APA sponsors second professional visit to Cuba
By Merry Bullock, PhD
Fifteen APA members traveled to Cuba this November 2013 as part of the APA International Learning Partner Program. The second visit in two years, the purpose of the trip was to learn about the Cuban health system and psychology, and to meet with and continue dialogue with Cuban psychology colleagues.
Why is the Cuban system important?
In the 1960’s Cuban health outcomes were among the highest in Latin America. Beginning in the 1960’s trade sanctions from the U.S. prohibited commerce in food, medicines and medical supplies. The effects in Cuba were not immediately apparent, because of aid and raw materials from the Soviet Union to Cuba. By the mid-1980’s Cuba was producing more than 80 percent of its own medical supplies from raw materials supplied from the Soviet Union and health outcomes were comparable to other Caribbean and South American regions.
After the beginning of the 1990’s, however, with the collapse of the Soviet Union, foreign aid faltered with strong effects on health outcomes in Cuba. Adult caloric intake fell 40 percent, underweight newborns increased 23 percent, the number of surgeries decreased 30 percent and overall mortality rate increased 13 percent. Medication shortages were associated with a sharp increase in TB deaths, diarrheal diseases and neuropathy associated with malnutrition. The tightening of the U.S. trade embargo on Cuba, and U.S. pressure on other national bodies not to trade with Cuba left it with a severe lack of medical supplies.
However, despite these challenges, and despite a generally low economic level (Cuba is classified by the world bank as a low income country), the current health outcomes in Cuba rival the rest of the world in terms of life expectancy (currently 79.3 years, compared to 78.7 years in the U.S.), infant mortality (4.2 per 1000 in Cuba compared with 5.9/1000 in the U.S.) and physicians per capita. At the same time health expenditures in Cuba occupy just 7.1 percent of the GDP at $355 a year, compared with 15 percent of the GDP in the US and over $6700 a year.
Cuban Health Care — Integrated, Community Based, Primary Care
How has Cuba achieved such exemplary population health outcomes? One answer is that they have adopted a proactive, primary, integrated health care system that focuses on prevention and public education. This system, achieved over the last 50 years, can serve as an important model to U.S. psychologists, as our system begins to consider the importance of prevention, primary care and population health as part of the Accountable Care Act. It is of particular interest to those psychologists who are advocating for integrated primary care, and who are themselves working within the health care system.
During their visit to Cuba, the APA group learned of the health care system through informational lectures with ample time for questions and discussion with representatives from the health ministry, and from psychology associations and educational institutions. They learned that psychology is well integrated into the health care system — psychologists train in medical schools and teach in medical schools (psychologists also train in and teach in universities), and follow a curriculum that prepares them to be part of integrated health teams. The group also learned first-hand of the system through visits to offices at different levels of the health system from community-based primary care to the health ministry.
The entry point into the health system for Cubans is the local, neighborhood consultorio — an outpatient office staffed by a doctor and a nurse, with weekly rounds by the rest of an integrated expert team, including psychologists, social workers, rehabilitation experts and the like. The consultorio is truly local— each neighborhood has one, with a catchment area of around 1200 residents, one of whom is the consultorio doctor — truly a neighborhood, family physician. Residents come to the consultorio for their routine medical needs and for a yearly checkup — including mental health screening. When we asked a consultorio physician what would happen if someone did not show up for their annual checkup he answered (with some surprise), “well, we would just go get them!”
Consultorios then feed into community health centers that are spread throughout the city of Havana. The group visited one that was in a populous neighborhood and met with the staff. They were struck both by the range of treatment options available and the lack of material infrastructure — equipment was spare and rudimentary, and the physical plant was, like most of the city we saw, in disrepair. Of the four pillars of the Cuban health system — prevention, education, treatment and rehabilitation, the strongest emphasis in primary care is on the first two.
The education and training of the health care workforce is aligned with the system — psychologists are trained together with other health care workers. Like health care services, training also focused on prevention and public education. During meetings, the group was provided with examples of posters and televised public health messages. They also saw special streets in the city where the street signs provided daily health encouragement and tips.
In addition to visiting ministries, universities and practice and research centers, the group was witness to a ceremony for signing a memorandum of understanding (MOU) between APA and the two major Cuban psychology societies — the Cuban Psychological Society and the Cuban Health Psychology Society. Through these MOUs, APA and the Cuban societies hope to encourage exchange at the organizational level as well as individual researcher-practitioner collaborations.
The trip to Cuba was transformative in many regards. The group learned how Cuba can provide a model to the U.S. on how an emphasis on primary care medicine, community health literacy, universal coverage and accessibility can contribute to high health outcomes, despite financial challenges and medical supply shortages.
The group also learned that in Cuba psychology is highly respected and well integrated into the health care system. Psychologists have much to learn about how this was accomplished.
Although health care is universal there are still access and disparity issues — not because of structural barriers, as the group learned, but because of what we might call resource or racial disparities, but what our Cuban colleagues characterized as “vulnerable communities” — those affected by recent natural disasters, many in rural areas and others in more socially vulnerable communities.
The APA group was well hosted by Cuban colleagues. In addition to rich lectures and discussions, there was time in shared lunches to exchange and share stories and personal experiences.
The APA group left Cuba with a resolve to facilitate the next steps in forging a truly collaborative relationship. Discussion is already underway for planning the next trip for 2014 — perhaps in conjunction with a health psychology conference organized by the Cubans Society for Health Psychology in November, Psychohealth 2014.