Spiegel Jerry M, Yassi Annalee
Liu Institute for Global Issues, University of British Columbia, Vancouver BC, Canada.
J Public Health Policy. 2004;25(1):85-110. doi: 10.1057/palgrave.jphp.3190007.
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.
人们普遍认识到，尽管古巴经济表现不佳，但其健康指标已达到并维持在与发达国家相当的水平——即古巴悖论。然而，令人惊讶的是，很少有学术研究评估这是如何实现的，尤其是在极端经济困难时期。此外，古巴被排除在“全球化”主流之外，这使我们能够深入了解伴随全球化的政策对人口健康的影响。古巴的经验挑战了传统观念，即创造财富是改善健康的基本前提。当世界各地的人们寻找具有成本效益的方式来改善福祉时，他们可能想了解诸如古巴所采用的替代性公共政策方法是如何有效的。因此，我们回顾了关于这个全球化时代健康与财富关系的文献；然后系统地研究了古巴的公共政策，不仅涉及卫生服务（融资、纵向和横向整合、预防和初级保健重点、部门间联系等），还涉及健康的非医疗决定因素。这些因素包括教育、住房、营养、就业等，以及古巴体系所产生的社区动员和社会凝聚力。似乎积极实施影响各种健康决定因素的公共政策解释了古巴悖论，而且国际社会可以从古巴的经验中学习。因此，健康公共政策的前景可以存在于全球化之中，而不仅仅是在其边缘。在这个全球化时代，随着古巴面临越来越多的挑战，监测其如何维持这些政策的重要性越来越值得关注。
