By Peter Young


Traveling to Cuba earlier this summer gave me an opportunity to think about the current state of the American healthcare system. Both Cuba and US healthcare have struggled through adversity, and both have attempted to regain balance through exercising resiliency. In this piece, I reflect upon parallels between these two movements, and point out how insights from the Cuban narrative might offer a new way forward to provide quality and affordable healthcare in the US.


The flight cabin erupted in cheers as we touched down in Havana, and I felt like I was joining, as a first-timer, a party that everyone else on board had known about for years. I had finally landed in Cuba, an oasis forbidden to most Americans for much of the past 6 decades.


As I exited through the airport’s front entrance and hopped in a taxi cab that was older than me, my immediate surroundings seemed to be frozen in time, stuck somewhere in the 1980s. We drove away from the terminal, and for the first time, I laid eyes on the lush, Cuban countryside in person.


View from the bell tower of the Museo Nacional de la Lucha Contra Bandidos, Trinidad, Cuba


Cruising at a modest pace, the driver, Omar, casually offered his thoughts about the political situation in Cuba, saying he’s not sure what President Díaz-Canel might do, but one thing is for sure, this country is in need of change. As he explained this, he drove us down a highway lined with tropical palms, and his occasional press on the brake pedal released terrible shrieks that sounded of metal scratching metal.


As we passed architectural gems and aging neo-classical facades that were now left for ruin, you could tell the city had faced serious hardship in the past. Several buildings had recently collapsed while other structures looked like they were on the verge of following suit. But despite the derelict nature of the city, I strode out onto the cobblestone sidewalk in Vieja Havana and found a lively spirit in the air – libations of rum were being poured into nacionales, salsa bands were filling narrow cobble-stone alleys with Guantanamera, and passerbys partook in Latin dance right on the street.


El Floridita, a historic restaurant and cocktail bar in Old Havana


It was around this time I met Emilio, my tour guide for the next week, who was already aware that I missed my original connecting flight due to bad weather. He gave his condolences for any trouble I had gone through the night before and advised me saying, “What happened is in the past and we cannot do anything about it. Instead, we might look to what the future can offer.” I wondered if this type of sentiment was what helped the Cuban people get through its recent, devastating past.


After my first Cuban meal and with my first Cuban mojito sufficiently drained, the group boarded our personal bus and embarked towards the first destination, Viñales. As we rode along the worn national highway, Emilio gave background to the country’s history starting with the indigenous peoples, up through the philosophical revolution instilled by José Martí, and to armed conflicts with American-backed forces in the 1950s. Then suddenly in 1989, he explained, following a decade of financial success, the USSR dissolved. Without its largest trading partner, Cuba entered a Special Period, the propagandized title used by the Cuban government to describe the economic depression where Cuba was cut off from many of its petroleum and energy resources. Emilio recalled the words of state-backed broadcasts aimed at reassuring Cuban society, saying, “No, we’re not in a crisis. We’re in a Special Period. We’ve never been better than now.”


Throughout the 90s and early 2000s, the Cuban people showed ingenuity, learning to repurpose tools and electronics and employing thriftiness to discover new uses for what would look like junk to most Americans. Not only were individuals pushed to change, but many of the public systems in place prior to the collapse of the Soviet Union would not survive the new economic hardships. As a result, the agricultural system was revolutionized, the Cuban diet changed, and the healthcare system was transformed. Cuban society shifted to compensate for harsh realities, and Cubans most certainly learned new skills that helped them overcome their struggles.


Now, I’m going to make a stretch here with the following analogy. While the tour bus rocked back-and-forth and others beside me were in a deep, rum-induced sleep, I wondered, is U.S. healthcare in a Special Period? This notion was prompted by my recollection of an enduring struggle in medicine. Much like the analogy of USSR’s departure from Cuba, there seem to be high altitude factors that affect the rising costs of medicine, notably, an increase in population, especially an increase in the aging population, and the price and intensity of services that have led to an increase in costs.


And what has been the result of all this? Some might argue: a healthcare system in crisis. The United States spends more on healthcare per capita and spends more on healthcare as a percent of GDP than any other country in the world, and shockingly, Americans have shorter life expectancies at birth, higher rates of infant mortality, and fewer hospital beds per 1,000 people when compared to other high-income countries around the world. To make matters worse, there are predictions of a 90,000 doctor shortage by the year 2025, and suicide is the leading cause of death among male medical residents and second most prevalent cause of death for female medical residents. It’s not surprising that clinician burnout, moral distress, and dissatisfaction with work-life balance seem to be more prevalent in the academic literature than ever.


Much like Cuban society during the Special Period, there is new emphasis on the changes American clinicians can make to accomplish more with less. These changes have been reflected by an increased focus on resilience from professional societies (Academy for Professionalism in Health Care, National Academy of Medicine, American Nurses Association, Society of General Internal Medicine), an approach that has brought new attention, positive energy, and high hopes for a better outlook in medicine.


Life in Cuba also looks like it is changing for the better. My accommodations during the weeklong venture included several stays in casas particulares, a type of Cuban homestay where families repurpose bedrooms to accommodate foreign guests. The pre-departure travel document from our tour agency explained the nature of Cuban poverty and how our casa hosts could benefit from used clothing, toiletries, toys, and snacks. I took into account the document’s suggestions and brought a bag of toothbrushes, toothpaste, lotion and Lindt Truffles thinking that I would be the savior of my Cuban host families. Was I in for a surprise! Not only did all my host families have their own WiFi, but some used better smartphones than me, and others watched translated American shows on flat-screen TVs. Even Emilio shared plans to travel abroad and visit family in Europe later this summer. You better believe I was embarrassed to hand over of tubes of Crest and hand cream to people who clearly did not need the stuff.


While the Cuban people might have held out indefinitely with austere economic policies, adaptations to hard times and changes in resource allocation are not wholly responsible for Cuba’s most-recent economic success. The most recent restorations and investments might not have come to fruition without the thawing of an antiquated US embargo. As a result of loosened American sanctions, development in Cuba exploded over the past few years, and the country received billions of dollars in foreign investment agreements last year alone. Joel, my final casa host in Havana, explained the gentrification of his own neighborhood, adjacent to Plaza Vieja. One of the restaurants that now stands on the square was a boarded building just 3 years ago. And now, as one walks through the city, they can visit El Capitolio, the national capital building with its newest renovation nearly complete; one can take a tour inside the revamped Alicia Alonso Grand Theater, which re-opened in 2016 after a 3-year restoration; and the Havanan skyline is now speckled with soon-to-be luxury hotels, slowly being pieced together by cranes.


From top to bottom: Plaza Vieja, El Capitolio, and the entrance space of the Alicia Alonso Grand Theater.


And, now I look back to the American healthcare system and think about what might serve to produce a similar end. The clinical workforce in the US has benefited greatly from a re-shifting and even re-imagination of resources, which was an effective step to bearing the hardships created through American healthcare’s Special Period. New studies have shown how burnout and workplace distress might be reduced by interventions focusing on mindfulness and resilience.


As clinicians gain a better understanding of how to achieve more with fewer resources through the resilience research program, I wonder if, like Cuba, American medicine could also benefit from a restructuring of the rules and laws that govern healthcare, that is, metaphorically speaking, dissolving our own self-imposed embargo.


One promising way forward could look at ways to cut healthcare costs. Some states, for example, have used state legislatures to control price increases. Maryland did just this in 2014 and implemented an all-payer approach that replaced a fee-for-service model with a system where all payers would pay the same rates for hospital services. In preliminary studies, the changes in Maryland have shown promising results, which suggests the unrealized potential of carefully crafted, systemic healthcare policies. Policies like this can amount to system-wide relief and might help ameliorate the distress that clinicians feel due to a lack of resources.


Much like how the changes from the American-backed thaw in 2016 prompted economic opportunities and relief to Cuban society at large, the situation in Cuba would seem to suggest that before we can see real change in American healthcare, restructuring the rules of the game are necessary.

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Peter Young

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