Cuban Health Care: Doctors without Band-aids
By Ruby Weldon | Location: Cuba | 01/18/09
We had read and heard so much about Cuba's health system – one of the
greatest successes of 'the Revolution' – and all of it good. More
doctors per capita than even most western nations, health clinics in
every neighbourhood, town, small village, health care free for all, and
a world-renowned pharmaceutical industry.
On our first trip to Cuba, one of our friends was around seven months'
pregnant. She'd been told her baby was breech, and would have to be
delivered by Caesarean section. For her and her family, which included
some medical practitioners, this was not just bad, but frightening news.
"The hospitals in Cuba do not have proper equipment," they told me. "You
cannot count on things being clean. The material they use to stitch
people up is often old, and falls apart. They often do not have the
right drugs. They re-use disposable needles." Their list of concerns was
long.
I agreed to examine the woman in the presence of her husband. By my
palpation, the baby was indeed breech, but it seemed mobile, and small
enough to turn. I asked her if her obstetrician had suggested she do any
exercises to help the baby turn to a head-down position. "No, he just
says I will have to have a Caesarean section."
I showed her the exercises, and was pleased to hear that at her next
visit to the obstetrician he found that the baby had turned, and was now
head down. She said that when she told him about the exercises he
expressed surprise. He wanted to know who had told her about this, and
what exactly she had done.
Before we left Cuba the family asked me to send some suture material,
sterile gloves and needles and medications to prevent hemorrhage to
them. These were the things they were concerned would not be available
when the woman went, in labour, to the hospital. I sent the package, and
they received it with no difficulty, and in time for the birth.
I was interested to talk with Cuban women about their childbirth
experiences, and heard many stories. I was surprised by the number of
women I talked to that had been delivered by Caesarean section – clearly
the majority. They were all happy to show me their scars. All of them
were vertical, from pubis to navel – the old 'classical' incision that
is no longer used in the western world, primarily because once a woman's
uterus has been cut in this way, she is at such risk in further
deliveries that repeat Caesarean sections are the rule.
Apparently this is not the rule in Cuba. Women with vertical incisions
do go on to have vaginal births. It would be interesting to know what
the rate of uterine rupture is in these deliveries. Perhaps the Cubans
know something we don't, or perhaps they are more willing to take these
risks.
Just as disturbing as the vertical incisions these women had were the
frequent signs of poor healing. Many of the scars were very wide and
looked, even after many years, poorly healed. Several women spoke of
having to go back to the hospital because their wounds had re-opened
and/or become infected. Many had taken months to recover from their
surgeries, and needed mothers, sisters, aunties and friends to look
after their babies for them.
But most disturbing to me of all was how little Cuban women knew about
their bodies, about health and care in pregnancy, and about labour and
delivery. According to them, care during pregnancy consisted of being
weighed, measured and given an ultra-sound – at every visit! All of them
had had blood tests done, although most of them didn't know what they
were for. (In fact, from discussions I had with a Cuban geneticist, I
learned that Cuba tests pregnant women for most of the same parameters,
including the risk of genetic disorders, that we do.)
Women went into labour and birth with a 'knowledge' based on stories
they'd been told by other women – often dreadful stories. They were
fearful and distrusting. Of those who'd had Caesarean sections, not one
of them knew the reason why. All of them just said "because they told me
my baby was in trouble."
There was little education about breast-feeding, and little overt
support for it. I was saddened to see the number of women who were
bottle-feeding their babies. And I was amazed, given Castro's hostility
to western capitalism, to see that Nestles appeared to have the corner
on the formula market in Cuba.
Although Cuban women do get a full year's paid maternity leave when they
have a baby, many of them go back to work within the first few months.
It's the only way to make ends even begin to meet. The baby is either
left with a mother or sister, or placed in an 'infant circle,' which
used to be provided as a service by the government, but which now must
be paid for.
All this aside, the Cuban government does provide one maternity service
that makes a lot of sense. This is the system of 'casas de mujeres,' or
women's (maternity) homes, which are in every city and town in Cuba.
Women who live at distance from hospital (no Cuban babies are
intentionally delivered at home), or women who have a problem pregnancy
that requires observation, are given beds in these homes. They are also
given meals, and they can enjoy, if not the comfort of their families,
at least the company of other women.
The 'casas de mujeres' are staffed by nurses who are able to monitor the
womens' health, and take the women to hospital as and when needed. This
may be one of the most important things that Cuba does to achieve its
very low infant mortality rates – the lowest in South America and lower
even than the rate in Canada – a very impressive achievement.
On our last visit to Cuba we met a fellow from Finland who had a truly
awful throat infection. He had been to an international health clinic
and been seen by a Cuban doctor. He'd been given a prescription for
strong antibiotics, and a nurse had administered the first shot.
Although he was a big and pretty tough-looking guy, he said the shot was
extremely painful – a burning sensation that lasted long after the
needle was withdrawn.
I looked at the medication. It was an antibiotic that's meant to be
given intravenously, not intra-muscularly. I offered to give him the
rest of his injections, but warned him that regardless of the technique
of the puncturist, the shots were going to hurt.
I gave him five or six more shots. The clinic had provided him with
enough disposable needles and syringes for each one. As a medical
practitioner, I was concerned about safe disposal of the needles. We
were all staying in a casa particular where one of the family members
was a doctor. I asked her if she could help with the disposal of the
needles. She said sure, I could just give them to her.
When I gave the used needles to her, she turned around and tossed them
into an open waste basket in the corner of the room. The same room she
shared with a couple of small children who, like most Cuban kids, were
playing on the floor not a few feet from the waste basket. I wondered
how needles were disposed of in Cuban hospitals and clinics... .
We frequently saw people with nasty open wounds and sores in Cuba. On a
couple of occasions I asked the people if they'd been to a clinic to
have the wound cleaned and dressed. The answer was either "yes, but they
had no ointment and no bandages" or "no, they have nothing there."
On one occasion we were helping a group of carpenters with a community
building project and one of the fellows managed to give himself a very
deep gash to his finger. It looked like it was almost to the bone, and
the last joint of his finger was bent at a sickening angle from the rest
of it. I suggested he go to the local hospital to have it cleaned and
sutured. He went, but came back with it looking just about the same. He
reported that they had looked at it and washed it, but that they had no
suture materials, no ointment, and no bandages available.
As we carry an antibiotic and antibacterial ointment with us, I asked
him to come back to our room, where I would at least apply some of this,
and cover the wound with a bandage. After applying a liberal glob of
ointment to the wound, I used some gauze and a well-wrapped couple of
band-aids to pull the finger-tip into alignment with the rest of his finger.
We saw him several days later. He ran over to show us his finger. It was
healing very well. The cut was closed, and the finger was straight. I
gave him another couple of band-aids to keep the finger protected as he
worked. Wherever we went in that town from then on we were greeted with
big smiles and hand-shakes. The story of the miraculous healing of the
carpenter's finger had spread by Cuban 'telephone' – the fastest
communication system in the world.
On another occasion we were walking near a pharmacy. A young man
approached us and asked if we would give him the money to pay for a
prescription he'd been given. In return, he offered to get us a
prescription for anything we wanted. We asked him if he couldn't get his
prescription for free. "No, nothing is 'free' here in Cuba. It doesn't
cost much, but anyway I don't have the money."
As it turned out, the drug he needed didn't cost much at all, by our
standards. But on his salary, $8 or $9 a month, even $2 was too much. We
bought him the prescription.
We also always brought vitamins – especially vitamins C and B – for our
Cuban friends when we came, as well as pain medications and specific
remedies for colds, rheumatism, arthritis and varicose veins. And
antibacterial and antibiotic ointments for cuts and wounds, creams for
skin disorders. None of these things were easily available, or cheap
enough for Cubans to buy.
At one of our bed and breakfast places, the woman's daughter had
insulin-dependent diabetes. She had great difficulty controlling her
diabetes not because she couldn't get the insulin – it was available.
The problem was that the diabetes centre in central Havana, although it
had the testing kits needed to determine one's blood-sugar level, almost
never had any testing strips. The kits are useless without the strips.
So for the woman's daughter, as for other diabetics in the country,
treatment of diabetes is based on guess-work. What do I think my
blood-sugar level is? How much insulin do I think I need? This is a
dangerous way to treat diabetes. And diabetes rates are reportedly high
in Cuba, likely due to the low protein and high carbohydrate nature of
the Cuban's limited diet.
On our last trip to Cuba we were told about Fidel's arrangement with
Bolivia. Bolivians come to Cuba for eye surgery. Once it's done, they
stay at one of the all-inclusive resort hotels to recover for a few
days, or a week. The same hotels that are off-limits to Cubans.
We asked a few Cubans what they thought about the 'free' health care and
hotel stays for Bolivians. They all expressed pride in Cuba's modern –
and obviously superior – health care system, and in Cuba's generosity in
providing this service 'free' to Bolivians. Only a couple of them seemed
aware that the Cuban government was in fact being paid.
The Cuban government also has an arrangement with the Venezuelan
government – doctors for oil. Cuban doctors, having received their
education courtesy of the state, must pay it back by going to Venezuela
for two years – or more – to work. This often results in the separation
of families – mothers and fathers leaving husbands, wives, babies and
children behind in Cuba as they go off to Venezuela for their tour of duty.
The Cuban doctor in Venezuela does get paid for his or her work – and
very well by Cuban standards: around $50 a month. For their families,
this is a tremendous benefit. The doctors can also, while they're in
Venezuela, buy all sorts of things that are simply not available in
Cuba: electronics, kitchen appliances and utensils, clothes, shoes,
cosmetics, jewelry – and food, glorious food.
But regardless of the perqs, the Cuban doctor is indentured to the
state. When he or she is 'invited' to go to Venezuela, it's an
invitation that can hardly be refused. We met several doctors who had
gone to Venezuela for more than one two-year stint. One of them had been
away from their family for six years. The doctor was estranged from his
wife, and hardly knew his own children, nor they him.
On our first trip I happened across a Cuban obsterician/gynecologist in
a cafe in Havana. We started off talking about the cockatoo in a cage in
the corner. It wasn't long before we were talking about maternity care
in Cuba, his work in the hospital in Havana, and his family – his wife
and two young girls. It was a pleasant chat. When it was time to part,
he took my hand and said: "Please, I am wondering if you could give me
some money. I do not get paid much for my work – not enough to support
my family. Please, if you could help."
On a subsequent trip I had the good fortune to meet and share a meal
with another Cuban obstetrician/gynecologist. We had a wide-ranging
discussion, during which it became clear that although he had been
fairly well trained, his knowledge was limited by the fact that he had
had very limited access to modern obstetrical or gynecological texts. At
the end of our conversation, the doctor said: "I do not ask you for
money. I ask you for information. Please, if you can send me
information. Here it is so difficult to get."
The doctor was unable to get any obstetrical or gynecological journals,
and was permitted only one hour a week of internet access – and even
that was restricted. He therefore had almost no way of keeping current
with advances in his field, or of getting information about specific
disorders, problems or issues he was encountering.
Although he was a bright and engaging fellow, I came to the conclusion
that his education and training was so limited that he was really at
what we would consider a novice level – a suitable assistant or
apprentice to someone with more training and experience, but not someone
who was equipped to manage complex cases on his own. But he is, of
course, doing just this.
If you go to Cuba, take as many vitamins and medications with you as you
can. In particular, take Vitamins C, B, and E and children's vitamins
with iron; cold and flu remedies, throat lozenges and cough syrups; pain
medications like Tylenol and Ibuprofen; specific pain relief for
rheumatism and arthritis; antibiotic and antibacterial ointments;
sterile gauze and band-aids. Tooth brushes, toothpaste and dental floss,
razors and razor blades, tampons and minipads, soap and shampoo are also
much appreciated items. And if anyone asks you to purchase their
prescription for them, as the Nike ad says: 'just do it!'
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