The principles of liberalism ultimately moved President Obama to charter a different course in our bilateral relations with Cuba. Will diplomatic engagement help usher in political and economic reforms in Havana? Perhaps, and these changes are sorely needed. What has been forgotten in this debate, however, is the progressively decrepit state of the Cuban healthcare system, often praised by health economists for its wide-reach and fiscal discipline. Contrary to its gilded mystique, the country's healthcare system is beset by long waiting lines, poor access to care, and minimal resources. Mr. Obama's diplomatic overtures are certainly a nice start, but meaningful reforms in Cuba will rest on the heels of restoring economic ties, something the US Congress appears unwilling to do currently.
Twenty years ago, a delegation of physicians, nurses, and diplomats representing the American Public Health Association visited Cuba to better understand the health effects of the long-standing U.S. trade embargo on Latin America's biggest island country. Their findings confirmed some long-held truisms on the oft-praised health system that provides universal health coverage (UHC) to all Cubans. One, people do try to access the free care available to them, both for preventive and therapeutic needs. This has been long used to explain Cuba's steadily rising life-expectancy, currently at 79 for the overall population, certainly the highest in Latin America and clearly well above the median life-expectancy of 74 years among other upper-middle income countries globally. The report also highlighted Cuba's impressively low infant and under-5-year child mortality, noting it achieved these results, including outperforming the United States, in spite of a vastly smaller health budget. As explained then, the Castro government maintains a strong commitment to maintain health-sector investments, even in the face of economic recessions.
Though these impressive health metrics have endured, ordinary Cubans are concerned about their durability -- and rightfully so. Unlike the early-1990s, when Cuba could still rely on an ever-weakening Russia and other pariah regimes like Venezuela for exchange of commodities and basic foodstuffs, the political climate 20 years hence has afforded less capable allies to fill Havana's economic void. Moscow's global economic reach has been significantly weakened and Caracas is no longer a reliable oil-exporter.
As a result, annual growth rates have plateaued at two percentage points over the last several years, sharply below the levels seen in the rest of Latin America, which as recently as 2010 approached six percent per annum. Poor governance, marked by rising income inequality, corruption and lack of accountability, additionally challenges the sustainability of Cuba's UHC scheme. Havana ranks 75th in the annually-published Global Peace Index, a metric that attempts to quantify effective governance in a variety of sectors, putting it on par with troubled countries like Djibouti, Nepal and Malawi.
On a recent fact-finding trip to Havana, I had the opportunity to engage with several small-business owners and other lower-middle income Cubans who expressed concern about their access to meaningful clinical care, given the country's bleak economic trajectory. All of the locals I spoke to asked for anonymity for fear of government reprisal; together, they represented the continuum of blue-collar Cuban society, with many running their own Casa Particulares, which are private-enterprise home stays, and several others working as stay-at-home caretakers for their families.
During my informal interviews, which were held independently and with verbal consent, consensus was reached on several aspects of the Cuban health system. First, with regards to accessibility of care, while every family in the country (both urban and rural), theoretically has access to an assigned family physician, waiting lines are often prohibitively long, even for urgent care needs. "We try to avoid going to the hospital at all costs, much less our assigned clinic, because you often may never get seen," said one young mother who noted that she raised her now-teenage boy through several childhood illnesses with the help of foreigners who would secretly provide her pharmaceuticals. Access to a dwindling supply of pharmaceuticals is a rising problem in Cuba.
Attributed to the Helms-Burton Act of 1996, an American law that made it difficult for foreign subsidiaries to export essential medicines into Cuba, the inability of families to access needed supplies is a frequently encountered reality. Those who have access to foreign supplies of medications are the lucky few, as multinational pharmaceutical companies are unwilling to risk litigation and skirt complicated international trade law.
Surprisingly, among the several interviews conducted, no one laid blame on the US trade embargo as causative. "We understand Obama is in a difficult political situation," said one former-physician now turned home-stay owner on the outskirts of Havana. "Most Cubans blame the Castro government for the embargo and lack of access to good healthcare; the numbers do not tell the whole truth about day-to-day reality," he lamented.
The poor pay of physicians and nurses also concerned many locals: "Why would they ever want to stay here," argued a homeowner in Havana's historic district. With weekly incomes often not exceeding 50 US dollars, brain drain would certainly be a much bigger problem if emigration were not so tightly restricted. Further, locals worried that headlines showcasing the exploits of Cuban physicians overseas providing aid to combat Ebola in West Africa would only further alienate their already underpaid, overworked health professionals. Added one Havana-based tour operator: "The government is image driven, that's all they care about. They do not mind forcing our health workers to do something that makes them look good."
Instead of continuing to admire Cuba for its purported universal health care coverage, Cubans are concerned about the sustainability of their health-care system. Their concerns are justified, given the country's bleak economic outlook and political sclerosis. Stopping short of expecting a complete removal of the trade embargo anytime soon, most locals hoped that some progress could be made to help improve the quality of healthcare in the country.
First, all wished that more American tourists would come to the island given the imminent lifting of travel restrictions, so that the mutual exchange of ideas may occur and spur grass-roots political and economic change in both Havana and Washington.
Second, all shared a strong, very understandable desire to see laws like the Helms-Burton Act amended to allow the open-trade of essential medications without fear of litigation.
This post is part of a Huffington Post blog series called "90 Miles: Rethinking the Future of U.S.-Cuba Relations." The series puts the spotlight on the emerging relations between two long-standing Western Hemisphere foes and will feature pre-eminent thought leaders from the public and private sectors, academia, the NGO community, and prominent observers from both countries. Read all the other posts in the series here.
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