Community Health Care in Cuba

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On September 27th 2009, Dr. Joan Beder, Dr. Susan Mason, and Joyce Wong, CSW spoke at Social Medicine Rounds on Community Health Care in Cuba. Drs. Beder and Mason have recently published a book of the same title which we have reviewed on the Portal (see: New Book on the Cuban Health Care System).

Breast Cancer in Cuba

IMG_0537Dr. Joan Beder began with a discussion of her work with breast cancer patients. Dr. Beder is a professor of social work at the Wurzweiler School of Social Work at Yeshiva University. She has an interest in oncology services and specifically services for women with breast cancer. She began her talk by pointing out some of the contradictory aspects of work in Cuba. Cubans have guaranteed rights to health and education; this something that we did not have in the US. Yet it was clear walking around Havana that Cuba is  an impoverished country where food was rationed.

Dr. Beder noted that the Cuban system provided essentially the same treatment options – chemotherapy, radiation, and surgery – that were available to patients in the US. But the supply of drugs was quite limited. Breast cancer screening programs had been impacted by the US trade embargo; the Cubans could not obtain the best mammography film and equipment because it was produced in the US. As a consequence higher than necessary doses of radiation were used in mammography.

Dr. Beder was asked by the  Cubans to provide some guidance on helping women with the psychosocial consequences of breast cancer. She worked with the Federation of Cuban Women which runs a series of Women’s Centers where breast self-examination and mammography are promoted. Initially they considered setting up a self-help hotline for breast cancer survivors. This turned out to be problematic due to the deficiencies of the Cuban system; people may not always have access to a phone in a private setting.  Her work led her to undertake a training program  in the special needs of oncology patients for Cuban social workers.

She concluded by pointing out that cancer is now the second leading cause of death in Cuba; cardiovascular disease is number one. Cognizant of this, the Ministry of Health has begun a special national program to train doctors in the prevention and early detection of cancer.

Schizophrenia and Mental Illness

Susan Mason teachingDr. Susan E. Mason is also a professor of social work at Yeshiva University; in addition she is  a professor of sociology and the chair of the college departments of sociology and political science. Her area of expertise is schizophrenia and she is the co-author of Diagnosis Schizophrenia: A Comprehensive Resource for Patients, Families, and Professionals, a fascinating book which uses patient stories to describe what it is like to have schizophrenia.

The Cuban approach to mental illness also has been shaped by a context where resources are limited and medications are in short supply; again, this is due – in part – to the effects of the embargo. Psychosocial treatments have been emphasized and mental health is based on three principles: community, prevention, integration. Arts and music programs are valued and accepted as mental health interventions. She described with a mixture of amusement and admiration how official meetings might be interrupted for a short break allowing the participants (“even the Ministers”) a chance to sing and dance. (It was later suggested that this would be a great idea for hospital rounds).

Care for mentally ill patients was often provided by social workers who live in the same community as the patient and make house calls as needed. When patients needed more supervision, family members were paid to stay at home and care for them. When a family member was not available, patients were placed in a foster home.  Since family members (or foster families) were paid, patients with mental illness were not typically viewed as an economic burden for their family or community.  Dr. Mason shared some pictures of a day program run from a private home. The atmosphere was quite domestic and she remarked: “It feels like you just want to hang out there.”

Did this model work? Dr. Mason expressed frustration that despite the theoretical advantages of this community model for psychiatric care, there was really no hard outcomes data to demonstrate that it was effective.

A Healing Environment

joyce wongJoyce Wong is a social worker at a Bronx community health center where she works primarily with South East Asian immigrants. She grew up in Washington Heights in a community that was largely Cuban and later traveled to Cuba to visit Havana’s Chinatown. This had once been one of the largest “Chinatowns” in the Western Hemisphere. With emigration, the population has dwindled considerably and now consisted primarily of the elderly.

In Chinatown, she interviewed elderly men to learn how they had managed to survive in Cuba after leaving their homes in China. She found the men relied on ethnic pride and identity, maintaining their language, and consciously suppressing painful memories. She described this not as a form of repression, but rather as a conscious decision to look for happiness and self-healing.

Ms. Wong made a short film about her trips to Cuba, a place she felt was a “healing environment.” La Magia de Cuba (Cuba’s Magic) is a montage of music and photos and is available on Picasa at this  link.

Thoughts

To read more about this work, please consult Drs. Mason and Beder’s book: Community health care in Cuba.

The situation of Cuban patients, denied access to the best possible care because of the US trade embargo was denounced by Amnesty International in September. Readers interested in learning about the health impacts of the embargo should consult their report: The US Embargo against Cuba: Its Impact on Economic and Social Rights.

posted by Matt Anderson, MD

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