In the shadow of plenty, Cuba copes with a crippled health care system
Robin C. Williams, MD
CMAJ 1997;157:291-3
Dr. Robin Williams is medical officer of health, Regional Niagara Public Health Department, St. Catharines, Ont. She visited Cuba last fall as part of a medical delegation verifying the findings contained in a report from the American Association for World Health. In this article she recounts how the US trade embargo is affecting the health of Cubans.
© 1997 Canadian Medical Association
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I met the joyful young Cuban boy with bilateral retinoblastoma on a ward round at the National Institute of Oncology and Radiology in Havana. Although he had already lost his sight in one eye, he was a candidate for an implant of radioactive iodine to treat the other eye. The medical skills were available in Cuba, but the US government had denied the pediatric oncologist a licence to import the iodine because "the radioactive medication was a threat to US security."
Thanks to humanitarian efforts, the child and his mother were being flown to the US for the surgery and treatment at a cost that was astronomical compared with what it would have cost to import the isotope. The physician, however, was delighted to have access to the care and she wanted to show me what they had taught the young Spanish-speaking boy to say on his trip to the US. The boy puffed himself up with pride at his newfound mastery of English and whispered "I love you."
I get a thickness in my throat even now as I write this, almost 9 months after I was part of a delegation of physicians sent to Cuba to validate the findings of the American Association for World Health (AAWH) on the impact of the 30-year-old US embargo on sending health and nutrition supplies to Cuba. For me -- a Canadian, a pediatrician and a public-health physician -- it was a week of mixed feelings: admiration for the work and energy of beleaguered physicians, sadness at the paucity of care and options for the sick, anger at the situation facing Cubans and pride at the stand our federal government has taken.
The trade embargo
The US trade embargo against Cuba has been in place since the 1960s. One of the world's few sanctions that explicitly includes food, it also imposes bureaucratic restrictions that effectively blockade medical supplies.
The factors that affect the Cuban economy are complex and numerous, and I am no expert in foreign policy. However, it was evident that regardless of other factors such as the economic collapse of the Soviet Union, Cuba's main trading partner, the tightening of the US embargo since 1992 has had a devastating impact on the health of all Cubans. Three other developments have contributed to the desperate situation: an unexpected wave of mergers consolidating US domination of the pharmaceutical industry, a ban on subsidiary trade (including food) and a requirement that US government licences be obtained before medicines and medical supplies are sent to Cuba.
Over a 12-month period in 1995 and 1996 the AAWH traced the implications of the restrictions on health care delivery and diet in Cuba. A multidisciplinary research team reviewed key US regulations, surveyed 12 American medical and pharmaceutical companies and documented the experience of Cuban import firms. To assess the impact of sanctions on health care, the team visited 46 treatment centres and related facilities and conducted 160 interviews with medical and other health care professionals, government officials and representatives from nongovernmental organizations, churches and international aid agencies.
The resulting 300-page report is full of examples of how the embargo has affected Cuba. Waterborne disease rates have more than doubled, making diarrhea the second most common reason to visit a Cuban physician. The country's mammography program is crippled by a shortage of film and spare parts. Surgical rates are down because of a lack of supplies and equipment, including anesthetics. Drugs for leukemia patients and children with heart disease are not available, since the embargo effectively bans Cuba from purchasing half of the new world-class drugs on the market.
Walking in their shoes
My delegation was asked to validate the draft findings contained in that report. Having the opportunity to speak to physicians in a variety of urban and rural facilities allowed us to see their situation at a grassroots level and attempt to walk in their shoes. The terrific challenges they face were evident everywhere we went, yet these beleaguered and battle-weary physicians still managed to summon the energy to face and solve problems while showing little evidence of anger or vengefulness.
More than once I was overwhelmed as I thought about trying to care for pediatric patients without access to what Canadian physicians would consider to be the most basic medications and equipment. There was no acetaminophen, only basic antibiotics like penicillin and ampicillin were available, and there were no third-generation products of any type. Equipment such as ventilators and oxygen monitors lay in disrepair in a "neonatal nursery" because Cuba cannot get parts from the US.
Our group toured a variety of hospitals, including America Arias Maternity Hospital, Havana AIDS Sanatorium, Juan Manuel Marquez Pediatric Hospital, the National Institute of Oncology and Radiology, the Cardiology Institute and the Nephrology Institute. Many facilities were dilapidated: paint and plaster were in poor shape, windows were dusty or broken, and furniture was often broken, worn and very basic. The latest journals and books in the hospital libraries dated from the 1970s and '80s. One pediatric ward "playroom" we visited had not a single toy, piece of paper or pencil. Patient charts consisted of microscopic handwritten entries jammed on every square inch of mismatched and reused paper. Isolation apparel was thin, torn, worn and shabby.
My understanding of the state of the Cuban economy came from the AAWH study, conversations with physicians and others, and from our guide, an affable young man who spent long hours with our group and described life at his parents' home.
He considered himself fortunate, since his interpreter's job provided not only a small income but also tips in US dollars. During our week in Cuba he ate as many meals as possible with us so his food rations could be used by his hungry parents and siblings. At one point he produced his ration book, which allowed for 4 ounces of beef twice a year, 8 ounces of poultry 8 times a year, 8 ounces of cornmeal 6 times a year, 3 ounces of bread each day, and 2 pounds of fish and 6 pounds of sugar a month.
The Cuban physicians we met could have been from any academic institution in North America. The profession is dominated by women, some of whom spoke freely of their long, 6-day work weeks; only on Sundays do families have time together at home.
Water supply and treatment is a serious problem. Cuba is not able to produce enough chlorine to disinfect the water supply, and water-treatment problems are compounded by distribution difficulties. The infrastructure for delivering the water was developed with American pipes and gauges. Attempts have been made since 1958 to introduce European equipment, but much of the delivery system continues to be in disrepair because American parts to repair pipes, pumping stations, pipe locators and the like are not available. Because of these problems, 8.5% of Cubans don't have "drinking-water service." Even those that do have water face restricted service: in 1993, residents of Havana had drinking water for only 8 hours a day.
A mammography program dies
Cuba's concern for women and children was once exemplified by an organized and comprehensive mammography program. Two units in Havana and 15 mobile units canvassed the island annually, screening women over 35 years of age. Over the last 5 years the program has faced many disruptions because of parts shortages. In 1994 it was disrupted for 2 months when the country ran out of x-ray film; it was shut down again in 1995 when film developer couldn't be obtained.
Now the screening program has been permanently discontinued because of equipment failure, inability to obtain the Kodak mammography film that requires a lower radiation dose, gasoline shortages for generators and the mobile units, and lack of film developer.
Another reason for discontinuing screening concerns the lack of resources for surgical and medical breast cancer therapies. The interpretive pathology examination of tissue required samples to be transported by a family member from the operating room to a pathologist with a functioning cytology laboratory across town; sometimes surgical closure would be required before lab results could be obtained.
On one ward round I trailed behind a prominent neurosurgery professor from Cleveland and our host, a Cuban neurosurgeon. The latter had just returned from an international medical meeting in Rome. The surgeon presented 2 complex cases and was seeking advice regarding surgical approach and management. Next we discussed an infant with hydrocephalus who required surgical treatment with a shunt; the neurosurgeon described his inability to obtain a valve for the child. He told of his despair as he begged for help at 2 drug company displays in Rome; although both initially talked business, they became cool and refused the sale when they learned where he was from. They explained that it would be too dangerous for their companies to deal with Cuba. To this day, I'm not sure how, or if, he obtained the valve.
The view from Canada
On returning to Canada I once again became involved in our community process to plan for hospital restructuring in the Niagara region. Like other communities we face dilemmas: there is an aging population with 418 000 people spread over a wide area, with hospital care being delivered through 8 acute-care facilities.
But the situation in Cuba underscores how fortunate we are to be "just tinkering" with our system. I hope that increasing awareness of the plight of that country will encourage governments and medical suppliers to search for a short-term rescue operation while the politicians and people sort out a long-term solution.
On quiet evenings, when I poke my head out of my own local trenches and look beyond our problems, or when I catch a glimpse of "Cuba" in a newspaper headline, I am thrown back to that week last October and the tragedies I witnessed. I am left to wonder what any single person can do to make a difference. It is easier to wallpaper over these concerns with an energizing trip to a local elementary school's "Health Fair Day," where I witness the opulence and the vibrancy of our Canadian kids. The forces that continue this embargo against Cuba seem mammoth, complex and immovable. I wonder if sending money, medical supplies, valves or journals -- all of which I've done -- helps in any meaningful way.
I've shared the details of my trip with friends and colleagues, many of whom have been interested and searched for ways to help. At the federal level, I sense a lack of interest in the details of the AAWH study, but I continue to speak to anyone interested, hoping that increased awareness of the urgency of this situation will help influence and improve the everyday, terrible lot of the average Cuban.
The full report and/or executive summary of the health implications of the US trade embargo on Cuba is available from the American Association of World Health, Suite 1208, 1825 K St. NW, Washington, DC 20006.
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