Cuba: Where Primary Care Is All About Community

MELINDA ABRAMS: When we were visiting Cuba we visited a family nurse practice. You know, it’s called a consultorio, it’s a clinic. One thing that happened when we were asking her, the physician, a number of stories, and about her experience, she talked about how she goes to local community meetings. Because she also lives in the community. And so when she went to one of these meetings, she heard a number of her patients who are also her neighbors and her community talking about how upset they are that the garbage isn’t being picked up on a regular basis. She reached out to the local health district and said, “If there is anything that you guys can do — because it’s, in addition to it being unpleasant, it is also a public health issue.” It drove home for us, the importance, or that integration of health care and public health and the role of community, and how everyone is kind of looking out for one another, and it was just very tangible and remarkable. It was a big-picture lesson.

SHANOOR SEERVAI: Hi everyone, welcome to The Dose. You just heard from Melinda Abrams, and I also have with me in the studio Yaphet Getachew and Laurie Zephyrin. They are all part of the Delivery System Reform team here at the Commonwealth Fund. And today we are going to be focusing on the Vulnerable Populations portfolio. Melinda was just talking about their recent trip to Cuba, and so I am going to start by asking them to tell me why they went to Cuba.

LAURIE ZEPHYRIN: We were really very interested in thinking through and understanding what makes a successful primary care program. Cuba, in terms of some of their indices, they’ve done really well on indices around infant mortality and have been able to drive down rates of maternal mortality, and then overall providing access to primary health care to all of its population as a priority. And so we just wanted to understand that better, understand what it looks like on the ground, how it impacts people, and talk to some providers to get a sense of what we can learn from that experience.

MELINDA ABRAMS: I think another thing to add is that we are looking at how to strengthen primary health care for vulnerable populations in the United States. When we started reading the global health literature, we realized that maybe there are some lessons to be learned, some practices to try to adapt, that we don’t have here. One of the inspirations that we are most curious about learning more about was the role of community. That is some of what you see when you look at Costa Rica or Rwanda or Chile or Cuba. And Cuba is actually often held up as a shining light, particularly for its primary health care system, but also in this role of community. One of the things I suspect might be part of the secret sauce that we are missing in the U.S. is this role of community.

SHANOOR SEERVAI: And that sort of takes us back to the story you started us off with, Melinda. That the doctor is a part of the community and is able to think about the health of her patients as the people she lives with, and literally and metaphorically bumps elbows with every single day. And that probably shifts the way you think about delivering care to someone, right?

LAURIE ZEPHYRIN: And health care is also more than just the doctor providing care. The community lives in their neighborhoods every day and understands some of the potential public health challenges that they may experience. And primary care has a really important role in that.

YAPHET GETACHEW: And this is something that they are also taught in school. There are classes in medical school about how you integrate the social needs into the way that you care for your patients and treat your patients.

SHANOOR SEERVAI: That’s really interesting, Yaphet. Were there providers you spoke to who would talk about how they learned this in medical school?

YAPHET GETACHEW: So we spoke to a professor actually who was with us for most of the trip, and he explained a lot about how medical school works. But when we spoke to providers, even though they didn’t mention the classes exactly, they did talk about how they care about the social needs. They showed us for example this sheet of paper that goes along with every single family record. It asks, for example, is your house overcrowded, are you happy with your income, do you have enough access to basic food?

SHANOOR SEERVAI: It makes me think of what two other primary care doctors who practice in the U.S. told me on an episode of The Dose a few weeks ago. And they talked about how they never learned how to talk to their patients about costs in medical school, and it was something that came up much further down the line on the job and was sort of intimidating to them. And I feel like this lens, this idea that you have a sheet of paper on which there are other questions you ask about income and overcrowding in the house — it’s just a very different way of understanding what it means for a person or a family to be healthy.

MELINDA ABRAMS: I think part of the reason why we may not have heard, like “Oh, I learned this in medical school,” is because it is actually part of the social fabric of Cuba, this notion of community. Yaphet can say it in Spanish with a proper accent.

SHANOOR SEERVAI: Yaphet, say it in Spanish for us.

YAPHET GETACHEW: Solidaridad.

SHANOOR SEERVAI: Great.

MELINDA ABRAMS: Thank you. So solidarity is just a key tenet of Cuban life. Taking care of your community, taking care of your neighbors. It is a big cultural difference from the United States.

YAPHET GETACHEW: The thing that I didn’t even mention with the whole social needs sheet is that this stuff isn’t just stuff that they hear from the patient, they are doing site visits to patients’ houses. And so they can see this on their own. So the patient could tell them something in a visit, but they are also doing at least one site visit per year per patient.

SHANOOR SEERVAI: Where does someone go in Cuba if their child is running a very high fever?

LAURIE ZEPHYRIN: So I think typically from what we experienced and what we’ve read is they would go to the family doctor. Or nurse. They would go to the consultorio, which is in the community. I would imagine it would also be possible for the family doctor or nurse also to come to that child’s house to evaluate them as well.

SHANOOR SEERVAI: Okay, and the consultorio is a clinic you said, where there would be the family doctor, the nurse?

LAURIE ZEPHYRIN: Right.

YAPHET GETACHEW: And to explain how the health care system is structured. It really is kind of in four tiers. The first one is the consultorio, which Laurie mentioned. That is your first stop.

MELINDA ABRAMS: And there are 11,000 of them around the country.

YAPHET GETACHEW: And above that are the polyclinics of which there are around maybe 450, a little more. And then above that it is hospitals. And then above that these more complex institutes, which do more complex care, and maybe research as well. We really focus on the first two things that I mentioned, because that is what primary care is. So that is the consultorio. And then from there your doctor can push you up the ladder based off of how complex it is, what you need, what specialists you need to see, but they are there the whole time. So it really is an example of continuity of care, and really well managed care as well.

SHANOOR SEERVAI: And now that you have seen how this primary care system is structured, what were your biggest takeaways?

MELINDA ABRAMS: So for me one of the big takeaways was how the primary care clinician or practice really doesn’t have to go it alone. There is a team — so as Yaphet and Laurie mentioned, there is this doctor–nurse dyad in the community. The doctor lives in that community. But the basic health team is not just that doctor and nurse, it also includes an Ob/Gyn, a pediatrician, a psychiatrist. All from the polyclinic, from that regional polyclinic. They visit the patients in the consultorio, in the community practice. It also includes a social worker, and it also includes a statistician.

SHANOOR SEERVAI: And so Melinda, just so I can be clear, the statistician — because we don’t hear as much about statisticians in primary clinics here in the U.S. — so this person is there all of the time so that they can really help to think about the whole population. Maybe if there is an outbreak of a certain disease in one part of the neighborhood, would that spread to another? That kind of thing?

MELINDA ABRAMS: So let me be clear, those additional people, whether it is the OB or the statistician, they are not there all of the time. They visit at least once a month, and more often if necessary. But even in the United States we don’t always have in a primary care setting a statistician visiting once a month.

YAPHET GETACHEW: Also, if you want an example of them doing a lot with very few resources. The consultorios — the family doctor and nurse offices, they don’t have computers. And they are recording all of their patient files by hand. And they have to deliver those by hand every single day to the polyclinic. And the statisticians there have a computer that they can then analyze stuff, and that gets passed up.

SHANOOR SEERVAI: It makes you think about what the word innovation means, right? Innovation, I think we feel like that needs to have the fanciest gadgets, but it really doesn’t.

YAPHET GETACHEW: No.

MELINDA ABRAMS: Definitely not.

LAURIE ZEPHYRIN: Well, it shows the importance of data too, like you had mentioned, Shanoor, in terms of tracking trends and being able to identify outbreaks before they come out, or determine priorities. And so being able to track that from the top down is something that they seem to prioritize.

SHANOOR SEERVAI: What are other things that you saw them prioritizing that you brought home with you?

LAURIE ZEPHYRIN: When I was in medical school I took a course around community health and social medicine. And just really the importance of community in health, and social, and medicine. And really this was to me being able to see that in action. And I know we have talked about the community piece, and the social needs piece. But really just driving home how important that is to work together, it really reaffirmed my commitment to primary care, and the importance of primary care and the health of a population.

SHANOOR SEERVAI: And Yaphet, what was one thing that has really stayed with you when you came back?

YAPHET GETACHEW: Something that I found really interesting was how they again just use data, but they use it to also risk stratify their patients. And how they do that is they put all of their patients based off of their medical needs into four different tiers, right? Ranging from healthy all the way up to having an acute illness. And every single person, no matter how healthy they are, gets at least one site visit a year. But people who are, say, at risk, have a chronic disease, or are the acutely ill, are people that get even more than that. So that means more site visits, more chronic disease management, more check-ups with the doctor. But everything is based off of what tier you are in, and that is how they build your care plan.

SHANOOR SEERVAI: So it is like even with fewer resources, we’re not trying to do a one-size, fits-all cookie-cutter thing, we are really trying to meet patients where they are and look at what their needs are.

YAPHET GETACHEW: Beautifully said, yes.

MELINDA ABRAMS: Yeah, and I think if you take a lot of these strands and pull them together, what we see is population health in action. It is kind of a little bit of a buzz word right now, but actually in Cuba it is alive and well. It is risk stratifying that patient based on need. It is having data about their unmet need. It is about having data around their social needs. And Yaphet touched on this, but the patient record is not by an individual, it is per household. So when you open up the record you see all of the people that live in that household. And across the bottom it is the social needs for the household. Do they have trouble buying food, or difficulty having — do they have enough money to meet the nutritional needs of the household, or the rent? So that combination of data, combination of risk stratification, combination of thinking about the community.

SHANOOR SEERVAI: Wow, it sounds like a lot to have everybody’s record from the same house all together as a family record. Here, we really think about a patient’s individual record, and a patient’s right to their own health data. Does this sense of community get too much, Melinda?

MELINDA ABRAMS: Definitely. We also kind of got the sense that sometimes community, while it means that you can take care of everybody — it sometimes can also feel a little bit like an invasion of privacy. We were also cognizant of the fact that not everything is perfect.

SHANOOR SEERVAI: When I was in college I took a class on Cuban literature, and really wanted to understand how this country — this small island that is so close to the United States — is able to be so different from the United States. And that was just fascinating to me. But one of the things that came up is that the country is facing a lot of challenges. And so I do want to ask, what are the challenges that they are facing as they try to provide this comprehensive community-based health care?

LAURIE ZEPHYRIN: I can speak a little bit to the challenges that we heard from the providers on the ground. I mean, they definitely work long hours. The primary care providers are under a lot of pressure to make sure that they take care of the health of the population and meet national health goals. And so similar to I would say primary care providers here in terms of just sometimes feeling overwhelmed and stressed possibly. The other thing is —Yaphet and Melinda talked about sort of the statisticians having to write the data and write the information and send it paper form to the statisticians. And so the lack of resources and outdated technology in some of our readings, access to medications, and even some basic medications such as aspirin or acetaminophen can be challenges to access as well.

SHANOOR SEERVAI: I suppose to take this issue of resource constraints and just zoom out a little bit, this has been the big challenge for the Cuban economy, right? Trying to do more with less. Trying to make sure that everyone can have access to the same sorts of things, but in that process of leveling out the playing field, actually the level is just very low. And that brings me to this issue of how much doctors get paid in Cuba. Yaphet, did you get a sense of that?

YAPHET GETACHEW: Yeah, so this is something that people talk about all the time, right? People asking or wondering why Cuban doctors make so little money.

SHANOOR SEERVAI: Yaphet, tell me how much doctors get paid.

YAPHET GETACHEW: Yeah, so doctors make the equivalent of about $60 US every single month, which is very, very little. And what’s crazy is, say a taxi driver can make that in a single day. So if you work in the tourism industry you can make so much more than you can working as a doctor.

SHANOOR SEERVAI: And that is because the taxi driver works in the tourism industry, and so is getting paid in this different currency that you get if you do that?

YAPHET GETACHEW: Yes, that is exactly right, and the currency that locals get paid in is 25 times less valuable than the currency that tourists use and then people who work in the tourism industry then get.

SHANOOR SEERVAI: Right. And even if you are a doctor, which is a very highly valued profession, you are still working with locals.

YAPHET GETACHEW: Yes.

LAURIE ZEPHYRIN: And the key thing is they still want to be doctors. There is still a priority to train doctors, and they still want to give back to their community by serving as physicians or nurses or in health care.

SHANOOR SEERVAI: That is amazing. Why do you think that’s the case, Laurie?

LAURIE ZEPHYRIN: Personally, I think being able to give back and help others, is probably at the heart of why most people go into medicine. And it seems to me in a society such as Cuba, the health of community is prioritized from the top down.

MELINDA ABRAMS: It’s cultural.

SHANOOR SEERVAI: And part of the culture is that there are spaces for people to go and spend time with each other. It seems like there is more social interaction than we have here.

MELINDA ABRAMS: There are a number of opportunities throughout one’s life span, where people are brought together. So for example we went to visit this place called Casa de Abuelos, which is essentially almost like an elder person’s day care. So if you live in a household where everybody else is working, and you are an older adult and you are retired, you can go to this Casa with other older adults, and there is social interaction, there are activities, a primary care clinician will visit on a regular basis. They can also review your meds — so there is a little bit of health care, but it is actually not about health care at all. It is just also about making sure that people in the community are taking care of each other. And then every community has one of these.

LAURIE ZEPHYRIN: We’re talking here a lot about loneliness in our society now.

SHANOOR SEERVAI: You mean in the U.S.

LAURIE ZEPHYRIN: In the U.S. And it seems that they understand that social isolation, loneliness is also a public health issue. And have ways of trying to address that, particularly with the elderly.

SHANOOR SEERVAI: There is one other public health issue that I wanted to ask you about, Laurie. The difference in maternal care in the U.S. and in Cuba. There has been a lot of attention right now here about the high maternal mortality rate. And I wonder if there is something that we can learn from Cuba’s primary care system, about maternal care?

LAURIE ZEPHYRIN: There are several things. One is reducing maternal mortality is the priority of the country. One of the family medicine physicians said to us, “Every maternal death, if there is one, is investigated down from the community level on up.” And so it is something that everyone is aware of, and it is prioritized, and it is tracked. And Cuba has actually been seeing a decline in their maternal mortality rate.

The other thing with primary care being the foundation, one of the things that I was really impressed at is that the family medicine provider not only risk stratifies the entire population as Yaphet talked about. And so women of reproductive age are in this risk stratification two out of four. And that just means that they are monitored more closely. And when they are pregnant they get into care early, and that family medicine provider continues to follow them throughout their pregnancy. They are not necessarily providing the obstetric care directly, there is an obstetric specialist that will do that. But they maintain that connection to the mom during that pregnancy. And after pregnancy they also are already involved in her care.

The other thing which was really impressive as well is that high-risk women, or women that potentially may have problems during pregnancy, whether it is high blood pressure or other potential problems, they can also go to a maternity waiting home which is near the hospital. And are more intensely monitored. And it could be weeks or months during their pregnancy. And so it is really something about a system that seems to prioritize the care of women at all levels across the life course.

SHANOOR SEERVAI: Yeah, this idea that we keep coming back to, it is community care and it’s for your whole life. It is not just isolated.

MELINDA ABRAMS: Right.

YAPHET GETACHEW: Maternal care also was an example of integrating behavioral health care as well. Because when women become pregnant, they meet with psychiatrists as well. So not just Ob/Gyn’s, but they have regular meetings with a psychiatrist, which I am not sure what happens in the U.S. I don’t know Laurie, but —

LAURIE ZEPHYRIN: It could be a challenge particularly with poor women who may not have access to mental health care during pregnancy.

YAPHET GETACHEW: Yeah, so that was really interesting to me.

SHANOOR SEERVAI: Well, before we close out I have one more question: Now that you are back in the U.S., and you had the chance to see on the ground how this entirely different system works, what is one thing that you would bring from a clinic that you visited in Cuba to your own primary care clinic here in New York? Melinda, let’s start with you.

MELINDA ABRAMS: When I think about it for myself, for my family, some things that I would love to see in the care that I receive is, I love this notion that either my primary care physician or my primary care pediatrician has very ready, integrated access to this broader team. So I feel like at any time there is some kind of issue that comes up, and I have got to go to some specialist, I feel like I am starting over. This broader notion of the team is one thing I would definitely like to bring back.

SHANOOR SEERVAI: Yaphet?

YAPHET GETACHEW: Just to second what Melinda said about the continuity of care. If a primary care doctor really shepherded you through the process, and really helped you understand what your next steps were, I think would be a big benefit.

SHANOOR SEERVAI: Thank you all so much for joining me today.

MELINDA ABRAMS: Thanks for having us.

YAPHET GETACHEW: Thank you.

LAURIE ZEPHYRIN: Thank you.

SHANOOR SEERVAI: Listeners, don’t go away, the show isn’t over yet. A few weeks ago, on Episode 20, we talked about Medicare for All. A ton of you wrote in — some of you said you think Medicare for All is a good idea, some of you said it is not. For me, it was great to hear so many stories. So here’s one of them I think you’ll find interesting.

AUDREY WYATT: Hi. This is Audrey Wyatt, calling from Los Angeles, California. I wanted to share my story about our 30th anniversary trip to Europe. We weren’t in Italy very long when my husband got sick. So, not knowing what to do, we went to the emergency room.

The whole experience took just under an hour. We were taken in to see a doctor. He did a history, and then sent my husband down for an X-ray of his lungs. In the time it took us to get from the X-ray department back to the doctor we’d seen, he already had the test results. He diagnosed my husband with bacterial bronchitis and prescribed an antibiotic and an expectorant.

My husband said, “Where do I go to settle the bill?” The interpreter relayed the question, and the doctor kind of chuckled, and he goes, “There is no bill. Try and enjoy the rest of your trip.” My husband got two medications which came in U.S. dollars to $21, less than we would have paid at a pharmacy in the States with our copay.

Well, I didn’t feel sick at that point, but a few days later we were in Prague, and I did get sick. My husband took me to the emergency room in Prague. Now, in the Czech Republic, they have health care for their citizens but they don’t make it available to visitors. The nurse explained to me in halting English that she had to charge me. And the look on her face was just embarrassment.

Now, my copay to go to the emergency room in the States — and that’s just to get in the door — is $500. My total bill in the Czech Republic for getting in the door, giving a medical history, getting blood work done, getting a diagnosis and a prescription, came to $69 US.

If you have a story to share or want to tell us what you think about The Dose, send us an email. Our address is [email protected]. Thanks for listening.