For my senior elective this year, I spent four weeks in Santiago de Cuba, the nation’s 2nd biggest city, located on the hotter eastern tail of the island. Two of these weeks were spent in the theatre anaesthetics department of Dr Juan Bruno Zayas Alfonso General Hospital, and two in various primary and community care settings.
I chose Cuba as I felt it offers a unique opportunity to see a preventative healthcare system and culture. Cuba spends £762 a year per head on healthcare, while comparatively the UK spends £3,1051; yet, it has a cancer rate of 218.0 per 100000 compared to our 272.92. Clearly, they are doing something right. While resource limited, Cuba is renowned worldwide for its standard of healthcare, its scientific advances and research, and its quality of training as well as the humanitarian brigades of doctors it sends all around the world.
The anaesthetics portion of my placement was interesting, and I enjoyed taking part in hands on procedures and seeing how the healthcare system works in a hospital setting. My time in primary care, however, was incredible and where I learned a lot about cancer prevention strategies in place in the country. It was hugely useful to see these from an outsider’s perspective – not only to observe strategies that could be of use in Scotland, but to recognise those that we do well in comparison.
Primary care in Cuba revolves around polyclinicos. These are buildings containing a variety of services, including medical and surgical specialists, an urgent care department, physiotherapy and rehabilitation and complementary therapies like acupuncture. The one I was linked to, Polyclinico 30 de Noviembre, caters to 13000 patients from the surrounding area. Linked to each polyclinico are a number of consultorios (mine had 32) which are GP-like clinics in each neighbourhood which patients can walk into for appointments.
Cuban healthcare has systematic advantages over ours to prevent cancer. For one, it is an explicitly preventative system, meaning significant resources and teaching time are given to doctors to ensure a preventative approach. A second important aspect is the amount of time doctors have to talk to patients. The 10 minute appointment rule is absent in Cuban consultorios – in fact, there appeared to not be any limitation. The sheer number of doctors – 1 for every 133 Cubans compared to 1 for every 354 Britons3 – mean that the time pressures to get through waiting lists that we see here are not so present. Regardless of their awareness of ‘teachable moments’ and the need for risk factor modification, doctors in the UK feel that they barely get through the acute presentations in front of them within the allocated consultation time, never mind delving into an analysis of patients’ behaviours. With more time to talk to patients, and a directive from high to ensure disease prevention is top of the agenda, Cuban family doctors are at a serious advantage to Scottish GPs before any other programs are even considered.
Cuba has a number of programs in place that would fit in with the European Code Against Cancer, but there is significant room for improvement in certain areas.
Cuba has a deeply entrenched cultural and economic relationship with tobacco – when people think Cuba, they think cigars, and this reputation means 1/5th of export revenue comes from tobacco4. As such, they grow a lot of it, in conflict with the preventative culture of healthcare in the country. In the words of Fidel Castro, “We can’t give it up, much less while we’re under a blockade. It would be wonderful if we could. But when we give a box of cigars to a friend, we say … the best thing you can do is give this box to your enemy.”5. Public health policy on tobacco is lax in comparison with the UK. Tobacco is cheap – cigars can be bought for 1 peso (~4p) and the cheapest packet of 20 cigarettes for 7 peso (~28p). Cigarette sales are prohibited by law to under 18s, but are easily available to young people sold singly by street vendors. Shops and take-aways also sell single cigarettes. Cigarette packets have text warnings of the harms of smoking but obviously these are absent if bought in this way. Plain packaging has not been instituted, nor have image based health warnings. Cigar packets of 25 also carry a written health warning, however, they are also sold individually and rarely bought in packets as the price is the same regardless of quantity. No safety warning is present when bought singly. Tobacco is available everywhere, in almost all shops and restaurants, and is visibly advertised where sold. The worst example of availability was a tobacco stall operating across the road from the hospital I was in. It was not rare to see doctors smoking. This put in perspective the relatively high quality policies we have in place in this area. Doctors asked all patients about smoking history, but often did not use this as a teachable moment.
As well as issues with smoking, Cuba has a rising problem with obesity6. The country is undergoing the ‘epidemiological transition’ – that is, mortality from communicable diseases is coming down as the burden of non-communicable, lifestyle related diseases increases.
Cuban food culture is not ideal for cancer prevention. Most people don’t understand the concept of vegetarianism and not a single person I met knew the word vegano. Traditional Creole meals of rice and beans are common but are almost always accompanied by fried chicken or pork. In cafes/restaurants/take aways it’s a choice between white rice and beans, pizza or pasta, all with meat (chicken, beef or processed ham) or a ham and cheese sandwich. Occasionally you will get a small side salad, rarely some plantain or yucca (root vegetables). A Cuban meal is not complete, though, without meat. The general lack of knowledge about vegetarianism betrays a lack of knowledge on the benefits of a plant based diet.
What makes this most bizarre is that it is the result of a planned economy. A governmental decision has been made that the food available on the street will be pizza and ham sandwiches, which does not tally with the preventative approach shown in healthcare. A serious step up would be the distribution of wholegrain plant based foods to restaurants and cafes, instead of the current ingredients. Economic factors, however, no doubt play a large part in limiting the scope for this.
There is also a national obsession with sugar – as with tobacco, historically sugarcane has been a major source of revenue for the country. Fizzy drinks and sweets are commonplace and sadly even young children can be seen drinking cans of Tropicola.
Doctors can prescribe diets to people, and often do for diabetics and overweight patients. These tended to include reducing red meat intake and increasing fruit and vegetable intake but there was no explicit mention of plant based diets. However, it was heartening to see these conversations take place regularly. Doctors genuinely attempt to make every consultation a teachable moment for obesity and therefore cancer prevention – and prevention of disease more generally.
Alcohol is available everywhere, all the time. When on the hunt for batteries, we discovered a photo development shop where you could get a beer (or a bottle or rum) while you waited. As a product of national pride, rum is extremely cheap, with 0.5L of the nicer brands being around £1.40. 1.5L plastic bottles of white rum are available for less than this. Beer is relatively expensive at around £1 a can/bottle. Drinking is allowed in public places, and bars and shops can sell alcohol whenever they are open. There are no health warnings on alcohol packaging, bar occasional logos prohibiting it for pregnant women, as well as no mention of units.
Beyond diet and smoking, breastfeeding is an effective way of preventing cancer in mothers. The breastfeeding rates in Cuba are higher than in the UK. This has been achieved mainly through public education and economic factors. As a communist state, formula companies have been unable to mount the advertising campaigns that have been seen in countries in SE Asia7. As this has been shown to effect breastfeeding rates8, it could be assumed that by keeping out corporate advertisers, Cuba has helped keep breastfeeding rates higher than they would otherwise be. Education also plays a key part here – especially in the setting of maternal homes. These are houses with beds offered to women with riskier pregnancies – anything from gestational diabetes to previous miscarriages. Doctors prescribe diets and specify calories to be consumed and supplements to be taken. In these homes, education programs are given on various aspects of parenting, including significant emphasis on breastfeeding. For pregnant women with normal pregnancies, advice on breastfeeding is given by doctors both before and after birth. Cuba has breast milk banks, from which mothers with lactation problems can receive donated milk for their baby. Breast feeding rates are still suboptimal – exclusive breast feeding for the first 6 months is only done by 33% of Cuban mothers9. But given that at 8-12 weeks only 25% of Scottish mothers are doing so10, it seems we have something to learn from the Cuban approach.
Despite the limitations, I was overall very impressed by the preventative nature of Cuban healthcare. It has allowed them to keep the population as healthy as many European states on a fraction of the budget. I was however saddened by the limitations placed on the system by geopolitical and economic factors. The USA has had Cuba under a trade embargo for almost 60 years, which is estimated to have cost the island $130 billion11. Considering how much they achieve at present, it’s not much of a stretch to say that Cuba could be one of the healthiest countries on the planet if they were released from the grip of this, but given the prevailing political forces in America today, this seems unlikely. The economic hinderance obviously reduces Cuba’s ability to invest in healthcare and improve services, but the embargo also places barriers in the way of getting the best medications and equipment. Cuba cannot purchase these from America or certain allies, so must source them elsewhere – often this means inferior products, or prohibitively inflated prices. In an interview with the head of the polyclinico I was placed with, I asked him about the effects of the embargo on cancer incidence –
I think the blockade is the main thing that stops us reducing all the rates. I think yes. That’s a reality, it’s not a speech…. it is just like a sword in our throat.
Cuba has a way to go in improving lifestyles for cancer prevention, and Scotland may be doing better in many areas. However, considering the vast economic difference between the countries, the policies that are in place are incredibly impressive. The level of investment in, and structuring of, the healthcare system such that it can be used to prevent disease is fantastic and something I would love to see here.
My time in Cuba was amazing and I would recommend it to any student considering doing their elective in the country. I found the placement hugely useful and thought-provoking and my travelling time afterwards to be fantastic. My experience has helped inform my intercalated studies in Public Health this year and will surely influence my work in the future. I extend huge thanks to the SCPN for their support, which helped me have this amazing opportunity.