Lessons from the margins of globalization: appreciating the Cuban health paradox.

It is widely recognized that Cuba, despite poor economic performance, has achieved and sustained health indices comparable to those in developed countries--the Cuban Paradox. There has been, however, remarkably little scholarship evaluating how this has been accomplished, especially during a period of extreme economic hardship. Cuba's exclusion from the mainstream of "globalization," moreover, allows us to gain insights into the population health impact of policies that have accompanied globalization. Cuba's experience challenges the conventional assumption that generating wealth is the fundamental precondition for improving health. As peoples around the world search for cost-effective ways to improve well-being, they might want to learn how alternative public policy approaches, such as those used in Cuba, may be effective. We therefore reviewed the literature on the health-wealth relationship in this globalizing era; then systematically examined public policy in Cuba, not only for health services (financing, vertical and horizontal integration, prevention and primary-care focus, inter-sectoral linkages, etc.) but for non-medical determinants of health as well. These included education, housing, nutrition, employment, etc. plus the community mobilization and social cohesion that the Cuban system has generated. It appears that the active implementation of public policy affecting a wide variety of health determinants explains the Cuban paradox, and that the international community can learn from Cuba's experience. The prospect for healthy public policy can thus exist within, rather than only on the margins of globalization. The importance of monitoring how Cuba sustains such policies as it faces growing challenges in this globalizing era is increasingly worth observing.