It’s been an eventful year for Cuba. The United States policy changes announced on Dec 17, 2014—the result of 18 months of negotiations—signified a new era for Cuba. On July 20, 2015, the United States reopened its embassy in Havana which has been closed since 1961.
Over the course of three visits to Cuba in the past year I have learned much about this nation, its people, its art, and its healthcare system. We’ve toured polyclinics, hospitals, and medical schools. I've met with professors and medical students. We’ve gotten the government’s healthcare statistics and double checked those with providers on the ground. I’ve seen facility standards that are disappointing and observed shortages of the most basic medical supplies and pharmaceuticals.
But everyone I have met on the street knows and respects their local doctor, assigned to them by the state. They have all described their doctors as accessible, empathetic, and caring.
So my goal for of this trip was to make an unplanned and unannounced visit to this front line: to visit a family practice doctor who is the fundamental link connecting every person to healthcare delivery.
I was able to do that in the Nuevo Vedado neighborhood in Havana, where we walked into a clinic in a multifamily housing unit. Dr. Mercedes Pina runs her family medical practice with one nurse for assistance. Together they are responsible for the wellbeing of 393 families.
The practice is on the ground floor of a concrete high rise building boasting none of the charm of Havana’s crumbling colonial and neo-classical architecture, and all of the minimalism of Soviet construction. Row over row of balconies give a glimpse into the lives of the inhabitants: laundry hangs to dry, potted plants perch on ledges, someone leans out and calls down to a neighbor walking below.
Dr. Pina’s office door stands wide open; we walk off the street directly into her waiting room and cross only one more threshold to get to her small exam room or her office. The furnishings are Spartan: a heavy metal desk and molded plastic chairs in the small waiting room. Handwritten check marks cover a map of the neighborhood on the wall. Inside Dr. Pina’s office, open racks of patient charts line one wall. In the exam room, a high window with metal shutters filters light onto a stainless steel exam table with stirrups on the corners. The walls are painted the same green as the scrubs I wore daily in my own surgical practice.
I am struck by the symbolism of the clinic’s floorplan. Cuba’s socialized medicine means there is no financial barrier. There are no charges at all to the patient. And the clinic structure itself presents no physical or social barrier.
Dr. Pina herself is accessible. A small woman about 50 years old with full black hair, she wears a white, short sleeved coat and an easy smile. She is happy to talk with us, candidly answering questions and telling us so much that our translator has a hard time keeping up.
Her work is like that of a priest, she begins. She lives in the community and she knows her nearly 400 patient families well. She knows their education, their family dynamics, their hobbies and their vices. She knows the children, the grandparents, and the family pets. In this community, privacy is scarce, and Dr. Pina can depend on neighborhood gossips to alert her to a patient who needs help. The clinic is open Monday to Saturday, and she spends two days a week seeing patients in their homes. She takes calls at night as well.
In America, doctors wait for our patients to come see us. In Cuba, I am increasingly convinced that doctors do indeed go to people in their homes, building relationships and intervening before health issues become serious. It is a cultural expectation. Their national leadership has stressed it. Health is embedded as a basic right in their Constitution. In the neighborhood where she and all of her patients live, Dr. Pina is a familiar and trusted figure.
She’s not, however, a well-equipped one. Medical supplies are horribly scarce. Bandages, aspirin, medications, and even the most basic medical supplies are in short supply. The government blames the U.S. embargo, or maybe it's in part because Cuba is simply among the poorest countries in the world. Cuba ranks 118 out of 228 countries by per capita GDP.
Dr. Pina acknowledged that medications could be hard to find, but insisted that her patients get what they need. She has no electronic medical records, no patient management systems. Her desk has no computer, and is instead scattered with paper files, a blood pressure cuff, and a coffee mug covered in red hearts holding four silk roses.
But even without supplies, she clearly connects with her patients. Doctors in Cuba make between $50 and $80 a month (the average Cuban salary is $280/year); doctors in a family clinic like Dr. Pina’s are at the lower end of that range.
If they travel abroad—medical workers are Cuba’s highest export and 25,000 Cuban medical doctors are currently working in more than 68 countries—they can collect more than that, but the actual numbers are hard to nail down. Specifics depend on the Cuban government’s agreements with various countries and the Pan American Health Organization (PAHO). Analysts estimate that the government generally keeps 50%-75% of the doctors’ earned income abroad. In 2014, the official Cuban newspaper reported that the government would receive an estimated $8.2 billion from its medical workers abroad.
Many Cuban doctors leave the practice of medicine after a tour abroad, but Dr. Pina has traveled as a doctor twice, and returned to her clinic. She hopes to go again. In her absence, the government will provide another physician to serve her patients and she’ll retake her post when she gets home.
With such extremely limited resources, Dr. Pina’s main goal in her community is to observe, educate, and carefully monitor her patients. She is one of 25 neighborhood family doctors assigned to each of the country’s 451 regional polyclinics to do more sophisticated testing and treatment. Specialists are based in the polyclinic and Dr. Pina works with a team that includes an obstetrician, geriatrician, pediatrician and a psychiatrist. She can refer her patients to the polyclinic when necessary, and the polyclinic team visits her office as well.
The Cuban government reports an astonishingly low infant mortality rate: 4.2 deaths for 1,000 live births. Based on my conversations to determine the accuracy of those numbers, my hunch is that the rate is a bit higher, but not by much; estimates from outside the country are about 4.7. I believe it’s clearly better than what we see in the U.S. Why? The extensive prenatal care which lets essentially no one fall through the cracks.
When I asked her about maternal and child health, Dr. Pina immediately parroted the government figures, but went on to describe the care she offers her patients in detail. She said she sees a healthy pregnant woman 13 to 14 times during the pregnancy; if the pregnancy is high risk she will visit the mother at home every week to 15 days.
Dr. Pina registers every pregnancy in her community before the 12th week. Within 15 days of registering, the patient has an appointment with the polyclinic obstetrician, and is referred to genetic specialists for genetic testing if necessary. The pregnant patient sees the obstetrician again at 26 and 34 weeks in addition to Dr. Pina’s care.
Once babies are born, Dr. Pina assiduously ensures that every child in her community is vaccinated, and the clinic nurse will travel to homes to do vaccinations if necessary. I conclude this is why the vaccination rate is so much better than here in the United States. Clearly this is something we can learn from.
The heavy emphasis on prevention aligns well with the health outcomes reported in Cuba: low infant mortality (even if not as low as reported), and long life expectancy. Dr. Pina said her priorities are illness prevention, which she said includes issues like clean water and vaccinations, and promotion of health, which includes discussion of nutrition. Cubans like pork more than fish, Dr. Pina said, she believes this must be changed. She also encourages her patients to exercise and stop smoking.
Again I’m struck by how powerful a tool healthcare can be for diplomacy. The differences between our country and hers are vast and complicated, but sitting down together—physician with physician—Dr. Pina and I find much common ground. We can learn from one another. We love our communities and we want to build healthy habits and enable healthy choices for the people in them.
