Paolo Fornaroli speaks to three UK-based doctors on their experiences during their elective placement in Cuba.
A poster along the highway outside Havana commemorating 65 years since the revolution / Paolo Fornaroli
Cuba, ever since its 1959 revolution, has sparked both romantic sentiments and contention in the global Left. Although a relatively small country, it played a central role throughout the Cold War – maybe most importantly demonstrated during the 1962 Missile Crisis. Cuba was also central to the establishment of the Non-Aligned Movement of countries in the Global South who wanted to promote their own interests after decolonisation on the global stage rather than those of the two superpowers, the US and the USSR. Led by brothers Fidel and Raúl Castro, together with Ernesto “Che” Guevara, the country’s socialist approach has led to social achievements unprecedented on the island. At the same time, many condemn human rights violations and the dire economic situation in the country. The decades-long trade embargo imposed on it by the US has made it one of the most isolated countries worldwide and has significantly contributed to the economic hardship on the Caribbean island. Cuba’s distinct political and social landscape is reflected in all aspects of life, including its unique health system.
And here I am, sitting on a rusty chair on a balcony in Havana’s Vedado neighbourhood. A few months earlier, my friend Alessandro had told me about his plans to go to Havana in the spring for a placement at the Manuel Fajardo hospital before starting to work in the NHS after graduating in medicine from University College London. I immediately knew I would have to visit him when he was there and ended up staying in Cuba for around a month in April and May. During that time, I met many other medics on placements, amongst them Maariyah and Suheyla. Both recently graduated from King’s College London’s medical school and completed their elective placement in the same hospital as Alessandro. Working in the general surgery unit put Alessandro in direct contact with patients as he was involved in planned and emergency surgeries in the operating room, sometimes together with Suheyla who completed her elective in anaesthesiology. Maariyah specialised in ophthalmology, and all three shadowed resident doctors visiting patients after surgery while also joining seminars with local medical students.
Cuba is often referred to as having one of the best health systems in Latin America and on paper, the results are certainly impressive. On important metrics for public health, such as the infant mortality rate and life expectancy, the Cuban government has managed to improve the situation in the country since the revolution. During the Covid-19 pandemic, the largest Caribbean island also recorded one of the lowest death rates in all of the Americas. Interestingly, Cuba managed to achieve all of this with relatively low levels of health expenditure when measured in US Dollars spent per capita. Compare their 1,186 dollars per capita on health in 2020 (in current US Dollars) to 11,758 in the US, 5,567 in Austria, 4,906 in the UK, or 1,281 in Chile – all countries with similar health outcomes as Cuba.
Interpreting metrics from afar always carries the risk of missing out on crucial aspects on the ground. Alessandro, Maariyah, and Suheyla all chose Cuba because they wanted to understand how the country manages to achieve such high health outcomes with extremely limited resources. They were also intrigued by Cuba’s internationalist approach to health with medical missions routinely being deployed during health emergencies around the world. I was eager to understand what insights all three medics might have after working in the Cuban system and whether it made them reflect on the challenges of our health systems more generally – and maybe I also wanted to check my own romantic assumptions about the island.
Asked about their general impressions, Alessandro and Suheyla first mention how impressed they were by the amount of doctors working in the system. In fact, according to WHO data, Cuba has one of if not the highest densities of doctors with 94 doctors per 10,000 population. The European average is 37.6, with the UK counting 31.7 and Austria 55. The average in the Americas currently stands at 28, with 36.1 in the US and 32 in Chile. As a result, doctors only see a few patients, granting each of them ample consultation time. “The administrative burden is lower too, meaning that doctors can focus on their skills instead of needing to document everything that happened,” says Maariyah. Alessandro adds: “I witnessed doctors spend up to 45 min at the bedside of patients to talk to them instead of dealing with administrative tasks.” Alessandro, Maariyah, and Suheyla all observed that during Cuban medical training, doctors would take a lot of time to explain cases to students and encourage students to ask questions while visiting their patients.
"One doctor told Alessandro that 'training is really part of the care'."
Alessandro in front of the Manuel Fajardo hospital in Havana / Alessandro Gressani
All three medics also agree that medical education in Cuba had a way stronger emphasis on practical training from the get-go. As a result, Maariyah found medical students to be much more skilled in Cuba than they are in the UK. One doctor told Alessandro that “training is really part of the care.” Maariyah also found that students are subject to heavier workloads during their education than in the UK. She tells me that it is common for final-year students to assist heavily during surgeries. “Cuban final year medical students would also have to do a 24-hour shift every 6 days where they would be working at the level of a doctor, whilst juggling university commitments,” she says. The classes of final-year medical students in Cuba are thus similar to what junior doctors in the UK might experience in their first year working. Suheyla and Maariyah compare this to the more paternalistic and protective approach to medical education in the UK, where the involvement of students in clinical procedures often implies the student being a passive bystander while the doctor works. All three agree that the doctors themselves are not at fault for this situation in the UK. They tell me that the number of administrative duties and time pressure means that during patient visits in the NHS, doctors have less time per patient and less time to answer in-depth questions from students. Alessandro adds: “Another interesting difference was that while clinical teaching is similar, political education is central to medical training in Cuba with lecturers putting a strong emphasis on solidarity.”
Cuba has achieved its health results by establishing free health services for all its citizens after the revolution, as access to healthcare had previously been strongly divided by class and inaccessible to the vast majority of the population. The revolutionary government also made medical education affordable for all social classes, which allowed Cuba to train a high number of doctors and focus on community-based, accessible primary care. Healthcare was seen as a political issue in the wake of the socio-economic struggle of the Cold War. The government recognised that by focusing on prevention, the need for costly cures could be reduced. This was compounded by the establishment of a national biomedical industry. For example, Cuba developed CimaVax, a highly effective vaccine that can be used against metastasised lung cancer which is now also being tested during a clinical trial in the US’ Roswell Park Comprehensive Cancer Centre. During the Covid-19 pandemic, Cuba also managed to develop its own Covid-19 vaccine.
While Cuba has made significant progress over the last fifty decades, its past achievements are now at risk of being corroded. A reduction in life expectancy was noted by the WHO for 2021 and, recently, Cuba made headlines by asking the UN’s World Food Programme for support in providing powdered milk to children under seven. Cuba is also facing probably the largest migration crisis in its history. Although there are no official figures on it, El País cites a recent study by Cuban demographer Juan Carlos Albizu-Campos that suggests that between 2022 and 2023 the island’s population fell by 18%, from around 11 million in 2021 to 8.62 million today.
"Everything is recycled – such as scissors and tubing – there is no single-use equipment because the state cannot afford to throw anything away."
Speaking about challenges in the Cuban health system, all three medics mention how the dire socio-economic situation manifests itself through the lack of medicines and resources. Alessandro tells me that while hospitals are old but quite clean, there is almost no medicine: “Post-operative infections were common, and although these do happen in the UK too, the real problem was how to deal with them. I saw honey being used to sterilise wounds after surgery because the hospital did not have antibiotics or did not have the most applicable type. Dressings were also not always available. Everything is recycled – such as scissors and tubing – there is no single-use equipment because the state cannot afford to throw anything away. At the same time, we produce tons of plastic waste due to mono-use equipment in the UK.”
Similarly, Suheyla observed shortages of drugs needed for anaesthesia. The availability of specific medications necessary during anaesthesia was a daily point of discussion during her placement. “The team always managed to find a way to ensure the list was running for the day, sometimes by using multiple drugs synergistically to achieve the desired effect or sometimes using another less favourable drug from the same class.”
Maariyah (left) and Suheyla during their placement / Suheyla Celik
The economic policies of the government since Miguel Diáz-Canel assumed the Presidency in 2018 have in many cases worsened an already crumbling economy. One of the most prominent policies was the Tarea ordenamiento of 2021, which ended the dual currency system and sought to revisit prices. Instead of bringing the promised improvement in the standard of living, inflation soared, making basic necessities like milk, bread, eggs, and coffee even less affordable for many Cubans.
In addition to systemic issues related to government policy, the trade embargo is behind many of the shortages. By far the most severe external pressure on Cuba, the embargo was implemented by the US under President Kennedy in 1962 and is still in place with some aspects having been tightened over the years. It makes international commerce extremely difficult for Cuba, as any US businesses, and businesses organised under US law or majority-owned by US citizens, are banned from trading with Cuba. Aside from severely limiting the amount of trade, it also makes sending remittances harder and hinders the work of UN agencies. The declared goal in 1962 was to isolate Cuba to such an extent, that the economic situation would push the population to overthrow the government – all in the name of stopping the spread of communism. It is exacerbated by the lack of foreign currency in the state’s reserves, Alessandro says, making the purchase of machines, technologies, and medicines extremely difficult. Importing highly specialised technologies such as ventilators, for example, from Europe or America is almost impossible. Many machines Alessandro saw being used are from Germany, but when these machines become too old or outdated it will be a challenge to replace them.
The Cuban approach combining a high doctor-to-patient ratio, community-based primary care, emphasis on prevention and a national biomedical industry were crucial in overcoming many of the difficulties the embargo entails. Yet, while the country can produce a certain contingent of medicines itself, new inequalities have developed. Cuban residents who earn foreign currency because they work in the tourism industry or receive remittances can purchase medicines in the black market, while those with salaries in the Cuban Peso rely on the poorly-stocked pharmacies.
"It is not hard to see why the Covid-19 pandemic propelled the country into the worst economic crisis since the Special Period."
I had many conversations with taxi drivers, waiters, bartenders, and the hosts of the houses I stayed in across Cuba. What I heard over and over again, was that the current all-encompassing resource scarcity really started in the 1990s. After the revolution, the Soviet Union became Cuba’s most important economic and political ally allowing the country to overcome many of the hurdles of the US embargo. So when the USSR collapsed in 1991, the country was forced into an extended economic crisis which led to severe food and fuel shortages commonly called “Special Period” – a euphemism coined by Fidel Castro himself. Cuba partially handled this crisis through a series of liberalisation policies, public investments and economic support from the leftist government of Hugo Chavez in Venezuela. This period also saw the tourism industry establish itself as one of Cuba’s fundamental industries. Yet, the fall of the price of petrol on whose sale Chavez’s support was contingent in the early 2010s, caused a new fallback for the isolated country. Add to this the additional economic sanctions of the Trump administration, which were not repealed by Joe Biden, and it is not hard to see why the Covid-19 pandemic propelled the country into the worst economic crisis since the Special Period.
Alessandro found that the state attempted to overcome the shortages in technologies and machines through a strong focus on physical exams. He noticed how, contrary to the UK, where CT and MIR scans are used frequently, in Cuba, the use of technologies is restricted to mostly X-rays and some ultrasound machines. While he says it is hard to infer what influence this has on the overall health outcomes, he mentions that the clinical and practical skills of doctors in Cuba are very good. Unable to rely on technology, they need to be able to do physical exams and talk to the patients to discover what is wrong. Consequently, physical exams and proper consultation with the patients are crucial during medical training.
"You can tell how much patients in Cuba respected their doctors as most people would come bearing gifts even though the vast majority of them will be poor or struggling to make ends meet. They were not extravagant gifts – they may be homemade cake, coffee brought in a flask, soft drinks or snacks."
Alessandro, Maariyah, and Suheyla all noted a different relationship between doctors and patients, which was more informal than in the UK. This also showed in how patients saw doctors. Even in cases with terrible medicine shortages, Alessandro says he never saw frustration or anger being targeted at doctors. Doctors were seen rather as victims of the inefficiency of the system than those responsible for it. Maariyah shared tender moments she observed between doctors and their patients: “You can tell how much patients in Cuba respected their doctors as most people would come bearing gifts even though the vast majority of them will be poor or struggling to make ends meet. They were not extravagant gifts – they may be homemade cake, coffee brought in a flask, soft drinks or snacks.”
In Alessandro’s experience, the large number of family doctors resulted in much shorter waiting times for patients than in Europe and as a result, certain diseases were caught much earlier. The most striking difference for Allesandro was noted not necessarily between Cuba and the UK, but rather between Cuba and other countries in Latin America. Alessandro also worked in the Dominican Republic for a placement a few years ago. There, he tells me, he saw a huge number of people who had diabetes and needed amputations because they had not been seen by a doctor and had no idea they had diabetes – and even if they had known, he believes many would not have had the money to get treatment. Contrasting this to Cuba’s focus on prevention, he says: “In Havana, I was aware of almost no amputations. My hypothesis is that diabetes is picked up much earlier because family doctors can provide testing, insulin and other drugs for free, and so patients do not develop such strong complications.” Beyond the country’s preventative approach, Cuba also developed a drug – called Heberprot-P – which helps heal diabetic foot ulcers that could otherwise lead to amputation. It has been shown to reduce the relative risk of amputation by over 70% and was approved for clinical trials in the US by the Food and Drug Agency this year.
"Cuba’s medical missions are fundamentally about solidarity with the global population."
Cuban healthcare has also made a name for itself through medical internationalism. Since 1960, Cuba has sent 400,000 medical personnel to countries in need of medical support with its emergency response brigades, primarily in the Global South but also in Italy during Covid-19 for example. Cuba has provided free ophthalmological surgeries to thousands of people in Latin America through Operation Miracle. It also sent brigades to Haiti after the devastating earthquake in 2010 and to West Africa during the Ebola outbreaks of 2014. In a blog post for the London School of Economics, Dr. Clare Wenham and Dr. Sonja Kittelsen highlight that Cuba’s medical missions are fundamentally about solidarity with the global population. This is a stark contrast to many other international approaches to epidemic response, which are often based on military or defence programmes to protect the domestic population from external threats of disease.
In addition to volunteer aid missions, Cuba also exports medical services as one of the few means to generate foreign currency under the US embargo. Essentially, the state contracts doctors and other medical personnel to foreign governments such as Brazil, Nicaragua, Venezuela, Mexico, or El Salvador. These medical exports are also used to build politically strategic relationships, as was the case with Venezuela in the mid-2010s. This approach has been criticised by many organisations, including Human Rights Watch, reproaching the Cuban state for exploiting doctors as exportable commodities to extract foreign currency. Discussing a Cuban medical mission in Qatar, The Guardian reported that the Cuban state sometimes takes up to 90% of the salary Cuban doctors make during missions abroad. However, some argue that these are also highly coveted opportunities for them, as even the 10% that they get to keep are higher than the salaries they would earn in Cuba, which Maariyah and Alessandro tell me range from 15 to 70 dollars per month, depending on their specialisation.
Alessandro got the chance to speak to many doctors who participated in such missions. “Already during medical training, the importance of such missions for international solidarity is regularly mentioned,” he says. The doctors he spoke to consider it to be a high achievement to offer their service to a less fortunate community. Yet, he also notes that once Cubans finish medical school, there are very strict rules on whether they can go abroad - one of the very few ways to do this is by joining a medical mission. The main reason might very well be that the government is scared that doctors will defect due to the difficult economic situation in the country and the relatively broad demand for medical professionals around the world.
A final aspect of Cuba’s medical internationalism is the Latin American School of Medicine (ELAM) in Havana. Founded in 1999, it is now the largest medical university in the world. By 2019, 29,000 doctors from over 100 countries had graduated from the school. It was installed as a response to the obvious lack of medical personnel witnessed by Cuban medical brigades in Central America following Hurricane Mitch. The school is open to students from around the world (including the US) as long as they can study in Spanish and provides many students from poorer nations with scholarships. “Cuba has very strong diplomatic ties with certain countries which they honour through hundreds of scholarship opportunities every year. I met many students from Palestine and The Gambia,” Maariyah says. What is exceptional about the school is that its aim is not to keep the doctors in Cuba. Instead, medical graduates are encouraged to utilise their skills in their home countries to serve in under-resourced communities.
"There is no way to be a good doctor without social justice and good living conditions for all – which are in themselves a ‘treatment’ for health conditions."
Fundamentally, the experience of these three UK-trained doctors has shown that healthcare is always political. At the end of our conversation, Alessandro stresses: “The concept of social determinants of health developed at UCL teaches us that inequality and poverty lead to bad health outcomes. There is no way to be a good doctor without social justice and good living conditions for all – which are in themselves a ‘treatment’ for health conditions.” Cuban doctors appear to have a great understanding of this, despite all the challenges they face with the economic crisis as medical professionals and as citizens. Even those understandably critical of the government are very proud of the country’s free healthcare. However, if Cuba cannot overcome its current economic crisis, the cracks that are already showing will widen and further threaten the achievements of the past decades.
Broader reading and listening recommendation on Cuba:
Podcast: Blowback Season 2 on Cuba
Memorias del subdesarrollo (Memories of Underdevelopment) - Film by Tomás Gutiérrez Alea, 1968
Tribune by Cuban writer Leonardo Padura in El País - for example: Cuba: More dust in the wind (see also his novel with the same title)
Leonardo Padura’s Mario Conde novels (Havana Fever, Havana Red, etc.) and La Transparencia del Tiempo (The Transparency of Time)
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