations”. Cuban genetic health professionals work and live within the communities they serve, creating a flavour of genetics that is community-first and collectivist.

This is poised in stark contrast to the Western narrative of genetic tools as personalized medicine. Cuban community genetics places little value on identifying genetic risk factors such as the BRCA genes associated with breast cancer. This is partly due to the unaffordability of routine genetic testing, but also because of the minimal utility of the information: there is little recourse available for Cubans identified with these risk factors. Instead, there is a focus on leveraging genetic and non-genetic factors like social context to strive for collective medical action like health promotion and raising awareness for diseases.

In this form, Cuban community genetics criticizes Western personal medicine for biomedical reductionism. By ignoring social, environmental and community factors, personalized medicine risks missing important lived context for holistic human well-being.

Cuba is a model country showing how healthcare outcomes can be achieved even in resource-starved nations, through policies of cost-reduction and prevention-based primary care. The challenges facing humanity in the coming century orbit the realization that resources are finite, in healthcare and otherwise. And countries with ageing populations and healthcare systems at risk of being overwhelmed, such as Singapore, have already started to take inspiration from Cuba by integrating family and community doctors into their healthcare strategies.

Preventive healthcare offers a different perspective on human well-being than our current healthcare system. Cuba demonstrates that model on the world stage, but it remains to be seen how alternative models to public health will complement and rebuild the current paradigm of resource-intensive, reactive healthcare.

Happily Ever After is inspired by the Cuban healthcare system which is why we emphasise a community-first approach to preventive healthcare. Through experimenting with different models of public health, we believe that a better, more efficient strategy for well-being can be unlocked.

We want to create health communities (online and offline) that are joyful, inclusive and seamless. The key lies in avoiding biomedical reductionism and addressing the various aspects of the social determinants of health. For that, we look to the Cuban healthcare system for lessons that move us toward our vision of universal preventive healthcare.