Are we still all right, Jack?

Around the middle of the 20th Century three countries introduced systems designed to provide primary health care to all their citizens: the UK, China and Cuba. All three nations had emerged from devastating conflicts with a political commitment to more equal societies. All achieved success in reducing health inequalities. Through universally applied public health programmes, education, and free family health care, each country combated the ravages of infectious diseases and ignorance, lowered childhood mortality and improved the expectation of life.

Half a century later, China’s barefoot doctors are a distant memory. In the UK the social contract that underpins the NHS is under threat. Only Cuba has kept the faith, to the advantage of the health of its citizens who enjoy a first world expectation of life for a third world cost.

When I worked for VSO in 1970s, Mao’s barefoot doctor system was the model for provision of healthcare in poor countries. Villagers, sometimes traditional herbalists, were given simple training and with the support of their communes provided free basic personal and public health care to their communities. The evidence is that it worked.

Fast forward 30 years: a few months ago a young doctor from Shanghai spent a morning in practice with me learning about our primary health care system. I enquired about barefoot doctors. She looked at me as if I had asked about sending boy sweeps up chimneys. “That was before I was born!” she said.

What happened? Barefoot doctors acquired shoes and aspirations, costs increased, and within 20 years the Chinese people were again having to pay for healthcare. Which means that millions of people, particularly in rural areas, now go without.

In the UK, the NHS still functions, in some ways very well, in other ways poorly. Most patients are appreciative of the service they receive, in fact more appreciative than the government wishes to acknowledge.

In Britain, health is a political football.  One could not claim that health in Cuba is not a political issue. Everything in Cuba is a political issue. But you cannot play football when there is just one team on the field. So the Cuban game is not driven by political point-scoring. Cuba’s healthcare system  has evolved, but in response to need not to politics.

Political stability must help to maintain a vision. So must social stability. Britain’s population, the way we live and the way we earn our living — or don’t — has changed a lot since the NHS was founded. If in doubt, take a look at films like ‘I’m All Right Jack’. In contrast, Cuba today probably doesn’t look so different from the early Castro years. For better or for worse. It is still dependent on sugar. There is very little traffic on the roads. True, tourism, so much a feature of the Batista era, is back, along with some of the old blights such as prostitution, but today’s package visitors are largely corralled on cayes which ordinary Cubans may only visit if they are employed there. For better or worse.

But there has to be more to Cuba’s achievements than that. The answer may lie in just what has made the NHS so popular and cost-effective: a family doctor system which puts the relationship between doctor and patients at the heart of the health of the community. Though Cuban family doctors have a stronger remit than UK GPs to promote healthy living. I wonder how many British GPs have taken a look in a patient’s fridge to check on their diet, or lead their patients in exercise classes?

It may be that the economic blockade fosters a shared self-help ethos in Cuba, and undoubtedly the absence of McDonalds and prudent use of scarce foodstuffs contributes to health. Just as blockade, rationing and digging for victory did in second-world-war Britain.

In Britain, recent governments have been trying to make health another commodity. But it isn’t a commodity. Good health is a privilege; it requires some luck and a modest amount of work, and the optimism to make the best of what you have. We GPs are privileged to accompany and advise our patients on their road through life. Surely we don’t need a Blitz mentality to preserve this?

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