A personal blog by Marianne Schwarz (2nd year medical student)
Sweat trickling down our backs and crammed into the few available seats in a Cuban doctor’s office, we struggled to follow our preceptor’s rapid and enthusiastic Spanish monologue. It was a typical hot, humid Cuban afternoon, and as much as we wanted to learn from Ania (the doctor), we struggled against the exhaustive heat and the difficulty of understanding her fast and impassioned speech. It was in the middle of this uncomfortable, sticky session, when the conversation turned to the payment of Cuban physicians, that she slowed enough for us to pick out a few words we would never forget: “La medicina es bonita” (“medicine is beautiful”). We all looked at one another in a (rare) moment of complete and mutual understanding.
We were a group of four UBC medical students fresh out of our first year, completing a medical exchange in the town of Santa Clara, Cuba. Our aim was to learn about the Cuban healthcare system, known for “salud a bajo costo”(“health at low cost”), where developed-world health outcomes are apparently achieved at a fraction of developed-world costs. How do they do it? It is a common – and a very good – question, the response to which is very complicated. It is beyond the scope of this article to explain why this is, so instead I have recounted some of the most memorable features of Cuban healthcare that I experienced. I hope by the end you will begin to taste the richness of our interactions in Cuba and understand why, after spending four weeks on that unique and inspiring island, I could appreciate the sense of ‘beauty’ to which our preceptor referred.
Let me start by describing the kind of practice this family doctor, Ania, works in every day. She consults with patients on the bottom floor of her small, two-storey, painted cement house akin to the other homes in her community. Upon graduation, doctors are given one such house where they are expected to live and work on a daily basis (with little freedom to move one’s practice elsewhere). The idea is that, as a member of her community, Ania is aware of the health needs of its population. For a similar reason, Ania makes house calls most afternoons; in visiting the patient’s house, it is thought, the doctor can better understand the socio-economic situation of that patient. For her services Ania is paid (very minimally) on an hourly basis and not per service provided.
There are several aspects of her practice that have the potential to positively impact her patient’s health. Making house calls is one such feature. In Cuba, doing home visits may mean walking through the hot afternoon sun in and around multiple apartment blocks, asking neighbours for the home of so-and-so and perhaps trying a few doors before you happen upon the right one. On finally finding the home and entering, though, one can immediately appreciate the kind of quality of life the patient has. I recall our first house visit where, without exchanging a word of Spanish, I could instantly imagine the kind of resources this patient may or may not have had at their disposal. Thirty seconds of absorbing the sights, smells and sounds of the home gave me more information than I could have gleaned in the few short questions typical of an in-office interview. It was a clear application of the Bio-Psycho-Social model of medicine, a chance to truly appreciate the social and economic determinants of this patient’s health. Ania also spoke favourably of the fact that she was paid per hour, as opposed to per visit. She truly seemed to appreciate the flexibility of spending as much time as she wanted with each patient, without the need to schedule patients with her salary in mind. After all, as she ended her talk with feeling, “…it’s about helping people, it’s about humanity, it’s about love.”
Unfortunately, Ania, like most Cuban health care providers, must work against the challenges of an ever-present resource shortage, often attributed to the US embargo against Cuba. Though most Cubans seemed proud of their universal health care system in which “todo es gratis” (“everything is free”), many regretfully commented on the problem of resource scarcity. Indeed, Cuba provides a whole range of health services, from plastic surgery, to community health prevention, to nutritional subsidies, with an amazingly inadequate supply of resources. It is an impressive feat, though of course, resource shortages have implications for patient care and physician practices. I remember the patient who quietly flinched as they were injected with a blunted, oft-reused needle. Or the sheepish look a clinician gave us when the back of her chair fell casually to the floor in the middle of a patient consultation. Even Ania, in her small community clinic, was equipped with a mini sterilizer that would help her clean and reuse various office supplies. Scarcity, and her partner frugality, walked everywhere in the streets of Cuban life.
In light of their clear resource problem, the Cuban people impressed me with their ingenuity, intelligence and care for one another. If the country can’t buy a vaccine from the world market, it will manufacture it and perhaps even invent a few at the same time. Meningococcal C, Tetanus and Pentavalent vaccines, among others, are all made in Cuba today. Cuba is also the birthplace of injections intended to improve the quality of life of lung cancer patients – a treatment now used in other Western nations but not yet available in Canada. Supplies are not only sterilized and re-used; they are also disassembled and recycled in ingenious ways. I remember a medical student describing how metal from an IV bag was reshaped into a surgical staple in the hospital he was training in. It was on a day-to-day basis, observing doctor-patient interactions, that I was touched by the care Cubans extended one another. Meals and babysitting hours are allegedly freely exchanged among neighbours, and we witnessed many interactions in which the patient would present their doctors with lunch, or maybe a coffee. When I inquired about this peculiar custom, the response I got was, “…it is necessary.” Sometimes it is a choice between surviving together, or not at all.
On the return trip home, I remember queuing for lunch wraps in the Toronto airport. I watched as the employee pulled out a fresh plastic container, lined it with a fresh plastic bag, filled the bag with fresh sliced veggies, mixed it all together and filled the wrap, swaddled the wrap with abundant plastic, and finally threw away all traces of the activity only to start with the next order. To go from a place where IV bags are reused for multiple medical procedures, to a place where bags (and by extension other resources) are thrown away carelessly, was a maddening contrast. It was “back to reality” for me.
Now home, and reflecting on the beauty to which Ania referred, I realize that she did not mean that there is never struggle in medicine, that all hurt can be fixed and smoothed over into an unmarred portrait. Rather, she meant that doctors observe the human experience in greater entirety than most: its triumphs, its struggles, its justice and injustice. And importantly, you are there to help in some large or small way. Cubans, physician or not, teach an even more profound lesson: that you can help even when your own circumstances are hardly ideal. In Ania’s words, medicine is “…about helping people…about humanity…about love.”
~Marianne Schwarz