Cigars, salsa, old American cars, and socialism. Anna Ellis spent her elective in Cuba to learn about this fascinating Caribbean island
Cuba's healthcare system is one of the successes of the revolution of 1959. Its doctors are highly skilled and very dedicated, and the concept of waiting for an operation or even an appointment is alien to a Cuban. Yet Cuba suffers from its dismal economy and remains an arch enemy of the United States, even finding itself on the US list of terrorist states. My interest in this contradiction and discovery of Cuban salsa took me to Havana in the sweltering heat of July and August 2002.
Cuba is a poor country. It is hard to fit around the traditional concept of a "developing" country because it has highly advanced health and education systems. Yet it is by no means on a par with the developed world.
How health care works
Health care in Cuba is totally free. Private medicine is illegal, and even corrective laser eye surgery and plastic surgery are available at no charge. The emphasis is truly on primary care and community based medicine. Each city is divided up into areas called municipios, and each of these has a policlinic. Each policlinic serves 32 family doctors, who work in their own consultario, serving between 450 and 600 patients. A policlinic is like an outpatient department; various specialists run clinics such as general medicine, paediatrics, rheumatology, obstetrics and gynaecology, psychiatry, and dermatology. An emergency department caters for minor injuries and emergencies such as asthma attacks. I spent six weeks based in a policlinic, spending time observing the various specialties and some consultarios. I also had sessions with the director of the policlinic, during which she taught me about the healthcare system and I could ask questions.
Each consultario is run by one doctor and a nurse, and usually has three rooms--the waiting area, the consultation area, and a treatment area. Such is Cuban culture that the doors between them (if there are any) are not shut. This is partly to do with the heat and to get as much air flowing around as possible, but nobody batted an eyelid even though the entire waiting room could hear exactly what was going on. Another Cubanism is the healthcare professionals' ability to juggle several patients at one time; they seemed to be able to examine one while writing a prescription for another and talking to yet another on the phone. This looked fairly detrimental to all I'd ever been taught about communication skills, but it was completely acceptable. Patients would turn up when they wanted and sit in the waiting room (listening) until they were seen.
Cubans hold two ideals about English people: the first that we have to pay for our healthcare system, and the second that we all go home to drink tea at five o'clock. They were surprised that the NHS is free, that each general practitioner has 1800 patients, and that we have to wait for operations and appointments. I also told them that we do love our tea and in fact drink it all day long.
Philosophy
The emphasis is on prevention rather than cure, as there are often shortages of medicines. As well as their day to day work, the family doctors have detailed prevention programmes to follow, consisting of categorising each patient yearly into a group (healthy, at risk, ill or chronically ill, and disabled) and visiting them in their home a certain number of times a year, according to what group they're in. Social factors, such as sanitation, are then further categorised, and even the family itself is labelled as "functional" or "dysfunctional." It felt as though Big Brother was truly watching; but it is accepted and is an important part of their health care.
The major health problems in Cuba are the same as in any Western country: heart disease, cancer, and diabetes. The doctor is still akin to God; patients respect their doctors and generally do what they tell them to. Abortion is common, and, although family planning programmes have been set up, women have had on average about four abortions by the time they have their first child. What we would call a medical abortion in the United Kingdom they call "menstrual regulation," and it's a regular occurrence. Infertility is roughly as common as it is here, although there are no services providing in vitro fertilisation. Family values are held firm, and the shortage of housing means that three generations often live together. The policlinic was piloting an "adopt a granny" scheme, where elderly people with no local family would live with an adopted one. The scheme is so far successful, even in its infancy.
Day to day life for Cubans
"Scratching the surface" of the real problems of the Cuban people is not enough--you need to have a spade and dig deep in this complex country really to understand it. The major problem is the dual economy. Workers are paid in Cuban pesos, the average salary being around 200 pesos a month. Supermarkets and general goods like clothes and furniture are in dollars, at prices as high or higher than goods in the United Kingdom. One dollar is equivalent to 26 pesos, meaning that the average salary is about $8 a month. When a tube of toothpaste costs about a dollar, you can see where the problems come from.
Hence the Cubans are an inventive lot. Crime is almost non-existent, socialism sees to that. People sell pizzas, sandwiches, or sweet things on the street for pesos. Some even have full scale operations going, involving the wife on the street taking orders and shouting them up to the husband in the kitchen at the top of the apartment block. A few minutes later the order flies down a pulley system in a bucket, and lunch has arrived. Everyone has something to sell on the black market; coffee, eggs, meat, even ice. Tourists may as well walk around with a neon dollar sign over their heads, ready to be tricked out of a dollar or two. People on the street will try to offer restaurants or places to stay (they call them jineteros, literally meaning jockeys), take you there, and then receive about $5 per person from the owners, which is added to your bill. Taxis slow down on the roads in the hope that you'll get in. While walking 50 metres from a bar to a phone in Havana's tourist centre I was offered eight taxis, three restaurants, and a boyfriend.
Cuba is a great place to explore and discover, and it's impossible to describe it in 800 words. You need a fairly thick skin as the jineteros and attention you draw as a white person (especially as a woman) can sometimes be overwhelming. A decent command of Spanish is essential, and even then people are not always easy to understand. It's an expensive place to be for both Cubans and tourists. My course cost US$900 for six weeks, and that was solely for the teaching. It wasn't "hands on"--more about understanding Cuban health care than learning new medicine.
Above all, the Cubans have a big heart (those who aren't jineteros) and will welcome you into their lives and explain their country to you. Ask as many questions of as many people as possible, and you will discover the many complexities and contradictions that make Cuba truly unique.
Key facts
* Population: 11 million
* Language: Spanish
* Capital: Havana
* Currency: Cuban peso of 100 centavos (Ps1.00=US$0.05; £0.03; a0.05 (rate 27 Aug 2002))
* International dialling code: +53
