Cristian Morales, an economist by training, has dedicated his career to improving health and health equity in the Americas through his work with PAHO/WHO. This has taken him from floods and earthquakes in Haiti to PAHO’s Washington DC offices, where he was instrumental in achieving consensus on a resolution aiming for universal health—coverage plus access—approved by all governments in the Americas. Since 2015, he has served as PAHO/WHO Permanent Representative in Cuba and has recently been appointed to the analogous post in Mexico. At the end of his three years in Havana, MEDICC Review talked with Dr Morales about his experience, the Cuban health system, and the values it shares with the organization he represents. This is part one of the interview, the second part to be published in our January 2019 issue, in which we’ll talk more about the health system in Cuba itself, its achievements and also its challenges.
MEDICC Review: Since our last interview, soon after your arrival in Cuba, we’ve seen many changes in Cuba, in the region, and in several bilateral relations. Now Cubans are even debating a sweeping constitutional reform. One thing you said to me then was that Cuba shares PAHO’s values in terms of health. Is that still true, and if so, in what sense?
Cristian Morales: Yes, I think the first thing we have in common is recognizing the right to health, not simply as a legal construct, which is important of course, and is included in the proposed Cuban constitution as well as the current one. But I’m speaking of the right to health as a value essential to structuring the health system. A health system structured from a strictly economic vision, a market where health services are consumed, isn’t the same as one structured based on health as a right, that guarantees universal access to quality health services of various kinds: health promotion, disease prevention and treatment, as well as rehabilitation. This kind of system is accompanied by access to comprehensive human development policies that address the social determinants of health. This seems fundamental to me.
The way Cuba’s health system is structured around the right to health is expressed quite well in the breadth of primary health care, with two important characteristics that PAHO espouses. The first is that the system itself rests on a strong primary health care approach, and the second is that it is immersed in the community. The family doctor-and-nurse offices have a role that goes beyond protecting health, caring for Cubans in their geographic area. They also play an important part in how the community is structured, the ties that bind it internally, and finally in community development itself.
Another common value has to do with solidarity, which of course is promoted by PAHO, but is also in the genesis of the Cuban health system since the very beginning of the revolution. Perhaps the great inequalities existing prior to 1959 in the health sector also pushed forward this concept of a health system based on solidarity, one in which those who couldn’t pay had the same rights and access to care as those with more means.
Those are the two main points of coincidence. But I could also mention a third value shared with PAHO, which is excellence. There are several expressions of excellence you can see in the Cuban health system: first, of course, is the excellence of its professionals, the excellence and quality medical sciences education they receive, and then the excellence of their professional practice. But you can also see this in innovation, in their capacity to generate innovations for world health, which is the foundation of Cuba’s specialized institutes, its biotech industry (BioCubaFarma). So this is another very concrete example of how a value-based construction can achieve results that benefit not only Cubans, but also all of humanity.
MEDICC Review: From the point of view of the system, and also its results, what does Cuba have to share with the rest of the countries of the Americas? What can its experience contribute?
Cristian Morales: The results aren’t a product of fortune or chance, but rather above all, a product of political will, very clearly expressed from the start of building Cuba’s health system. I think this is important to emphasize, and personally, I believe these results have been achieved mainly thanks to the strength of the primary level of care built into the system. By this I mean not only the doctor-and-nurse offices, but also the network of community polyclinics that act as a bridge, integrating primary health care with more complex levels.
That is, there is sufficient capacity nationally to learn the needs of the population, using the local health situation analyses that are intended, for example, to determine the various problems that affect Cuban families, and from there decide the resources needed to address these problems. But this also means the national capacity to refer patients [from the family doctor] to the polyclinic or to more complex levels of care when needed. This is what we would call care centered in people, families and communities. I think this is the key to their success and their results, which are many.
Starting towards the beginning: Cuba was the first country to eliminate polio, in 1962; (certified by WHO in 1994); and in the 1970s, malaria was eliminated. These are just two important examples of diseases that continue to affect countries in the Americas, in particular the Caribbean. In Cuba, measles was eliminated in the 1990s, and more recently in 2015, WHO certified elimination of mother-to-child HIV transmission and congenital syphilis.
These are impressive results. Infant mortality has been less than 5 per 1000 live births for the last 6 or 7 years, and in 2017, it was 4, with the goal of reducing it further. There are not many countries in the world where you can observe such an indicator. And you have to remember that we’re talking about a country with few material resources, with few natural resources, but with a lot of determination and human resources that are ultimately responsible, through the dedication of their health professionals and scientists, for these contributions to the health of Cubans and people throughout the world.
I mentioned that one of the values underpinning the Cuban system is solidarity, and this is concretely expressed in its health outcomes. You can also see it expressed in results achieved beyond Cuba, across the world, through the contributions of Cuban medical teams in over 60 countries. Some 30 to 40 thousand health professionals are posted abroad in a given year. This extent of cooperation indicates an important level of solidarity, which has an impact in the health of other peoples. Not only are thousands of health professionals providing services daily, but the Henry Reeve Emergency Medical Contingent is also activated in cases of disaster or health emergencies. Thus, for example, many lives were saved by Cuban health professionals during the Ebola crisis in Western Africa in 2014.
We could also be talking about Haiti, Pakistan or Algeria (the latter the first country with long-term Cuban health cooperation, in 1963), and also about my own country, Chile, to illustrate how rooted this concept of solidarity is in Cuba’s health system. In 1960, we experienced the greatest earthquake recorded in history, and Cuba immediately organized a medical team that spent several months helping in our country, which was simply devastated. That is, over the decades, the lives of tens of thousands of people . . . the precise number difficult to say . . . have been saved thanks to the Cuban health system and its professionals.
MEDICC Review: The experience in Chile was very personal for you . . . and that in Haiti, too, where you have been posted. More recently, the PAHO/WHO offices in Cuba and Brazil received an important PAHO award for their participation in the Mais Médicos program in Brazil, where Cubans have also played an important part. Can you tell me a bit more about this collaboration?
Cristian Morales: We’d have to start by saying that Mais Médicos (More Doctors) is the largest project that PAHO has been involved in during the last few years, perhaps in its entire history. This is true not only because of the number of human and financial resources involved, but also because of its impact in the Brazilian population. In Mais Médicos, which began in 2013, PAHO has played a facilitating role between Cuba and Brazil, which decided to collaborate to provide health care for people who had never had access before. In its first phase, the program mobilized over 11,500 Cuban health professionals, who went to Brazil’s most vulnerable municipalities. That is, they didn’t go just anywhere but rather to places that had a level of vulnerability that was much worse, weaker than the rest of Brazil’s municipalities. Thus, in this first stage, some 65 million people received health services, many who had never seen a doctor before. So you get a sense of the magnitude of the program. Of the 65 million, it’s estimated that 40 to 45 million were cared for by Cuban doctors, because Mais Médicos also involves health professionals from Brazil and other countries.
The program revolves around three pivotal points: a main one is urgent care, which doesn’t mean in a hospital emergency room, but rather the urgent need to get essential services to an entire underserved population. And this is where Mais Médicos–Cuba–Brazil–PAHO is inserted, in which we have the potential to recruit Brazilians in the first round, and then if vacancies still exist, appeal to doctors from other countries who are licensed to practice in Brazil. And when those vacancies aren’t filled, we then have the possibility of recruiting Cuban physicians. So in addition to 11,500 Cubans, the first phase involved several thousand more from Brazil and other countries reaching a total of 18,000 doctors. This was the “emergency” or urgent care part of the program.
The second pivotal point of Mais Médicos has to do with expanding primary health care infrastructure in Brazil’s universal health system. This means construction of more health care centers. The third pivotal point, very important, is increasing the number of Brazilian physicians in these areas, because the intent of a program like Mais Médicos is that it be a transition, until the country has enough of its own doctors per inhabitant to provide the services required by all Brazilians. So the success of Mais Médicos will come when it ends with Brazil being able to provide quality health services to its entire population, services being provided now in part by Cuban doctors.
This is a very complex program, whose success is reflected in very clear indicators. For example, patient surveys reveal satisfaction at over 85% in terms of the quality of care offered by Cuban physicians. And we’re talking about physicians who, before going to Brazil, were not familiar with Brazilian culture, didn’t know Portuguese or how the Brazilian health system worked. Nevertheless, they have managed to successfully integrate into that system.
There are zones in Brazil covered 100% by Cuban physicians, in particular indigenous areas. Every one of the indigenous districts today is served exclusively by Cuban doctors. This is important, because these are services provided in the most remote areas, where Cuban physicians sometimes have to travel several days to get to a village, or a place that connects to the rest of the world. This is a measure of tremendous dedication, of sacrifice, and represents part of the contribution they’re making.
It’s also important to mention that these Cuban doctors are literally inserted into Brazil’s health system, into teams that work at the primary care level. This is enriching, because insertion in another system can result in new learning for professional and clinical practice back home and may also contribute to addressing some of the challenges in terms of efficiency that Cuba still faces. So for us, this sharing of experiences is part of the success of Mais Médicos.
The final element worth noting about Mais Médicos is that learning is formalized. That is, collaborators return to Cuba with postgraduate diplomas in primary health care. So they aren’t only acquiring new learning and experience in daily practice, but also in a formal teaching environment to further consolidate their technical capacities.
Today, we’re in the second phase of Mais Médicos, 2016 to 2019. In this period, there has been an important political shift in the Brazilian government. Nevertheless, the program not only continued but was consolidated, and goes forward despite political differences. And I think this is one of PAHO’s merits, putting the health of people at everyone’s center of attention, of concern, and one of the reasons why our office and Brazil’s received PAHO’s 2017 prize for outstanding team, awarded in 2018. We were able to fulfill, to concretize, PAHO’s mission of facilitating collaboration among member states to achieve the highest levels of health for whole populations.
MEDICC Review: Another element of Mais Médicos that seems interesting is that it provides financial support not only to the Cuban physicians involved, but also to Cuba’s health system, since the salaries are divided between the two.
Cristian Morales: Yes, correct. I think it’s worth noting that Brazil’s is considered one of the emerging economies, one of the 20 most important of the world’s economies. It is part of the BRICS group, along with China, Russia, South Africa and India. Thus, in this context, they receive cooperation in a project like Mais Médicos, in which they also provide compensation for Cuba’s technical assistance. And this is certainly interesting, because it allows Cuba to earn the hard currency so important to ensure the functioning of its own universal health care system.
MEDICC Review: Now that we’re speaking about solidarity in various directions, it seems we should talk a bit about Havana’s Latin American School of Medicine, the training of international medical students by Cuba. What are your thoughts about this education and the possibilities for graduates to insert themselves in health systems, as the world aims for universal health?
Cristian Morales: The Latin American School of Medicine (ELAM) is another of the Cuban health system’s great expressions of solidarity. Nearly 30,000 doctors have graduated from the school. When you go to ELAM and talk with students there, you begin to understand the real significance of what that means. I think very little is known about ELAM, which in 2019 will be 20 years old. It seems to me that we should further disseminate what ELAM has done, training so many thousands of physicians, first for Central America, then for Venezuela, all of South America, and finally we have ELAM graduates nearly the world over.
These 30,000 have been educated in the competencies needed to practice medicine, but also to practice a different kind of medicine, very different from that taught in most countries of the Americas. What do I mean? First and above all, they are taught to approach medicine from the perspective of primary health care, which means they are doctors concerned mainly with people, people in their environment, that is, their families, their communities. This is the foundation, not only of ELAM, but of all Cuban medical education. This is what distinguishes it and allows Cuba to prepare professionals beyond the technical aspects . . . and the technical aspects are important. But they’re able to instill different values in their graduates, interacting with the community, potentially becoming the true agents of change needed by the countries of the Americas.
In 2014, PAHO’s member states passed a transcendental resolution that today we call the resolution on universal health, including both universal access and universal coverage. And that resolution proposes four essential lines of strategic action to transform our health systems, to be able to reach the main objective, which is to resolve people’s health problems, and above all, to preserve their health.
The first of these strategies is to change the model of care, from the hospital-centered one prevalent in most countries, which concentrates on diseases and privileges specialization and super-specialization. It’s not that such specialization is bad, since specialists and subspecialists are needed in hospitals, but health systems need to be centered on people, their families and communities. And health services need to be organized starting there, not the other way around.
That is, when we say that this is a pivotal point, we’re being very concrete: appropriate human resources—in number, kind and quality—constitute ELAM’s contribution. And not only ELAM’s, but the contribution of Cuban medical education in general: physicians and health professionals concerned with preserving health, with looking at people, at the environment where these people evolve, in order to understand better the characteristics of their families and have an impact on the social determinants of health.
MEDICC Review: I know you prefer not to talk about yourself, but I’d like to ask you what you think is the most important contribution you made while in Cuba, and what do you take with you from Cuba, both professionally and personally?
Cristian Morales: The contribution is perhaps easier for others to judge than for me. There have been important milestones that I’ve had the privilege to accompany in these three years, which give me great personal and professional satisfaction. And I hope that others see them that way, too. Undoubtedly important for me was being able to participate as PAHO in bringing the US and Cuba closer together in favor of better health, two countries that had not formally spoken for some time . . . although dialogue was always the practice in the spheres of health and science. At the beginning of my term, this was very important.
I recall the regional meeting on arboviruses held in Havana in October 2016, in midst of the Zika epidemic. Here, for the first time, a US secretary of health came to Cuba and we were able to work together on a series of actions—not only organizing the meeting itself with Cuba, but also at the highest level with our PAHO Director. Being able to establish a dialogue that, apart from any other consideration, concentrated on what was most important: people’s health. I think that was a key moment.
The other was the Cuba Salud 2018 convention, organized by Cuba’s Ministry of Public Health (MINSAP), which we supported every way we could. There, we had the privilege of participation by WHO’s Director General and PAHO’s Director, as well as thousands of attendees, including over 60 health ministers from the Americas, Africa, Asia and Europe, plus 90 high-level leaders, a once-in-a-lifetime experience. And this also represents a constant in our work, integrated as it was with MINSAP here. That’s the greatest satisfaction I take with me from Cuba on the professional side: having achieved a high level of working relations with the ministry that corresponds with PAHO’s mandate of collaboration, and thus being able to carry forward that mandate during these three years.
On the personal side, I’ve learned about everything. I’ve learned much, very much, every day and through the last day I’m here, I’ll continue learning from each of the conversations I’ve had with the great figures of Cuban public health, with current leaders in Cuban public health, from the times I’ve been able to talk with students, workers, all kinds of people visiting the periodic health fairs. I’ve gained something from each one, and I think I leave with a very, very positive balance for myself personally, and with the satisfaction that I’ve given the job the very best I could. And I have had a great team here at the PAHO offices that has proven its mettle facing the challenges, willing to do what was needed even after hours, on weekends, and I think together we have learned much and achieved all this that gives me a great sense of tranquility. You always think you could have done more and better, and undoubtedly that’s true, but I leave knowing I did my best, and I think we accomplished a great deal.
MEDICC Review: Any special memory you’ll take with you to Mexico and beyond?
Cristian Morales: Yes, it was when, jointly with the MINSAP, we recognized those physicians who graduated before [the revolution of] 1959. They were the ones who laid the foundation for the health system we know today. The privilege of meeting them, getting to know those professionals, now quite elderly, was something extraordinary that will go with me wherever I am, the kind of thing that leaves an indelible impression and accompanies you always.
