Lessons from Cuba

Monday, May 6, 2013

One of A Tu Lado’s newer members, Will Heegaard, recently returned from a research trip to Cuba. Will joined a group of emergency clinicians, educators and responders from California. They spent two weeks surveying Cuba’s public health, emergency medical service (EMS), and disaster management systems.

Reflecting on his experience, Will wrote this post sharing lessons learned from Cuba:

“I do not believe there is such thing as a natural disaster,” the meteorologist told us. “Hurricanes, tropical storms, earthquakes, they are all normal planetary phenomena, as normal as the ocean tides or wind currents that we see every day.” Speaking Spanish, and his voice rose to fill the tiny conference room of the Meteorological Institute of Cienfuegos, Cuba, where we had gathered to listen to him talk.

“What makes a disaster a disaster,” he said, “are the human societies involved. A hurricane in the middle of the ocean isn’t a disaster. Nor is an earthquake in a city if the buildings are structurally sound. A disaster only occurs when human communities aren’t prepared for the threats that face them. Don’t blame nature, blame the shortcomings in human organization, communication, and preparation.”

The old saying “necessity is the mother of invention” epitomizes Cuba’s approach to human health and safety. Isolated from the modern global economy, Cuba compensates for its shortage in money and supplies by carefully developing their human resources.

The UN Development Program claims that one dollar spent on preparedness saves seven in emergency response. By focusing their limited capital on high-return investments like education, preventative medical care, early warning systems and evacuation plans, the Cuban government affords its citizens healthier, safer lives than do most countries in the Americas. Even compared to the US, they boast a lower infant mortality rate, less HIV prevalence, fewer disaster-related deaths and longer life expectancy. The Cuban health care system offers a great case study for anyone interested in securing human life on a budget.

Cuba’s strategy of preparedness and prevention starts with the community. Doctor/nurse teams live in the neighborhood they serve, receiving patients in small offices quite literally “around the block” or “just down the street.” Each team cares for an average of 500 families, somewhere between 1500 and 2500 patients depending on the area. They visit every home at least once a year to develop a comprehensive risk assessment for each patient, along with the family as a whole. Patients suffering from chronic disease or disability are visited more often as needed. For an issue requiring more equipment than the team has on them or in their office, the patient’s primary physician refers the patient to the community’s polyclinic.

The polyclinic we visited in Managua was a two-story, mostly open-air compound built next to a dirt road that trailed off into a village of small homes. A receptionist seated behind a wooden desk greeted us as we walked in. She led us around the courtyard, past groups of plastic chairs set around doors marked Optometry, Dentistry, Rehabilitation, Emergency, among others. Mothers holding infants sat outside the Maternal-Child Care station. The compound was clean but bare; a tropical breeze blew through un-shuttered windows and the receptionist’s heels clicked on the concrete floor. She led us to an unadorned conference room where we met the clinic’s physician director.

Each polyclinic provides a home base, the director explained, for the doctor/nurse teams practicing prevention in the field (twenty to forty per polyclinic according to the WHO). Each polyclinic’s Records Office compiles all the data collected from surrounding the population, and public health officials use it to tailor the polyclinics’ services to each community’s specific health risks. By extending comprehensive primary care into the community, the polyclinic acts a buffer for the regional hospitals, keeping beds open for patients who really need them. And for rural health emergencies, it’s a lifeline. The Managua polyclinic’s ER isn’t much – two tables, a gurney with ripped cushions, an old defibrillator, a sink on a concrete counter and a small cupboard of IV supplies – but it offers a space to stabilize and prepare a patient for transport to a more advanced facility.

Staffed with the right people, that little room can make all the difference. We stepped inside to find a nurse spraying down the floor and wiping the table with bleach. Looking up, she explained that they just treated two trauma victims from a freeway traffic accident. “But don’t worry, they’ll be fine,” she said with a tired smile. Through the wall we could hear the crunch of tires on gravel as the ambulance pulled away. No siren necessary, the patients were stable.

In a recent trip to Colombia, A Tu Lado learned that Colombia’s EMS system uses RNs and MDs as their primary pre-hospital caregivers. Cuba is very similar. Their Sistema Integrada de Urgencias Medicas, SIUM, coordinates all medical transportation for the country, dividing their ambulances into Intensive, Urgent, and Non-Urgent units similar to our Critical Care Transport (CCT), Advanced Life Support (ALS) and Basic Life Support (BLS) services in the United States. However, all Intensive ambulance units are staffed with a paramedic driver, a nurse and a physician trained in pre-hospital emergency medicine. Putting physicians on ambulances allows more intensive care to be delivered on-site and minimizes unnecessary transports. Integrated into the network of neighborhood doctor/nurse teams and community polyclinics, Cuba’s SIUM provides a blanket of emergency medical care for the island’s twelve million people.

Cuba’s strategy of prevention – identifying health problems before they cause an emergency – extends past the individual patient to inform policies of disaster preparedness. Quite simply, the government cannot afford to evacuate people off rooftops with helicopters, so it has designed early-warning systems and evacuation plans to avoid that emergency from arising. Cuba’s meteorologists, like the inspired speaker from the Meteorological Institute in Cienfuegos, are instrumental in providing the information needed to inform Civil Defense decisions and save lives. The results are striking: while the US lost over 1,600 people to Hurricane Katrina, Cuba’s death toll from Hurricane Dennis (a more powerful storm that hit a similarly-sized population the same year) was sixteen.

As ATL explores ways to advance pre-hospital care in medically underserved communities around the world, Cuba provides an example for achieving high standards of community health while using very few resources. (In Cuba, providers lack the basic materials – modern defibrillators, textbooks, CPR dummies – that we take for granted in the United States.) Their system of pre-hospital care, community preparedness and education offers a path to follow for other resource-tight nations seeking to improve the health and safety of their citizens.

 

Statistics cited in this article were sourced from Will Heegaard’s interviews and WHO and UNICEF databases. For more information on Cuba’s health care system, see:

“Cuba’s primary health care revolution: 30 years on.” Bulletin of the World Health Organization, Vol. 86: May 2008. http://www.who.int/bulletin/volumes/86/5/08-030508/en/

Campion EW, Morrissey S. “A Different Model – Medical Care in Cuba.” New England Journal of Medicine, 2013;368(4):297-9. http://www.nejm.org/doi/full/10.1056/NEJMp1215226