President's Message: Exceeding expectations

April, 2012

I landed in Havana with modest expectations. En route from Panama, I reflected on some of the concerns that tempered my enthusiasm about traveling to Cuba for the third Congress of the WONCA Iberoamericana-CIMF region.

Perhaps it was because of my disappointment a decade earlier when the group I was leading was denied a travel visa at the last minute following the imprisonment of Cuban journalists. Perhaps it was because getting to Havana was not easy for someone from the United States. Travel to Cuba is permitted only for specific purposes, such as attending a professional meeting. An American must purchase a tour package from a government approved travel agency outside Cuba and fly through an intermediate country, such as Panama, Canada or Mexico. Perhaps it was because I was frustrated that details about the travel and meeting were communicated infrequently and were a challenge for my struggling Spanish. Perhaps it was because I was worried that Cuba, which has a brief history with WONCA, might not appreciate the historic, regional, and global importance of a WONCA Iberoamericana-CIMF regional conference. Perhaps it was because my readings and briefings by others had me prepared for a country frozen in the Cold War era: vintage cars, decrepit colonial or dreary Soviet architecture, and public events used to trumpet party loyalty and promote the cult of Fidel.While my concerns had some basis in reality, I learned that they were only part of the story of Cuba. It is the rest of the story that I would like to share. It is the rest of the story that exceeded my expectations.

Clearing passport control and customs at José Marti International Airport proved relatively painless. Awaiting our group were Professors Eduardo Alemañy, President of SOCUMEFA (Society of Cuban Family Medicine) and Vice-Rector at the Universidad de Ciencias Médicas de la Habana, and Niurka Taureaux Diaz, also a family doctor at the same university. Their warm hospitality, candor, and attention to every detail began to ease my worries about the week ahead.The 20 minute drive to the Convention Center hotel on the far west edge of Havana showed some of the contrasts that comprise today’s Cuba: there were old and new cars on the lightly traveled highway; the buildings were a mix of old and new as well. My walks around the area suggested that Cubans love to promenade and to play sports – people were walking and talking in great numbers along all the major streets; every corner lot seemed to have groups playing baseball, basketball, futbol, or volleyball.

Old Havana is a wonderful mix of colonial and art deco buildings along small alleyways filled with shops, tavernas, and assorted eateries. The historic fort and cathedral, surrounded by the blue-green Caribbean waters, make for a picture that likely causes cruise ship operators and developers to be misty-eyed at the sight of missed opportunity. One other thing about Old Havana – there is music, everywhere all the time. From lone guitarists in courtyards on a sunny afternoon to Son dance music in the evening to Timba rappers late into the night, Cuban life is infused with the sounds and moves of Cuban music.

Rich Roberts listening to music - Buena Vista Social Club

Health care and education are the principal focus of the Cuban government, and reflect 80% of the budget. Cubans take great pride in their enviable health statistics and universal literacy and education. The average life expectancies of 80 years for women and 76 years for men, and the infant mortality rate of 4.5 per 1000, place Cuba ahead of many developed countries with significantly greater resources spent on health care. Understanding these achievements requires an understanding of the well organized nature of Cuban health care.With a population of 11 million (2 million in Havana), Cuba has about 40,000 practicing family doctors and about 40,000 physicians in other specialties. There are 219 hospitals, 142 maternity homes, 156 nursing homes, 135 facilities for the disabled, and 11,000 consultorios (doctor’s offices) in Cuba. All Cuban physicians first train as family doctors, with six years of medical and three years of residency, although the final year of school and first year of residency can overlap. There are 16 medical schools distributed across the 15 provinces. The average family doctor earns about 500 Cuban pesos per year (24 Cuban pesos [CUP] = 1 Convertible peso [CUC] = 1 U.S. dollar [USD] less a 10% conversion fee).

Profs Faisal Al Nasir (2nd from left), Rich Roberts (4th from left) and Nabil Al Kurashi (3rd from right) at the consultorio with colleagues. Photo courtesy of Viviana Martinez-Bianchi (3rd from left).

Dental clinic in polyclinic

Health care is organized at a very local level. A local patient council provides advisory oversight. Family doctors and nurses live and practice in the community. They live in an apartment or house provided by the local government, which is often in the same building that contains their consultorio. About 40 consultorios will be located in the area of a polyclinic, which provides a wider range of services including ECG, x-ray, ultrasound, dental care, and urgent and after hours care. In addition, the polyclinic offers multidisciplinary services for diabetes (35% adult prevalence rate), cancer, older adults, and maternal and child health. One important aspect is that the polyclinic can provide additional specialized services, but patients are re-directed back to their local consultorios for most of the follow up care.Along with Professors Nabil Al Kurashi (Saudi Arabia), Faisal Al Nasir (Bahrain), Viviana Martinez- Bianchi (USA - Argentina), Fernando Coppolillo (Argentina) and Macarena Moral (Chile), I was privileged to spend part of a day at the Policlinico Universitario Vedado in Havana. We also visited several area consultorios. The facilities were clean, well organized, and staffed by professionals who appeared to be well trained and dedicated to their patients. At the same time, there was a relative lack of supplies, amenities, and privacy, compared to similar facilities in middle and high income countries.

Health care is also an important part of Cuban foreign policy. There are about 30,000 foreign students studying in Cuban medical schools, with about 10,000 from 29 countries at the Escuela Latino American de Medicina (ELAM). Cuba also sends numerous brigades of doctors and nurses to multiple countries. The shift to family medicine began in earnest after the system was rebuilt in 1984 around a model of primary care. Dr Cosme Ordoñez was celebrated at the Congress as a key proponent of this new model of care and served as the Honorary President of the Congress.The Congress was an overwhelming success. There were more than 1000 registrants, with 80% visitors from 24 countries. The Brazilians attended in great numbers, representing more than half the foreign guests and most of the poster presentations. The meeting included a heartening number of younger doctors, as well as an inspiring meeting of the leaders of the Waynakay Movement of young family doctors. The conference was just the right mix of science and socializing, learning and laughter.

Prof Rich Roberts with Cuban medical students

On my return flight to Panama, I thought some more about the origins and success of the Cuban health care system. After the start of the revolution in 1959, many professionals – including doctors – fled the country. Those who remained had to make do with less in the way of resources and fewer professionals. They were compelled to focus on the basics and to build a system from the ground up. Family Medicine provided them a solid foundation to better health care, and better health. As management guru Jim Collins would say, the Cubans have been “brilliant on the basics” of health care. They have achieved improved sanitation, high levels of immunizations, and a system built on prevention and primary care.

Dignitaries including Rich Roberts on stage.

I recalled two experiences that reflected the tensions in present-day Cuba. During one of the afternoons, Dr Martinez-Bianchi and I explored Old Havana. We were approached by a couple who turned out to be jineteros (hustlers). They directed us into a restaurant to listen to the Buena Vista Social Club. I was persuaded by the man to buy a round of mojitos; Dr Martinez-Bianchi was asked by the woman to purchase milk for her. She said she had the money for the milk, but her food card allowed only so much per month. Yet, it was acceptable for a visitor to buy and give her milk, which at 6 CUC per liter was twice as expensive as rum.On another day, I was the sole occupant of a taxi driven by a family doctor. He lauded the wonderful Cuban health care and education systems. He was happy with the pace of life and sense of safety for himself and his family. Yet, he acknowledged that “we live in a bubble that is going to change.” When I asked him why he drove taxi, he indicated that the athletic shoes and jeans desired by his children cost more than he made as a doctor, so he supplemented his income with the ready cash of tourism.

Thus concludes my brief story on Cuba. My modest expectations were exceeded, by a considerable margin. The warmth and openness of the people, the vibrant culture, the design and success of its successful health system, and the Caribbean sun all proved to be the dominant memories of my Cuban story. I hope that I get to go back to learn more of the story, because I have so much more to learn and the Cubans were such generous and congenial teachers. If you want to learn more about the changing island known as Cuba and its health system, I would recommend two recent publications. One is a special section on Cuba in the 26 March 2012 issue of The Economist, americasview/2012/03/week-print-2 and the other is the book, Revolutionary Doctors: How Venezuela and Cuba Are Changing the World’s Conception of Health Care by Steve Brouwer (Monthly Review Press, New York, 2011).

Buen viaje.

Professor Richard Roberts
World Organization of Family Doctors