Cuban publishing on primary health care: an inexcusable absence
Mikhail Benet MD PhD
Primary health care (PHC) constitutes the fundamental pillar of Cuba's universal public health system. The doctor-and-nurse teams next door, community polyclinics, maternity homes, mental health centers, seniors' day centersall form part of a network of over 12,000 facilities dedicated to resolving some 80% of population health problems, compared to under 200 facilities at other levels of care. The people and institutions in PHC are on the front lines of health promotion and disease prevention. Their work is critical to the impressive population health indicators Cuba has managed to achieve, even in the toughest economic times. Others worldwide, especially in developing countries, could benefit from this experience. Cuba's own health system needs the scientific power represented by PHC research publishing potential, driving solutions to the country's main health problemswhether diseases, risk factors and unhealthy lifestyles, or inefficient services.
Yet, when it comes to publishing that stems from research in primary health care, the pages are nearly blank. The number of articles emerging from authors in the PHC trenchesoriginal research commentaries, reviewsdoes not correspond with the responsibility they shoulder in the health system. To illustrate: a literature review of five broad-spectrum Cuban journals (one published in eastern Cuba, three in the central region, and one in the west) revealed under one third of their articles (31.9%) devoted to PHC themes, and these not necessarily written by health professionals working at that level.
At first blush, this result may not seem problematic. But the alarm sounds if you consider the number of health professionals in primary care as a proportion of the total. Of the 91,415 physicians and dentists at work, 44,372 or 48.5% are dedicated to primary care.  And this counts only family physicians and dentists in communitiesnot the thousands of pediatricians, internists, OB/GYNs, epidemiologists, school hygienists, psychologists, nurses and other professionals at this level, for whom data are not available.
These findings are still more worrisome if you consider that a family medicine residencycomplete with research thesisis required of virtually every newly graduated physician. Master's degree and doctoral dissertations in public health and related fields also contribute to the potential research pool.
In other words, although we cannot calculate the extent of scientific investigation at the primary care level, or emanating from its health professionals, we know that studies are being done. However, returning to the five journals reviewed and the proportion of their articles devoted to PHC, another fact comes to light: health and health care problems identified in the annual community health situation analyses are not sufficiently reflected in print.
An example of this is cancer. Over the last 40 years, cancer rates have been climbing in Cuba, a curve becoming steeper over the last decade. Cancer is the second cause of death nationally, and already has displaced heart disease as the number one cause in some provinces. However, in the five-journal review, not a single article was found about cancer or cancer prevention in primary health care. Subsequent review of other journals found scant PHC treatment of this essential theme.
Other examples abound, pointing to the urgent need to more closely align PHC manuscripts with research on the most important health issues identified nationally, provincially and locally, such as:
- the rapid aging of the Cuban population, in all its dimensions;
- increases in obesity and diabetes mellitus;
- dengue and newly appearing epidemics, such as the recent cholera outbreaks;
- menopause and its consequences for older women;
- new challenges for PHC, its structure and functioning, and the need to apply more interdisciplinary and intersectoral strategies;
- economic issues affecting the health system and health care costs;
- health system and services analyses;
- social participation and empowerment; and
- development of policies, plans and management capacities to support public health efforts.
The causes of PHC's under-representation in scientific publishing have not yet been investigated and they must be. One could venture a complex set of explanations, including workload, life situations of these professionals (often younger people with small children), insufficient capacity-building in research and scientific writing, and lack of access to international bibliography.
While these are only hypotheses, the latter two points are of particular concern for all Cuba's health professionals, and certainly those in PHC. We need a national program to strengthen scientific writing capabilities, especially given the dearth of this material in undergraduate or even graduate-level education. Second, the lack of access to international scientific literature needs urgent attention: until 2013, the WHO's HINARI service made available online full-text articles from over 2000 journals at a modest cost and otherwise unaffordable for Cuba. However, this year, HINARI has declared Cuba ineligible, ironically due to the country's rise in the Human Development Index, thus leaving Cuban health professionals without this service, vital to research and practice.
The strength of evidence for actionagainst disease, towards health-promoting strategies, and to improve patient care and system-wide efficiencyrests on the strength of research shared in publication. Cuban studies in PHC leading to important solutions and innovation are sorely underpublished. Correcting this absence should begin now.
1. National Health Statistics and Medical Records Division (CU). Anuario Estadístico de Salud 2011. Havana: Ministry of Public Health (CU); 2012. Spanish.
Submitted: February 20, 2013
Approved for publication: April 21, 2013