Keywords: Cuba, acupuncture, acupuncture education, teacher education, health care, sick care, medical college, neuroscience, curriculum, hypno-digito-acupuncture.
|Introducing Cuban Medicine
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:
The information reported here derives from three main sources:
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.
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.
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 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.
Bui Quoc Chau: Cybernetic Facial Therapy.
B. Jensen: TENS Treatment.
K. Yamashita: Acupuncture Conferences.
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.
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.
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.
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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