For additional information regarding this trip, contact Maria Elena Ruiz, PhD, RN, FNP-BC, Latin America-Cuba program coordinator
We could not have planned a better day to arrive! On December 17th, our group was in Miami, ready to board our flight to Havana when news broke out that President Obama and Raul Castro were simultaneously announcing a historic shift in US-Cuba relations; after 54 years of the embargo, the US and Cuba would begin to open up discussions. The energy and passion was evident, as Cubans started to ask other passengers waiting to board the plain "eres Cubano?"-everyone wanted to share the news with others they thought might be Cuban. One hour later, we were in Havana and it was exhilarating! At the hotel, the manager rushed to greet us with much joy and hugs-thanking us for bringing such happiness to their country. From that day on, we were embraced and continuously told, "we have been crying tears of joy, thank you for bringing us search great news."
This is our second public health adventure to Cuba. Although we wish the program could have been longer, the university and exam schedules limited our visit to five very full days of public health activities. In these long days, we had a whirlwind of presentations, field visits and exchanges with key education, health, community and government leaders from various public health agencies, medical and nursing schools, senior care homes, sex education and environmental centers in central Havana and outlying rural areas.
Cuba is a beautiful island, full of sound, energy, and vibrant colors, where culture, politics and medicine are intertwined. The intersection of culture and politics was obvious as soon as we landed at the Jose Marti Airport in Havana, where posters of Fidel and Raul Castro, and the Cuban 5 are prominently displayed. Throughout the city, the only billboards one sees are the same-all highlighting the same message of government, politics and community. Unlike the United States, there are no advertisements for cigarettes, alcohol, coca cola, fast foods or anything else.
From the Students:
At the Cuban Institute of Friendship with the Peoples (ICAP), we learned that Cuba was able to foster international relationships despite the blockade. Solidarity was frequently heard, and I learned the real meaning of solidarity, as it really counts when you have solidarity with a group. In public health, we also apply this when we work with at risk populations, with our actions and commitments.
Cuba continues to amaze me; I came in with certain preconceived notions that have now been proven wrong. We talked a lot about Cuban values today; equality, integrity, excellence, solidarity. Historically, in the US, we focus a lot on individual interventions with individual plans of care. But I think we need to shift our healthcare model to a more population and collective based system
The themes of solidarity and humanism became clear to me. It seems embedded in the Cuban culture that that solidarity, collaboration and humanism are tied in as a way to maintain relationships throughout the world.
Our 2nd day in Cuba started at the Instituto Cubano de Amistad con los Pueblos (Cuban Institute of Friendship with the Peoples of the World (ICAP). Again, we are greeted by wide smiles and friendship, along with a brief historical overview of life in Cuba, the sociopolitical, housing, health, and international medical brigades.
Students Enjoy Lively Discussion at PAHO
Our group then meets with Dr. Di Fabio, the PAHO/WHO representative. This year, Dr. Di Fabio looks ecstatic with the change in US-Cuba relations-many more hugs given all around. Students become engrossed with the health data presented; including how Cuba is "privileged" with its universal prevention/comprehensive focused public health system, the family doctor-nurse team approach, high doctor-patient ratio, and interwoven clinic-home visit community based system We have lively discussions, as students asked tough questions about rising rates of obesity, infections, minimum evidence based publications and resources. Unlike the US, medicine here is viewed as a service, and not a profit making business.
With our hosts at the Nursing School
We're on a whirlwind trip, so on to our next stop-the Facultad de Enfermeria (Nursing School. We learn that 16 year olds can begin their nursing careers; either as a technical nurse, or licensed registered nurse (5 years). While the number of master's prepared nurses is growing, Cuba still needs to advance research and doctorate programs. Just like physicians, the nurses are assigned to live in the neediest areas-mostly their own communities. We gasped upon hearing nurses and doctors earn 20-30 CUCs per month.
Of course, these exchanges with key health professionals in Havana led to lively and insightful pre/post conferences!
From the Students:
The United States is a developed country and Cuba is a third world country. Cuba can provide health care to all of its residents. However, it seems that health care is a privilege in the U.S. How did Cuba make this system a success?
Health care in Cuba is nationalized. This is important, because it is a start difference with America's multi-payer system. Because of this, a log of the components of Cuba's health care system that has resulted in positive outcomes may be possible to replicate in the US. While we cannot directly change the system at a macro level, we can take key elements from the microsystem and utilize them in patient education, unit practices; and contribute knowledge for patient advocacy.
In Cuba, it is not the individual that matters nearly as much as "the people". In Cuba, healthcare is highly regulated by the government and it is the government that determines what is good for the people. That can be of great benefit – high vaccination rates, low infant mortality, long life expectancy. The U.S. spends more on healthcare than any other country, yet still has outbreaks of whooping cough.
I look at U.S. healthcare and I see a system that is broken. I think there is something to be said about the Cuban model and thinking about the health of a nation, rather than the individual.
We continue with our whirlwind field trips, to the Casa de Maternidad and the policlinic. We have been holding pre- conferences and reviewed assigned readings wherever we found available space (the hotel lobby, a closed cabana/pool area, a snack area before customers arrived), but the readings do not compare to what we experience in person.
Our visits to a large Maternity Home and Policlinic in Havana left everyone amazed. Unlike the boutique small scale Maternity Home we visited last year, with rocking chairs, and limited daytime activities for the young mothers, this Maternity Home was larger, and bustling with activities for the women.
Prior to the 1960s, with limited health care and lacking transportation and safe roads, many women faced poor maternal-child outcomes. Today, there are over 300 Casas de Maternidad, and almost 100% of pregnant women obtain hospital deliveries with good infant outcomes. Any woman considered at risk during pregnancy is referred to the neighborhood maternity home (where she remains until her delivery), including women considered young/older age, women expecting twins, low/high weigh gain, or various other risk factors. Women may spend as little as a few weeks, to even months in these homes, separated from their children and families.
The women we spoke with today share large units (wards), with limited furniture, a few TVs, floor fans to keep them cool, and a bedside stand. During our visit, the women appeared happy, chatting, or walking around the grounds. One woman was even sewing with a portable sewing machine by her bed!
Our next stop was a large, multispecialty policlinic. Policlinics are the core for public health, and today they have evolved into the well-recognized primary care family doctor framework where nurses and doctors work as a team with the community (the Cuban Health System model). The two field visits today challenged the students the most to "think out of the box."
From the Students:
Maria del Ruth:
Patients are called "the people", not patients; nurses and family doctors know the people from infancy on. The people are given care according to categories; Care I, for healthy individuals; Care II for smokers; Care III for those with chronic conditions; and Care IV for those with co morbid and chronic diseases. Regardless of where the people go, they are referred back to their primary care provider and all information is shared back with the doctor and nurse.
The maternity home idea, as Americans, we can view this as taking away an individual's freedom, but the benefits cannot be overlooked. Though there is much social pressure for pregnant women to go into the Maternity Homes, the women seemed to understand that there was a great need for their health, and they were willing to sacrifice in order to have a healthy pregnancy.
The concept of the Maternity Home was very impressive, although I personally would not want to be displaced from my family; I understand how difficult it would be for some pregnant women. The amount of care and work that health professions are able to do with so little to help high risk mothers is incredible.
I'm starting to understand how the Cuban health system works and to appreciate the resourcefulness of the health providers. I was amazed to see dental care provided at the polyclinic, and how they reuse soda bottles as receptacles for drainage. I was also impressed with the nurse, and how they encourage and combine traditional and western medicine in the clinics. As my second day here is ending, I can't help but feel emotional about my stay in Cuba.
Another beautiful learning day. Two things stand that we keep hearing: prevention and continuity, as the primary doctors and nurse teams stay with you throughout your lifetime. I wish the US would put more focus on prevention and continuity of care, as they could really make a difference in the nation's health.
We continue moving on, with our fast paced public health field visits and exchanges with health providers in Havana, Cuba. This afternoon, we get to experience life in a Casa de Abuelos (senior care center/home). While Cuba has a relatively young population, almost 18% of residents are over 60 years old.
Lat year, the medical director explained that these are lovingly referred to as homes for abuelitos (grandparents), as the medical and nursing providers care for the residents as a member of the family-and not as a patient.
Today we get to visit some abuelos in Havana. Our group bus enters a very busy and crowded street, and we could not imagine any senior home being in this older and congested neighborhood. We enter and are surprised to find 30 residents smiling, sitting in chairs, ready to greet us. Several nurses, all in white uniforms, wearing nursing caps welcome us and are ready to give us a tour. This is not what we envision as a senior care home, as the building is older, with minimum furniture, with small winding staircases, and some of the walls are cracked. But as the student comments reveal, both the staff and residents were friendly and eager to welcome us.
Our next stop was quite different, as we travel to the Escuela Latinoamericana de Medicina (ELAM), housed in beautiful lush green grounds of a naval academy. The school caters to low-income international students, all receive free tuition and a small stipend (including students from the US), and all are expected to return to their home country and to practice in underserved areas. Again, we were warmly greeted by one of the founders of the school. As usually, we were offered refreshments and Cuban coffee.
From the Students:
As part of my NP program, I have spent quite a bit of time at long-term facilities, and so several similarities and differences stood out for me. One of the biggest differences is that many of the seniors appeared to be more active and functional than American home residents.
Visiting the senior care site was the highlight of my day. I was surprised to see that despite the run down appearance, it did not smell, the residents were neat, and they looked well cared for. This shows how Cubans make the most with their limited resources.
My first thought was SAFETY HAZARD! From the narrow staircases, to the open balconies, I wondered how they keep the patients with dementia and Alzheimer's safe from falls and injuries.
The housing was in a state of disrepair; the quarters were small, with large common areas. While getting these types of services would be a hardship for loved ones in the US, the monthly cost here was only 1 CUC (or almost $1.00).
The medical school we visited, ELAM, was very unique as it accepts individuals from different countries all over the world, even from the United States. The school provides a six year program in which the first four years is used to teach the medical curriculum and the last two years are spent in the individuals' home countries so that they a gain exposure to the population they will be working with when they return home to work as physicians.
This is our final day in Cuba. We begin with a walking tour in La Habana Vieja (Old Havana); its magnificent beauty, fantastic colors, sights and sounds amazes everyone. Founded in the 1500s, it became a main shipbuilding center for the Spanish by the 1700s. Today, the buildings display various architectural Baroque and neoclassic designs. But history, battles, neglect, and even hurricanes have taken a toll on the city. Many buildings are now in ruin, while others are undergoing repair, so that we easily witness decay and demolition in one block, and glowing vibrant colors and repairs in adjacent buildings. Even with a short walk, we get a glimpse of Cuba's history; the main plaza with it's monuments to it's heroes, splendid cathedrals, a fortress, palaces, the grand plaza for the famed Cuban ballet, and of course, new restaurants, grand hotels, shops, and artist selling their goods. This walking tour took longer than expected-how could we not stop and take so many photos-along with our need to taste all the cool fruit drinks, pastries, ice cream. Our group also gets a historical lesson with a visit to the Museo de La Revolucion, then off for shopping at the mercado, where we interacted more with the Cuban residents and perfected our negotiation and bargaining skills. Many of us willingly gave up our hand sanitizers to the vendors-they eagerly accepted these gifts.
Our final stop today was at Las Terrazas, located 50-miles west of Havana and designated a biosphere reserve by UNESCO in 1984. The beautiful, enchanting nature reserve was a result of the reforestation project begun in 1968. Originally, Las Terrazas was created as a village for very poor rural villagers who lived without water or electricity. Today, the reforested area is a tropical forest, with over 8 million trees, hundreds of plant and bird species, a coffee plantation, man-made lake and a river flowing through it. It is a model for rural self-sufficiency and green living, with over 1,000 residents and several local artists sharing space. The beauty and tranquility provided a spiritual awakening.
One final note-last night, several of the students attended a free concert given by one of the many musician poets (Silvio Rodriguez). Today, the group is exhausted; they easily fall asleep on the ride back to the hotel. With fond memories, but some sadness, we prepare to take leave of Cuba.
Final thoughts from the students:
Multiple students repeatedly expressed the overwhelming sense of solidarity, human spirit for friendship, holistic nursing, hope, and the need global health and service to the community-these well all concepts and ideals found throughout the daily clinical logs maintained by the students.
At the international medical school (ELAM), the founder expressed that despite the multiple cultures and belief of the many students and visitors, the differences should not be seen as barriers. Instead, the differences should be seen as bridges and windows that connect one with others. I thought this was beautiful.
Carol: I had a heartbreaking experience today in Old Havana. A woman had a child in a stroller, around 2 years old. She came up to me and asked me if I could pour some of my water into the child's cup. I watched as the young boy drank it quickly and made this "ah" refreshing sound. I saw my daughter in his place and could not hold back the tears. It didn't feel fight to walk away without giving him the rest of my water bottle, which the mother took and she was grateful. This is the side that is not seen when we are on our tour bus. It really puts things into perspective, and shows how materialistic we can be. Another experience was when an elderly man, approximately in his 80s, looked thin, malnourished, selling newspapers. All he asked for was a PEN! When I gave it to him, his face lit up! He was so thankful. I would have never thought of a pen making someone this happy.
At Las Terrazas, what I greatly appreciated was the unity and resourcefulness, how they work together to build up the economy. It was quite admirable. We saw how we do not need to be as wasteful as we are as Americans. We really need to take a step back and view our selves. I admit I was hit with culture shock when we arrived, but after spending a few days here, I'm to think of how much I've taken for granted. I am sad to see our adventure come to a close, but remain hopeful that our relationships will grow and our countries can find peace with one another.
Our last day was a perfect way to end our trip. I learned a lot about culture and Cuban's health care system; and I look forward to incorporating my new knowledge and look forward to being a health care professional.
Students discuss the public health model (above).