For Whom The Bells Toll: Cuba Stares Down Sea Of Change In EMS Delivery

“I may not be as strong as I think,” the old man said. But I know many tricks and I have resolution.” –Ernest Hemingway, The Old Man and the Sea

There’s a simple trick you can do in any big city to determine the level of emergency medical care available throughout the entire country: count how often you hear an ambulance’s sirens. Through the work I’m involved in with Trek Medics International, I’ve learned that counting ambulance sirens can be a useful way to figure out both the level and distribution of a country’s EMS system in most any country regardless of what the official story is.

I live in New York City steps away from a six-way intersection in the heart of Manhattan. I hear an ambulance go by every couple hours during the business day, sometimes more. The sounds of ambulance sirens in New York are so intrusive that a Russian tourist I recently met wondered if it wasn’t a political trick.

In Tijuana, with a population of 1.3 million people, and where EMS workers typically drive with their sirens on whether they’re on a call or not, sirens can be heard fairly often in city centers. This makes sense, because Tijuana has fairly good ambulance coverage, though not nearly as good as just across the border in San Diego, California, with 1.3 million people. There, ambulances are sent with sirens blaring on most every 9-1-1 call.

On a recent two-week trip to Santo Domingo, Dominican Republic, a city with about 1 million people, I probably heard ambulances 3-5 times a day. This was pretty impressive for a city that has only had their new 911 system for less than two years.

In Port-au-Prince, Haiti, a capital city nearly six times as densely populated as Santo Domingo with close to two million residents, you hear ambulances 1–2 times a day depending on where you are. Those numbers correlate pretty well to how I’d rank my preference if something bad happened to me in any of those cities: San Diego, Tijuana/Santo Domingo, Port-au-Prince.

I recently returned from a week in Havana, Cuba, where I had the chance to attend the DevelopingEM conference and learn more about EMS in Cuba. For the first time I think my trick has found an outlier. Even though I spent my time in some of the most populated parts of the capital, I only remember hearing one siren the whole week,  and it very well may have been a police vehicle. That’s the fewest times I’ve ever heard sirens in a capital city, which should make me nervous. After learning about their transport system, I can’t say for the life of me that I’d rather be in a car accident in any other developing country than Cuba. It doesn’t hurt that Cuba’s so close to the U.S., either.

Salud Para Todos (As Best We Can)

The reason I believe Cuba’s EMS system likely ranks among the best in developing countries isn’t because Cuba has more than anyone else—they don’t. What the Cuban healthcare system offers is a third model for preventing premature death and disability in spite of chronic shortages by using a mix of strong, community-based healthcare, militant public health messaging and the judicious use of limited resources.

Thanks in no small part to the United States’ decades-long embargo against the Caribbean’s largest island, Cuba has had minimal access to only a fraction of the medical supplies and technology that we’ve been enjoying in the wealthiest countries for the past 50 years. Yet, in defiance of (and the need to survive through) chronic shortages and limited access to commercial markets, the Cubans have developed a sophisticated approach to emergency care and transport by sticking to a disciplined and evidence-based distribution of whatever’s available.

By relying on a deep network of community physicians, and reinforced by a militant focus on health prevention, free and easy access to primary care and a strongly health-conscious population (save the whole tobacco thing), Cuba has made political art of community-based health care with minimal resources. And quite literally too: Instead of seeing McDonald’s and Starbucks billboards along the highway, Cuban billboards sell Communist propaganda extolling, “Salud para todos” – Health for all.

As Dr. Haywood Hall, an emergency physician and founder of PACEMD, a global health training institute in Mexico, noted: “Cuba has proven that there is no correlation between health spending and patient outcomes.” This non-correlation also extends to prehospital care where standard vehicles, equipment and supplies are consistently lacking across the country. Into this void, the Cuban Ministry of Health has placed a dogmatic emphasis on health awareness at the community level, ensuring that many emergencies are avoided (e.g. through mandatory helmet laws and low vehicle ownership) while ensuring that those emergencies which can’t be prevented are brought to the local hospitals by bystanders and other community members in a timely fashion. Unlike many other developing countries, however, Cubans have high levels of trust in their healthcare system and feel safe that once at the hospitals, the few resources they do have—transport vehicles, supplies, medical equipment and advance-training personnel—will be used to their best efforts. That’s to say, the most amount of good for the most amount of people, albeit with very little.

Is it ideal? No. Is it impressive? Sí.

Base Nacional de Urgencias Medicas (BNUM)

As part of the DevelopingEM conference, emergency physicians, researchers and policy makers from across the Caribbean, Latin America and the South Pacific presented for several days, and we had the chance to meet and talk with both local paramedics and members of the Cuban Ministry of Health. Part of the conference included a visit to the Base Nacional de Urgencias Médicas (BNUM) in downtown Havana. BNUM is the hub of Cuba’s ambulance services, providing coordination and dispatching for patient referrals across the nation. Serving as the national call center and fleet station for both high- and low-acuity patient referrals, BNUM’s dispatchers and paramedics manage the consistent coordination of inter-facility transports between all of the country’s tertiary care and specialty clinics, including via Soviet-era helicopters to the country’s many islands and a few off-shore oil platforms.

The vehicle fleet we saw consisted of several German-made ambulances capable of transporting most patients, conditions and equipment, a lot of which had been donated by visiting medical professionals (see video of gurney). The advanced equipment we saw included ventilators, EKGs and IV drips, and would be considered outdated by the standards of most high-income countries. But like the vintage ‘54 Chevys and Buicks that cruise Cuba’s wide calles, BNUM maintains their equipment in the best shape they can, utilizing it based upon strict protocols and with a collective understanding that things aren’t replaced easily. BNUM also serves as the capital’s training center for paramedics, trained to different levels to assist doctors and nurses for specialized transports, like neonates and post-transplant transports. While the trip was short, it was clear the Cubans were truly transporting patients, not just rolling out the vehicles and equipment for a dog and pony show. They took real pride in the care they were providing. This was evident across all the local medical professionals I met at all levels. There’s a lot one could wish for the Cubans to teach other countries in similar circumstances.

BNUM and Ebola

As it turns out, the Cubans do teach a lot of other countries about health care, and their model for delivering it in resource-limited settings, both by taking foreign students into their many medical schools for free and by sending “medical brigades” to other impoverished nations that provide medical care in local clinics and hospitals. As a result, the Cubans have a lot of experience in international response, regularly offering medical relief during international health crises and often being on the ground when the problems first happen, as was the case in Haiti for the earthquake and cholera, and in West Africa for Ebola. BNUM’s international experience was also used recently during the Ebola outbreak when their collaboration with compatriots in West Africa helped poorer African nations improve their own preparedness efforts.

For Whom The Bells Toll

A lot is changing in Cuba and it’s likely these changes will only increase as they continue. As more foreign and private investment comes in Cuba actually has a pretty good chance of replicating the EMS delivery models employed in the wealthiest countries—if not for their nice, wide roads alone. Though Cuba has a better chance of transplanting Miami’s EMS system than most other Caribbean countries I’ve visited, it’s still going to take a lot of investment. So when the money comes rolling over Havana’s picturesque seawall, with all its bells and whistles in tow, we might find ourselves watching another Hemingway ambulance tragedy in the making, anxiously waiting to see if Cuba’s minimalist model of community-based healthcare will be seduced and overtaken by the promises of advanced technology with all its sirens.

Jason Friesen, MPH, EMT-P, lives in New York City and is the founder of Trek Medics International, a nonprofit organization that improves emergency medical systems in developing countries.