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Exploring Interdisciplinary Collaborative Public Health Research in Cuba:  Exploring Interdisciplinary Collaborative Public Health Research in Cuba Lanny (Clyde Lanford) Smith, MD, MPH, DTM&H; Matt Anderson, MD, MSc; Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University With David Strug, Ph.D. and Dr. Susan Mason, Wurzweiler School of Social Work of Yeshiva University Crossroads in Global Health: The Dual Challenge of Infectious and Chronic Diseases 21 April 2006 Why Cuba? 1 :  Why Cuba? 1 Despite vital statistics comparable to countries which spend far more money per capita on health, the Cuban system receives relatively little attention in the Western, non-Latin health literature. The reason for this ignorance is explained by the political, described by Aviva Chomsky, in Dying for Growth: Global Inequality and the Health of the Poor as: "The Threat of a Good Example." Why Cuba? 2:  Why Cuba? 2 Yet Cuban physicians are also at work in much of the developing world, teaching in medical schools, giving expert advice to health ministers in times of outbreak, and providing care in areas too isolated or poor to attract the efforts, or perhaps even the attention, of local health care professionals. Contribution to Global Health:  Contribution to Global Health Why Cuba? 3:  Why Cuba? 3 Cuba has also actively promoted its vision of health as a human right by training health professionals from other countries--more than 9,000 students from throughout Latin America (and more than 150 from disadvantaged communities in the USA) are receiving excellent medical training on scholarship at the Latin American Medical School (ELAM) in La Habana. Why Montefiore, AECOM, YU?:  Why Montefiore, AECOM, YU? Residency Programs in Social Medicine (Primary Care and Social Medicine, Family Medicine and Pediatrics Residencies) “Good Night and Good Luck” to AECOM (McCarthy era) Roberto Belmar, MD, physician of Dr. Salvador Allende; survivor of 9/11 (1973’s) unlike the 10,000 killed (see Missing) by Dictator Pinochet in the Santiago Stadium Liberation Medicine Perspective South Bronx Mandate Journal of Social Medicine www.socialmedicine.info Visita: December 2005:  Visita: December 2005 Social work, psychology and medical (IM/PM and FM) faculty from Wurzweiler and Montefiore/AECOM Goals: Exchange information about community based health care and social service delivery in NYC and in Cuba Discuss possible collaborative public health research projects with the team’s Cuban counterparts on the Island Field trips to community-based health centers enhanced discussions about client-practitioner interaction. MEDICC www.medicc.org:  MEDICC www.medicc.org Cuban Health System 1:  Cuban Health System 1 The population of Cuba is 11 million, 75% located in cities (about 2,100,000 in La Habana). Cuba's life expectancy at birth 77 y.o. (2002, from UNICEF), infant mortality 7 (2002, was 39 in 1960, from UNICEF—note current US infant mortality and life expectancy are the same as for Cuba—more recent reports place current Cuban infant mortality at 6 . The adult literacy rate is 97% and the adjusted maternal mortality rate is 33 (2000, from UNICEF). Ninety nine percent of EPI vaccines are covered by the government (UNICEF); DPT coverage 99% up to 1 year, 97.6% from 1 to 8 years. (Mcintire). Thus Cuba has health statistics similar to highly developed countries. Cuban Health System 2:  Cuban Health System 2 One of Cuba's tools to having such health excellence in the face of difficult access to resources comes from an integrated basic needs approach, where the government has assumed responsibility of its people's health as a human right in the fullest WHO definition of physical, mental and social well-being. In this approach, the Cuban government does its best to provide access to housing, food, employment and education as well as health care for mental and physical needs. The most vulnerable, especially the children, have priority. Community Cultural Center:  Community Cultural Center Cuban Health System 3:  Cuban Health System 3 Integrating public health (including a sophisticated system of country-wide data analysis for decision making) and primary care with a system which is capable of complex tertiary care, Cuba's Ministry of Health assumes primary responsibility for the provision of universal health care distributed equitably. At the community level, there is a physician, often trained in family medicine, living "on every block" (1 physician for every 175 people persons, Macintyre), with a nurse as part of a team. Even in most rural areas the population has ready access to a highly trained health professional. Cuban Health System 4:  Cuban Health System 4 One step up from the community clinic and family doctor is the neighborhood poly-clinic, which provides secondary care and specialist care. Cuba has 442 poly-clinics, which are the principle sources for epidemiological data collection. Services provided in the poly-clinics include: specialist care (orthopaedic surgery, OB-GYN, and pediatrics), basic laboratory, radiology, and a pharmacy. (Macintyre) Secondary care takes place in municipal hospitals; most births take place in these hospitals. Polyclinic:  Polyclinic Cuban Health System 5:  Cuban Health System 5 Sub-specialist and emergency, as well as other tertiary care, is available in each province hospital. Per year Cuba has 131 admissions per 1000 population, 1,284 hospital days per 1000 population, 5,232 visits per 1000 population and 8,898 clinic visits per 1000 population. (Macintyre) The nationwide referral hospital is the Hermanos Ameijeiras Hospital in La Habana, with over 1000 beds and 30 specialized services (including cardiac and renal transplants, treatment for retina pigmentosa). (Macintyre) This hospital also serves as an international referral center for Cuba's health tourism industry. Cuban Health System 6:  Cuban Health System 6 This intense distribution of health providers trained in both primary care and public health enables a very high level of individual attention to children (especially newborns, whose mothers have a visit or telephone call by the local health team every day for the first two weeks post-partum, after being assured of adequate pre-natal attention), the elderly and other vulnerable populations. The population in turn seems to have a high level of trust and appreciation for this access to primary care, and uses it. Cuban Health System 7:  Cuban Health System 7 The leading cause of death in Cuba is from cardiovascular disease, lead by myocardial infaction (mortality 205.9 per 100,000). Malignant tumors come next, at 140 per 100,000, then cerebrovascular disease. Accidents and injuries are fourth for all Cubans, but represent the leading cause of death from 1 to 49 years of age. Respiratory illness is the main cause of morbidity. Chronic diseases such as asthma, diabetes and hypertension are highly prevalent, leading to about a tenth of all physician visits. Cuban Health System 8:  Cuban Health System 8 HIV/AIDS, while highly prevalent in other parts of the Caribbean, has a prevalence of only 0.05 % in Cuba, with 4,517 HIV positive cases registered since the beginning of the pandemic, 928 with an AIDS diagnosis in 2002, and 3,413 still alive then. Cuba managed this level of control by creating an AIDS commission in 1983, which addressed the destruction of blood products and restricted the importation of the same. The first case of HIV was diagnosed in 1985. Immediately, all blood products were screened for HIV (at a cost of 2 million USD) and sexual case contacts enrolled in partner notification with every 3 month testing. From 1986 to 1993 Cuba employed a public health measure akin to tuberculosis control in decades past—special sanitaria where patients received adequate care but at first were required to live. With more clarity as to disease transmission, Cuba moved in 1996 to an ambulatory care system with the sanitaria as optional, with 80% of those living in the sanitaria deciding to continue, while only 20% of new cases choosing that option. Since 1997, pregnant women with HIV received AZT and breast milk substitutes, and since 2001 HAART has been available for Cuban patients meeting criteria, with 1,533 patients enrolled as of June 2004. (Farmer, p. 15-16) Cuban Health System 9:  Cuban Health System 9 All of the above health initiatives were done under duress, not only of a limited budget but also of a low-intensity conflict imposed by the government of the United States of America. The blockade began shortly after the 1959 revolution and has been in place since, recently increasing in intensity under the current United States administration. During the nineteen sixties there were active initiatives on the part of the US within Cuba, involving not only the famous Playa Giron (Bay of Pigs) and "Cuban Missle Crisis" but also including such horrors as burning crops, blowing up bridges, and other forms of so-called “low-intensity conflict.” The blockade has caused the Ministry of Health significant budget difficulties(3 times the cost of meds), and the Cuban people a lack of access to certain meds and medical supplies beyond the control of the Ministry of Health (pacemakers, certain specific childhood leukemia meds patented in the USA, etc.). Tropical Medicine Institute IPK:  Tropical Medicine Institute IPK Cuban Health System 10:  Cuban Health System 10 Funding for the Cuban Health System is though taxation under the national budget, with preventive, curative and rehabilitation services, as well as pregnancy care, provided for free (depending on availability of medications, which can be very problematic with the blockade). Vulnerable groups: pregnant women, children and the elderly, have priority in the system. In the Children’s Theater Company, “La Colmenita,” special and ordinary children work together to produce all kinds of theatrical spectacles. Their love and happiness were palpable and the psychiatrist we met reported a reduction in medication use when children join the company. Megan Charlop, MSW:  In the Children’s Theater Company, “La Colmenita,” special and ordinary children work together to produce all kinds of theatrical spectacles. Their love and happiness were palpable and the psychiatrist we met reported a reduction in medication use when children join the company. Megan Charlop, MSW Cuban Health System 11:  Cuban Health System 11 Lessons learned from Cuba include the integration of curative and preventive health and public health into a basic needs approach; prioritization of health in the national budget; equitable distribution of health and other basic needs resources throughout the country; integration of health and education; and overall the perception that health is and should be a basic human right. References for Cuban Health System Slides::  References for Cuban Health System Slides: Chomsky, Aviva, “‘The Threat of a Good Example’: Health and Revolution in Cuba,” in Dying for Growth: Global Inequality and the Health of the Poor, Common Courage Press, 2000, p. 331-357. Danielson, Ross, Cuban Medicine, New Brunswich, NJ: Transaction Books, 1979 Farmer, Paul and Arachu Castro “Pearls of the Antilles? Public Health in Haiti and Cuba,” in Unhealthy Health Policy: A Critical Anthropological Examination, Eds. Arachu Castro and Merrill Singer, Walnut Creek, CA: Altamira Press, 2004, p. 3-28. Feinsilver, Julie M., Healing the Masses: Cuban Health Politics At Home And Abroad, Berkeley, CA: University of California Press, Inc., 1993 Macintyre, Kate C. E. and Jorge Hadad, “Cuba,” in World Health Systems: Challenges and Perspectives eds. Bruce J. Fried and Laura M. Gaydos, Chicago, IL: Health Administration Press, 2002. UNICEF, “The State of The World’s Children 2004” Personal visits to Cuba of author: 1995 (APHA), 2000 (HSPH), 2001(IHMEC) 2005 (Montefiore/AECOM) Joan Beder, DSW:  Joan Beder, DSW As I have a particular area of expertise – psychosocial support programming for breast cancer survivors and cancer patients in general – a beginning collaboration, based on my training and skill, was forged. At my meeting with two surgeons and two breast cancer survivors who are beginning to develop a breast cancer support program, I was asked whether I could return to Cuba to help them further refine and develop their program, meet with others at the National Cancer Center and collaborate on research. I see this collaboration as beneficial to Cubans and a meaningful expression of the values of Yeshiva University and Wurzweiler School of Social Work. Alison Karasz, PhD (Psychology):  Alison Karasz, PhD (Psychology) There are many, many fascinating research projects, related to the provision of services, that one could imagine in association with this hospital [Children’s Mental Health Inpatient Facility]. For example, how do children get referred? What is the nature of the family support that is offered? What happens to children when they return to the house? What is the “discourse” used by parents, childrens, & care providers to describe the nature of the ‘illness’, and does it differ among these three stakeholders? What is the relationship between the inpatient facility and the local, community based treatment providers (an issue Michele [Cuban-trained US physician] said has become quite conflictual recently)? David Strug, Ph.D.:  David Strug, Ph.D. Social work exists in Cuba on multiple levels and in multiple sectors. Social workers are trained by the Ministry of Public Health and also by the University of Havana. This has produced a creative tension between government trained social workers and those trained by the more academically oriented university community. Currently there are three levels of social workers: the level of technicians, the level of emergentes (to address emergent social problem), and the level of licenciatura. The licenciatura is a six-year training program that is more than our Masters level and less than a doctorate. In addition, the University of Havana is now planning a Masters level program that is more advanced that the licenciatura. Eventually, the university would like to have a doctorate in social work. An effort is now underway to centralize social work training at the university level. Dr. Susan E. Mason:  Dr. Susan E. Mason I shared with Drs. Lamba and Castilla some of my work with patients with schizophrenia and other mental illnesses. They expressed interest in a joint project where we would share our work methods, successes and challenges in an article to be published in an international journal. This would be a first step in establishing a relationship between us for future research projects. It seems that Cuban mental health professionals are eager for more communication outside of Cuba and for some recognition of their work in the world academic community. They, however, do not have the training for this writing and would like help in publishing and conference presentations. On my side, this is a unique opportunity to address many of the issues of mental illness from a global perspective and to the degree that I can, share my knowledge to help patients live a productive life. Matt Anderson, MD, MSc with Lanny Smith, MD, MPH, DTM&H:  Matt Anderson, MD, MSc with Lanny Smith, MD, MPH, DTM&H See the Social Medicine Portal for a write-up of the visit to Cuba: www.socialmedicine.org Further collaboration with the Journal of Social Medicine, peer-reviewed online journal (Dr. Francisco Ochoa among the editors) www.socialmedicine.info Web page for South Bronx Health Center at inspiration of Cuban Polyclinic Site. Journal of Social Medicine www.socialmedicine.info:  Journal of Social Medicine www.socialmedicine.info What Continues from December 2005: interdisciplinary work with US and Cuban Professionals :  What Continues from December 2005: interdisciplinary work with US and Cuban Professionals A significant outcome of the program was the formation of a working group to further develop a trans-disciplinary approach to collaborative research with Cuban health care and social service practitioners. First project will involve United States Citizens studying at the Latin American Medical School and the social effect of their education on both themselves as physicians and the United States Medical System. Megan Charlop, MSW:  Megan Charlop, MSW I have one last impression that has stayed with me as I journeyed home, the many times I heard the word “love” throughout the week. Love as an essential ingredient in psychological therapy and health care and love as a critical factor when developing social services for children, adolescents and troubled families. Since the early days of the revolution, I was familiar with a popular Che poster that reads, “at the risk of sounding ridiculous, let me say that the true revolutionary is guided by great feelings of love.” But it is one thing to read an old poster and quite another to actually hear and feel the word used by highly educated people to describe an ingredient fundamental to their success.

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