Feature

A health service with its hands tied

Cuba is suffering from the impact of the intensified US trade embargo. Zoë Kenyon reports on first hand
experience of a health care system under strain

Healthcare in Cuba is delivered in a simple pyramidal structure. A family doctor working with a nurse serves a population of some 160 families. Both live within their area and are constantly available. Within our own experience, we recognised many similarities in terms of presenting symptoms and disease patterns, but the striking difference was the epidemiological role of this small team. Information is collected on an opportunistic basis but also the doctor and nurse are expected to know all their patients. Time is spent identifying risk factors, contributing to health profiles and generally being more proactive than in the UK.

Family doctors can refer to polyclinics where patients have access to a wider skill-mix (including a pharmacist and an acupuncturist).

Family doctors and polyclinic staff can refer on to district general hospitals which provide similar services to their counterparts in this country.

Outpatient waiting areas contained the same resigned faces and people sit on the same inhospitable chairs. Patients have access to the same range of diagnostic services. Therapeutic options have been restricted by the shortage of drugs caused by the effects of the trade embargo on the Cuban pharmaceutical industry. Cacti are grown for fibre used as suturing material and the hospital garden has plants cultivated for their pharmacological potential. (Issue 12 of healthmatters described the innovative use of herbal medicines in Central America.)

Embarrassed apologies were made when we asked about waiting lists. After defensive explanations about a shortage of prostheses and so on, we finally learned that some patients have been known to wait four to six weeks for a hip replacement.

Coronary care was necessary and available in the district general hospitals. The wards were simple, even austere, but resources were spent on essential equipment and the staff exuded warmth and enthusiasm. It is tempting to consider that their high morale reflects a regime which funds health services as a top priority. When the need arises patients are transferred to tertiary care. These specialist units are centres of professional excellence, highly regarded in Central and South America.

The concept of twinning is becoming a reality in Cuba. We were inspired by the compassion manifest in the medical care and the hospitality shown to victims of the Chernobyl disaster, and the provision of Cuban aid to the third world. At any one time at least 700 Cuban doctors are serving overseas.

Fidel Castro’s influence and charisma are evident in everyday life. Consistently we heard people talking of his role in their lives - at the grandmothers’ club; staff at a centre for adults with severe learning difficulties; residents at a home for the elderly; patients in hospitals and polyclinics; revellers at a street party - all spoke with respect and with understanding of the current difficulties (the ‘special period’) and many spoke with obvious affection for ‘Fidel’. We were told of his visits to support various ventures, for example to day centres and agricultural projects, but we saw his image rarely.

It seemed to us that Cuba was reaping the benefits of 32 years of making education and health priorities. Within a population of 10 million, the Health for All targets have been met, there is almost universal literacy, and population growth is controlled by voluntary measures.

At times it is obvious that individual choice is subservient to the public good. There is a controversial policy for HIV control. A decision was made eight years ago to restrict freedom of movement for the individual. This was made when the rest of the world was ignoring the dangers of HIV infection. Cubans are now reviewing and modifying those restrictions, and again and again we saw examples of a rolling audit.

The process whereby the opinions and concerns of the people are incorporated into the political structure is reassuring. It exhibits a flexibility and willingness to review and adapt.

Two weeks intensive introduction to a revolutionary regime has not made us instant experts. Nonetheless, we were a group of professionals trained to ask questions, to be objective and analytical, and we were all eager to draw our own conclusions.

Overall we were inspired. We have much to learn from a country providing equality but expecting commitment.