Health in Cuba

Abstract

The poorer countries of the world continue to struggle with an enormous health burden from diseases that we have long had the capacity to eliminate. Similarly, the health systems of some countries, rich and poor alike, are fragmented and inefficient, leaving many population groups underserved and often without health care access entirely. Cuba represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialized countries. Areas of success include control of infectious diseases, reduction in infant mortality, establishment of a research and biotechnology industry, and progress in control of chronic diseases, among others. If the Cuban experience were generalized to other poor and middle-income countries human health would be transformed. Given current political alignments, however, the major public health advances in Cuba, and the underlying strategy that has guided its health gains, have been systematically ignored. Scientists make claims to objectivity and empiricism that are often used to support an argument that they make unique contributions to social welfare. To justify those claims in the arena of international health, an open discussion should take place on the potential lessons to be learned from the Cuban experience.

Full text

Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2006;35:817–824
Ó The Author 2006; all rights reserved. doi:10.1093/ije/dyl175
REVIEW
Health in Cuba
Richard S Cooper
1
* Joan F Kennelly
2
and Pedro Ordun
˜
ez-Garcia
3
Accepted 4 May 2006
The poorer countries of the world continue to struggle with an enormous health
burden from diseases that we have long had the capacity to eliminate. Similarly, the
health systems of some countries, rich and poor alike, are fragmented and
inefficient, leaving many population groups underserved and often without health
care access entirely. Cuba represents an important alternative example where
modest infrastructure investments combined with a well-developed public health
strategy have generated health status measures comparable with those of
industrialized countries. Areas of success include control of infectious diseases,
reduction in infant mortality, establishment of a research and biotechnology
industry, and progress in control of chronic diseases, among others. If the Cuban
experience were generalized to other poor and middle-income countries human
health would be transformed. Given current political alignments, however, the
major public health advances in Cuba, and the underlying strategy that has guided
its health gains, have been systematically ignored. Scientists make claims to
objectivity and empiricism that are often used to support an argument that they
make unique contributions to social welfare. To justify those claims in the arena of
international health, an open discussion should take place on the potential lessons
to be learned from the Cuban experience.
Keywords Cuba, public health, developing countries, international aid
What is up with Cuba?
Cuba remains an enigma to North Americans and Europeans
alike. Two generations ago there was no society with the
exception of Canada that was more tightly integrated into the
US cultural and economic sphere.
1–3
After the revolution of
1959, however, Cuba acquired the pariah status of a wayward
child and has been variously vilified in rhetoric, attacked
militarily and economically, and consigned to cultural oblivion.
Within the US academic community, Cuban dialogue has been
maintained primarily by social scientists and historians, many
of whom are second-generation Cubans.
4–6
Despite occasional
‘discovery pieces’ the biomedical literature in English has been
almost entirely silent on the Cuban experience
7–10
and US
government policy temporarily forbade publication of articles
from Cuba by US journals or their foreign subsidiaries.
The historical context that explains the absence of Cuba from
the global conversation on public health and medicine is
self-evident. This absence cannot be dismissed as passive
acquiescence of the health professions to the demands of
real politik, however. The raison d’etre of the health sciences is
the discovery of new knowledge and the use of that knowledge
to improve health. Both the professional and commercial
reward structures within the discipline insure that evidence of
a major advance will attract further sustained attention. This
dynamic, however, is conspicuously absent from the debate on
international health. While the undisputed priority in public
health from a global perspective is the need to rescue the
populations of poor countries from diseases we have been able
to prevent or cure for many decades,
11–13
nothing is said of
one of the most striking examples where that challenge has
been most effectively met. This silence stands in stark contrast
to the impassioned rhetoric of the many conferences, declara-
tions, and gatherings of world leaders where the imperative to
find solutions is so often reiterated.
14–16
The unwillingness to take account of the Cuban experience,
or to even view it as an alternative route through which some
societies can move toward the universal goal of health
promotion, represents an important oversight. The achieve-
ments in Cuba thereby pose a challenge to the authority of the
biomedical community in countries that define the scientific
1
Department of Preventive Medicine and Epidemiology, Loyola University
Stritch School of Medicine, Maywood, IL, USA.
2
Department of Community Health Sciences, University of Illinois School of
Public Health, Chicago, IL, USA.
3
Hospital Universitario ‘Dr Gustavo Aldereguia Lima’, Cienfuegos, Cuba.
* Corresponding author. Department of Preventive Medicine and
Epidemiology, Loyola University Stritch School of Medicine, 2160 S.
First Avenue, Maywood, IL 60153, USA. E-mail: rcooper@lumc.edu
817

agenda. This assertion by no means rests exclusively on Cuba’s
success in climbing the vital statistics charts. In virtually every
critical area of public health and medicine facing poor countries
Cuba has achieved undeniable success; these include most
prominently—creating a high quality primary care network
and an unequaled public health system, educating a skilled
work force, sustaining a local biomedical research infrastruc-
ture, controlling infectious diseases, achieving a decline in
non-communicable diseases, and meeting the emergency
health needs of less developed countries. In the following
discussion, we attempt to substantiate these claims with
evidence and speculate on some of the implications of
having allowed the debate over the Cuban experience to be
silenced.
Economic growth and the public health
experience in Cuba
The public health experience in Cuba has several distinctive
features. Although economic productivity is an important
determinant of population health, Cuba does not conform to
the expected relationship. International agencies like the World
Bank have suggested that per capita income in Cuba is under
$1000 per year; Cuban estimates, which take account of
subsidies, are higher, in the range of $2–5000 per year.
18
Using
either measure, however, when health outcomes are correlated
with GNP, Cuba clusters with North America on the former
scale and countries like Bolivia on the latter (Figure 1). Abrupt
economic disruptions also provide evidence on how social
forces shape population health. The economic crisis which
began in 1991 after the withdrawal of the Soviet Union
wreaked havoc on many aspects of Cuban society. The impact
on health indices was relatively modest and short-lived,
however, further demonstrating that economic measures
alone are poor predictors of physical well-being within a
society. One potential explanation of this anomalous pattern
may be the relative absence of extreme poverty, which is the
most powerful economic correlate of ill health and can
confound the effect of average GNP. Cuba has a high degree
of income equality and lacks the marginalized slum populations
of most of Latin America, although the growing dependence on
the tourist economy and, to a lesser extent, foreign remittances
has widened the income distribution.
While useful for descriptive purposes, correlations of social
indicators among countries require strong assumptions about
the accuracy and comparability of the measures. This device
should therefore serve only to frame the question of Cuban
exceptionalism. The most striking feature of the Cuban health
experience has, in fact, been the broad range of successes,
many of which would not be captured by vital statistics data
(Table 1). A heavy investment in biotechnology or foreign
assistance, for example, would not be expected to have
any near-term impact on the health status of the domestic
population. Progress across this range of disparate challenges
reflects a broad policy initiative rather than a narrow,
goal-oriented programme. Rather than viewing health as a
product of economic development, the well-being of the
population has provided the target against which to gauge
achievements in economic and cultural development.
The Cuban public health infrastructure
The 1959 Cuban revolution inherited a heterogeneous health
sector. A single university hospital and medical school existed
alongside a dominant private sector and a rudimentary
public system.
19–21
Two-thirds of the 6300 physicians lived
in Havana.
21
‘Mutual aid’ health facilities served employed
groups, especially in the cities, while primary care for the poor
and rural population was weak or non-existent.
19–21
By the
mid-1960s 3000 physicians had left the island, primarily for the
US, and the various elements of curative medicine and
traditional public health were gradually incorporated into a
single structure organized under the Ministry of Public
Health.
21
In the early stages emphasis was placed on basic
public health improvements, such as sanitation and immun-
ization, and medical care was extended to the rural areas.
20
A
system of regional polyclinics and hospitals subsequently
evolved, complemented in the 1980s by a reorientation of
the entire system toward primary care and the education of
large numbers of family doctors. By the 1990s the strategic goal
was reached whereby a team of a family physician and a nurse
lived on every block and provided care for 120–160 famil-
ies.
19,20
At present there are 31 000 family physicians, with a
total doctor:population ratio of 1 : 170.
22
Argentina
United States
Canada
GNP per capita adjusted for inflation
Cuba
Brazil
Bolivia
0
10
20
30
40
50
60
70
0
5000 10000 15000 20000 25000 30000 35000 40000
Infant mortality per 1000 live births
Figure 1 Infant mortality and gross national product (GNP) in
selected Latin American countries and the United States, 2003
Table 1 Indicators of Cuba’s accomplishments in public health
First country to eliminate polio—1962
First country to eliminate measles—1996
Lowest AIDS rate in the Americas
Most effective dengue control programme in the Americas
Comprehensive health care; 1 physician per 120–160 families
Highest rates of treatment and control of hypertension in the world
Reduction in cardiovascular mortality rate by 45%
Crude infant mortality rate of 5.8 per 1000
Development and implementation of a ‘comprehensive health plan for
the Americas’
Free medical education for students from Africa and Latin America
Support of 34 000 health professionals in 52 poor countries
Creation of a national biomedical internet grid (INFOMED)
Indigenous biotechnology sector; producing the first human
polysaccharide vaccine
818 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

The most basic infrastructure requirement for progress in
public health is a surveillance system that generates accurate
and timely information. Some observers are skeptical of the
Cuban data, suspecting that a political message is being
transmitted in the vital statistics. In contrast to all other
Caribbean and most Latin American countries Cuba has
published extensive mortality and morbidity data by cause
and province since 1970.
22–24
National data are presented
promptly, currently within the first 3 months of the following
year for some causes. High autopsy rates lend support to clinical
diagnoses and the number of deaths attributed to
ill-defined causes is very low (0.7%), an important indicator
of incomplete or inaccurate vital statistics.
22,25
Based on
comparisons to demographic models that predict expected
rates, under-reporting in other Caribbean countries generally
ranges from 10 to 20%, yielding falsely low mortality
estimates.
26
Given the extensive vital statistics tables presented
for Cuba by age, gender, cause, and region, manipulating the
original counts while maintaining consistency across categories
would be extremely difficult. In the case of the infant mortality
statistics, for example, in 1965 only 54% of infant deaths were
reported overall, and only 30% in the rural areas.
20,21,24
At
the present 99% of infant deaths are reported from hospitals on
the day of occurrence.
20,24
The patterns of variation for
provincial and national estimates are what would be expected
in a complex vital records system (i.e. counts and trends
are consistent over time and region, subunits sum to the
national rate, no excessive smoothing or discontinuities are
observed, etc.).
22
Cuba spends ~16% of its GNP directly on the health system,
roughly $320 per year per person. As would be expected,
tertiary medical facilities lack both the amenities and the
technology found in industrialized countries. A recent mod-
ernization campaign, however, has brought interventional
cardiology and MRI, for example, to the 48 referral hospitals
and ultrasound and endoscopy to polyclinics. Cost-effective
interventions, like dialysis and organ transplantation, have
been widely available for a number of years.
27,28
In relative terms, Cuba has invested heavily in biotechno-
logy, focusing on biopharmaceuticals.
29–31
With consistent
state support, even during the collapse of the Soviet partner-
ship, a robust local infrastructure has been created which now
generates significant export income and has been characterized
as ‘the envy of the developing world’.
29
Production of the
first vaccine for meningitis B and a vaccine for Haemophilus
influenzae type b, which for the first time incorporated a
synthetic antigen, are two of the most important recent
accomplishments.
30
A recent initiative between a US corpora-
tion and the Center for Molecular Immunology in Havana
to work jointly on a cancer vaccine reflects the growing
international importance of this research.
31
Linkage to an
organized health system provides an efficient mechanism to
conduct trials and assess clinical applications, further enhancing
the productivity of the biotech sector.
29
Maternal and child health
Established in 1970, the centralized Maternal–Child Pro-
gramme (Programa Nacional de Atencion Materno-Infantil—PAMI)
has the main responsibility for assuring the health of women
of child-bearing age and their children. With PAMI’s leader-
ship, governmental sectors as well as community organiza-
tions work collaboratively to provide a supportive network of
community-oriented services. The success of this approach can
be evaluated against a series of key indicators. Cuba’s statistical
time series for infant mortality documents one of the most
rapid declines ever recorded (Figure 2). Since 2002 Cuba has
had the second lowest infant mortality in the Americas, 20%
below the US rate for all ethnic groups and just below the rate
for US whites (Figure 2; Table 2).
22,32,33
The prevalence of low
birth weight was 5.5% in 2004.
22
Thirty-five per cent of the
Cuban population is black or mulatto, yet the infant mortality
rate is less than half of what is observed in US blacks (Table 2).
National data are not systematically analysed by race; however,
in a study from the province of Cienfuegos no differences in
pre-term birth or mean birth weight were noted between
blacks and whites.
33
International comparisons of infant mortality rates are
potentially biased by definitions, reporting practices, and
differential use of technology, thus the rank order of countries
within a narrow range should be interpreted cautiously.
35,36
While Cuba adheres to WHO reporting recommendations and
attempts to resuscitate all live births, the perinatal mortality
rate is higher than is found in industrialized countries,
22
suggesting a potential shift in events from infant to fetal deaths.
Even with careful attention to case definitions comparisons are
difficult since technological interventions, particularly in the
US, result in the live delivery of more very low birth weight
babies.
36–38
However, the slope of the infant mortality decline
is potentially less biased and by this measure Cuba compares
favourably with societies with the best reproductive health
records (e.g. Japan, Sweden, and Singapore). Although
maternal deaths are rare events, the 2003 rate in Cuba was
39.5 per 100 000 live births; in Canada and the United States
maternal mortality is 7–8 per 100 000 overall, and 20 among
black women in the US.
22,39,40
The resilience of Cuba’s child health programmes was
tested in 1991–94 when the collapse of the trading partnership
0
5
10
15
20
25
30
1975
1
9
77
19
79
1
9
81
1
98
3
19
85
1
98
7
1
98
9
1
9
91
1
99
3
1
9
95
1
99
7
1999
2
0
01
2
00
3
Year
Infant Mortality Rate per 1,000 live births
Cuba
US Total
Figure 2 Trends in infant mortality, Cuba and the United States,
1975–2004
HEALTH IN CUBA 819

with the Soviet Union and the tightening of the US embargo
provoked the unprecedented economic crisis known as
the ‘special period’.
41–44
The economy contracted by 30%
and access to foreign commodities—including everything from
oil to pharmaceuticals and agricultural inputs—was virtually
cut-off. An epidemic of optical and peripheral neuropathy,
subsequently traced to a sharp decline in protein, vitamins,
and some other micronutrients, afflicted 50 000 Cubans.
42
During this period a modest increase in mortality from
infectious diseases, particularly tuberculosis, was also
observed.
22
A variety of internally generated initiatives, like
small-scale organic farming and return to the use of draft
animals, allowed the society to regain food security and redirect
the economy.
45
As would be anticipated in a period of severe food shortage,
the incidence of low birth weight increased, accompanied
by a modest rise in infant mortality (Figure 3). While average
calorie intake was reduced from 3000 to 1800 kcal/day,
42,45
supplemental food for pregnant women was available through
cafeterias in work places and ‘maternity houses’. Within 2 years,
well before the economy overall had recovered, the health of
child-bearing age women and infants had experienced ‘catch-
up’ and the trajectory of the decline in infant mortality was
regained. Maintaining social cohesion and high public health
standards while simultaneously undertaking a coordinated
economic reorganization of that magnitude posed enormous
technical and social challenges.
Cardiovascular disease and cancer
Considerable attention has been focused on the threat posed
by non-communicable diseases in developing countries.
46,47
More than two-thirds of cardiovascular (CV) deaths are
already occurring in poor countries of Asia, Africa, and
South America, and risk factors are increasing rapidly, leading
to dire predictions about the size of the coming epidemic.
48,49
Unfortunately, the epidemiologic data required for an accurate
description of the trends in mortality and causal risk factors are
not available for most countries in these regions, nor has
evidence emerged to support prevention and control strategies
that can be used effectively in low resource settings.
Cuba provides a unique opportunity to study the CV
epidemic in the non-industrialized world because of its robust
public health data system. CV diseases have been the leading
cause of death since at least 1970
22,50
and within its resource
limitations the medical care system has responded vigorously.
For example, all major classes of anti-hypertensives are
produced locally and the levels of treatment and control of
hypertension are the highest reported for any country.
51–53
A
sustained downward trend in coronary heart disease began
in 1982 with a slope close to the maximum achieved in
Europe and North America (~ 1.5% per year) (Figure 4) and
the cumulative reduction in age-adjusted mortality reached
45% by 2002.
50
Acute care for myocardial infarction meets
international standards and pre-hospital treatment units exist
in most municipalities. Locally manufactured recombinant
streptokinase is used routinely; at present, based on data
from at least one province, the total thrombolysis rate is .60%
and the ‘door-to-needle time’ is 30 min or less for .90% of
all patients with ST elevation on the electrocardiogram.
54
This
experience demonstrates that non-industrialized countries can
in fact move decisively to prevent and control CV diseases
without accumulating the extraordinary medical technology
and infrastructure of Europe and North America.
Less progress has been made in the control of cancer,
consistent with the experience in industrialized countries.
The age-adjusted death rate from all malignancies combined
rose from 115.9 per 100 000 in 1988 to 125.6 in 2003.
22
Lung
and prostate are the two most common causes of cancer death,
Table 2 Infant mortality in Cuba and selected countries in the
Americas, 2004
Country Rate, per 1000
Canada 5.4
a,b
Cuba 5.8
a,c
US Total 7.1
d,e
Cuban American 3.7
f,g
Mexican American 5.4
f,g
White (non-Hispanic) 5.8
f,g
Puerto Rican (mainland) 7.9
h,i
Puerto Rican (island) 10.2
h,i
Blacks (non-Hispanic) 12.8
f,g
Chile 7.8
a,c
Argentina 16.5
a,c
Mexico 12.5
j,c
Brazil 25.1
a,g
Dominican Republic 35.4
a,c
Bolivia 54.0
a,c
b
2000;
c
2004, preliminary data;
e
2003, preliminary data;
g
2002;
i
1998–2000.
a
Available at: http://www.paho.org/english/dd/ais/BI-brochure-2005.pdf
(Accessed March 10, 2006).
d
Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_15.pdf
(Accessed March 10, 2006).
f
Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_10.pdf
(Accessed March 10, 2006).
h
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5242a2.
htm#tab2 (Accessed March 10, 2006).
j
Available at: http://www.inegi.gob.mx/est/contenidos/espanol/rutinas/ept.
asp?t5mpob55&c53232 (Accessed March 10, 2006).
0
2
4
6
8
10
12
14
16
18
19
8
5
1
98
7
19
8
9
19
9
1
1993
19
9
5
1997
1999
2001
20
0
3
Year
IM Rate per 1,000 Live Births; LBW
Percent of Live Births
IM
LBW
Figure 3 Trends in low birth weight and infant mortality
in Cuba, 1985–2003
820 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

followed by breast and colorectal cancer.
55,56
Some progress
has been made against tobacco. Smoking rates fell by one-third
over the past two decades—average per capita consumption
of cigarettes was down from 2690 in 1970–72 to 2280 in
1990–92, and the prevalence of smokers declined from 53
to 36%—although serious obstacles remain.
57
Prohibitions
against smoking in public places, for example, are generally
ignored and the limited success against smoking relative to
other public health challenges probably reflects a lack of
political will and Cuba’s special historical relationship to
tobacco. In fact Cuba has shown signs of ‘medicalizing’ the
strategy to control chronic disease and will need to translate
earlier lessons on the value of prevention into this new
domain.
50
Infectious diseases
The combination of high levels of community participation,
access to primary care and an aggressive public health approach
has made the Cuban campaign against epidemic infectious
diseases particularly successful.
58–60
A number of common
illnesses have been eliminated altogether, often for the first
time in any country [poliomyelitis (1962), neonatal tetanus
(1972), diphtheria (1979), measles (1993), pertussis (1994),
rubella and mumps (1995)]. In 1962, against the advice of
external health officials, ‘vaccination days’ were established
with the goal of reaching the entire population. When this
method quickly proved to be effective in eliminating polio it
was subsequently adopted elsewhere as the primary strategy.
58
After dengue was introduced in 1981 Cuba adopted a campaign
of community mobilization, focusing on elimination of
mosquito breeding sites, which lead to prompt control.
20,58,59
International attention for infectious disease control in Cuba
has focused primarily on HIV/AIDS.
10,20,61–63
Among 300 000
military personnel returning from Africa in the 1980s 84 were
found to be infected with the virus [Ref. (20), p. 85]. A
nation-wide screening programme which began in 1987
reached 80% of the sexually active population (~3.5 million
people) and identified 268 HIV-positive individuals.
20
In the
initial phases, the Cuban HIV/AIDS strategy provoked contro-
versy, some of which was negative.
20,64
While assessing
the public health impact of this unknown epidemic, persons
infected with HIV were quarantined in health facilities where
they received supplemental nutrition and available medical
care.
20,61,62
Treatment is now provided in the outpatient
setting; domestically produced triple therapy has been
provided free to all paediatric patients since 1998 and to adults
with HIV or AIDS since 2000.
62
With the rapid increase in
foreign tourists, and the development of a local sex trade, the
HIV incidence has risen in the past 5 years, although it remains
the lowest in the Americas.
23
Increased integration into the
global economy may continue to pose challenges which Cuban
public health has not previously had to address.
Cuba’s role in global health assistance
Given its limited economic resources, Cuba can only rarely
afford direct aid.
20
Instead it has adopted a strategy that
relies on human resources. First targeted to Africa, the
programme has now placed physicians, nurses, dentists, and
other professionals in 52 countries.
20,65,66
The most prominent
episodes involved sending doctors to post-apartheid South
Africa, providing long-term care for Chernobyl victims, and
giving disaster aid to Central America after hurricane Mitch.
Cuban personnel also staffed a new hospital in Gonaives,
Haiti, which had been constructed with the Japanese aid; this
facility was subsequently destroyed during the anti-Aristide
strife in 2004 although the Cuban physicians have remained.
67
To move from emergency assistance to a sustainable
programme, a multicountry collaborative plan has recently
been developed to improve health services in poor Latin
American countries.
66
A medical school was established in
Havana in 1999 and more than 6000 students, primarily from
Africa and Latin America, are currently being given a medical
education at no expense.
7,68,69
In the past 3 years more
than 14 000 physicians and dentists have been placed in slums
and rural communities in Venezuela as part of the new the
partnership between Cuba and the Chavez government, and
this number is set to rise to 20 000.
68
Cuba has also agreed to
educate 40 000 new physicians for Venezuela over the next
several years.
69
Cuba’s medical assistance campaign has a number of
dimensions. Like all foreign aid programmes, it assumes that
some political benefits will be forthcoming in return. However,
most of the countries that have been assisted, for example,
Ethiopia, The Gambia, and Haiti, have nothing to offer in
return. Unlike many donor programmes, placing physicians
where none have practiced before has been overwhelmingly
well received by the local communities.
69
Thus, while the
arrangement with Venezuela has direct economic benefit to
Cuba, it has also transformed the health system by giving large
segments of the Venezuelan population access to modern
medical care.
69
The special character of health sector development in Cuba
can perhaps be best appreciated by considering the challenge
any other society would face if it tried to send tens of thousands
of physicians to live in slum communities in a foreign country
for 2 years. While a range of incentives and motivating
factors unique to the Cuban social context are operating, these
assignments are accepted as a professional obligation by the
0
50
100
150
200
250
197
0
198
0
198
2
198
4
1986
1988
1990
1992
1994
1996
1998
2000
2002
Year
Rate/100,000
Heart Disease
CHD
Stroke
Figure 4 Age-adjusted mortality from cardiovascular diseases,
Cuba, 1970–2002
HEALTH IN CUBA 821

vast majority of the Cuban practitioners and they perform
effectively in the host communities. Much like the experience
of military personnel on long tours of duty, the Cuban
programme of assistance does nonetheless require extraordin-
ary sacrifice and the hardship is not always borne lightly.
Furthermore, the mobilization for assistance to Venezuela
has meant that many Cuban neighbourhoods must share
facilities. These sacrifices must, of course, be balanced against
the conditions of desperate need in the communities on the
receiving end. Many of these countries, particularly in Africa,
have watched helplessly as the majority of their health
professionals emigrate to the US and Europe.
70
Offhand
dismissal by observers in industrialized countries of the
Cuban medical aid programme, which has such a powerful
impact on these marginalized communities, is a clear indica-
tion of how perilously divided the discourse over global
development has become.
Does Cuba’s experience have broader
significance?
The history of science is replete with stories of the delayed
acceptance of unpopular or unfashionable ideas. The approach
to improving global health taken by the donor community and
academic medicine in rich countries is no exception. While
criticisms of the basic approach are voiced—as in the recent
assertion that the external measures of development have no
meaning for the general population
71,72
—these critical voices
have little influence on the practice of large international
agencies. It is not the intent of this article, however, to
summarize and make a judgment on economic assistance and
progress in global public health. Instead, based on the weight of
the evidence presented on the Cuban experience, we pose the
following question: ‘Why has the debate on solving the most
urgent challenges in public health in poor countries ignored the
experience of success?’ Traditionally, whether the experience is
derived from randomized trials, high survival rates in clinical
series, or favourable trends in vital statistics, biomedicine
embraces the winner and seeks to imitate it. Precisely the
opposite has happened in this instance.
There is, of course, no shortage of historical and ideological
reasons why a debate on the ‘Cuban question’ has never
reached maturity. Blind optimism is thought to have discred-
ited the sympathetic scholarship about the Soviet Union, and
to a lesser extent China, in an earlier era.
73–75
Some observers
are too concerned about putative restraints on civil liberties and
the independent character of its foreign policy to develop any
enthusiasm for the objectively more successful aspects of
Cuban society. None of these concerns, however, undermine
the force of the question, why have we ignored what works?
Before recommending components of the Cuban model for
use in other settings, a thorough and balanced assessment of
the strengths and weaknesses of those components would be
required. That assessment would require a very different study
of the health system’s organization, capacity, and services. Our
intent here is to demonstrate that sufficient cause exists to
undertake that assessment. For an objective evaluation of the
Cuban experience to succeed, an acceptance of certain ground
rules would be required. First, this evaluation cannot be
undertaken with the goal of winning a political argument.
Although the trajectory of social development in Cuba over the
past 50 years is both complex and controversial, as in all other
countries, the public health experience should be subjected to
judgment on the basis of the usual rules of science. Second,
this judgment cannot be permanently postponed by skepticism
about the validity of the data or concern over unrelated
broader social questions. Ongoing, careful scrutiny of Cuban
public health data is justified and to be welcomed; however,
sufficient data now exist in several key areas to demonstrate
that skepticism can no longer be the basis for a refusal to
engage the question. Likewise, many societies embrace
domestic and foreign policies that are questioned and even
condemned by broad segments of the world community, yet
the attempt to evaluate progress in improving the health of
their populations is not thereby condemned as illegitimate or
unnecessary. Third, the apparent successes recorded by Cuba
should be seen as consequences of a well-defined strategy; the
value of these underlying principles, not the accumulation of
better numbers, is what holds implications for other poor
countries, and not a few well-resourced societies.
Two aspects of the Cuban experience serve as reasonable
demonstrations of the value of that strategic approach. In
the area of infectious disease, for example, the operative
principles are particularly straightforward: once a safe and
effective vaccine becomes available the entire at-risk popula-
tion is immunized; if a vaccine is not available, the susceptible
population is screened and treated; where an arthropod vector
can be identified, the transmission pathway is disrupted by
mobilizing the local community which in turn requires
effective neighbourhood organization and universal primary
health care. The joint effect of these strategic activities will
result in the elimination or control of virtually all serious
epidemic infectious conditions. In terms of child survival, a
‘continuum of care’ that provides for the pre-conceptional
health of women, prenatal care, skilled birth attendants, and a
comprehensive well-baby programme can quickly reduce
infant mortality to levels approaching the biological minimum.
Many observers will regard these propositions as reasonable,
yet hopelessly too ambitious for the poorer nations of the
world. It must be recognized, however, that these principles
have been successfully implemented in Cuba at a cost well
within the reach of most middle-income countries.
Although other aspects of society, such as education and
housing obviously make independent contributions to the
success of public health campaigns, the Cuban strategy outlined
here serves as a model that should be thoroughly evaluated.
Needless to say, its implementation would face many chal-
lenges specific to the geography and politics of a region. Other
models that dictate public health strategies face the same gamut
of uncertainties and challenges, however, and none can be said
to have met with similar success.
76
The World Health
Organization, for example, promulgated a set of principles in
the Alma Ata ‘Health for All’ Declaration of 1978, many of
which were incorporated into the Cuban approach.
77
In recent
years, however, international agencies have favoured privat-
ization and reduction in state support for health systems.
78
The
record of achievement with privatized systems in poor
countries has often been very limited.
79
A debate which can
use as a point of departure extensive empirical evidence of
822 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

progress would provide a healthy reorientation in a discipline
distracted by controversy and divided over political aims.
The health professions have little opportunity to intervene
directly on historical events. However, in the conduct of our
science we have both choice and responsibility. Challenging
the acquiescence of the scientific community to ostracism of
some of its members in an earlier era, Einstein remarked,
‘Political considerations, advanced with much solemnity,
prevent... the purely objective ways of thinking without
which our great aims must necessarily be frustrated’ [Ref. (80)
p. 80]. If the accomplishments of Cuba could be reproduced
across a broad range of poor and middle-income countries the
health of the world’s population would be transformed. This
fact creates an obligation for health scientists. We should
debate the merits of the principles embedded in the Cuban
attempts to improve the health of populations.
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