Medicine in Cuba Today: A Series of Shortcuts and Scarcities / Jeovany Jimenez Vega

Medicine in Cuba Today: A Series of Shortcuts and Scarcities / Jeovany
Jimenez Vega
Jeovany J. Vega, Translator: Unstated
By Alfredo Felipe Valdés

The professional trained for at least a decade, with a high educational
rigor, who once he or she graduates has a high level of knowledge, is
not treated by the State with the consideration deserved from the years
and personal effort it took to complete the training.

This includes how other social sectors are vastly better paid despite
not playing a social role even remotely comparable. This worker, who
economically belongs to the medium-low social class, and leads a life of
unjustifiable deprivation, has to witness how the government uses the
results of his work as a trump card and banner to export an image of
concern and anxiety for the good of the people and the rest of the Third
World.

At this point the consolidated successes of past decades, such as the
eradication of polio and other rash diseases by mass vaccination
campaigns, and the low levels of infant and maternal mortality, are used
to present them as achievements only possible under socialism, and are
incorporated into the advertising discourse that seeks to mask the real
social situation.

The Public Health Situation in Cuba

In 1964, the government of Fidel Castro took exclusive control of the
Cuban Health System, just as it took control of most other spheres of
social, economic, and political life in Cuba. For the half-century in
which it has had this control, the Cuban government has presented the
health system as a model to follow and did not hesitate to classify it
as a "world power." However, it is possible that in this area are seen
most clearly the violations and trampling that for all these years have
defined the relationship between the State and the individual. The most
grave situations of this sector are described below.

Situation of Public Health Personnel

The professional trained for at least a decade, with a high educational
level, who oncehe has graduated has a high level of knowledge, is not
treated by the State with the consideration deserved from the years and
personal effort it took to complete the training.

This includes the fact that other social sectors are vastly better paid
despite their not playing a social role even remotely comparable. This
worker, who economically belongs to the lower middle social class, and
leads a life of unjustifiable deprivation, has to witness how the
government uses the results of his work as a trump card and banner to
export an image of concern and anxiety for the good of the people and
the rest of the Third World.

At this point the consolidated successes of past decades, such as the
eradication of polio and other such diseases by mass vaccination
campaigns, and the low levels of infant and maternal mortality, are
presented as achievements only possible under socialism, and are
incorporated into the advertising discourse that seeks to mask the real
social situation.

Health professionals face restrictions on travel, and are punished if
they apply to do so
Deserving of special mention is the extreme subjection of all workers
under the Ministry of Public Health (MINSAP) under Ministerial
Resolution 54 of July 2, 1999, by the then Minister of Public Health,
Dr. Carlos Dotres Martinez, which is one of the most exquisite
aberrations dictated by the Cuban government. According to the terms of
this Resolution, every employee under the Ministry of Public Health, who
desires to go abroad, either temporarily or permanently, is forced to
apply to the Ministry to be "released" from the public health sector; on
submission of the application the employee is held by Ministry for a
term of five years, with no exceptions.

This regulation applies equally to a recent graduate or to someone who
has worked for 20 years, all will be held for at least 5 years before
being allowed to travel. There are a great many cases where the
prohibition on travel has been extended to 7 years. Even doctors and
dentists who are already retired, are held for 3 years against their
will by this former minister, who is not required to specify an exact
term and who is the one who ultimately decides, according to his
personal will, who will be "freed" and when.

During this time, this professional is given medical assignments, which
are virtually forced on him, and which most of the time under spent
deplorable conditions with regards to meals and often of hygiene; it is
not uncommon for the staffof a polyclinic or hospital to have no running
water for hand washing, the food is limited to a little rice, an egg and
some root vegetable.

Salaries are low, and often not paid

The overtime medical shifts, are every 5 or 6 days, and the personnel is
not paid for them for decades. Nor are they paid for seniority,
bio-hazard risk, nor night shifts; for example, for many years nurses
were paid the absurd figure of 6.00 Cuban pesos monthly for night
shifts, that is about 30 cents on the U.S. dollar. Nor are those who
take on teaching and administrative tasks — which adds $2 to $4 USD
monthly to their salary — paid appropriately.

The Ministry of Work, through its Resolution No. 16 in 2005, fixed the
basic monthly salary for this sector between 257.00 pesos (a little less
than $13.00 USD) for technicians and 627.00 pesos (a little more than
$31.00 USD) for specialized doctors at the second level. With this lean
salary, this worker, given the high cost of living, will barely be able
to feed his family for 10 days — as a result of which he is forced to
engage in a variety of activities on the informal market or the black
market.

In the case of doctors, this wage increase is around 48.00 pesos (less
than $2 USD) relative to the monthly salary that they have at the
moment. This was received by the workers with indignation and was seen
to demonstrate a profound lack of respect. Despite this, the government
then boasted about a disbursement of about 200 million pesos every year
(about $8 million USD), of which only two would fall into the pocket of
a mistreated doctor every month.

Asking for a raise brings loss of medical license

Amid these conditions, the aforementioned "augmentation" wage of 2005
led to two physicians, Drs. Rodolfo Martínez Vigoa and Jeovany Jimenez
Vega, then working in the Guanajay municipality west of Havana Province,
to draft a letter to then Health Minister Dr. José Ramón Balaguer
Cabrera where they presented the majority opinion generated by this wage
proposal.

To try to prevent their carrying forward with this initiative they were
coerced and threatened in every way, including the classic acts of
repudiation organized by the Party and the Union. This letter was
endorsed by the signatures of 300 workers who shared their views and was
delivered on November 11, 2005 to the Ministry of Public Health.

The Ministry never responded. The only response, was that the two
doctors who had the initiative were barred from the practice of medicine
throughout the country for an indefinite period, by a Ministerial
Resolution that cannot be appealed.

To try to justify these penalties, those who handled the case resorted
to falsification of documents and the manipulation and misrepresentation
of facts, accusing both doctors of having deceived their colleagues by
presenting them with a document unknown to them and which they covered
up, at the time they collected the signatures. This was disproved by the
copies of the document made at the time.

Here it is not possible to determine whether, at that time, there were
similar reactions in other provinces, but it is suggested in the case as
being very illustrative of the modus operandi that continues to be the
posture of the State and the way in which the Ministry of Public Health
solves its differences with its workers.

Any initiative, from any worker anywhere in Cuba will be treated in the
same way. At the time of writing both physicians continue to be barred
from practice, after 4 years, for something they never did. This abuse
has gone on for years with the full knowledge of all the central
authorities of this country, including the Attorney General, but remains
unpunished.

One of these doctors decided to leave the country after 4 years of
humiliation, He was required to apply for the aforementioned
"liberation" from the Minister, but despite not having been a part of
the Public Health System for 4 years, having been separated for from it
against his will, the waiting time was determined to begin now so he
will have to wait 5 additional years before he can leave.

This last evidence, even more than the rest of the elements outlined
above, demonstrates that the Minister and other senior leaders of the
circles of power in Cuba have no limits on their abuse and violation of
the rights of workers this sector.

Primary and Secondary Health Care Understaffed and Undersupplied

The situation of care in primary health care has deteriorated
considerably during the last decade as a direct result of the priority
set for sending doctors and technicians to Medical Missions abroad,
which now represents about half of practicing doctors. When a doctor
leaves his workplace he does not always have an immediate replacement
and generally the population is affected in various ways, either because
the person who comes to relieve him only works part-time or because the
patient has to move to a clinic further away and, because the clinics
are now more crowded, the wait to be seen can extend to hours. In most
cases, the Municipal Health Directors choose to concentrate the patient
population in fewer clinics, given the scarcity of doctors working in
primary care.

The doctor who is here to bear the work of those who leave. There have
even been occasional very dramatic situations where a Polyclinic made up
of 22 individual clinics has, for a time, had only two doctors
overseeing all services.

It is valid to note that when any of these situations occurs, the doctor
in question continues to receive exactly the same salary for taking on
the work of their absent colleagues. It is even very common that an
entire municipality or a territory will be deprived of certain specialty
service because the only specialist has been sent abroad on one of those
Missions.

For secondary care, the care situation also suffers from this
involvement but rather more attenuated fashion, because the Medical
Mission solicit all the specialists, especially the internal medicine
specialists in primary care. In the case, more acute situations in
hospitals and institutions are caused by problems of logistics and
infrastructure assurance.

The doctor's work is limited by the frequent lack of resources such as
disposable material for clinical and surgical treatments, the limited
availability of laboratory reagents, plates for x-rays, or even the
drugs themselves are often lacking. This is compounded by the structural
deterioration of many facilities that often do not have running water,
have poor ventilation and no air conditioning. There are cases of
Surgical Units closed for months because of structural problems.

Also affecting medical management is the dismal state of the available
ambulances, which often results in the involuntary abuse of patients who
have to wait, sometimes for 6 to 8 hours, to be transferred, sometimes
in life-threatening clinical situations in which the time is critical.
The Problem of Infrastructure

Although a little over 5 years ago the country began a program of repair
of many health facilities — in most cases the only repairs in decades —
this did not reach all of them nor did it always end with the best
quality, as is usual when the reconstructions are excessively delayed
and at times what should take months takes years, which is causing
inconvenience to the population, the theft of construction materials,
and results in cost increases for the final execution of the work.

Generally, once the repairs are finished, there is no follow-up with
regular maintenance, which is causing us to already see signs of
deterioration in these new facilities.

In primary care we see a heterogeneous situation. The original plan,
from over two decades ago, was to ensure one typical doctor's office —
with a doctor, nurse and all equipment — for every 120 families. Thanks
to the progressive deterioration over the years, in the current state we
can't say precisely the number of patients per doctor, but it can rise
to the thousands, and sometimes there is a sixth year intern to help.

This typical office model has only been preserved in a handful of cases,
and in general over the years has been taken over clinic, which, in the
best of cases, are located in homes confiscated from people who
emigrated, or some vacant locale adapted for this use. As a general
rule, the typical site is small, badly lit and ventilated even worse, in
most cases without running water for hand washing.

In secondary care, save in fortunate exceptions, the majority of
hospitals are more or less markedly deteriorated structurally, with a
lack or scarcity of running water in the rooms, sanitary facilities in a
deplorable state, bad conditions with regards to cleanliness, and often
infested with insects and the associated risk of spreading
hospital-acquired infections.

Medical Education: Creating a University in Every Large City

The so-called "municipalization" of university education, that is, the
intention to create a university in each municipality in this country,
has had a detrimental impact on the quality of teacher education, at
least in the case of medicine. This experiment, conducted over the last
decade, emerged as a direct result of the arrival of tens of thousands
of students of the Latin American Medical School (ELAM) following the
disaster of Hurricane Mitch.
And it's very good to help others, but everything should be studied
carefully and they should create the infrastructure necessary so that
this does not lead to problems, especially if it is ultimately decided
to extend the ELAM program beyond the 10 graduate programs included at
the time the idea was launched.

Foreign students displaced Cuban students at the historically recognized
faculties in the City of Havana, and from the provincial capitals to the
municipalities, where now the Cuban student sits in front of a computer
and takes lessons from teachers who often are not prepared with the
rigor that this level of education requires.

The results of the above combination and the desire to produce graduates
at all costs and at any price to ensure the continued availability of
relief staff to cover Cuba's Medical Missions abroad, has been to weaken
every link in the teaching chain. During the last decade and at least
until last year, there has been a degeneration of the requirements
demanded at all levels.

Simply to detail them: the high school graduate who already carries the
aftermath of the failed counterpart experiments in previous levels of
education, comes with a poor background, and the grade point average
required to enter these careers is increasingly dropping. The study of
the preclinical subjects that were once taught in prestigious schools
such as the Victoria de Girón Institute (Bay of Pigs Victory Institute),
by teachers with decades of experience in their subject, are now taught
at a computer in a local polyclinic with teachers who are just starting out.

Then for the rest of the stage of clinical training the student would
assist only twice a week at the hospital. In his sixth year he would
complete the internship stage, decisive in the consolidation of the
knowledge of the future graduate, by standing in at a clinic and
performing the work of a doctor who would be on a Medical Mission abroad.

Now graduated, this young doctor might complete the specialty of General
Medicine (MGI) in just 2 years, when the traditional method before 2000
required a total of 4 years. And to take it one step further, this MGI
resident can do a second, so-called "parallel specialty," for example
ophthalmology, and will graduate from both specialties in just two
years, although the combined specialties may be as complex as Intensive
Care Medicine and Anesthesiology.

Students of different Health technologies, after passing the first
semester but without completing the first year of training, have been
sent to any of these dozens of Medical Missions in Third World countries
which, incidentally, have netted the Cuban government, in recent years,
billions in hard cash dollars.

Artemisa, Provincia La Habana. October 2010.

Published on the Internet by Alfredo Felipe Valdés, before leaving for
exile in Spain with his family, as part of what he called "Cuba Report."

Originally posted on Citizen Zero Blog: February 22 2012

http://translatingcuba.com/?p=17891