The Atlantic November 29, 2016
A kindergarten student in Havana poses in a doctor costume Photo by: Enrique De La Osa/Reuters
On public-access TV in 1985, Bernie Sanders defended an element of Fidel Castro’s regime: It was rarely mentioned that Castro provided health care to his country. Sanders grumbled that the same could not be said of then-President Reagan.
The comment came back to haunt Sanders in the wake of Castro’s death. On Sunday on ABC’s This Week, host Martha Raddatz played the old clip and then asked Sanders if he was aware that “this was a brutal dictatorship despite the romanticized version that some Americans have of Cuba.” She reminded Sanders that Castro rationed food and punished dissidents, then hit him with the big question: “So have you changed your view of Castro since 1985?”
Sanders said he didn’t exactly remember the context for his comment (being 31 years ago) but that Cubans “do have a decent health-care system.”
Many consider it more than decent. After a visit to Havana in 2014, the director-general of the World Health Organization Margaret Chan called for other countries to follow Cuba’s example in health care. Years before, the World Health Organization’s ranking of countries with “the fairest mechanism for health-system finance” put Cuba first among Latin American and Caribbean countries (and far ahead of the United States).
Cuba has long had a nearly identical life expectancy to the United States, despite widespread poverty. The humanitarian-physician Paul Farmer notes in his book Pathologies of Power that there’s a saying in Cuba: “We live like poor people, but we die like rich people.” Farmer also notes that the rate of infant mortality in Cuba has been lower than in the Boston neighborhood of his own prestigious hospital, Harvard’s Brigham and Women’s.
All of this despite Cuba spending just $813 per person annually on health care compared with America’s $9,403.
In Cuba, health care is protected under the constitution as a fundamental human right. As a poor country, Cuba can’t afford to equivocate and waste money upholding that. This pressure seems to have created efficiency. Instead of pouring money into advanced medical technology, the system is forced to keep people healthy.
It’s largely done, as the BBC has reported, through an innovative approach to primary care. Family doctors work in clinics and care for everyone in the surrounding neighborhood. At least once a year, the doctor knocks on your front door (or elsewhere, if you prefer) for a check-up. More than the standard American ritual of listening to your heart and lungs and asking if you’ve noticed any blood coming out of you abnormally, these check-ups involve extensive questions about jobs and social lives and environment—information that’s aided by being right there in a person’s home.
Then the doctors put patients into risk categories and determine how often they need to be seen in the future. Unlike the often fragmented U.S. system where people bounce around between specialists and hospitals, Cuba fosters a holistic approach centered around on a relationship with a primary-care physician. Taxpayer investment in education about smoking, eating, and exercising comes directly from these family doctors—who people trust, and who can tailor recommendations.
The system requires around twice as many primary-care doctors per capita as we have in the U.S., made possible because the country also invested in medical education, creating in 1998 what U.N. Secretary General Ban Ki-moon called “the world’s most advanced medical school.” Cuba has become known for training not just domestic doctors, but those from around the world—and sending its doctors to help other, wealthier countries when needed. During the recent Ebola crisis in Sierra Leone, more than 100 Cuban doctors and nurses were at the front lines.
Castro justified sending so much support with a brutally holistic understanding of disease as a global phenomenon. He wrote at the time: “By completing this task with maximum planning and efficiency, our people and sister peoples of the Caribbean and Latin America will be protected, preventing expansion of the epidemic, which has unfortunately already been introduced, and could spread, in the United States, which maintains many personal ties and interactions with the rest of the world.”
That spirit also underlies Cuba’s vaccination program, implemented in 1962, which has left the country with some of the world’s lowest rates of vaccine-preventable infectious disease.
The much wealthier U.S. also has vaccines and primary-care check-ups, of course. The key difference is that in Cuba, these things are mandatory. They’re seen as akin to doing routine maintenance on a car to keep the warranty valid. If the system is going to take care of people in dire situations, people must also let the system take care of them before those dire situations occur.
This is the opposite of the U.S., where people demand the former but forego the latter. There are costly barriers to primary care and preventive medicine, but showing up at an emergency room is easy.
While Cuba’s situation is far from ideal, it serves as an elegant counterpoint to the three-trillion-dollar U.S. health-care system—which is controlled by corporations (privatized insurance, pharmaceutical, medical-device, and hospital systems) that drive people to pay exorbitant costs (either directly or through taxes). Cuba offers a dire reminder that efficient health care can be provided at much less cost to the people—when the focus is on primary care and prevention.
As Salim Lamrani of Paris-Sorbonne University put it, excellent health care can exist in the absence of wealth “if political will exists to put human beings at the center of the project.”
In that light, Sanders’s comments were valid, then and now. After defending Cuban health care on the ABC show on Sunday, he continued, “the Cuban economy is a disaster.” And then, unequivocally, he added: “No, I do not praise Fidel Castro.”
This exchange highlighted a fundamental barrier to progress in health care. Do you praise Fidel Castro? If you had to answer yes or no, the answer is no. But good and bad co-exist here, as everywhere. The first step is overcoming the human tendency toward ‘all-good’-or-‘all-bad’ dualism. It can be true that Castro did horrible things, and that Cuba’s health-care system is lacking in many ways, and also that there’s much to learn from it. newsletter.
This post originally appeared on The Atlantic.