Turning clinicians into community leaders: perspectives from a recent trip in Cuba and beyond

Medicine has been always a big part of my life – both as a professional and a patient. Not only did I have the privilege and opportunity to work on more than 20 health and medical areas over the course of my career in global health, health communication, and international development but medical practices have also deeply shaped me and the way I see the world both as a patient and a human being. One of the fondest memories of my childhood growing up in Italy are about our family pediatrician – and a family friend – who used to come to our home to make us feel better when we had a cold, or any other kind of illness. Those encounters were never dry and were revolving on many issues beyond healthcare (e.g. birthday celebrations, family economics, and more) while also being deeply seated in the tradition of physician ‘home visits’ many patients in Italy still enjoy.

So, it was not surprising that the aspect that most impressed me during a recent February 2017 trip in Cuba to learn about the country’s health system was the neighborhood-based approach to primary care, and the role of physicians and nurses as community leaders who are effectively engaged on advancing health and social outcomes. The trip was organized by the international nonprofit organization MEDICC (http://medicc.org/ns/), which is dedicated to fostering mutual learning opportunities between the United States and Cuba in the fields of public health and global health equity, and included health equity leaders from national and local organizations, and universities from across the United States. Now there are other aspects to the Cuban health system, such as universal healthcare coverage, which are equally important and distinguishing but not as unique if one considers that many European countries, including my own native Italy, have similar healthcare benefits for their citizens.

The purpose of this piece is not to propose that any model from Cuba should be actually implemented in any specific country without taking into account and adapting to the reality of those countries. Moreover, Cuba is a very complex place that is difficult to fully understand in a one-week trip. On one hand, it is hard to ignore that after all this is not a democracy and that too many people live in austere conditions. On the other hand, people seem to have a strong sense of community, are well educated, caring, and appear content with each other, which all contributed to the feeling of safety I experienced walking around with my colleagues. With that said, there are many aspects of the Cuban model for primary care that are grounded in community health and preventive medicine principles and best practices, and therefore can inform other models and experiences.

Many other authors have written about the primary care system in Cuba and its results – the country’s high immunization rates, falling infant mortality rates, and impressive life expectancy gains, among other achievements [1–3]. Yet meeting the physicians in a local ‘policlinico’ (neighborhood primary care clinic), as we did as part of our visit to Cuba, is a special experience that brings to life the kind of dedication and passion clinicians who participate in the country’s Family Doctor and Nurse [3] program lend to their work. The program covers the patient, the family, the community, and the environment, and includes both office and home visits by clinicians. Physicians and nurses not only provide diagnostic and primary care services but also work with communities on participatory research and needs assessment as well as on identifying and helping address issues that may contribute to physical and mental illness.

‘Home visits are an opportunity for the family doctor and nurse to assess and address the living conditions and other environmental factors that may contribute to disease, for example social issues such as economic conditions, family violence, violence against women, etc.’, we learned from the clinicians throughout our visit. Family doctors are trained in health promotion, and work with families and communities to address barriers to improved health outcomes, as well as to increase health literacy and disease knowledge, and provide essential preventative services. Physicians are ultimately well-respected and proud community leaders. The emphasis on prevention and the social determinants of health seems to start in medical schools, so training is a key precursor to leadership.

Now, we only scratched the surface of what there is to know about the Family Doctor and Nurse Program. Nor did we have an opportunity to conduct any specific research or analysis. Yet knowing that family clinicians in Cuba live in the neighborhood they serve – and actually with their families in the same building as the ‘policlinico’ – is already somewhat reassuring and familiar – just as my great-grandfather, a family physician, lived for all of his long 102-year life in the small town in Italy where he practiced. In this way he got know the people, the stores, the gossip, and more, and to provide the kind of empathetic care that in the age of cost-cutting interventions and increasing demands on clinicians’ time we all too often miss. In Cuba, clinicians are not viewed as strangers … and often use their voice to resolve community issues.

The concept of a neighborhood-based primary care model that intersects with community-based interventions to address existing barriers to improved health outcomes – namely the social determinants of health – is already valued by key organizations and opinion leaders in many economically developed countries, including the United States. In this context, the medical neighborhood is being conceptualized as a primary care medical home ‘(PCMH) and the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations and State and local public health agencies’ [4]. Reports and neighborhood-based initiatives are flourishing in the United States both in the public, academic, and private sector [5,6]. For example, as part of the NYC Department of Health’s investment in key neighborhoods, more traditional and yet ‘successful District Health Centers that started in Manhattan almost 100 years ago’, were recently transformed in Neighborhood Health Action Centers, which revitalize ‘underutilized Health Department buildings by co-locating health services, community health centers, public hospital clinical services, community-based organizations and service providers’ [6]. Across the United States, public health and preventive medicine physicians are already working by focusing their efforts ‘on the population rather than individual practice’, that is, on ‘assuring the availability of essential public health services to a population using skills such as leadership, management and education as well as clinical interventions’ [7].

As much as we should celebrate the above efforts and many others, the integration of public health and clinical interventions to advance health equity, promote understanding of the value proposition of population health, and ultimately support the clinical-community setting continuum in all kinds of programs and endeavors, is very far from being the norm – whether in the United States or globally [8]. Communication can greatly contribute to progress through its many action areas. First, integrated public advocacy and policy communication interventions can support increased funding and policies for this type of effort. Communication programs can also help promote behavioral, social, and organizational change across communities, institutions, and governments, so that neighborhoods and their residents can have access to the kinds of services and social support that are needed to advance health equity-ultimately providing hope and resources to vulnerable and underserved populations (e.g. the elderly, children, minorities, groups who are unfortunately discriminated or stigmatized). Professional clinical communication interventions can serve as the framework for increasing our investment in continuing education, in-service training, and other initiatives to make sure clinicians are supported in their efforts to turn into community leaders. The practice and theory of constituency relations can help communities, organizations, and healthcare providers to identify partners and engage in multisectoral interventions and strategies to remove barriers to health equity.

Finally, communication and its many action areas, strategies, and media can support the ‘resistance’ against all forms of ideologies that may create divides instead of bridges, separate people into ‘us’ versus ‘them’, and/or support a view of the world in which we would abdicate on our collective responsibility for taking care of each other and our future generations – especially when it comes down to health and health outcomes, which are key determinants of people’s ability to thrive and prosper. Given the highly esteemed place clinicians have in our society, turning this important group into community leaders may also be key to the ‘resistance.’

In this issue

While finishing up this editorial, I was thinking that this issue of the journal focuses on two very pertinent topics in today’s health communication landscape, which also resonate with the theme of this editorial: a special themed section on patient engagement and shared decision-making (SDM), and an article collection on youth health and communication. In both cases, clinician’s leadership could not be more important to advance strategies that may help improve overall patient outcomes and satisfaction and/or the health and wellbeing of future generations. I want to acknowledge editorial board member Dr T.J. Jirasevijinda of Weill Cornell Medicine, who originally proposed the special themed section on SDM and contributed a commentary on the topic that we are honored to publish in this issue. Finally, special thanks to editorial board member Dr Isabel Estrada-Portales of the National Institute of Health for contributing what is perhaps one of the first book reviews this Journal publishes. This is another milestone and an area on which we seek to expand.

As the Journal’s Editor-in-Chief, it is a great honor to count on the support of our readers, authors, reviewers, and editorial board members. Thank you all – and special thanks also to the Taylor & Francis team and to the Journal’s Senior Editorial Assistant, Radhika Ramesh. We wish everyone a wonderful summer, and hope the articles in this issue will inspire innovation in research, policy and practice.

Disclosure statement

No potential conflict of interest was reported by the authors.