Commentary: Daring to learn from a good example and break the ‘Cuba taboo’

When confronted by observations of unusually positive or negative outliers, epidemiologists and other scientists are typically drawn to better understand what could be producing such results. Recognition of diminishing HIV/AIDS prevalence in Uganda, for example, appropriately triggered activity to examine and learn from associated policies and practices that could be accounting for this.1 So when a low-income country can be seen to be systematically producing excellent health indicators, one would think that this would attract considerable scientific attention. Think again. Despite the remarkable health achievements that the small island nation of Cuba has registered, there has been limited discussion of this in scientific circles. To set the record straight, the paper by Cooper et al.2 has done far more than provide an extremely useful chronicle of impressive Cuban achievements in areas such as lowering infant mortality, improving cardiovascular health, making health services accessible, developing new biotechnological breakthroughs and providing assistance to countries in need. They draw explicit attention to the coherence of the policies that have produced these accomplishments, stressing that these are the ‘consequences of a well defined strategy; [and] the value of these underlying principles, not the accumulation of better numbers, is what holds implications for other poor countries.…’ However, Cooper et al. also reflect on the anti-scientific implications of failing to recognize Cuba's achievements—something of even more far-reaching and disturbing consequence. At a moment in time when global failures to reach Millennium Development Goals are being acknowledged and the need to strengthen the health systems of low and middle-income countries is receiving heightened recognition,3 the ignoring of what has been attained in Cuba could not be more ironic. In recent years, the agencies whose policies have systematically failed to produce development and health in low-income countries have undertaken extensive studies such as the Macroeconomic Commission on Health4 and related efforts to develop new directions for rectifying the situation—all the while continuing to ignore the Cuban experience. Attributing this glaring ‘exclusion bias’ merely to the strong US political pressures for isolating Cuba, which has even extended to blocking publication of scientific articles by Cubans,5 provides too narrow an explanation for why this has occurred. The virtual taboo against recognition of what can be learned in Cuba suggests deeper roots that perhaps call into question the epistemology of how we seem unwilling to understand how good health results can even be created. In a previous examination of this phenomenon,6 we suggested that Cuba's success ‘on the margins of globalization’ might in no small part be related to its remaining outside the sphere of influence of policies that promoted development models and structural adjustment policies that have proved to be deleterious to coherent health system capacity (something Fidel Castro had rhetorically attributed to Cuba's ‘privileged position as a non-member of the International Monetary Fund’7). The implication of this observation is that social and organizational priorities and approaches may be of especially great significance in producing results—something that undermines the faith that there are merely technical solutions to be found and applied. The ideological set of blinders that sustain this viewpoint are not ‘political’ in the Cold War lexicon of Socialism vs Capitalism. They fundamentally point to how we solve problems and are open to possible solutions. The tendency to place a ‘taboo’ on Cuba is thus a symptom of the strong inclination to narrow the boundaries of what are deemed to be possible approaches. This circumstance has been experienced before. When Alma Ata placed the challenge of ‘Health for All by 2000’ on the agenda, and suggested that there must be a more systematic organization of primary health care services, a contrary orientation of ‘Selective Primary Health Care’ was promoted and ultimately carried the day in shaping the policy of donor countries.8 This tendency to emphasize cost-effective single interventions rather than systemic strengthening, combined with the impact of structural adjustment policies, helped seal the fate of the colossal failure to reach Alma Ata's goals. In fact, a fundamental legacy of such policies was the weakened health systems that left low and middle-income countries unprepared to meet today's global health challenges. When the Macroeconomic Commission on Health met to consider the global health challenge it essentially did little more than recommend implementation of Essential Health Interventions, a more systematic way to provide the quasi-technical solutions that ‘Selective Primary Health Care’ had promised. And yet, while this was occurring, Cuba was able to develop a set of coherent policies to adopt a national strategy, develop a comprehensive primary care capacity, and achieve excellent health outcomes. Some time ago, it was suggested that the threat of a good example (or a politically alternative development trajectory) was an ideological factor in explaining why US policy was uncompromisingly hostile to Cuba.9 The openness to consider Cuba's achievements is clearly called for now, and the taboo on evaluating this experience should be lifted. The question ultimately should then become less of ‘whether’ and ‘why’ the successes are being achieved and more of ‘how’ this can be done. Over the past 10 years, our team of Canadian and Cuban researchers has documented how it is not just the organization of health services but the broad way in which health determinants are addressed that plays a major factor in the ‘social production of health’—with the possibility of fruitfully engaging the health service workforce as part of a broad-based ‘population health team.’10,11 Our joint Canadian–Cuban team is presently undertaking a study to better understand and evaluate how determinants of health are being managed inter-sectorally and how evidence is being used to close the ‘know-do’ gap in a country where the political commitment to act on evidence has been manifest. As Cooper et al. point out, before undertaking a research agenda into how positive results can be achieved, it is first essential to recognize that other approaches to produce health are possible—and that the Cuban experience provides an extremely instructive natural experiment. There is much room for mutual learning, and Cooper et al. have provided an excellent basis for considering why we should move in this direction.

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