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Keywords:   Cuba,  acupuncture,   acupuncture   education, teacher  education,  health  care, sick  care,  medical  college, neuroscience, curriculum, hypno-digito-acupuncture.

Introducing Cuban Medicine

Infomed: the Cuban Medical Informatics Network

Ralph Alan Dale's website: http://acupunk.com/

East and West Meet in the Caribbean: Is Cuba Developing the World's Best Health Care Model?

Ralph  Alan Dale, Ed.D., Ph.D., C.A., Dipl. Ac.,  Ernesto  Bravo Matarazzo, M.D. and Blanca Cantera, M.D.

Abstract: Cuba is now developing and integrating acupuncture in the medical curricula, in clinical practice and in research throughout the country. Health care, which is free to all Cubans, is considered a right rather than a privilege. The emphasis on prevention and on natural and benign methods has been leading to an increasing role for  acupuncture  in their health care system which  has  already become a model that many countries have been studying.

Cuba is in the process of embracing acupuncture as a basic component of national health care. Acupuncture has begun to permeate medicine through:

  1. the efforts of a recently formed National Commission of Acupuncture,
  2. the introduction of formal courses in acupuncture in the medical colleges,
  3. a Teacher Education Program designed to prepare a national faculty of doctors and dentists,
  4. a program to teach acupuncture to all family doctors in all provinces, and
  5. the increasing role of the Cuban Acupuncture Society and the Cuban Neuroscience  Society  in  furthering  acupuncture  research  and development.

The  information reported here derives from  three main sources:

  1. The observations of Dr. Dale in three trips  to Cuba  in  1990, 1991 and 1992;
  2. The summary  reports  of  Dr. Cantera who is a neurophysiologist and neurosurgeon, a member  of the  National Commission of Acupuncture, a professor at  Victoria de  Giron Medical College, and one of the leading  architects  of the  incorporation of acupuncture in medical curricula,  clinical practice  and research. Dr. Cantera and her  colleagues  recently contributed  a  research  study to the  American  Journal  of Acupuncture. and
  3. The summary data and evaluations of Dr.  Bravo who  is Professor of Basic and Preclinical Sciences, Victoria  de Giron  Medical  College,  editor of Filosofia  y  Medicina  (1987 Havana)  and  author of the forthcoming book  on  the  innovative contributions  of  Cuban medicine.

Acupuncture is therefore mainly evolving through medical clinics, hospitals  and colleges, although finger acupuncture is in  wider use,  for   example  by  psychologists.   

There   were   many opportunities  for Dr. Dale to observe the use of acupuncture  by psychologists  since  his  lectures in Cuba in May  1991  and  in October  1992 were sponsored by the Cuba Hypnosis  Society  whose President,  Braulio Martinez Perigod and Vice-President, Enrique Grenet  Cordoves are both psychologists and whose  membership  is largely composed of psychologists. The clinical practice of  many of  the Society members includes both hypnosis and acupuncture. Dr. Grenet has just completed a book explaining a combined method which  he  has created  that  he  calls,   Hypno-Digito-Acupuncture, and for which Dr. Dale wrote the Preface.

The National Commission on Acupuncture.

A National Commission of Acupuncture was appointed this year by the Ministry of Health to facilitate the development of acupuncture throughout the country by:

(1) developing acupuncture curricula in the medical colleges,

(2) creating a Teacher-Education Program to provide a faculty to teach acupuncture to every family doctor in the country,

(3) to encourage acupuncture research and

(4) to help to extend the practice of acupuncture among all the medical specialties.

The implementation of these goals are in process as indicated in the following observations.

The Medical Curricula.

There are eight or nine medical colleges in Cuba, all of which will soon incorporate acupuncture as an important part of their curricula.

All medical colleges have a six-year program. In addition there is a three to four year internship requirement. Acupuncture will become an integral part of every level of this program.

Acupuncture has already been incorporated into the curriculum at many medical colleges, specifically, Giron and Julio Trigo colleges in Havana, and the medical colleges in Holguin, Oriente (Santiago de Cuba), Villa Clara and Cienfuegos.

I was fortunate to have visited Victoria de Giron Medical College on the very day they were celebrating the 30th anniversary of the College  which  before the revolution was a  private  school  for girls.  The College now occupies a very extensive campus, beautifully landscaped and providing the kind of quiet and serene environment  that  is  conducive  to  intellectual  and  clinical studies.    The acupuncture students had set up an exhibit clinic. Models and posters were displayed along  with needles,  moxa and electro-instrumentation. Along the four  walls of  the  room  were mini-clinical demonstrations where student patients were being treated by student doctors. I was impressed with the accuracy in the placement of needles, with the  knowledge displayed by the students, and most of  all,  with the high level of enthusiasm.

At  Victoria de Giron Medical College about 50% of all first  and second   year   students  receive  an introductory   course   in acupuncture  that  meets four hours per week throughout  the  two sixteen-week semesters that comprise the academic year. The other twenty  weeks  of  the year are  devoted  to independent  study, examinations, voluntary work in the countryside that  contributes to the overcoming of the present food shortages, and vacations.

During the third through sixth years at Giron, many of the students continue with their acupuncture studies, while some students who were not able to begin their acupuncture studies, in the first and second years, have the opportunity to begin them in the third year. About 40% of the medical students at Giron are currently involved in the acupuncture program which is intended soon to be able to include all students in the college from the first through sixth years.

There are discussions now going on in the medical colleges, in the Acupuncture Society and in the National Commission of Acupuncture as to the best structure and methods for integrating acupuncture into the curricula. On the postgraduate level, acupuncture is in rapidly growing clinical use in the main specialities, for example, in family practice, internal medicine, gynecology and obstetrics, psychiatry, and others. Medical students are thereby beginning to receive clinical acupuncture training during their internships.

The Teacher Education Program.

The National Commission on Acupuncture has organized a Teacher Education Program recruiting those already advanced in their understanding of acupuncture and in their clinical experience. Some of the participants have been practicing acupuncture for as much as twenty years.

The Program was originally designed as a one month intensive, meeting eight hours a day, six days a week. The Program has been extended to eight weeks and more recently to ten to twelve weeks. There were at first ten to fifteen in a class. Now sometimes there are as many as twenty-two participants. Dr. Cantera feels that the Program works much better with a smaller number so that sufficient time can be devoted to working with each individual student. Approximately 300 doctors are currently enrolled in the Teacher Education Program.

The goal of the course is to introduce a standard curriculum that may be employed to teach acupuncture to every family doctor and dentist. One such course will be given in every Province in the country and one in each District of Havana. Three such courses have already been given and the graduates already have begun to teach family doctors.

Doctors and dentists who participate in these Teacher Education Programs are given a leave from their clinical positions and paid their regular salaries while in attendance.

While visiting Almajeda Hospital, I was introduced to one of these classes that was then in session, and was being taught by Dr. Francisco Perez Carballas, the father of Cuban acupuncture who wrote the first acupuncture books for Cuban medical students. I presented some ideas that might be useful in the teaching of family doctors, and was very impressed by their discussion and by their creative incorporation of new ideas into their paradigms. Cuban doctors in general seem to have the kind of expansive consciousness that those of us in teaching so appreciate and that we find, unfortunately, is more the exception than the rule among physicians in the U.S.

The selection of the doctors and dentists to participate in the Teacher Education Programs is made by a written examination and a practical examination by two teachers who were not the original teachers of the candidate. Doctors are selected from every province and from every district in Havana City, and from all the main medical specialities, thereby insuring participation from pediatrics, gynecology and obstetrics, internal medicine, anesthesiology and integral general medicine (family practice).

The course concludes with a Board Examination composed by three professors unknown to the student. The teacher candidates are required to pass the Board Examination with scores higher than 90% to qualify as facilitators in the Family doctor instruction program.

The Teacher Education Program began this spring. It is expected that by the end of the year (1992) every family doctor will have received the basic courses that will permit them to make use of acupuncture to relieve pain and to treat most of the ailments they are generally confronted with in their practices.

The curriculum of the Teacher Education Program is divided into nine themes:

Theme 1. General Aspects of the Nervous System<D>: the vertebral system, metameres, nerve fibers and pathways, autonomic nervous system, neuronal system, bioelectric conduction, neurotransmitters and neuropeptides.

Theme 2. Western Theories of Acupuncture: Melzak and Wall, neurological peptides (endorphins, enkaphalins and dynorphins), reflexotherapy, noceptive theory, autonomic theory.

Theme 3. Research, Prophylaxes and Pain Treatment.

Theme 4. Oriental Criteria: the Chinese concept of energy, Tao, Yin and Yang, 5-Element theory, Zang-Fu organ theory, circulation of energy theory.

Theme 5. Chinese Diagnosis: the Eight principles, Clinical aspects of traditional diagnosis, pathogens.

Theme 6. Acupoints, their Actions and Possible Relations to Neuro-Hormonal Function: the meridians, the acupoints (definition, measurements, localizations, points on each meridian), general action points, local and distal points, Alarm points (Shu and Mu), Luo points, Ah Shi points, Reunion points, Analgesic points, Tonification and Sedation points, homeostatic points, regulating points, immunological points, general strategies of treatment according to the 5-Element theory, the functions of the meridians, the metameres and the specific action of the points.

Theme 7. Stimulation Techniques: tonification and sedation, advantages, disadvantages and special functions of different types of stimuli, e.g. needling, acupressure, moxa, pharmaco-acupuncture, laser, massage.

Theme 8. Electro-Acupuncture: general characteristics of stimulators, e.g. biphasic and monophasic waves, tonification and dispersion, indications and contraindications, basic methods and techniques for acupuncture analgesia.

Theme 9. Micro-Acupuncture Systems: definition, relation with meridians, holograms, ear, face and other micro-systems, techniques of stimulation, usage in relation to traditional and western medicine, indications and contraindications.

The textbooks that they are using for this course are:

R.A. Dale: The Micro-Acupuncture Systems, Books I, II, III, IV.
A. Jayasuriya: Clinical Acupuncture.
D.J.Sussman: Acupuntura.
Bui Quoc Chau: Cybernetic Facial Therapy.
B. Jensen: TENS Treatment.
K. Yamashita: Acupuncture Conferences.

Acupuncture and the Family Doctor.

The graduates of the Teacher Education Program have begun to launch the nationwide program to teach all family doctors and dentists acupuncture. Since Family doctors already know the concepts and language of neuroanatomy and neurophysiology, their first introduction to acupuncture is presented in these terms. After the physicians understand the mechanisms of acupuncture, they explore the traditional concepts of diagnosis and treatment. In this program, it is assumed that the family doctor knows much more about Western than Chinese diagnosis, so there is a greater reliance on Western diagnosis by the Family doctor who is still an acupuncture novice. Those who acquire deeper understanding and more extensive clinical experience begin to rely upon acupuncture diagnosis as well.

The format of the introductory Family doctor program consists of 4-hour sessions meeting once a week for at least three months, plus clinical practice at polyclinics. They particularly address the twenty pathologies most frequently seen by the Family doctor.

It was pointed out to me that dentists who learn acupuncture are not restricted, as they are in the U.S., to the treatment of the face, head and neck. Cuban dentistry recognizes that the body is not divided functionally into specializations, as allopathic medicine has come to be divided. Points like LI 4 (He Gu) or ST 45 (Li Dui), which may relate to problems of the mouth, are freely used even though they are in a part of the body that the dentist is not specifically trained to treat. Moreover, patients who come to the dentist and who happen to have another acute problem, for example, asthma, at the time of the visit, might be treated for this problem by the dentist who knows acupuncture. They make a soft line separating specialties, partly because there is no vested interest defending different professional "turfs," as in our profit medicine, and partly because of the Cuban recognition that holistic realities transcend the arbitrary division of allopathic medicine of body parts and functions.

The Role of the Cuban Acupuncture Society and the Cuba Neuro-Science Society.

In  Cuba, there is a close relationship, in  research,  teaching, leadership  and  membership, between the Acupuncture  and  Neuro-Science  Societies.  In my recent visit, I addressed  a  combined meeting  of  both societies in Havana with about 100  doctors  in attendance.

There are approximately 600 members of the Neuroscience Society at the present time. The section of the Society devoted to reflexotherapy, pain and acupuncture includes about 75 members, about 20 of whom are from the provinces. Next month a new section of the Neuroscience Society will be organized in Oriente Province at the eastern end of the country.

The membership of the Neuroscience Society consists of medical doctors and researchers. The Acupuncture Society, although, in the main, composed of medical doctors, is open to all who are interested in and engaged in acupuncture research and clinical practice. I do not at the present time have figures on the membership of the Acupuncture Society.

Other Programs Now Offered.

An International Course on Electro-Acupuncture is offered to doctors from abroad every May. This course is taught by Dr. Francisco Perez Carballas, Dr. Cristian Mendoza and Dra. Blanca Cantera.

An International Course on Basic Acupuncture is offered each July and/or January.

General Observations and Conclusions

None   of  this  remarkable  progress  in  the   development   of acupuncture in Cuba can be understood apart from the context  and premises of Cuban health care which may be summarized as follows:

(1) Since the advent of socialism in 1959, public health has been the  responsibility  of the government in  cooperation  with  the active  participation of grass roots organizations. The two  main such organizations  are:  the Committees for Defense of the Revolution  (CDR) which are neighborhood organizations that  take responsibility for projecting and fulfilling the economic, health and  cultural  needs  of each community, and  the  Poder  Popular (Peoples  Power Assemblies) which are elected representatives  on municipal, provincial and national levels. The Ministry of Health itself  is  under  the authority of the  Poder  Popular,  thereby insuring  that policies and programs derive from peoples  current needs rather than from removed bureaucratic decisions.

(2)  All  medical  colleges in the country,  just  as  all  other schools and colleges are free. Any qualified student may  enroll. If  a  student cannot live at home and be  supported  by  her/his family  while  attending medical school, room and board  is  also provided free as well as a stipend for other necessary  expenses. Before the Revolution, there was only one medical school in Cuba. There are now 15. Each of the 14 provinces in the country has its own medical school.

(3)  No  part of the public health system functions  for  private profit, including the pharmaceutical industry, the  laboratories, clinics, hospitals , the doctors, nurses and all other  personnel involved in health care. That has eliminated all vested interests in  "disease," a contradiction in health care practices built  in to  all  systems based  on  private  gain.   Conversely,   the socialization  of health care has provided the foundations for  a national priority on prevention.

(4)  The prioritizing of prevention has led to the  incorporation of three streams of alternative medicine that have been  welcomed freely by all branches of health care in Cuba: acupuncture, green medicine  and the use of meditation and other altered  states  of consciousness, the latter broadly subsumed under hypnosis.

(5)  Further  consequences of eliminating profiteering  from  the pharmaceutical  industry  are: (a) The  focus  of  pharmaceutical research  on  breakthroughs  in  eliminating  various  types of illnesses  rather  than in the manufacture of costly  drugs  that tolerate pathologies while masking their symptomatic discomforts.

(6)  The  release  of  medical curricula  from  control  by  drug companies which, by virtue of their funding medical research, get to  "call the curricula tune." (c) The release of  the  physician from  the  moral contradiction that increases medical  wealth  in proportion both to the incidence of illness and to the numbers of patients that can be treated in a single day, thereby freeing the physician to practice health care through a singular professional motivation:  to help people remain healthy. (d) Medicine  becomes freed of  its  lucrative romance  with  modern  technology,  and incorporates  traditional methods such as acupuncture  and  green medicine which are both cost and health effective.

(7)  Since  the 1980's the Family doctor in Cuba has  become  the backbone  and first line of defense in health care which  is  now organized  in  a three-tier organization. On the  first  line of defense  is the Family Doctor who lives and works in a  specially designed  doctor's  house set in the community  of  300  families he/she  treats.  The lower floor comprises the clinic  while  the second  floor is the residence of the doctor and his/her  family. In  the newer doctor houses, there are two  apartments  upstairs, the  second  one for the nurse and her family. The  mornings  are devoted  to  clinical hours, while in the afternoon,  the  doctor goes out to make house calls to those who are too ill or too  old to come to the clinic. The doctor also advises on prevention  and sometimes  goes  out  into the town square  to  teach  exercises, especially to children and to elderly retirees.

The  second  line  of health defense is the  polyclinic  that  is technologically better equipped, and has a larger staff than  the Family doctor clinic, usually including doctors of two, three  or four specialties, for example, internal medicine, obstetrics  and gynecology.  The  Family  doctor  is  also  associated  with  the neighborhood polyclinic.

The  highest  tier of health defense is the hospital.  There  are both  general and specialized hospitals, each with a  variety  of medical specialties. When the Family doctor program was first introduced, most medical students served two years in this capacity as a prerequisite  for further  specialization. At the present time, the  Family doctor enjoys such popularity and appreciation that most Family  doctors would rather continue their Family practices rather than shift to a speciality in a hospital milieu. Family doctors serve not  only to  treat  and prevent illness, but also as a friend in  time  of emotional stress. For example, on a visit to a Family doctor in a suburb  of Havana, it was observed (by Dr. Dale) that a  man  had come  in for emotional support because his girl friend  had  just left him.

(8)  Infant  mortality and longevity in Cuba is no  longer  third world  statistics.  It  is now on a par with  the  most  advanced industrialized nations.

(9)  The history of Cuban health care might be divided  into  two phases.  The first phase involved the control and eradication  of contagious  "diseases."  The success of this phase  has  allowed Cuban health care to focus on the problems of chronic  illnesses, such  as  heart "disease," diabetes, arthritis and  cancer.  Such problems  are  more  typically suffered  by  older  people,  who, because of increasing longevity, are now comprising a  relatively greater part of the population.

(9)  Cuban research has made a number of important  contributions to  therapeutics and prophylactics. For example,  a  Computerized Ultra  Micro  Analytic  System (SUMA)  has  been  developed  that diagnoses  twelve  different pathologies  through  blood  profile screenings.  SUMA is being used not only for diagnosing  patients but,  increasingly,  for  prophylactics.  For  example,  now  all couples who are about to get married take the SUMA tests.

Another  computerized  system  has  been  developed  to  diagnose neurophysiological  problems of children, detecting  hearing  and other abnormalities at early stages.

Still  another  type of breakthrough has been  in  biotechnology. Many  new vaccines have been developed and are produced both  for home  consumption and for use abroad. For example,  an  effective vaccine for meningococcosis, has been developed which at a recent international  medical meeting in Mexico, was recognized  as  the most effective vaccine for meningitis. One institute in Havana is devoted  exclusively to the development of monoclonal  antibodies for diagnosis, treatment and prevention. An interferon  treatment has been  discovered  that  is  especially  effective against hepatitis.    Bioenginerring  has created  an  effective streptokainases  enzyme  and  an epidermal  growth  factor  cream especially useful in the treatment of burns.

A cure has been found for vitiligo, a chronic pigmentary  anomaly that modern medicine has held, until now, to be incurable. A  new  kind  of  ocular surgery  has  been  developed  by  Cuban ophthalmologists to treat pigmentary retinosis successfully.

Orthopedic  apparati of various kinds have been invented and  are in use in Cuba as well as exported to other countries.

(10)  The  high  quality  of Cuban health  care  along  with  the breakthroughs in the treatment and prevention of various kinds of illness  has led to a new international role for Cuban  medicine. Three main types of international contributions are made: (a) The development of international emergency health care. For  example, the treatment in Cuba of hundreds of children who were victims of the Chernobyl disaster. (b) The creation of what is called Health Care  Tourism, the treatment of patients who come from  countries all over the world to receive quality and new method  therapeutic or prophylactic care at very inexpensive fees. (c) The sending of Cuban  physicians to other countries to help establish  a  better health care system. For many years Cuban doctors have been going to  Third  World  countries which have  needed  their  assistance desperately. More recently, the industrialized nations have  been calling  for Cuban advice and assistance. During the most  recent visit  (October 1992) of Dr. Dale and wife, Hendrina  Ophey,  Ms. Ophey  met  with  a  group of  medical administrators  from  the Netherlands since she is originally from Holland which has one of the best health care systems in Europe. They had come to Cuba  to request that several Cuban physicians come to Holland for one  or more years to help improve their health care.

(11) There is a relative openness and lack of armoring among  the Cuban  people,  including a great warmth in  human  relations,  a sense of joy and sensuality, and a relative absence of the moral, sexual and racial hypocrisies in which we in the U.S. often  seem to  get stuck. In this respect it was refreshing to  observe  how free of sexual and racial prejudice Cuban medicine is. Women  and people  of  color  are prominent in  every  level,  as  students, clinicians,  professors, administrators and as high officials  in the Ministry of Health.

The  recent  election  in  the  U.S.  has  focused  considerable attention  on  the crisis in American medicine.  Almost  everyone agrees  that radical change is necessary if American medicine  is to survive and if Americans are to survive their medical  system.

However,   President-elect   Bill   Clinton   projects   only   a modification  of the system, simply extending insurance  benefits to  the millions of Americans who have none, and diminishing  the astronomically  growing  costs.  But there so  far  has  been  no national  outcry  that demands health care as a right and  not  a privilege, that takes all medicine and health out of the realm of profit  and  into  the  realm  of  public  responsibility,   that recreates  an  educational system, including  medical  education, that  is motivated by self-actualization through  service  rather than  personal  profit, that prioritizes health  care  over  sick care, and in effect that establishes our humanity rather than our selfishness  as  the foundation for health and life.  Indeed,  is this   not  the  philosophical  foundation  of  ancient   Chinese medicine?

We  live in a world of paradoxes. Cuba, a small country  with  a minuscule  budget, has created a health care system that  is  the envy of patients in every country.

The U.S., a giant country, spends more than $800,000,000,000 a year on disease care, and makes medicine a privilege for the privileged, a potential economic disaster for the middle class, and an iatrogenic risk for any patient.

Cuba is nearer to Florida than any of the 49 other states of  the U.S. Why can't we open the channels of friendship,  communication and exchange? It seems that we now have the need as well as  the opportunity.

 

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