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Yul Ejnes, MD | Physician | July 3, 2017
A guest column by the American College of Physicians, exclusive to KevinMD.com.
For many years, I’ve wanted to visit Cuba. When travel restrictions to Cuba were relaxed a few years ago, I hoped that I would get there before the first Burger King opened in Havana. I had my chance in May, as a member of a delegation representing the American College of Physicians (ACP) that visited Cuba to meet with government health officials, physicians, and other participants in the Cuban health care system. Most of the delegation members were current and former leaders of ACP, all of whom paid their own way to be part of this historic visit.
This is not ACP’s “official” summary of the visit; instead, I will share some of my reflections from the five days that we spent in Havana.
Like the cars in Havana, their medical home is also antique. Primary care offices located in communities, with teams of doctors and nurses supported by specialists, dentists, physical therapists, and others, managing populations of patients, providing basic preventive care and coordinating specialty care for that population. Sound familiar? We thought we were innovative in the mid-2000s when we rolled out the patient-centered medical home (PCMH), but the Cubans were way ahead of us.
It’s not all about tropical diseases. I suspect that most people believe the greatest health care challenges on a tropical island such as Cuba are malaria, dengue, chikungunya, and other infectious diseases. However, the most common medical diagnoses affecting Cubans are non-communicable diseases. When it comes to medical conditions, the US and Cuba have the same leaders: hypertension, diabetes, cancer, and cardiovascular disease (even though you can’t buy a Whopper and fries there, yet).
They lack resources, not medical knowledge. Over the years, I’ve had the privilege of representing ACP in several countries, and on each of my journeys I’m reminded that while physicians in economically disadvantaged countries lack the resources to provide the kind of medical care that they would like to provide, they are not lacking in knowledge of the science of medicine. Acquiring that knowledge is costly, as we learned that journal subscription fees are a significant barrier for the Cuban physicians, who must be selective about which journals or online databases they will purchase. (Some academic institutions accept donations of medical journals and books for distribution to developing countries – if yours doesn’t, a list of programs can be found online.)
Quality counts, even where there is no competition (or EHR). Despite the absence of a health information technology infrastructure and the continued use of paper records, the Cuban health system tracks various metrics similar to ones we follow, such as immunization and cancer screening rates. They do it manually. At a visit to a primary care office, we saw a clipboard with a sheet of paper listing the day’s patients and the services provided. At the end of the day, the report was taken to the regional health clinic, where it would be compiled. No online registries, health information exchanges, or electronic health records. Interestingly, despite the fact that the Cuban system has no competition, its providers still want to score as high as possible on their measures.
Internists in other countries seem to be better able than us to define our specialty. I have participated in two extensive efforts by ACP to develop a “definition” of internal medicine, culminating in statements about the specialty that went beyond just saying what we were not or what we didn’t do. In Havana, I was struck by how easily the internists there could describe what an internist is and what one does, as I also observed during my visits to Dhaka and Caracas. Moreover, they showed great pride in their being internists. Next time we consider a PR campaign for our specialty, we should consider outsourcing it to our international colleagues.
They don’t seem to hold a grudge – why do we? Before I venture into what may be interpreted as a political statement, I will remind readers that what follows is my personal view and not official ACP policy. From the start of our visit to Havana, I was moved by the great hospitality that we received from the Cuban people, especially the members of the Cuban health care community. This, even though the embargo is still in effect, and the resulting harm to the average Cuban continues. We heard stories of medical equipment having to travel through several European countries to sidestep embargo rules, of shortages of basic medications such as insulin, of having to import from Asia items that could be easily obtained a couple of hundred miles and an hour’s flight away in the US. We saw an infrastructure in need of modernization and many beautiful buildings and historical sites in disrepair. Scientific exchanges between our two countries occur, but with great difficulty because of onerous rules. Yet, despite this, I did not sense any bitterness on the part of our hosts. Frustration, yes, but no blame – just hope.
This was truly a historic trip, as our Cuban internist colleagues pointed out to us, and we felt it throughout our time there. I am grateful that I was invited to participate and look forward to returning someday.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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