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Abstract

Aim:

To compare following the Cuban Revolution, Cuba’s economy and civil society was transformed by the initiation of a program of nationalization and political consolidation. The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the healthcare of its citizens. Other industrialized nations continue to surpass the US in health-related outcomes indicating areas of improvement in its healthcare system. Assessing the successes and failures as well as the advantages and disadvantages of other countries’ healthcare systems may be instrumental in the development of modifications to the organization and delivery system of healthcare in the US. This paper aims to report the information attained from previous literature as well as from first-hand observations from a public health trip to Cuba in order to compare the healthcare systems in Cuba and the United States.

Materials and Methods:

A group of New York University College of Dentistry faculty and students traveled to Cuba in April 2019 for professional research and professional meetings (CFR 515.564). While in Cuba, the researchers took written notes of the lecture-based material and conversations. Upon return to the United States, published literature was searched for the collection of any additional data and all qualitative data and quantitative data was compiled and organized. Since 1959, Cuba has made continuous adjustments and improvements to its universal, free and accessible healthcare system.

Results:

There have been notable improvements to the country’s public health status, such as the implementation of an immunization program and subsequent eradication of communicable diseases, such as polio and rubella. Additionally, the implementation of the National Program on Dentistry guarantees dental care to all Cuban children under the age of 19. Today, the Cuban National Health System (NHS) initiatives have evolved to combat the novel coronavirus (COVID-19) pandemic.

Conclusion:

Recognizing the advantages as well as the disadvantages of the Cuba’s National Health System (NHS) would be useful for future policymakers in the United States. Cuban approaches to health could be tailored to the United States environment to improve healthcare effectiveness and population health status in the future.

Keywords

Cuba United States Dentistry Dental Public health Fluoride Oral cancer Coronavirus COVID 19

Introduction

The National Research Council and Institute of Medicine¹ suggest that the United States is among the world’s wealthiest nations, but not among the healthiest. When examining population health outcomes, such as heart disease, disability, and obesity and diabetes, the United States continues to lag behind other industrialized nations. Changes in the US health care’s organization and delivery methods are needed if the country aims to reduce medical costs and establish an improved population health status commensurate with current technology.² Despite differences in the political–social system and available resources between the Unites States and Cuba, the history and details of the Cuban health system indicates that their health system merits attention as an example of the implementation of a national integrated approach and subsequent improvement in population health status.³

The Cuban Revolution’s ensuing transformation of the political and economic relationship between Cuba and the United States has directly and indirectly impacted the health-care system in Cuba. Over the past 60 years, the hostility between the two countries, as well as the US embargo barring normal trade of medicine, food, and medical equipment, posed as obstacles for Cuba’s national health system (NHS). This also posed an obstacle for Cuba’s positive health outcomes to be considered by the US public, media, or policymakers.³ Additionally, with the United States embargo and various travel restrictions in place, there has been limited opportunity for US health-care professionals and researchers to examine Cuba’s NHS from within the country’s borders. In 2015, The Obama administration created amendments on travel restrictions to Cuba based on 12 different criteria for authorized travel.⁴ One of these, described in Section §515.564 by the Office of Foreign Assets Control (OFAC) enabled travel from the United States to Cuba for professional research and professional meetings.⁵

As a result of easing travel restrictions, a group of faculty and dental students from New York University College of Dentistry (NYUCD), in New York, NY, were authorized under Section §515.564 certification to travel to Cuba for professional research and professional meetings. From April 6th to April 15th, 2018, two faculties and six students from NYUCD partook in various educational and professional research activities to collect observational data on Cuba’s NHS. The next year, from April 22nd to April 30th, 2019, the same two faculties and a new group of five dental students from NYUCD partook in similar activities to continue this collection of observational data. This article aims to report the information attained from previous literature as well as from first-hand observations from a public health trip to Cuba in order to compare the health-care systems in Cuba and the United States.

The Beginning Years of Cuba’s National Health System

The 26th of July Movement victory resulted in the overthrow of the military dictatorship of Cuban President Fulgencio Batista as well as the establishment of a revolutionary government led by Fidel Castro.⁶ With the end of the Revolution and the ensuing United States embargo against Cuba, Cuban civilians were faced with numerous inequities. Such inequities were especially prominent within the health-care system. The United States embargo against Cuba prevented the import of food, medicine and medical equipment which led to an increase in disease prevalence and infant mortality rates throughout the 1960s.⁷ Prior to the Revolution, the infant mortality rate was recorded as 33.4 in 1958 and it rose to 46.7 in 1969.⁸ The Revolutionary insurgent and physician, Che Guevara, delivered his goals for the Cuban health-care system reformation in an essay titled “On Revolutionary Medicine” on August 19th, 1960, to the Cuban Militia.⁹ In this essay he states, “The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices.”⁸

As a result, nearly half of the nation’s physicians fled the country to the United States, resulting in a subsequent shortage of medical professionals.¹⁰ Only 16 medical professors at the University of Havana’s Medical College and approximately 3,000 doctors remained in the country as of 1963. Inequity and limited access to health care was an issue that Castro’s regime quickly sought to overcome; the government aimed to establish a prompt, free, and comprehensive national health-care plan that would be accessible to all Cuban citizens in all 14 provinces. Volunteer doctors from various Latin American countries as well as Cuban medical students in their training years offered their medical expertise and care to overcome the shortage of doctors.¹⁰ Additionally, the Ministry of Public Health (MINSAP, the Spanish Acronym) initiated a program of nationalization and regionalization of medical services; this involved teams of doctors being sent to remote towns and villages to treat Cuban citizens that had never been examined by a medical professional.³ Since the end of the Revolution, the nationalized initiatives in the prevention of disease has continued to be a hallmark of Cuban health care.

Cuba’s National Health System

Structure of the NHS

The MINSAP, established in 1909, has regulated the development of the NHS in Cuba since 1959.¹¹ The Cuban health-care system is designed and operated with a community approach, involves intersectoral collaboration, and aims to provide universal, free, accessible care to all Cuban citizens. In Cuba’s current health-care system, there are three well-defined levels of health care. The first level, also known as primary care, is the closest, most direct form of healthcare for the population. This includes family medical consulting, consisting of a team of nurses, doctors, dentists, and dental assistants that work as a local team. Additionally, community clinics, also known as polyclinics, provide primary care through access to a pharmacy, optician, maternal home, mental health center, elderly center, and family medicine.¹² Primary health care serves as the cornerstone of the health-care system in Cuba where prevention and health promotion are the primary responsibilities of primary-level care providers. Additionally, primary-level care providers, such as dentists, may be responsible for providing patients therapeutic treatment for various conditions and diseases within these primary-level care centers.¹¹

The second level of health care is for patients requiring more specialized care that cannot be adequately treated within primary-level care centers. In secondary care centers, such as referral hospitals, patients receive care by professionals with a more specialized area of expertise. The third level of health care is formed by high-technology hospitals and specialized institutions. The third levels of health care is regionalized and aims to provide all Cuban citizens care that is close in proximity to their place of residence. The Cuban government also provides health care in all three levels, when indicated, to all of its citizens despite of sex, race, religious affiliation, or political affiliation.¹¹ Furthermore, health care is universal, and most health care is free.¹³

Education and Training of Health-care Professionals

In 1976, the training of health professionals was turned over to the MINSAP. It was given the responsibility to define the knowledge base, competencies, and scope of duties and responsibilities for each of the university-level health sciences professions.¹⁴ In that same year, a selection process for entry into medical school was established, which considered not only academic qualifications but also individual characteristics, such as vocation, responsibility, and commitment to solidarity.¹⁵ Health status improvements in the Cuban population can be attributed to NHS’s initiative to provide health care to all Cuban civilians, as well as the expansion of training of health professionals. Additionally, changes targeted health-care professional schools to establish a commitment to improving health care in other developing countries through providing health services and medical education to nonCubans. MINSAP implemented changes to the health-care training system which resulted in an expansion of the number of medical specialties as well as the development of new medical training schools. As of 2018, Cuba has 13 universities of medical sciences, with 37 faculties: 25 of medicine, 4 of dentistry, 4 of nursing, and 4 of health technologies as well the Escuela Latinoamericana de Medicina (ELAM) and School of Public Health (ENSAP, Spanish acronym).¹⁵ The medical school, ELAM was opened in 1999 in Cuba to train international students from rural, remote, resource-scarce, and other disadvantaged communities throughout Latin America. For most of these international scholarship recipients, the students are expected to return to work in remote, disadvantaged communities following the completion of their education.¹⁵ The education is free for the student; however, in case of wealthier nations, the government contributes to the education, with no charge to the student.⁸ By 2015, ELAM had graduated almost 25,000 international students from 84 countries, almost all from low-income families and over half of them female.¹⁶ As of 2018, nearly 150 of these graduating students were from underserved communities of the United States.¹⁷

Public Health in Cuba

Prevention and promotion of health encompass the whole Cuban society and are at the heart of the NHS. The prevention measures and health promotion strategies in place continuously change to reflect the current needs of the population. The MINSAP is responsible for collecting up-to-date data of the hygienic and epidemiological profile of the country in order to define the country’s determinants of health.¹⁸ It is from these determinants of health that political approaches are established, such as the development of the country’s health priorities and health programs. To ensure that vulnerable and at-risk populations received adequate care, four comprehensive health programs were established. These four programs were developed to provide care for child-bearing women and newborns, the elderly, individuals suffering from chronic noncommunicable diseases, and individuals suffering from communicable diseases.¹⁸

In 1959, the epidemiologic profile was characterized namely by communicable diseases, some of which could be prevented with vaccination. Thus, the NHS placed a specific emphasis on the administration of prophylactic vaccines.¹⁹ As a result, the polio, tetanus, diphtheria, and rubella have been completely eradicated in the Cuban population. In order to lessen the maternal transfer of HIV and syphilis, national health programs served to provide additional testing to pregnant women and medication when indicated.²⁰ In 2015, Cuba became the first country to eliminate maternal transfer of HIV and syphilis.²⁰

Following the Cuban Revolution, an increase in infant mortality rates resulted in the development of more thorough health-care delivery to pregnant women. Founded in 1962, Cuba’s maternity homes were an example of the government’s initiative to extend health services to the whole population.²¹ The maternity homes were founded to improve the health of pregnant women, mothers, and newborns in order to decrease morbidity and mortality rates. Today, pregnant women are required to have a minimum of 12 consultations during a full-term pregnancy and are enlisted in the immunization program. As a result of the programs in place for pregnant women, 99.9% of deliveries occur in health institutions.¹⁸

Since 1959, the developments of the NHS have increased the life expectancy from 60 years old to 78.8 years old. With a population of over 11 million people, around two million people are among the aging population.¹⁷ In the early 1980s, Cuba’s aging population was rising with a morbidity and mortality concentrated in an adult population plagued by chronic health conditions, such as cardiovascular disease, diabetes, and cancer.³ Currently, cardiovascular diseases, malignant tumors, neurovascular disease, influenza and pneumonia, and accidents are among the leading causes of death.¹⁸

In order for the NHS to reduce the country’s mortality rates, the implementation of targeted preventative measures and health promotion strategies are necessary. These strategies, however, can only be established once risk factors are determined. Abundant literature has shown the association between alcohol consumption and smoking as risk factors of cancer. In 2010, the Cuban population revealed a high prevalence of smoking, for both males and females over the age of 15 (23.7%); however, the data did not specifically identify how smoking was defined.²² Because oral cancer was a leading cause of death in Cuba in recent years, studies have examined the association between risk factors and oral cancer prevalence in the Cuban population. In 2001, 82% of oral cancer cases in Cuba were attributable to tobacco smoking, and only 19% to smoking cigars or pipe.²³ The combination of smoking cessation and oral cancer screening on a public-health level is necessary to reduce oral cancer rates.²⁴

Dentistry in Cuba

The Field of Dentistry in Cuba

Oral health care in Cuba has improved since the end of the Cuban Revolution. As of 1959, there were only 1,400 dentists and one dental school in Cuba.¹¹ At that time, tooth extractions were the only guaranteed treatment and there were not any oral health promotion or preventative programs in place.²⁵ Nearly 60 years later, in 2018, there was a reported number of 17,542 dentists, 5,250 dental chairs, and 303 dental labs in Cuba. The NHS guarantees access to all dental services to patients, recognizes four dental specialties, and provides regular caries preventative care for patients under 19 years of age.²⁶

The Cuban health-care system characterizes dentistry as a field of medicine encompassing dental medicine and oral medicine. In Cuba, the education pertaining to dental medicine and oral medicine is not restricted to the curriculum of dental students. Instead, all medical professionals receive training on dental and oral health. Similarly, dental students receive thorough training on overall health of the various organ systems. Because the medical and dental training programs consist of similar curriculums, Cuban patients are referred from dentist to physician as well as from physician to dentist, when necessary. All clinicians are trained to provide comprehensive intraoral and extraoral exams; thus, referrals of patients from family doctors to dentists are regularly performed.²⁵

The field of dentistry can be found in primary-level, secondary-level and tertiary-level care in the Cuban health-care system. Most dentists are among primary-level care providers and prioritize prevention and health promotion strategies in their regular care of patients. Within the field of dentistry in Cuba, comprehensive dentistry aims to treat the social and biopsychological factors that affect oral health to improve the quality of life of the patient.¹⁸ Additionally, there are no dental hygienists within the Cuban health-care system; thus, comprehensive dentists are responsible for providing patients hygiene treatments. The NHS recognizes four other dental specialties: periodontics, prosthodontics, orthodontics, and oral maxillofacial surgery, which require care from the secondary-level of care.²⁵

Cuba’s Public Health Initiatives in Dentistry and Oral Health

The current national program on dentistry for the Cuban population was implemented to promote oral hygiene to improve oral health in the Cuban population. Oral disease prevention and oral health promotion for children begins as early as in the womb. At prenatal visits, oral hygiene instruction is provided to the mother. Once the child becomes school-aged, oral hygiene instruction and preventative care is provided within the school setting. Children will either be treated by a dentist who is permanently stationed at the school or by a visiting dentist who conducts scheduled rotations of care delivery. If a student requires further dental care, he or she will resume care with either the school dentist or at the visiting dentist’s regular clinic site. In terms of oral hygiene instruction, tooth brushing four times a day is promoted. Cuba does not have fluoridated water; therefore, all children from 6 years old to 18 years old are given fluoride rinse supplementation 16 times a year within their school settings. Additionally, children are examined and classified into caries risk to guide the prescription of topical fluoride varnish application. Patients from 11 years to 18 years of age characterized as having a high caries risk receive fluoride varnish four times a year, while those characterized as having a low caries risk receive fluoride varnish two times a year in addition to the fluoride rinse that is administered at school.²⁵

Oral health promotion and prevention of oral diseases in the elderly is also a priority of the national program on dentistry for the Cuban population. As the aging population in Cuba continues to rise, the NHS has established a program to ensure dentists are extending their services to the elderly within nursing homes and day centers, which lessens the barriers and promotes facilitators for this vulnerable population to receive the care that they may need. There is no fee associated with preventative care or prosthetic restorations; however, the monetary value is of a prosthetist is communicated to the patient in order to discourage abuse of the system and loss prevention.

In recent years, oral cancer is among one of the most prevalent forms of cancer in the Cuban population.²⁵ Dr Julio César Santana Garay was a leading figure in the Cuban health-care system in the prevention of oral cancer. As a result of his public health pursuit, Cuba established an oral cancer detection program (OCDP) in 1982.²⁷ The OCDP resulted in all patients in primary health care receiving educational instruction on how to provide self-exams of the intraoral hard and soft tissue. Additionally, the OCDP established a referral protocol following the detection of suspicious lesions. After a general dentist rules out other factors and classifies a lesion as suspicious, the dentist refers this patient to secondary-level care for a biopsy by an oral maxillofacial surgeon. Patients with malignant lesions are referred for oral cancer treatment at a tertiary-level high-technology hospital. In this hospital, a patient may be treated by head and neck specialists, otolaryngologists, oral maxillofacial surgeons, and oncologists depending on what therapeutic treatment is indicated.²⁵

Discussion: Comparing Cuba and the United States

Health-care System Structure

The qualitative and quantitative data collected and compiled by the authors can be further utilized in a comparison of the health-care systems of the Cuba and the United States. Structurally, the health-care systems of the two countries are fundamentally different. Unlike the United States’ health-care system, Cuba’s NHS provides free health care to all Cuban citizens. In order to ensure access to all of its citizens, Cuba has implemented national programs to put concerted efforts in the health-care access and delivery to higher-risk populations, such as children, child-bearing women, the elderly, and the disabled. Cuba’s NHS extended health services to rural areas with previously scarce access to care within the country through the establishment of various initiatives, such as rural medical service and ELAM. The United States government also has established similar initiatives, such as the Indian Health Service, an agency within the Department of Health and Human Services responsible for providing federal health services to Native American and Alaska Natives.²⁸ The key difference between these systems is that the United States aims to increase access to care to civilians, while Cuba’s NHS aims to provide care to all civilians.

Health-care Professionals

Many advantages of the Cuban medical industry are a result of the Cuban educational system that is responsible for educating the various health-care professional fields. Education is free; thus, Cuban students are not burdened with stresses frequently experienced by students pursuing their degrees in the United States, such as tuition- and loan-related stress. Furthermore, upon graduation, these students are also not burdened with the stress of finding a job, or, the fear of struggling to find a job. These newly graduated doctors are placed into a designated professional position by the government, thus lowering unemployment rates for these fields.

The volume of professionals in each field is predetermined by the government; this results in ideal proportions of health-care workers in the various health-care fields to support the needs of the public. The government prioritizes the need to educate and train health-care professionals to assure that the health-care needs of all Cuban people are met. The World Health Organization’s Global Health Observatory conducted in 2017 explored the density of medical doctors; Cuba had 81.9 medical doctors, while the United States had 25.948, per 10,000 population.²⁹ Under oral health, in 2003, Malmo University determined that Cuba had 10,167 dentists for a population of roughly 11 million, while the United States had 173,574 dentists. This translates to roughly 10 dentists per 100,000 persons in Cuba and 59 dentists per 100,000 persons in the United States. By 2014, the number of dentists in Cuba rose to 16,630.³⁰ While the ratio of dentists per 100,000 in Cuba persons is smaller, compared to the US population of 328 million people, the ratio of dentists to people is better in Cuba. Dental care in Cuba is more accessible than in the United States. Cuba’s Ministry of Health has further increased their number of dental professionals to better serve the country. Increasing the number of dentists in the United States is also not as simple, as Americans choose their profession and where they practice. America also does not have a Ministry of Health that determines the number dentists needed to serve the community.

Public Health

Since 1959, the health-care programs in Cuba have continuously adapted, yet the role of prevention, health promotion, and equity into the establishment of these programs has always been a hallmark of Cuba’s NHS. While health care in the United States also incorporates health promotion and disease prevention strategies, there are a number of notable differences within the public health domain between the two countries. Prevention is at the core of the health care system in Cuba. From a public health and epidemiologic perspective, prevention is imperative in the pursuit of reducing morbidity and mortality rates. Cuba has been a global leader in the development of vaccinations that have reduced mortality rates for several life-threatening diseases. The nationalized utilization of various vaccinations has led to Cuba’s eradication of polio, tetanus, diphtheria, and rubella.³¹ Furthermore, proper screenings and subsequent indicated treatment of pregnant women with syphilis as well as HIV led Cuba to be recognized as the first country to eliminate maternal transfer of these infections.²⁰

Oral Health

The United States and Cuban populations are afflicted by similar noncommunicable diseases. The key to combatting noncommunicable diseases involve the identification of risk factors, the formation of screening protocols, and the utilization of preventative strategies. Noncommunicable diseases of the oral cavity are of particular interest in this study. A widely known risk factor of dental caries is low fluoride exposure. Both the United States and Cuba have implemented preventative strategies to lessen the prevalence of caries. In Cuba, all civilians receive dental examinations to screen for the presence of dental and oral health diseases. In the United States, not all civilians receive regular dental examinations; however, community water fluoridation, implemented 75 years ago, continues to serve as a preventative mechanism in the development of dental caries.³² It is important to point out that water fluoridation in the United States does not benefit all civilians in the United States. Today, there are areas of the United States that are not provided fluoride in the water systems. Similarly, there are areas of the United States that have been found to have tap water with unsuitable drinking conditions, such as in Flint, Michigan. Although the public health policies in the United States continue to provide fluoride to its civilians through water sources, there are, unfortunately, areas that still remain without access to healthy, fluoridated water sources, including entire states, such as New Mexico.³³

Although Cuba does not have water fluoridation nor salt fluoridation, like that of the United States, the NHS does provide additional preventative care in schoolchildren through school-based fluoride varnish application. Although caries is a disease that can occur throughout a lifetime, the Cuban NHS only provides fluoride varnish application services to children under the age of 19.²⁵ Furthermore, there is little data suggesting the use of preventative treatments in the Cuban population above the age of 19. In the United States, preventative care, through fluoride varnish applications, or the placement of sealants, is available throughout a lifetime in dentate patients, but can be limited starting at the mid-teenage years, due to dental insurance regulations. The United States embargo is largely responsible for Cuba’s limited resources of food, laboratory equipment, medications, and medical supplies.⁷ Cuba’s limited dental materials results in a health system that emphasizes prevention and health promotion, in order to avoid the progression of disease that would otherwise necessitate an inaccessible treatment regime. The United States, however, does not have dental material shortages like that found in Cuba, and can depend on a health-care system that can readily and commonly provide treatment to diseases.

Oral cancer is another noncommunicable disease of the oral cavity that affects the United States and Cuban populations. Smoking and alcohol are two common risk factors in the development of oral cancer. The preventive initiatives of oral cancer in Cuba rely almost solely on screening protocols and do not emphasize tobacco-cessation or alcohol-cessation strategies.²³ Because tobacco and cigars are a leading contributor of the economy and of the Cuban culture, there is a direct conflict with national priority to reduce tobacco use among Cuban civilians and the national culture. Since tobacco use is high among Cubans, the population is at increased risk of developing oral cancer. To protect its population, however, Cubans receive regular and thorough oral cancer screening tests during health-care consultations. In 2005, the rate of oral cancer (lips, oral cavity, and pharynx) stood at 5.2 per 100,000 persons in Cuba³⁴; in the United States it was 10.4 per 100,000 persons.³⁵ The death rate in Cuba in 2010 was 5.9 per 100,000 persons³⁶; in the United States that figure was 2.5 per 100,000 persons for the same year.³⁴ There is a high prevalence of oral cancer, which is a deadly disease in both Cuba and the United Stated. One thing to note is that the death rate is higher in Cuba, compared to the United States, further supporting a link between the wide spread tobacco use in Cuba and oral cancer. Health-care providers are responsible for educating patients on oral cancer self-exams. Health promotion strategies in the United States pertaining to tobacco-use and smoking educate patients to prioritize the public’s health over the economic benefits of tobacco-product consumerism. This can be demonstrated in warning labels printed on tobacco products, aiming to educate the consumer on the dangers of the product as well as to deter purchase and consumption of the product. Additionally, this can be seen by the increase in taxes of tobacco products. While public health initiatives in the United States continue to seek a reduction in tobacco use, the self-detection of oral cancer is uncommon, as self-examination skills are not commonly taught to the general public. Thus, the public health measures in place seem to promote for early detection of oral cancer in the Cuban population as opposed to the United States’ strategy to lower the prevalence of smoking, a known risk factor in the development of oral cancer, in the US population.

Future Research

This article aimed to report on Cuba’s health-care conceptualization, delivery, and associated outcomes. This information was used to compare the health-care system of Cuba to that of the United States. Recognizing the advantages as well as the disadvantages of Cuba’s NHS would be useful for future policymakers in the United States. Cuban approaches to health could be tailored to the United States environment to improve health-care effectiveness and population health status in the future.

In light of the recent pandemic, Cuba’s health-care system has done its best to contain the novel coronavirus and institute contact tracing. Gail Reed, editor in chief of MEDICC Review, reported that asymptomatic cases in Cuba are identified through contact tracing followed by antibody testing. When a positive antibody test is reported, a polymerase chain reaction test is used for diagnostic confirmation. Additionally, Cubans suspected of possibly having the virus are diligently placed in isolation.³⁷ These thorough preventative and diagnostic measures have been made possible by Cuba’s high doctor-to-patient ratio. Reed believes Cuba’s universal health system has allowed the government to direct a unified strategy as opposed to a rather fragmented strategy that can be seen in other nations exhibiting different health-care organizational structures. As of June 7, 2020, there have been 2,173 reported cases and 83 deaths in Cuba.³⁷ Further exploration of the Cuban NHS’ tactics its continuous pursuit to handle the novel coronavirus (COVID-19) may be valuable in further comparison of the health-care systems of the United States and Cuba.

The recent global pandemic has prevented any further travel to Cuba in 2020 or 2021. We have to continue our study of dental care in Cuba by observing how dental care is approached in the more rural areas of the country, particularly in the mountainous area where travel is more treacherous.

Footnotes

Acknowledgements

We are grateful to Educational Experiences Abroad (EEAbroad) team for facilitating our site visits, interviews, and lectures while in Cuba. Thank you to Dr Mark S. Wolff (Dean of University of Pennsylvania School of Dental Medicine) for supporting my vision in the study of dental public health. A personal thanks to Dr Cheryline Pezzullo.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Travel expenses were covered by the individual traveler, a small portion of the airfare was subsidized by a NYU College of Dentistry

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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