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Land of the Free (Health Care)


The New Physician July-August 2001
Wearing my white lab coat, I walked down the street toward the clinic. The vintage Fords and Chevys rolling by made me feel as though I had traveled back in time to the 1950s, while the billboards lining the road were unlike anything I’d seen before coming to Cuba. They weren’t advertisements for car dealerships or cigarettes; they were political propaganda. One sign proclaimed Hasta la victoria, siempre (Toward victory, always) in bold colors, while another declared Todo para la Revolución (Everything for the Revolution).

I crossed through a garden of medicinal herbs to Consultorio No. 44, a whitewashed, two-story square building in Pinar del Rio, a city southwest of Havana. The first floor was the clinic of Dr. Jesus Daniel, the primary care physician with whom I worked. The second floor was where Daniel lived with his wife and child.

“Are you ready to get to work?” Daniel asked as I entered the consultorio. We interviewed and then examined a patient, a pregnant woman in her third trimester. Daniel placed a small, aluminum funnel on her abdomen and listened for the baby’s heartbeat. When it was my turn, I fumbled with the funnel and lingered longer than Daniel had, trying to focus on the heartbeat. The simplicity of listening for fetal heart tones this way stood in sharp contrast to the Doppler devices I’d seen used at my medical school in Chicago. No electronic amplifying device distanced me from the patient and baby. Finally, as I closed my eyes, I heard the heartbeat; I was amazed as mother, baby and I converged in an instant in time.

Each day I went to the consultorio, I learned a new skill. I learned to take a blood pressure, to percuss for the liver span of a patient with hepatitis, and to perform well-baby and prenatal physical exams. It was incredible. I began to really feel like a physician.

Daniel’s medical equipment consisted primarily of a stethoscope, a blood pressure cuff and his hands. With no lab tests to rely on, patient interview and physical diagnosis—formerly known as the art of medicine—became essential. Daniel told me that an intimate knowledge of his patients was just as important as any instrument.

He was responsible for the health of the nearly 500 people who lived in the five apartment buildings flanking his consultorio. Living among his patients, he said, gave him insight into their lives. He knew who smoked, who drank and who worked stressful jobs. He knew all of these things and more because he interacted with them as neighbors going about their lives.

Daniel not only lived among his patients, but he also spent most of his afternoons making house calls. We visited a variety of patients, from an adult with congestive heart failure to a child recovering from a tonsillectomy. We even saw people who weren’t sick; for example, we showed parents how to childproof their homes.

The first time I had ever stepped inside a patient’s home was with Daniel; with my American sensibilities, I felt as if I were intruding. Patients didn’t seem to act as if we were imposing, however. Offering coffee from precious grounds of rationed Cuban beans, they asked us to sit and chat about work, family and life in general. As I sipped the coffee and talked, medicine began to seem so personal, much more so than the clinical algorithms I’d learned in medical school. Surrounded by the artifacts of patients’ lives, I took note of the professor’s books, the toddler’s toys, and even the alcoholic’s empty bottles. These home visits gave Daniel the opportunity to get to know his patients from inside their homes and to better understand their perspectives.

Perhaps more unusual to see was how Daniel paid no consideration to the business side of medicine. Unlike offices in the United States where business and medicine seem interwoven, there was no clerk in the consultorio taking care of billing. There was no billing to worry about thanks to Cuba’s socialist structure.

I found Daniel’s physician–patient relationships to be simple. Removed from the influence of money, his priorities weren’t muddled. His role as a healer came first. I began to see, in contrast, the complexities of that relationship in the United States. American physicians are not only healers and patient advocates but also gatekeepers of health-care resources. The art of medicine lies buried somewhere beneath the rules of HMOs, Medicare and private insurance companies. Physicians have been forced into other roles, and I wonder if this leaves many American patients feeling alienated.

The Cuban medical system operates in a much different atmosphere. Cuba is a sort of “Galapagos Island” that has developed a distinct culture and life. Following the county’s sharp turn toward the political left, the United States placed an embargo on it in the early 1960s. This has led to its isolation from much of the world. And not only did the country’s cars and politics evolve into rare “species,” but so did its approach to medicine.

In the United States, physicians who live in the community and make house calls are a dying breed. In Cuba, they are the standard. Paid by a government that views health care as a right, Cuban physicians are taught that it is unethical and illegal to take money from patients. All Cubans have access to medical care, and they are never supposed to pay for it.

Of course, Cuban physicians have their own problems. They make only the equivalent of U.S. $20 a month, I was told. Although this is higher than most local salaries, Cubans can earn far more by catering to tourists as cabdrivers, waiters or hairstylists. And since most tourists tip in U.S. dollars rather than in Cuban pesos, this is money workers keep without government knowledge. The salary hierarchy is turned upside down, with professionals earning less money than service workers make. As a result, some physicians leave medicine to make more money in other lines of work.

My curiosity piqued by this system, I asked many Cubans what they thought of Fidel Castro. While their opinions were divided, many said Castro had made great strides in health care: He had made health care free to everybody and developed an immunization program for the entire country. For Castro, some physicians said, excelling in medicine despite the U.S. embargo had become a moral battle. Cuba’s medical schools have built reputations strong enough to attract students from many Caribbean and Latin American countries, while Cuban physicians are known around the world for their innovative techniques and excellent training. They are also known for their altruism: Teams of Cuban physicians are often sent abroad to provide crisis relief.

To conserve resources, Castro made preventive health care key. Pregnant women are required to come to the consultorio weekly, and the chronically ill are monitored closely. With such a strong emphasis on prevention, most physicians practice primary care medicine; there are few opportunities to become a specialist.

At some point while I was in Cuba, I started to believe that health care is a right of all people. I came to believe that the health of an individual is so important and fundamental that it should be kept outside the realm of money. Once money is introduced into the equation, I reasoned, there arises the possibility that some people will be left without access. I wondered about the system in the United States. How did we end up deciding that health care should be a profit-generating industry? How did we end up deciding that we would profit from the health problems of others?

Before I went to Cuba, I was jaded by the infiltration of business into the practice of medicine. I began to think the two must go hand in hand. In Cuba, however, I saw that medicine could be practiced in a more pure form, removed from the business aspects. It was more like what I’d envisioned when I decided to become a physician.
Archana Reddy is a fourth-year medical student at the University of Illinois at Chicago. She participated in the Medical Education Cooperation with Cuba program for one month after her first year of medical school.