A delegation of US pediatricians co-led by Dr. Stephen Berman of Children’s Hospital Colorado (Children’s Colorado) and the Colorado School of Public Health, travelled to Havana to establish relationships with local physicians and collaborate on ways to improve child health in both countries.
The delegation was co-led by Dr. James Perrin of Harvard University and Massachusetts General Hospital. Gladys Abreu Suarez, the president of the Cuban Pediatric Society and a pulmonologist at the William Soler Children’s Hospital, led the delegation of Cuban pediatricians.
The Cuba Journal spoke with Dr. Berman about his experience during his trip to Cuba and his broader perspective about the future for children in two countries with healthcare systems that can only be described as diametrically opposed.
Dr. Berman, whose wife’s family is Cuban, has decades of professional interaction with Cuba. This long history has exposed him to a sustained inquiry about the impact of a healthcare system very different from the system in the US. Both are flawed, but there are lessons to learn from each.
Over the years, building cross-border relationships with his counterparts in pediatric medicine, politics encroached on his efforts. Yet Dr. Berman’s persistence in bridging critical thinking with hope has led to an emerging collaboration that aims to address issues vital to both countries’ ability to shape healthcare – and health – for a generation.
One of the more fascinating aspects to Dr. Berman’s Cuban exposure is his front row seat to the architecting and implementation of a national healthcare policy that today has delivered the lowest infant mortality rate in the Americas, including relative to the United States, among other successful healthcare metrics.
Dr. Berman describes the influence of Dr. Pepe Jordan, a Cuban pediatrician, who played a key role in organizing Cuba’s healthcare system after the revolution in 1959. “Cuba concentrated on ‘upstream care’ by emphasizing public health, prevention and primary care,” he said. “Studies show that social, environmental and behavioral factors account for about 60% of a person’s health status, genetics 20% and access to healthcare services accounting for another 20%. Therefore an effective public health approach focusing on prevention and primary care is most likely to achieve the best results.”
“Both our healthcare systems face an existential crisis” – Dr. Stephan Berman
The policy resulted in the building up of a small army of doctors and nurses dispersed evenly throughout the country’s rural and urban populations: 66,502 physicians, 76.6 physicians per 10,000 population (1 doctor for every 130 people) – which compares to 24.5 physicians per 10,000 people in the United States. Cuba’s emphasis on maternal and child health made mothers and children the policy’s main beneficiaries.
Cuba’s healthcare policy played to its strengths by employing thousands of medical professionals at a low wage and by concentrating efforts to increase universal healthcare access at a neighborhood level. The US alternative, an expensive free enterprise system that concentrated resources in beautiful modern hospitals brimming with the latest technology, equipment and procedures, was not feasible for Cuba, then or now.
While prospects for receiving the most up to date care for complicated conditions are low today, the policy’s generational impact is easy to see in the array of statistics about Cuba’s pediatric and childhood healthcare outcomes compared to the US.
Cuba’s healthcare priorities morphed into a kind of industrial policy by bringing its primary care model to other countries with sympathetic ideologies. For example, a barter relationship with Venezuela involves the dispatch of thousands of Cuban medical services professionals to Venezuela in exchange for oil, grants and investments. This aspect of grannacional, Misión Barrio Adentro (MBA), is a bi-lateral social-political barter system intended to avoid dependence of imperialist states (ie. the United States). Former International Monetary Fund economist Ernesto Hernandez-Cata suggests the value of medical services was, “just over $7 billion, or 11 percent of Cuba’s GDP,” in 2011.
The island nation’s ability to sustain its current healthcare system will likely not survive the forces of change washing over it and its trading partners. Due to an economic crisis, Venezuela’s economic system and the MBA are expected to end at any moment.
Another current challenge for Cuba is its transition from an economy dominated by the government to one that has a much larger private sector. This circumstance is beginning to have an impact on the country’s ability to train and retain medical professionals. Dr. Berman says, “The tourism industry is creating real problem for the government because driving a cab or working in the tourist sector is far more lucrative than being employed by the government as a doctor.” In addition, there are concerns about a significant brain drain because of the low salaries physicians earn in Cuba.
In contrast with Cuba’s success in developing its upstream primary care system is the United State’s policy to build a healthcare system that emphasizes hospital-based procedures and the use of technology to cure diseases that likely can be prevented with better primary care. The result has been the pairing of two of the worst healthcare statistics on a national level: at 18% of GDP, we spend more than any other industrialized nation – and we have the worst healthcare outcomes among industrialized nations for infant and child mortality. And in terms of racial differences, the US healthcare system contains profound inequality – a condition not present in Cuba.
In a country where the tomato paste on a slice of pizza is a vegetable for the purpose of school lunches, Dr. Berman’s conclusions attract attention to the idea that a destructive inner poverty lurks in our own spectacularly abundant system. [The lobbyist for the frozen pizza industry failed to inform Congress that tomatoes are a fruit.]
“Both our healthcare systems face an existential crisis,” according to Dr. Berman. “We have a great opportunity to help the Cuban healthcare system incorporate new technology and procedures.” And in terms of Cuba’s experience, Dr. Berman says, “We can learn a lesson from Cuba about how to reduce prematurity; which is quite high in the US compared to Cuba. In Cuba all pregnancies are closely monitored with monthly visits so that complications and risks are identified early. When these risks are significant the women move from their families into a maternity home where they are closely monitored until they deliver. In certain situations, such as high-risk adolescent pregnancies when there is little social support, this approach may be quite beneficial in the United States.
The Cuban system also emphasizes early childhood growth and development both in the home and in childcare settings.
The trip was sponsored jointly by the Cuban Pediatric Society (CPS), the American Academy of Pediatrics (AAP), the Pan American Health Organization (PAHO), Children’s Colorado, and the Center for Global Health at the Colorado School of Public Health at CU Anschutz. The pediatricians traveling to Cuba paid their own travel expenses to attend this historic meeting.
“Caring for children in Cuba and the United States: Sharing experiences and creating opportunities for cooperation” – Event Slogan
The delegation is planning future collaborations around a variety of issues and practice areas to improve healthcare for children in both countries. Newborn hearing, Zika virus and infectious disease, hemophilia and oncology have been identified as common interests.The American delegation hopes to provide medical equipment to Cuban pediatric hospitals through Project Cure.
Stephen Berman, MD, FAAP, Steve Berman is a Professor of Pediatrics at the University of Colorado School of Medicine and School of Public Health and holds an endowed chair in Academic General Pediatrics at the Children’s Hospital in Colorado. He is also the director of the Center for Global Health in the Colorado School of Public Health. Dr. Berman is a past President of the American Academy of Pediatrics.
Dr. Stephen Berman’s interest in global health began on the late 1970s when he worked in Santiago de Cali, Colombia studying acute respiratory infections. This research experience and additional work at University Hospital’s Emergency Department as well as at several community health clinics drove his passion for global health initiatives and provided an entre into his subsequent work with the World Health Organization and Institute of Medicine.
