Insights from Cuba: Primary care as the focus of COVID-19 prevention
Today our focus is on Cuba, a Caribbean island with about 11 million population and a very different economic and political regime. Canadians know Cuba well through their tourist visits – more than one million in 2019 – enjoying the beaches, food, music and friendly welcoming from the Cuban people. Today, we are interested in a different facet of Cuban society – the community focus of its health system and their success, so far, in controlling the COVID-19 pandemic. There are important insights for us in Ontario.
By Ontario standards, Cuba has done excellent, so far, in terms of flattening the COVID-19 wave, although it is now facing an upsurge in cases. As of yesterday’s count, it reached a total of 3,174 cases overall and 89 deaths. Ontario, in contrast, with a population of about 14 million, has had 40,459 cases and 2,788 deaths. We provide next an excerpt from an article on Cuba’s initial COVID response by UK Professors Emily Morris and Ilan Kelman and we then follow with our own commentary.
Coronavirus response: Why Cuba is such an interesting case (excerpt)
Cuba has several advantages over many states [in handling the COVID-19 pandemic], including free universal healthcare, the world’s highest ratio of doctors to population, and positive health indicators, such as high life expectancy and low infant mortality. Many of its doctors have volunteered around the world, building up and supporting other countries’ health systems while gaining experience in emergencies. A highly educated population and advanced medical research industry, including three laboratories equipped and staffed to run virus tests, are further strengths.
Also, with a centrally planned, state-controlled economy, Cuba’s government can mobilise resources quickly. Its national emergency planning structure is connected with local organisations in every corner of the country. The disaster-preparedness system, with mandatory evacuations for vulnerable people such as the disabled and pregnant women, has previously resulted in a remarkably low loss of life from hurricanes.
However, COVID-19 presents differences. Cuba’s lack of resources, which hampers recovery from disasters, also contributes to a housing shortage that makes physical distancing difficult. And the island’s poor infrastructure creates logistical challenges.
Also, the pandemic comes at a particularly difficult time, as tightened US sanctions have sharply cut earnings from tourism and other services, deterred foreign investment, hampered trade (including medical equipment imports) and obstructed access to international finance – including emergency funds.
Given these strengths and weaknesses, Cuba provides an interesting case study in responding to the current pandemic.
Cuba’s reaction to the coronavirus threat was swift. A “prevention and control” plan, prepared in January 2020, included training medical staff, preparing medical and quarantine facilities, and informing the public (including tourism workers) about symptoms and precautions. So, when the first three reported cases were confirmed on March 11, arrangements were in place to trace and isolate contacts, mobilise medical students for nationwide door-to-door surveys to identify vulnerable people and check for symptoms, and roll out a testing programme. [Editor’s note: the term “medical” in this paragraph includes nurses and nursing students]
On March 20, with 21 confirmed cases reported, the government announced a ban on tourist arrivals, lockdown for vulnerable people, provision for home working, reassignment of workers to priority tasks, employment protection and social assistance.
As issues arose, the Cuban government adjusted its response. For example, when face-masks and physical distancing proved insufficient to keep public transport safe, services were suspended and state and private vehicles and drivers were hired to transport patients and essential workers. And to reduce crowding in shops, the distribution system was reorganised and online shopping introduced. Physical distancing enforcement has also been stepped up in response to instances of non-compliance.
Cuba’s approach to COVID-19 and RNAO’s insights for Ontario
Cuba promotes itself as recognizing health as a human right. Although it is not a rich country and has suffered the continuous impact of the US blockade for 60 years, it has an effective universal health system focused on primary care and localized services reaching people in their communities. Many years ago I had the opportunity to visit a family clinic in Habana (here is a more recent account). The clinic was situated inside a large apartment complex, and the clinic was a regular apartment in the building where a family doctor and a family nurse worked under spartan conditions doing very effective work. The nurse and the physician lived in the neighborhood and knew the community members closely. They served around 120 families (about 600-700 people of all ages). The most striking difference with our patterns of health-care provision was that the doctor and the nurse did not see their role as waiting for individuals from their catchment community to walk into the clinic. Instead, they acted on health promotion and active surveillance of health risks in their community. The dyad team worked extremely collaboratively and took much pride in the results, which at the time were recorded in hand-made charts.
During COVID, since their first positive case, Cuba has tackled quickly and effectively case and contact tracing followed by the 14-days WHO recommended isolation. The doctor and/or nurse visit community members daily at their home and if any present the slightest symptoms they are transferred to the hospital to be tested. In addition, a national search plan was launched, going house by house, using doctors, nurses – and students in these professions – to find out if someone in the family has symptoms. A journalist recalls someone knocking in his door and asking “Is everyone okay, someone with a cough or fever?” Cuba’s Minister of Health stated that the strategy “is not to wait for the virus to appear, but to go out and look for it.” The New York Times calls Cuba “a rare success story in Latin America for its textbook handling and containment of its coronavirus outbreak through contact tracing and isolation of potential asymptomatic carriers of COVID-19,” and its network of local family clinics closely knit within their communities stands at the core of this success.
Since late July, Cuba has been confronting an upsurge in COVID-19 cases. With single digit number of new daily cases in June, numbers have jumped to an average of 57 new daily cases during the last week. Although from an Ontario perspective this is a very low case number, the Cuban government has responded assertively to put down the latest upsurge. In Havana, restaurants, bars and pools are once again closed, public transportation suspended and access to the beach has been banned. Several other measures have been implemented and the Habana area has been isolated from the rest of the country where with few exceptions no cases have been reported in more than two months.
What can we learn in Ontario from Cuba’s experience? There are many factors that are intrinsically different. Cuba is an island and does not have thousands of kilometers of southern border with a country suffering from an inept federal government that has given rise to the largest COVID-19 crisis in the world. While there are aspects of Cuban society we would not want to emulate, such as the struggle to democratize political institutions, their approach to community-led health delivery and focus on health promotion and disease prevention is something we should learn from. In an earlier article, we spotlighted a primary-care/home-based model to confront COVID-19 in the Balearic Islands, in Spain – another excellent example of community-lead health services.
We have characterized our experience in Ontario with the first wave of COVID-19 as a tale of two pandemics. One is the management of the spread of the disease in the general population, and its containment though physical distancing, self-isolation and hospitalization, when necessary. During the first four months of the pandemic, Ontario’s response was slow in coming and was focused mainly on the role of hospitals, while other sectors remained an afterthought. Hospitals prepared very well and were given priority in access to PPE and other equipment; although they reached intensive levels of activity during the April-May peak, they were never overwhelmed (thankfully). In contrast, all other sectors and especially primary care and homecare were on the verge of collapse, and long-term care (LTC) did collapse. Local public health units were activated with delays to carry out the vital work of intense case and contact tracing.
RNAO released in May its Enhancing Community Care for Ontarians (ECCO) 3.0 report. It was intended as a call, in the context of Ontario’s health-system transformation, to both government and health-system partners to strengthen community care and anchor the health system in primary care to better meet the needs of all residents. ECCO 3.0 calls for an integrated health system that can always effectively serve Ontarians, even when confronted with a deadly pandemic. RNAO has argued for over a decade that Ontario must recalibrate its heavy reliance on hospital care with much-needed and strengthened community care – and that the health system must be anchored in primary care tightly linked to public health. This is a vision that focuses on health promotion and disease prevention and on improving people’s health at their homes – which is where most Ontarians wish to live.
As RNAO has strongly argued, “improving people’s health at their homes” includes LTC residents for whom nursing homes are their home, as well as strengthening homecare services – another sector that is underfunded, neglected, and in pressing need of reform. There are many advantages to supporting people remain in their community rather than rely on institutionalization, when that can be avoided – whether hospitals or nursing homes. Not only is it better for individuals to be well supported in our communities – a strong community care anchored in primary care delivers a high functioning and cost-effective health system. It also addresses concerns such as ”hallway healthcare” in hospitals and the large number of alternate level of care (ALC) patients. In October 2018 there were 4,635 ALC patients waiting in an acute or post-acute hospital bed. How many could have been nursed to return and remain in their homes, if we had a robust homecare sector?
Ontario’s health-system transformation, including the launch of Ontario Health and its now existing 29 Ontario Health Teams (OHT), was a step in the right direction. Our struggles with COVID-19 suggest we need an even more integrated system of care. However, government decisions during COVID-19 went the opposite direction. For example, aligning LTC homes struggling with COVID-19 with hospitals rather than with primary care or homecare was puzzling. Why did we not benefit from a homecare sector that saw sharp decreases in care volumes due to cancelled surgeries? It would have helped nursing homes with better suited health human resources and helped homecare agencies keep their staff employed.
More recently, the Ontario government announcement of its Accelerated Build Pilot Program to build LTC homes at hospital sites and under their oversight, is equally puzzling. Why, instead, not invest in smaller nursing homes geared to persons with Alzheimer’s who require personalized environments? Why not invest in homecare so persons in need can remain active members of our communities? Centralizing our health system through hospital-led models is wrong-headed and does not advance a comprehensive health system of care. Strong community care expertise exists in Ontario – it just needs to be utilized and given the priority it finally deserves.
Real reforms require resources, but experiences in middle-income Cuba or in Spain’s Balearic Islands shows it is not simply a matter of resources – it is also a matter of vision and mindset. We should put the spotlight on community-based care and emphasize decision-making from a wellness perspective. The focus should be on health promotion and disease prevention, education, nutrition, housing and other basic necessities of life – these are resources that help people live better and healthier lives in the midst of our communities, rather than segmented out.
It is not enough to have organizational change such as implementing OHTs. We require a change in mindset, which is not going to be achieved by placing hospitals – whose primary mission is to cure illnesses – in charge of community care organizations such as homecare, or of organizations that ought to be treated as community care, such as nursing homes.
RNAO was so hopeful when OHTs came to be. We were proud to inform the Request for Proposals, we were thrilled to read the embargoed draft, we joined many of the announcements and thought “Wow, this government is really serious about recalibrating the health system towards community care.” Today, after several announcements of hospitals taking over nursing homes and seeing no real investments to strengthen primary care, homecare and LTC services (i.e., improvements in staffing), I wonder if we are back to Ontario’s same old, same old. A quote attributed to Albert Einstein says: "The definition of insanity is doing the same thing over and over again, but expecting different results."