Health care is considered a human right in Cuba, and it's free. The country spends far less than the U.S. on health care, yet Cubans have the same life expectancy as Americans.
But after students from Michigan State University's medical school were embedded in Cuban clinics and hospitals, they discovered the situation there is ... complicated.
Let's look at the good aspects of Cuba's system first.
In Cuba, the focus is on primary care, prevention and early treatment
Dr. Luis Alberto Solar Salaverri works at the Pediatric Hospital of Central Havana. Like all Cuban doctors, Solar is a government employee, which means he is poorly paid. He is well aware he could make more money driving a taxi or giving tours of Havana to English-speaking tourists, but he has too much passion for the work to quit.
Doctors like Solar are justifiably proud of the health system here. Cuba had to develop its own vaccines because of the U.S. embargo. Today, close to 100% of Cuban children are vaccinated against a wide array of diseases. Cuban researchers developed a treatment for diabetic foot ulcers the U.S. doesn't have – and a lung cancer vaccine. And there's a family doctor in every neighborhood. Universal access to primary care means illnesses can be diagnosed and treated very early, minimizing the need for hospitalizations.
"Once you build a health system based on primary care, you have a good system," asserts Solar, "and that's what happened in Cuba."
Clinical skills can substitute for high-tech diagnostic tests (much of the time)
Diagnostic machines like CT and MRI scanners are in short supply in Cuba. Solar says Cuban doctors develop highly advanced clinical skills to make up for the lack of technology.
How advanced those skills can be was shown when a Cuban surgeon who specializes in breast cancer cases was invited to Grand Rapids, Michigan recently to observe a surgery there.
Advanced imaging had already shown the U.S. surgeons where the tumors were, and how large. To test her skills, the Cuban surgeon asked if she could manually examine the patient before seeing the images.
She was able to pinpoint the location and size of the tumors with the same accuracy as the diagnostic images.
Still, when it comes to access to technology and medicines, the U.S. embargo hurts, says Solar.
That's especially the case in cancer treatment; cancer drugs have to be purchased from other countries at greater expense, and they can be in short supply.
And, Solar says, while Cuban doctors have adapted to the lack of technology, "We need it. Believe me, we need it."
Accomplishing great things with few resources
Gail Reed is the founder of Medical Education Cooperation with Cuba (MEDICC), a group that encourages ties between U.S. and Cuban medical professionals. Reed says there's no doubt that Cuba's focus on prevention and early treatment accounts for much of its successes in health care.
But she acknowledges there are cracks in the system – many caused by the former Soviet Union withdrawing its financial support in 1989.
"The Cubans went through a devastating economic collapse in the 1990s," says Reed. "And it played havoc with all the institutions, and you can see it today still in many of the hospitals and infrastructure, and also in the availability of some medications."
Despite this, Reed says Cuba has some real public health bragging points. Special wards for women with high-risk pregnancies reversed an uptick in low birth weight babies. So far, a massive educational and mosquito abatement campaign has kept the zika virus, which is devastating other Caribbean nations, from gaining a foothold.
Reed says this explains why, despite the shortcomings, Cuban people have confidence in the health care system, "because they know when there's a major danger they're going to do something about it."
MSU medical students see what's behind the health care curtain
Cuban authorities take pains to show the country's health care in the best possible light.
But they couldn't hide some of the more disturbing aspects of routine health care practices when they agreed to embed medical and doctoral nursing students from Michigan State University in Cuban clinics and hospitals.
After the first week, as nursing student Kendra Kamp puts it, "the glow started fading."
Take Cuba's success in reducing infant mortality and low birth weight in newborns.
Officials don't usually talk about what many Americans would likely view as the dark side of the program: coercion. Pregnant women at high risk face intense pressure to move to special maternity wards, sometimes for months at a time, and if a woman balks, the police will come to her home to insist.
In clinics and hospitals, students say standard equipment was often missing. The students were permitted to interact with patients, and on occasion diagnose and treat them, but by default, it was Cuban-style.
Gierec Laput, a fourth-year student who intends to specialize in internal medicine, says there were no proper kits available for a catheter insertion; he had to re-use his gloves and do the procedure without using an alcohol swab on the patient.
"At the E.R, I saw treatment of a trauma patient where aseptic technique was not followed," says Laput, "including hand washing. It's not ideally how we practice medicine."
Jack Swan says it appears that Cuban doctors seem to look at pain as a symptom that aids diagnosis, rather than a condition that requires treatment.
Swan observed a patient undergoing a painful procedure to scrub dead tissue off his arm, with no pain relief save a cloth in his mouth, and a patient with a long bone fracture who was not given morphine, which would be typical in the U.S.
The worst incident was a botched abortion of an eight-week old fetus. Kendra Kamp says the doctors used a speculum that was too small, resulting in extensive tissue damage to the patient.
"In comparison to the U.S.," she says carefully, "where we focus on the patient and what is best for the patient, it seemed – from our point of view – that the focus in Cuba was making do with little resources."
Students also felt some cost-saving measures are counterproductive, like not doing routine blood screening of newborns.
Medical student Bo Pang says bluntly, "I'd much prefer going back to America for my care."
No disagreement here: Cuba and the U.S. can learn from each other
To be fair, these MSU medical students believe the U.S. still has plenty it could learn from Cuba, especially from Cuba's focus on primary care, prevention, and public health.
For his part, pediatrician Luis Solar says people need to understand that Cuba developed the kind of health care system that is right for Cuba. He says comparisons between the American and Cuban systems can only go so far, because of political, cultural, and other differences.
But, says Solar, while Cubans are eager to improve what they do and learn from Americans, they are just as eager to share Cuban expertise with them.
"Not just in health care," he says. "In everything – take our good things. This country is your country."