When I arrived, I found several international ELAM graduates (http://elamedicosinternacionalistas.wordpress.com), including 7 United States graduates (http://www.michaelmoore.com/words/mike-friends-blog/cuban-trained-us-docs-complete-haiti-mission), and a number of Haitian medical students working alongside the Cuban doctors. We were stationed at a field hospital set up by the Henry Reeve Brigade of Cuban doctors on January 28th in a small central park of Croix des Bouquet, just outside Puerto Prince. Together we served displaced earthquake victims and patients suffering from inadequate health care services.

In the first six months the hospital was established, we addressed the needs of more than 70,312 patients; 53,588 at the hospital and 16,723 in the field. We performed a total of 2,506 operations on-site, with 786 major surgeries; including emergency caesarean sections, ectopic pregnancies, thyroidectomy, hernias, hydroceles, hysterectomies of uterine fibroids, orthopedic surgeries and more. We assisted 116 natural births. We diagnosed 3,533 patients with our on-site laboratory and diagnostics center. We saw 3,192 patients for x-rays and ultrasounds. We treated 8,778 patients with physical therapy, and we hospitalized 2,053 patients on-site (Information provided by the Henry Reeve Brigade of Croix des Bouquet Statistical Report, June 2010).

When you stepped out of the hospitals and into the streets the only question that came to mind had to be, “where is the aid?” It was obvious, even six months after the earthquake that little progress had been made, with little to no evidence of monetary support. Hundreds of thousands of people were still living displaced in make-shift tent cities. The city still resembled a disaster zone with buildings teetering above cracked foundations, while corpses remain beneath the rubble. The doctors seemed to be the only relief effort making a difference.

The Cuban doctors were accomplishing more than what the international community was willing to recognize. Croix des Bouquet was just one of several field hospitals established by the Henry Reeve Brigade to serve communities in and around Puerto Prince free of charge. CNN even had to apologize after interviewing one of the Cuban doctors and crediting him as Spaniard. Fortunately, Cuban doctors aren’t looking for recognition; they are out to save lives and continue to do so all over the world.

The Henry Reeve Brigade has since moved on to other emergencies, like the fires plaguing Russia. Other Cuban doctors have replaced them to continue serving the Haitian community free of charge. Brazil and Cuba have signed a trilateral accord with the Haitian Health Minister to establish three hospitals staffed by Cuban doctors located in communities surrounding Puerto Prince where health services are limited to non-existent. Cuba has been dedicated to sending doctors to Haiti for 11 years. Amidst the unfortunate circumstances of the earthquake, they continue to fulfill their commitment to the Haitian community by sending doctors. With the success of the students working alongside the doctors, they now have plans to send more students in the years to come.

Note: Article written by Joanna Mae Souers. Photograph titled, “Joanna Mae Souers on Wound Care” was taken by Cuban photographer, Juvenal Balán. The other photographs were taken by Joanna Mae Souers.

The Economic Crisis and Public Health

Barry S Levy, Victor Sidel

The current global economic crisis seriously threatens the health of the public. Challenges include increases in malnutrition; homelessness and inadequate housing; unemployment; substance abuse, depression, and other mental health problems; mortality; child health problems; violence; environmental and occupational health problems; and social injustice and violation of human rights; as well as decreased availability, accessibility, and affordability of quality medical and dental care. Health professionals can respond by promoting surveillance and documentation of human needs, reassessing public health priorities, educating the public and policymakers about health problems worsened by the economic crisis, advocating for sound policies and programs to address these problems, and directly providing necessary programs and services.  Full Text: PDF

An Interview with Sir Michael Marmot

The Editors

In August of 2008 the WHO Commission on the Social Determinants of Health concluded its work with the publication of a report entitled: “Closing the gap in a generation: Health equity through action on the social determinants of health.” The Commission’s chair, Sir Michael Marmot, was kind enough to answer our questions about the Commission’s recommendations. This interview was conducted by email in May of this yea

Participation and empowerment in Primary Health Care: from Alma Ata to the era of globalization

Pol De Vos, Geraldine Malaise, Wim De Ceukelaire, Denis Perez, Pierre Lefèvre, Patrick Van der Stuyft

With the 1978 Alma Ata declaration, community participation was brought to the fore as a key component of primary health care. This paper describes how the concepts of people’s participation and empowerment evolved throughout the last three decades and how these evolutions are linked with the global changing socio-economic context.

Latin American Social Medicine and the Report of the WHO Commission on Social Determinants of Health

RAFAEL GONZALEZ GUZMAN

In October 2008 the Latin American Social Medicine Association (ALAMES) organized an international workshop entitled “The Social Determinants of Health.” Representatives of ALAMES’ seven regions participated in discussions of the various consultative papers prepared by the working groups of the WHO Commission on the Social Determinants of Health as well as the Commission’s final report. The workshop considered how ALAMES should respond to the work of the Commission. In this paper we summarize the main points outlined in the position paper prepared by the Organizing Committee1 as well as a synopsis of the main contributions made by each of the workshop’s study sections.  Full Text: PDF

For the full Table of Contents visit: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/issue/view/38/showToc

posted by Matt Anderson, MD

It is important to begin this story with 1958 Cuba where there was only 1 doctor for each 1,051 Cubans.  This statistic actually hid very large geographical disparities.  Most of Cuba’s doctors were concentrated in the towns and particularly Havana.  There were very few doctors in rural areas.  In the years immediately following the Revolution this situation only grew worse.  Many doctors emigrated, including much of Havana Medical School’s faculty.  By 1967 there was only 1 doctor for every 2,000 Cubans.  The health care system had, quite literally, to be rebuilt from scratch.

In a way this provided the Cubans with the opportunity to create an entirely different type of medical system, one established on principles of primary care and equal access to all.  By the mid-80′s the country had adopted a system of Comprehensive General Medicine (Family Medicine in US terms) based on doctor/nurse teams who served (and lived in) a neighborhood, typically of 800 people.  By 2007 there were 3 Cuban generalists per 1000 population as compared to 0.7 in the United States.  Many people attribute Cuba’s excellent health statistics to this commitment to primary care and equality of access.

However, developments on the island of Cuba are only half of this story.  Cuba had sent physicians on missions of medical solidarity since the early 1960′s.  This solidarity has accelerated notably in the past 10 years.  The 1998 Programa de Salud Integral (Comprehensive Health Program) sent brigades of Cuban doctors to Haiti, Guatemala and Honduras in the wake of Hurricanes George and Mitch.  These brigades led to semi-permanent Cuban health presences in these countries, particularly in the countryside.  Brouwer also examines the crucial role of Cuba in the Barrio Adentro program in Venezuela.

Sadly, the response of the Bush Administration has been the Cuban Medical Professional Parole Program,  an attempt to lure Cuban medical personnel to the US.  The existence of such a program is a backhanded compliment to the quality of Cuban medical personnel.  And a statement of the threat they posed to the Bush Administration.

The article closes with a discussion of Cuban medical training.  Brouwer highlights the Latin American Medical School (ELAM) as well as Cuban training in Venezuela and Yemen.   Brouwer notes that:

Cubans, with the help of Venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the United States, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs. The U.S. students emerge from their four years of study burdened with an average of $140,000 of debt. So it’s not surprising that they have a desire to earn high salaries, either to pay that debt or simply enjoy the upper-middle-class lifestyle to which most first world physicians are accustomed. Consequently, very few U.S. medical school graduates go into residencies in family practice, the lowest paying specialty.

Interested readers are encouraged to consult the full text of the article which is available free online.

Further reading

One of the best English sources for current news about health and  medicine in Cuba is the MEDICC Review, publication of Medical Education Cooperation with Cuba.  Those who read Spanish may also want to visit the official Cuban Health Portal.

Our online journal, Social Medicine, has published articles on Barrio Adentro, the Latin American Medical School and the experience of a US student working in a Barrio Adentro clinic in rural Venezuela.

This Portal contains numerous postings about Cuba and the ELAM school.  Readers should note that Cuba still has several hundred  full scholarships for US students to attend the 6 year medical school in Havana.

posted by Matt Anderson, MD

Earlier this year we invited Asa Cristina Laurell, a prominent Mexican public health activist to prepare a special issue on progressive health reforms in Latin America. Dr. Laurell was the head of the Mexico City Health Department from 2000-2006 and – had the Mexican elections not been stolen by the right – she would currently be Mexico’s Minister of Health. She contributed a paper describing the Health Department’s experience with providing free medicines and medical care to people who did not qualify for coverage under Mexico’s employment-based Social Security System. Other papers examine Brazil’s Unified Health System, the SUS, which is one of the world’s largest public health systems; the Venezuelan attempts to provide free health to the all citizens with assistance from the Cubans; Uruguay’s moves to a public-private system that will guarantee the right to health; and finally Bogota’s experience with providing poor communities with access to health care through the Health at Home program.

American readers may be particularly interested in the article by Razel Remen and Lillian Holloway, two US students studying medicine at the ELAM school in Havana Cuba.

We publish two articles of original research. A Hong Kong team reports on public attitudes during the SARS epidemic in 2003, while Dr. Paula Acevedo presents data on reproductive patterns among Latin American immigrants in Spain.

Sadly, we publish the last article written by Edmundo Granda, one of the founders of ALAMES, the Latin American Social Medicine Association. He passed away in April of this year. He approved the final galleys of the Spanish version of his paper via blackberry from the hospital on the week he died. His paper considers the historical trajectory of ALAMES and where Latin American Social Medicine may be heading.

Finally, Dr. Lanny Smith interviews Chilean activist Victor Toro, a political refugee from Pinochet’s Chile, who is now facing deportation from the US, his home of nearly 2 decades. Ironically, he has been a immigrant rights activist (and patient of Dr. Smith) in the Bronx, New York, for most of these years. His account of becoming ill in an ICE detention facility mirrors the concerns discussed in our July 10^th posting about Dr. Homer Venters.

Posted by Matt Anderson

The Cuban Health System

In early December the editors of the Social Medicine Portal visited Cuba. This month we bring back some notes concerning Cuban health and health care.

Cuba’s health system is unique in the world. Built on a strong foundation in primary care, Cuba provides comprehensive health care to all residents of the island. Given extremely limited resources Cuba has amassed an impressive set of accomplishments in public health. The special position of Cuba is well seen in a graphic international comparison of deaths in children less than five prepared by the Karlolinska Institute.

Most health care is delivered by family physicians. Family doctors are responsible for a defined community and they typically live above (or near) the small consultorios located in the neighborhood they serve. The family physician we visited cared for some 800 people in the five blocks surrounding her consultorio. During the mornings she saw patients in the clinic; in the afternoon she did home visits.

For more complex problems, patients visit one of approximately 400 polyclinics distributed throughout the island. A polyclinic is similar to the outpatient department of a small hospital. Some emergency room functions (including administering Cuban-produced streptokinase) occur here, but primarily this is a place for specialist consultation, diagnostic procedures such as ultrasound and more sophisticated therapeutics (physical therapy, acupuncture).

Consultorios and polyclinics are considered to be primary care in Cuba. In the secondary care tier are the municipal and regional hospitals. Both WHO and PAHO provide health profiles on Cuba that are full of statistics. For a more political portrait, see Aviva Chomsky’s “The Threat of a Good Example: Health and Revolution in Cuba.”

As US clinicians, we are accustomed to the never-ending paperwork associated with figuring out what health services different patients are or are not entitled to; this exists because we have a two-tiered market-driven health care system. It was almost exhilarating to see a system in which such barriers to care did not exist and there was an overall health system. But is it was sobering to realize the enormous burdens under which Cubans work. Food is rationed (in a very thoughtful way), housing is in very short supply (particularly in Havana), many people wear used clothing from overseas and transportation is limited. Adding to these burdens is the embargo imposed by the US government. (see below).

The official Cuban website for health information is Infomed, a sophisticated site full of information. Unfortunately Infomed is available only in Spanish. Infomed provides links to the major Cuban health publications, including the Revista Cubana de Salud Pública. We were fortunate to meet its editor, Dr. Francisco Rojas Ochoa, a 2005 recipient of a PAHO Public Health Award. He shared with us a copy of their recent book “Salud para todos: Si es posible”, an explanation of how Cuba was able to achieve the goals of health for all through the development of a primary care system. English readers may wish to consult the website of MEDICC (Medical Education Cooperation with Cuba, see below) for more detailed information on the Cuban Health System.

Amongst the medical centers we visited was the Instituto Pedro Kourí (IPK) an internationally recognized center for research into tropical diseases. Science recently profiled an IPK researcher, Dra. María C. Guzmán for her work on dengue hemorrhagic fever and the development of a dengue vaccine. IPK hosts an international course on tropical diseases; US citizens, due to the travel embargo, can no longer participate in this course.

International Solidarity

For several decades Cuba has sent physicians throughout the world as a form of solidarity. MEDICC Review now devotes a column towards the activities of these internacionalistas. As we learned during our trip many healthworkers have been sent to Venezuela to participate in that country’s Barrio Adentro health program.

One of the most visible expressions of this international solidarity is the Latin American Medical School or ELAM. ELAM was set up to train generalist physicians with a primary care orientation. It provides scholarships to students from the Americas and Africa; in August of this year some 10,000 students from 27 countries were enrolled in ELAM. MEDICC has published interviews with a number of them. Interestingly enough, there no less than 348 US medical students studying on full scholarship at ELAM. How US students ended up in Cuba is the subject of a fascinating short article by Fitzhugh Mullan in the December 2004 New England Journal of Medicine (“Affirmative Action, Cuban Style”).

Cuba & the US: The bad…

The US government embargo against Cuba has essentially frozen all relationships between the two neighboring countries. There is an extensive literature regarding the negative health impact of this embargo, see for instance “The Impact of the U.S. Embargo on Health Care in Cuba: A Clinician’s Perspective” by Javier H. Campos, MD, or the detailed report on the impact of trade sanctions on Cuba, Haiti and Iraq by Richard Garfield. The gel in Cuba-US relations is fed by the enormous misunderstanding among North Americans of Cuban realities (see Alfredo Prieto González’ “The Image of Cuba in the U.S. Mass Media” and Jane Franklin’s “Looking For Terrorists In Cuba’s Health System”).

And it is not possible to discuss health in Cuba without mentioning the disgraceful conduct of the US military-including medical personnel-at Guantanamo Naval Base located in southwestern Cuba. See “Doctors and Torture” by Robert Jay Lifton as well as “Doctors and Interrogators at Guantanamo Bay” by M. Gregg Bloche and Jonathan H. Marks; both of these articles were published in the New England Journal of Medicine.

Cuba and the US: …and the Good

A non-governmental organization, MEDICC (Medical Education Cooperation with Cuba) was founded in 1997 as a bridge between U.S. and Cuban clinicians, faculty, students and researchers. For many years MEDICC sent US medical students to learn within the Cuban medical system. MEDICC’s activities have been sharply curtailed by the recent tightening of the embargo; educational trips to Cuba are now prohibited. MEDICC is currently concentrating on its excellent online journal MEDICC Review.

Project Infomed, run by the US-Cuba InfoMed Project maintains an excellent page of links to Cuba resources. Medical Students for Cuba, at the University of Michigan Medical School, was set up to provide humanitarian and medical supplies to Cuba.

-Matt Anderson and Lanny Smith