NURSING LEADERSHIP FOR UNIVERSAL HEALTH
To the Editors:
Since the 1960s, the Cuban health care system has focused on primary preventive health care that meets community health needs and results in optimized population health outcomes. This foresight to train the Cuban health workforce has resulted in three significant milestones: free health professional education (1960s), establishment of community polyclinics (1970s), and development of family doctor-and-nurse teams in the 1980s (described in Gorry’s Feature in January 2017).[1] The Cuban health system highlights the key role of nurses in clinical practice, following the World Health Organization’s (WHO) promotion to strengthen nurses’ training and leadership,[2] and serves as a model for international health systems in two ways.
First, high-quality academic training provides Cuban nurses with didactic and clinical training at three specialty levels: specialist (e.g., postgraduate level), professional (e.g., baccalaureate-level), and technical (e.g., associate-level). By promoting the continuous assessment and risk evaluation (CARE) process for medical evaluations in clinic and home visits, nurses can assess physical and psychosocial health, unhealthy behaviors (e.g., physical inactivity, toxic behaviors), and environmental risks (e.g., poor air and water quality, mosquito-breeding sites). Hence, nurses understand that social determinants of health can impede health equity and optimal family and community health. They are skilled in coordinating disease prevention and medical treatment plans in their designated communities or as part of the Henry Reeve International Medical Contingent global deployments to disaster sites.
Second, collaborative teamwork and communication between Cuban nurses and physicians in clinical practice foster increased efficiency of task coordination in community clinics and home visits. This practice emphasizes shared decision-making with patients, complemented by nurses’ holistic training in health and wellness and physicians’ expertise in the medical model. As they work side-by-side in domestic and international communities, they gain insight on fruitful interdisciplinary collaborations based on professional autonomy, respect, and solidarity in primary care.[3]
The future global health workforce requires highly trained nurses who can promptly identify health risks, participate in shared decision-making with patients, and provide appropriate holistic care in communities. Recognizing the universal health coverage targets of the Sustainable Development Goals, we are pleased to see that Cuban nurses, alongside their global counterparts, will continue to lead efforts in providing health service delivery to citizens of all ages.
- Gorry C. Cuba’s family doctor-and-nurse teams: A day in the life. MEDICC Rev. 2017;19(1):6−9.
- World Health Organization. Nursing and midwifery in the history of the World Health Organization, 1948–2017. Geneva: World Health Organization; 2017.
- House S, Havens D. Nurses’ and physicians’ perceptions of nurse-physician collaboration. J Nurs Adm. 2017;47(3):165−71.
Marianne Mathewson-Chapman PhD MSN ARNP (mmchapman60@gmail.com), independent nurse consultant, Treasure Island, FL.
Helena J. Chapman MD MPH PhD, Research Scientist, University of Florida College of Medicine, Gainesville, FL.
AUTISM MANAGEMENT IN CUBA
(Edited for brevity and reprinted with permission from Association for Science in Autism Treatment Media Watch. Original available from: https://www.asatonline.org/media-watch/asat-responds-medicc-reviews-autism-spectrum-disorder-cuba-comprehensive-coordinated-response/)
To the Editors:
We are writing in response to Gorry’s article, Autism Spectrum Disorder in Cuba: Comprehensive and Coordinated Response, in MEDICC Review’s April–July 2017 issue. First, we applaud you for disseminating your analysis on autism prevalence in Cuba and how families receive services for their children. The Association for Science in Autism Treatment (ASAT) supports families and offers them resources on scientifically based autism practices. It can be difficult to access information on clinical and educational trends in Cuba, so we are pleased to see through your analysis that Cuba may be using such practices in their schools and with professionals working with children with autism spectrum disorder. By utilizing applied behavior analysis (ABA) and specific evidence-based practices within occupational and speech therapies, Cuba appears to be on the right track to assist this population by using the best available treatments.
You start your article with the personal accounts of three young Cubans who have been diagnosed with autism and who have received services through specialized schools and government-backed funding. Their notable improvements mirror what can often be seen in the USA when parents are able to take advantage of federally funded, evidence-based early intervention programs. We would welcome future articles with more details on how the programs you mentioned are run. For example, how many Board Certified Behavior Analysts work in a single specialized school or set of schools? Are there any experimental teaching practices occurring in these educational settings that you are aware of? Receiving more in-depth insight into practices from a country that has been relatively cut off is vital to increasing access to appropriate services for all, and we applaud you for your efforts.
In addition, it is wonderful to see that Cuba is using tools that many US pediatricians and professionals employ to help diagnose autism, such as the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. However, you mention that Cuba still needs an extensive research project to map national autism prevalence. This would improve efforts to collect as much empirical data as possible, which may help advance programs and assist professionals in the field. We hope the USA and Cuba will soon have increased opportunities to join forces and share with each other their knowledge and expertise in autism research, which may also help advance programs and assist professionals in the field. When we collaborate to advance scientific research and critically evaluate outcomes, we can more efficiently expand effective practices for all.
We take this opportunity to make a few clarifications. Regarding specific intervention, you mention, “Although autism has no cure, symptoms and functionality can improve through a combination of psychosocial interventions, speech therapy, behavioral modification, special education, and alternative and complimentary therapies,” and you go on to say that “treatment must be individualized.” While treatment should certainly be individualized (and we are grateful that you included Dr Whilby’s cautionary statement to parents that “improvements aren’t always made”), we would like to add that every individual treatment should be backed by scientific evidence of effectiveness. Hundreds of touted “treatments” exist that are not backed by adequate research, and they can end up causing more harm than good. These include some of the “therapies” mentioned in your article. You can find more information on the evidence behind potential treatments on the Learn More About Specific Treatments page of ASAT’s website (https//www.asatonline.org). Our website contains information on a variety of topics that you might be interested in sharing with your readers in future articles focused on evidence-based treatment for individuals with autism.
You also mention that ABA “is an integrated and individualized treatment protocol designed to modify behavior and increase skillset by using positive reinforcement; a baseline is established for each child measuring their responses to a series of trials desired behavioral responses are rewarded, negative or incorrect responses are ignored and their progress tracked as they improve, with positive reinforcement provided to motivate them to keep striving and learning.” While there are aspects of this statement that are true, we would like to clarify that practitioners of ABA aim to improve socially important behavior by using interventions that are based on principles of learning theory and that have been evaluated in experiments using reliable and objective measurement. By and large, positive reinforcement is a key aspect of any ABA program, but it is not necessarily the only way to effect behavior change, nor are “negative or incorrect responses” always ignored or “responses to a series of trials” the only way behavior is measured. All ABA interventions should be based on the function of (or reason for) behavior, and are highly individualized.
Thank you for giving the world a glimpse of the essential job that Cuba is doing for its people in need. We hope Cuba will continue to refine their pursuit of evidence-based practices for individuals with autism.
Elena M. Escalona MS Ed (mediawatch@asatonline.org), Association for Science in Autism Treatment
Renee Wozniak PhD, BCBA-D, Association for Science in Autism Treatment
