Bill Wagner

 

The recent thaw in relations between the United States and Cuba has generated new hope for bi-lateral exchanges, although for now, the potential remains largely in the realm of collective imagination. The tourism industry imagines white sand beaches and resorts visited by American cruise ships, the telecom industry imagines an explosion of cell towers and Internet providers on the island, and a number of Americans imagine smoking Cohiba cigars and sipping Havana Club rum. But, thanks to the Oakland, California-based Medical Education Cooperation with Cuba (MEDICC), a trans-national exchange that prioritizes people over profits does not need to be imagined. It has existed for nearly two decades.

 

In 2012, I joined a group of New Mexican public healthcare providers, administrators, advocates and researchers, with an interest in improving the health of residents of Albuquerque’s South Valley, on a weeklong MEDICC trip to Havana. MEDICC is a nonprofit organization that promotes cooperation among U.S., Cuban and global health communities to improve health outcomes and equity and uses the Cuban experience to inform global debate, policies and practice. MEDICC, in conjunction with Francisco Ronquillo and doctors Art Kaufman, Martha McGrew and Pope Mosely from the UNM Health Science Center, organized two separate groups of 15 people from Albuquerque to visit Havana. The purpose of the trip was to gain a better understanding of the Cuban healthcare system. The week included visits to consultorios—community-based clinics that are also the homes of the local physician and nurse, polyclinicas—regional, specialty clinics, and to tertiary level hospitals. The visit also included opportunities to meet with scholars at the National School of Public Health (ENSAP) and with international students at the Latin American Medical School (ELAM), one of the largest medical schools in the world. We were even able to sneak away to hear the incomparable Nueva Trova singer and songwriter Silvio Rodriguez playing a street concert.

 

Our experience observing and learning from the Cuban healthcare model provided a counterpoint to the disparities in health access and outcomes in the South Valley. Despite being one of the poorest countries in the hemisphere, Cuba is among the countries with the best health indicators in the world. Cubans told us, “We live like poor people, but die like rich people.” With the average life expectancy at 78 years, they live almost as long as the average American. Yet they have a higher doctor-patient ratio (6.7per 1,000 people in Cuba vs. 2.6 per 1,000 people in the U.S.) and a lower infant mortality rate than the U.S. (4.7 per 1000 live births in Cuba vs. 5.9 in the U.S.). Cuba has universal access to free healthcare. In New Mexico, even after the implementation of the Affordable Care Act (ACA) and the expansion of Medicaid benefits, more than 15 percent of the state’s population remains uninsured.

 

The secret to Cuba’s success, we learned, was an investment in human capital. Economic hardships generated from the embargo and exacerbated by the collapse of the Soviet bloc in 1989 generated a period of crisis in the early ’90s known as the “special period.” Food, clothing and medication were scarce, and the situation forced Cubans to economize in every aspect of their lives. During this time, Cuba developed strategies including emphasis on upstream, cost-saving policies. Epidemiological focus, cross-sector collaboration and early intervention in Cuba have been undeniably successful and contrast with downstream, individualized and crisis-response focus that characterizes the U.S. system. I spoke with Cuban doctors who couldn’t fathom why on a good year in New Mexico only 75 percent of children are fully immunized, when in Cuba the rates are 99 percent.

 

The big takeaway from our trip is that New Mexico and U.S. healthcare systems have much to learn from the Cuban experience. Healthcare provider education in the U.S. struggles to keep pace with population healthcare needs. The effects of outdated and fragmented systems in the U.S. include a focus on specialty care and emergency intervention at the expense of primary care, fragmentation and poor teamwork. Cuba’s return on investment from its high-quality primary care and public health system is unparalleled in the Western Hemisphere. The Cuban government prioritized educating and supporting a skilled professional healthcare workforce. The resulting surplus of doctors allowed Cuba to care for its population at home and embark in international healthcare diplomacy, sending doctors to less fortunate countries, often in exchange for commodities such as oil. During the recent Ebola crisis in Africa, Cuban doctors were some of the first and most effective responders. As an anthropologist working in Guatemala from 2001-2003, I witnessed doctors from the Cuban medical mission providing services in rural Maya communities where no Guatemalan doctor had previously set foot. A fundamental commitment to the idea of access to healthcare as a basic human right underpins the Cuban health mission and reinforces the esprit de corps.

 

Inspired by successes of the Cuban healthcare system, our group returned ready to take on the challenge of making health access and equity our first priority in Albuquerque’s South Valley. Supported by MEDICC, our group formed the Community Partnership for Health Equity (CPHE) and began implementing programming in the South Valley that adapted lessons learned in Cuba. CPHE participants that traveled to Cuba represented organizations including UNM Health Sciences Center, Molina Healthcare, The South Valley Economic Development Center, First Choice Community Health, The Bernalillo County Health Council, PB & J Family Services, Casa de Salud, Centro Sávila, the Partnership for Community Action, Bernalillo County Place Matters, La Plazita Institute, Albuquerque Public Schools and others. One of our first activities was to form a walking group with patients and staff from Casa de Salud and Centro Sávila. Every Friday morning we met at the West Side Community Center to walk together.

 

Many of the participants were Spanish speakers with diagnoses of diabetes or pre-diabetes. An hour of walking each week supported the physical health of patients and healthcare providers alike. The walking group served as a metaphor for the model of healthcare that we sought to build. Instead of talking at our patients in abbreviated 15-minute checkups, we walked beside them for an hour. Our group included MDs, social workers and community health workers or promotoras. Not surprisingly, we learned a lot more about their healthcare needs, their strengths and the barriers that they faced trying to access care. We learned about the scarcity of affordable, nutritious food in the South Valley. We learned recipes using locally grown produce that our patients shared with us. We learned how often diabetics had to go without insulin because of problems with insurance, prescriptions and access to transportation. We learned the difficulties many of our clients faced when, every year, they were kicked off the rolls of Medicaid and had to reapply, even though their income had not changed. We learned about how hard our clients worked to overcome barriers that made it hard to manage their chronic diseases, which were, all too often, accompanied by bouts of anxiety and depression.

 

Our South Valley CPHE walking group helped us to better understand how health disparities in the South Valley were reinforced and maintained. Despite the enactment of the ACA and the expansion of Medicaid in New Mexico, over 100,000 Bernalillo County residents remain uninsured and more than 30,000 will not be able to find coverage. Hispanic and immigrant families have the largest health and economic disparities in New Mexico. With the guidance of Dr. Camilla Romero and Guadalupe Fuentes, a health promotora, we began engaging Spanish-speaking diabetics to participate in the Girasol program, which offers a series of hour-long, one-on-one classes focusing on nutrition, active lifestyle and stress management to help manage the chronic disease more effectively. The program also invites family members of diabetics to learn ways of supporting healthy nutrition and exercise in their family as well as peer support for participants. The program also developed a therapeutic garden club at Centro Sávila.

 

In 2015, MEDICC, supported by a seed grant from the Robert Wood Johnson Foundation, funded the South Valley CPHE 2.0 program. The seed grant funds similar CPHE groups in cities throughout the country, including the Bronx, Milwaukee, Oakland, East L.A. and San Diego. This program strengthened collaboration and coordination of outpatient mental health services at Centro Sávila, diabetes prevention and management with the Girasol program and afterschool educational arts, cultural, science and sports programming through the ACCESS (Arts, Community, Culture, Education, Sports and Science) program.

 

ACCESS was founded by Fernando Ortega. Working with Spanish-speaking South Valley residents as a healthcare navigator, Ortega knew of the scarcity of afterschool programming for children. Economic, geographic, language and cultural barriers that made exercise prohibitive increased children’s risk of diabetes and obesity. Ortega collected input from parents and children and developed a series of events including a co-ed soccer league, karate and kick boxing classes, arts classes, gardening, educational and cultural activities. The group meets multiple afternoons each week and offers varied programming that also provides support for adults. Adult programming in the ACCESS program includes ESL and GED classes, student advocacy training and assistance with health insurance enrollment.

 

The South Valley CPHE 2.0 program has brought together similar CPHE groups that have formed in other cities throughout the country where MEDICC has organized delegations to visit Cuba, including San Diego, East Los Angeles, Oakland, San Francisco, Milwaukee, The Bronx, Ohio and New Orleans. Two national conferences have taken place in Albuquerque and Oakland to share our work, our successes and our challenges. CPHE groups across the U.S. are moving forward together to increase our collective impact at building health equity and eliminating health disparities.

 

Perhaps our greatest challenge in the U.S. lies in the imperial blind spots of our national memory and imagination. Cuba occupies a special place in the history of American imperialism. From military occupation to revolution to thwarted invasion, the Cuban people have endured offense after offense. Nevertheless, Cubans have imagined a country that, despite a lack of economic resources, could ensure long healthy lives for its people. As the U.S. and Cuba move toward normalizing relations and allowing Cold War animosities to be, at long last, laid to rest, the South Valley CPHE 2.0 program provides an example of U.S.-Cuban cooperation that can help both countries to imagine a future of greater equity and health.

 

Bill Wagner, Ph.D., LCSW, is the founder and director of Centro Sávila, a nonprofit outpatient behavioral health program in Albuquerque’s South Valley that provides affordable mental health and social services. Centro Sávila is the fiscal sponsor and a collaborator with the ACCESS and Girasol programs in the South Valley Community Partnership for Health Equity.

 

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