Tuesday, November 19, 2013

1192. The Principles of Health, Cuba and the U.S. Embargo

By Richard Horton, The Lancet, July 2013

Although officially classed as an upper-middle-income country, the American embargo against Cuba continues, punishing not only a government but also an entire people. (Article 33 of the Fourth Geneva Convention states that “No persons may be punished for an offense he or she has not personally committed. Collective penalties...are prohibited.”) The Cuban Assets Control Regulations were established 50 years ago this month (on July 8, 1963) under the US Trading With The Enemy Act. It is a violation of those regulations if an American citizen travels to Cuba, engages in any kind of trade with Cuba, or even brings back goods of Cuban origin. There is a complex bureaucracy around the supply of medical products, which limits their supply and use. 50 years of trying to hurt 11 million people enough to encourage an insurrection to overthrow their government has taken its toll. Infrastructure in Cuba is fragile. Incomes are low. The Castro regime—Fidel or Raul, it is the same party that has been in power since the Revolution of 1959— is struggling to open up an economy without suffering the depredations that plunged its one-time banker, the Soviet Union, into criminal mayhem. (When the Soviet Union imploded, the GDP of Cuba collapsed by a third within 24 hours, a moment Cubans, with seemingly wry humour, call the “Special Period”.) Yet, despite Cuba’s problems, there are few public protests. The government does not fire rubber bullets at its citizens. It does not need tear gas. Why? Could it at least partly be thanks to universal health coverage?
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Cuba was the first Latin American country to implement a comprehensive primary health care system. The vice-minister for health spoke last week in Havana of her government’s priorities. Her first concern was “user satisfaction”, followed by quality and efficiency. Reducing maternal mortality was her overriding objective. Could universal health coverage be a political instrument for national peace, order, and stability? That is certainly the explicitly stated objective of China’s health reforms. But the reason the Cuban people do not riot, the reason they endure the American embargo without condemning their government, and the reason they seem to accept the absence of freedoms usually seen as litmus tests for legitimate political regimes
elsewhere goes beyond the health system (although it is linked to it). Ever since the 1950s, when the USA exploited Cuba as a playground for gambling and corruption, and for over 400 years of colonial rule before that, the goal of Cuba’s leaders has been to restore the dignity of their people by winning independence and autonomy. Cuba’s Government is certainly imperfect. But its imperfections are considerably fewer than its successes. Castro won independence and autonomy. He restored dignity. He established highly effective health and education systems. Under his brother, Raul, Fidel’s victory must now meet the challenge facing all nations (and health systems)—sustainability.
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Within that challenge lies one approach to health that does make Latin America distinct from other regions of the world. As part of a symposium to review the hidden contributions of Latin America to our understanding of health, Nila Heredia, a former Minister of Health in Bolivia, set out a view of social medicine that makes western notions of public health seem anaemic by comparison. Heredia described four principles of social medicine, all of which one can see intimately connected to Cuba’s success under the Castros. First, health is a fundamental right. Second, health is socially deter- mined. Third, health can only be achieved through universal (non-discriminatory) policies. Fourth, health can only be achieved through social participation at all levels. These four principles are influenced by four additional forces—interculturality (how rarely we take culture seriously in western medicine), gender, labour, and the environment. At the heart of this notion of social medicine lies our attitude to health—is health a good to be traded and exchanged or is health a right? Here is the most important lesson of all from Latin America—it was the only region of the world that took the 1978 Declaration of Alma Ata seriously. 35 years after Alma Ata, and after 50 years of American sanctions against Cuba, perhaps it is time to look again at why universal health coverage is the most powerful force to achieve human dignity, equity, and self-realisation.

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