Learning from Cuba

Barone and Skinner in Viñales
Adam Barone, OMS-I , (left) and Daniel Skinner, assistant professor of health policy

Daniel Skinner and Adam Barone

For a week in March 2019, we were privileged to visit Cuba to learn about the nation’s health care system. Our contingent ran the health professions gambit, including people in nursing and medicine, health care administration, global health, health communication and health policy. But our mission was unified: to learn about health care in Cuba and use the experience to reflect on our situation in the United States.

While in Cuba we met with physicians (both urban and rural), diabetes and vaccine researchers, farmers, educators, medical students, HIV-AIDS patients and more. We visited medical schools, clinics, physicians’ offices, rural villages and more. We walked the streets of bustling Havana and rural Viñales. At night, we processed what we had seen and explored our thoughts – often with the sound of salsa music in the background.

Though Cubans acknowledge that their system is not perfect (and what system is?), they are proud of what they have accomplished in health care. Despite widespread poverty – compounded by a lack of resources that has been intensified by the American-led embargo – Cuba’s infant and maternal mortality and life expectancy rates are comparable to those in the United States, and lack the racial and class-based disparities that plague American health outcomes.

Cuba is deeply invested in medical education, for aspiring physicians both in Cuba and around the world. A drive through the western parts of Havana reveals a vibrant, sprawling complex of buildings immersed in vaccine and other biotechnological research. In a nation that cannot afford the high costs associated with widespread acute and chronic illness, Cuba’s focus is on prevention, from frank talk about STI prevention, to mandatory vaccines that are not part of our regular vaccine schedule in the United States – such as vaccines against tuberculosis, leptospirosis and typhoid fever – to the much-discussed treatment they are exploring for lung cancer, to genomic research that aims to prevent diseases before they arise.

Cubans emphasize the hyper-rational organization of the system’s three-level approach to health care delivery, with family physicians located in communities serving as the first point of contact (including house calls), “policlínicos” serving as a community-based second tier and hospitals serving as a last resort for cases of acute need. While Cubans are allowed to access any of these tiers at any time, most opt to utilize the system as it was intended. Few Cubans go to the hospital when they do not need to. The system incentivizes this through unfettered access and by building trust in the overall design.

A particular highlight of the trip was when we American students were afforded an hour to converse with Cuban medical students at the Victoria de Girón Institute of Basic and Preclinical Sciences.The students compared notes on their experiences. Despite significant resource differences in education systems, the students found they utilized common textbooks and study strategies. Perhaps the most important takeaway was the revelation that their lives – their aspirations, as well as challenges – were not so different. Two days later, as further evidence that friendships were in the making, the students met again, this time in an unplanned run-in at a fashionable Havana art and music center, where yet more conversation and connection took place.

Cuba has a lot to offer osteopathic medicine in particular. After all, osteopathic approaches to health care emphasize the importance of the physical exam and prevention, turning to pharmaceuticals and technologies only when necessary. In Cuba, where many drugs and expensive equipment are hard to come by, there is an opportunity to reflect on core principles and see what osteopathic principles can accomplish in a resource-poor environment. It is well known that Americans overuse medical technology and testing; in Cuba, the problem is the inverse, where the American embargo is making it hard for Cubans to get some of the medical equipment they need.

In the weeks and months to come, we plan to explore ways to strengthen connections with Ohio University and Cuba. The clinicians and researchers with whom we met emphasized their hope that we could see past diplomatic tensions and focus on mutual goals of addressing pressing health needs, such as collaborative diabetes and cancer research. Sometimes, working on common projects can serve as a kind of diplomacy in its own right. Other osteopathic colleges have found value in such connections as well. Clearly, as our experience reminded us, the future of medicine – from the training of clinicians to research – is in global connectivity.

Daniel Skinner, Ph.D., is assistant professor of health policy. He is director of Ohio University’s Comparative Health Systems – Cuba program, administered through the Global Health Initiative.  

Adam Barone, M.S., is a first-year medical student.

 

The importance of breastfeeding then and now: A response to U.S. threats against Ecuador over their resolution supporting breastfeeding

Wolf_JackieJacqueline H. Wolf

For every 100 infants born in the United States in 1900, 13 died before their first birthday. More than half of the babies who died, died of diarrhea. Physicians and public health officials recognized, and widely publicized, the cause. In the late 19th– and early-20thcenturies, feeding babies cows’ milk-based infant food, what we now call “formula,” was a deadly practice. Public health posters, circulated nationwide by municipal health departments, advertised that fact. “Mother’s Milk for Mother’s Babe Cow’s Milk for Calves” implored one particularly popular poster. “To Lessen Baby Deaths Let Us Have More Mother-Fed Babies.”

The American dairy industry was largely unregulated before 1930. Milk, shipped in large, open vats, took up to 72 hours to travel in unrefrigerated railroad cars from rural dairy farmer to urban consumer. By the time the milk reached its destination, it was spoiled and greying. To whiten the milk, shippers and merchants often threw handfuls of powdered chalk, and worse, into the vats.

Beginning in the 1890s, urban newspapers heralded what they dubbed “the milk wars,” to urge states to pass legislation regulating the shipping and sale of milk. Headlines about the progress of these “wars” dominated newspapers for the next 30 years. The Chicago Tribune wrote of cows’ milk: “It is worse than fraud…[and] play[s] no small part in this colossal crime of infanticide.”

I recalled this history when news broke that the United States had threatened Ecuador with trade sanctions and the withdrawal of military aid after Ecuador sponsored what they thought was an uncontroversial resolution at the World Health Assembly to “protect, promote, and support breastfeeding.” Breastfeeding is especially important in developing countries where populations still contend with unclean water that can be life-threatening to formula-fed infants. But human milk is more than just a sanitary food – it is a living substance that contains antibodies, beneficial bacteria, oligosaccharides and countless other bioactive factors not found in formula. In all countries, breastfeeding prevents respiratory and gastro-intestinal infections among infants and lowers the incidence among older children of obesity, type 1 and type 2 diabetes, allergic diseases and cancer. In 2016, scientists writing for the Lancet estimated that universal breastfeeding would prevent 800,000 children’s deaths and yield $300 billion in health care savings annually.

We should all be grateful that cows’ milk, and therefore cows’-milk-based formula, is safer than it was a century ago. But because human milk is essential to short- and long-term human health, infant formula should be used only when mothers are unable to breastfeed, for whatever reason. In other words, the formula industry should not be a growth industry. Rather than protect formula companies at the expense of the health and life of the world’s children, the U.S. government should join the rest of the world in a full-throated endorsement of societal supports for breastfeeding, the most effective way to ensure that every child lives a healthy, long life.

Jacqueline H. Wolf is a professor of the history of medicine in the Department of Social Medicine at the Ohio University Heritage College of Osteopathic Medicine and the author of Don’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the 19thand 20thCenturies and, most recently, Cesarean Section: An American History of Risk, Technology and ConsequenceThe opinions expressed in this piece are her own.