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“One Medicine - Many Tools”

Kofi Kondwani, PhD

Morehouse School of Medicine, USA

PROMETRA USA

Background

From January 16-23, 2005, six medical doctors and Dr. Kofi Kondwani, PROMETRA USA Board Member, traveled to Cuba from the United States on a special program to investigate the integration of complementary and alternative medicine (CAM) into Cuba’s national medical education and health care systems.  To be eligible for this delegation, each participant was required by the US government to be on faculty at a US medical school, teach CAM and be published as such in the medical literature.

Cuba’s Health Indicators compared to the US

Cuba is located only 90 miles south of the US borders yet there has been very little positive interaction between the US and Cuba for more than four decades.  Cuba has a population of 11.2 million.  Annually, Cuba spends 6.7% of their GNP on health expenditures compared to the US at 13.1%. Of that, 82.5% is spent on public health in Cuba compared to only 45.3% in the US.

Cuban’s say they “live like poor people but die like rich people” because their life expectancy at birth is 76.3 years.  This is within one year of the US life expectancy of 77.2 years.  The US compared to Cuba has a higher female life expectancy at 80.5 years compared to Cuba’s 78.6. For males however, Cuba’s life expectancy exceeds that of the US at 74.7 years compared to 74.0 years in the US.  This speaks volumes about Cuba’s health care system when you compare Cuba’s life expectancy to the poorest country in the region- Haiti that reports a life expectancy of only 54.6 years. The infant mortality rate of the US and Cuba are equal at 7.2 per 1000 births compared to Haiti at 80.3.  Cuba reports a 100 percent vaccination rate against diphtheria, pertussis, and tetanus for infants less than one year. The US has a 95% vaccination rate.

In Cuba, the physician to patient ratio is the highest in the region. Cuba reports 58.2 physicians per 10,000 inhabitants whereas the US reports 27.9.  How are these physicians trained, how do they integrate what they call “traditional natural medicine” (TNM) into their medical education and how is TNM applied in clinical settings are questions I wanted to research while in Cuba.  The remainder of this article will reflect my findings to these and other important questions.

Selection of Medical Students

                 All education from pre-school to post graduate training is free in Cuba.  At the high school level, students prioritize their choices for advanced degrees.  If selected for medical school, they will enter the 6-year program directly out of high school.  Selection is based upon test scores in science, pre-medical knowledge, and students' knowledge of Cuban culture and history.  Classmates also evaluate each other for interpersonal and social skills.

Basic Medical Curriculum

There are currently 23 medical schools throughout Cuba. All medical schools are associated with polyclinics, hospitals and community-based clinics. During the six years of basic medical education, a minimum of 160 hours of CAM education is required. CAM education is an integral part of the medical education. The goal of the Cuban medical school is to teach students “there is only one medicine with many tools”.  Therefore, CAM is not a separate course for those with a special interest in natural medicine.  It is integrated into every course for every student.  For example: when anatomy is taught, so too are the meridian points on the body that forms the basis of acupuncture.  When Pharmacology is taught, the 49 basic herbal medicines and their pharmacological grouping are also taught.  When philosophy of medicine is taught, Chinese philosophy of Taoism is included.

When a third year student learns how to conduct a physical exam, they also learn how to examine the tongue from a Chinese perspective.  They learn how to take and interpret the pulse as an indicator of specific internal problems not directly associated with the heart rate, or blood pressure. They learn to look and feel for signs of diseases before the patient even complains of symptoms.

In the fifth year, students are required to take a 6-week rotation in CAM in various CAM clinics and polyclinics throughout the country.  This CAM rotation may focus on acupuncture, herbal medicine or other CAM modalities.  During this rotation, students will get hands-on experience of acupuncture needle placement, moxibustion usage and herbal medicine usage for specific diseases.

Postgraduate Curriculum

Upon completion of the 6-year curriculum, students are required to complete two years of community service before entering a residency.  After this compulsory service, students who wish to pursue clinical work start a first residency in general internal medicine for two years in which CAM is integrated through the curriculum.  This prepares them for medical service in neighborhoods, schools, workplaces, family doctors offices, polyclinics or hospitals. Doctors may also choose to complete a second residency in a field of specialization for an additional three-four years.  Currently, there are approximately 60 medical specialties available to graduates. Doctors can receive a Diploma (Masters) Degree in CAM with 240 hours of specialization in one or two CAM modalities. 

In 1997, a four-year residency in Natural Traditional Medicine was implemented.  Some training may be abroad in China, Korea, or Vietnam where students are welcome to learn and practice the art and science of natural medicine.  Graduates of this program can teach CAM in medical schools and practice at various locations throughout Cuba.

Application of TNM in Clinical Settings

Cuban officials estimate that 52% of all medical treatments in Cuba are with traditional natural medicine.  In the year 2002 alone, more than 26 million applications of traditional medicine have been documented, including over 9 million prescriptions of herbal medicine, nearly 4 million applications of acupuncture and related modalities, almost a half-million uses of muds and medicinal waters and over 13,000 uses of acupuncture for general anesthesia and tooth extractions.

For patients where general anesthesia is contraindicated or considered to be a high risk for complications, acupuncture is used.  In financial terms, the cost of general endotracheal anesthesia is $214.83 per patient whereas acupuncture use as an anesthesia for the same procedure costs only $19.71.  Between 2001 and 2002, Cuba reported a savings of nearly 5 million dollars due to the use of acupuncture instead of general anesthesia.

During our brief tour of CAM in Cuba, our team was able to visit several sites that specialize in CAM either as a stand-alone clinic or as a wing of an existing hospital or polyclinic.  In our visit to the Pain Clinic, at the October 10^th Surgical and Clinical Teaching Hospital in Havana, the Director, Professor Fe Bosch, MD, allowed us to tour the clinic and visit with the patients waiting for medical services.  About 25 Cubans were patiently sitting in the waiting room.  Six to eight patients were seen simultaneously in a large room with beds separated by curtains.  Each patient had a written prescription from their doctor as to the type of acupuncture treatment required, location of the points to be treated, length of time for each treatment and the number of treatments to be given over time. 

Acupuncture is applied in several different ways.   Acupuncture procedures include: reusable needles, disposable needles, acupressure, electro acupuncture, and laser or infrared stimulation of acupuncture points.  Nurses carry out the treatment plan under medical supervision.  As long as the patient was responding positively to the treatment, the plan was continued.  If however, the patient did not improve or got worst they were referred back to their prescribing physician for further evaluation.

At the Matanzas Provincial TNM Center located about 80 miles outside Havana, we observed a variety of applications of CAM.  Physicians and nurses provided Tai Chi and Chi Gong instruction, aerobic exercise, nutritional counseling and diet management, acupuncture, herbal medicine, ozone therapy, and magnetic therapy.   From the perspective of our delegation, the most controversial therapy was the ozone therapy.  Ozone gas was injected into various acupuncture points or administered rectally.  One patient we interviewed with complaints of a stiff shoulder found relief from pain and greater mobility with regular weekly ozone treatments.

The most interesting to me was the magnetic therapy.  In one room where there were beds for other treatments, a bench sat in the back of the room with two sets of four large 40-pound natural magnets.  There was an elderly gentleman sitting on the left side of the bench with his hands to his sides resting on two of the magnets and his feet resting on another two magnets.  He was being treated for arthritis pain and for pain he still feels in three fingers that had been severed on his left hand in an accident many years ago.  Even though his fingers were gone, he still felt pain in the areas where his fingers were.  He reports he feels relief after he sits with his hands and feet on the magnet for about 20 minutes.  I sat next to this gentleman placing my hands and feet on the second set of magnets.  I found the experience to be very subtle yet exhilarating and very grounding.  When the patient next to me spoke, I could feel a reverberation deep inside me that could only be related to the magnet field he and I were sharing.

Even more interesting, the magnets that were used for this treatment had been dismantled from an old Soviet missile.  Magnets are used as a part of the guidance system for missiles.  The Cubans have converted a weapon designed to kill into a treatment designed to heal.  This to me captures the essence of the Cuban spirit. We can all learn from Cuban ingenuity and their commitment to the health of its people.  Out of decades of blockades, boycotts, diplomatic isolation and threats by the US, Cuba has prevailed to have an impressive integrated system of health care. There is much more we can learn from the Cuban’s regarding the application of traditional natural medicine.  They are decades ahead of the US in providing access to natural health care as a preventive and treatment strategy for all of its citizens.