Volume 78
Number 2

Miracle of an Ordinary Life

Commencement 2002

Cuba: Paradox Island

Without Sanctuary

Alumni Authors

Elizabeth Dewberry ’89PhD

Previous issue: Spring 2002






















































ON THE VERDANT GROUNDS of the century-old mansion that now serves as Los Cocos AIDS Sanitorium in Rincón, on the outskirts of Havana, a group of Rollins School of Public Health students meets Roberto. After he was diagnosed in 1990, Roberto, like all HIV-positive Cubans, was quarantined in the sanitorium—a policy denounced internationally as a system of AIDS “concentration camps.”

In 1994, however, President Fidel Castro’s government tacitly acknowledged that its policies were rooted in fear and discrimination. It redesigned the system, encouraging patients to live with or near their families and receive care at home. The government also formed an education and prevention program and a network of AIDS care centers. Even so, Roberto chose to stay in the sanitorium.

“I feel good here,” he tells the Rollins students through an interpreter, flashing a smile. “I have all the medical care I need. Life would be difficult on the outside. What if something happened to me? The first thing I do every day is see my doctor.”

Countless stories of paradox, irony, and success against the odds have drawn these Emory public health students to Cuba. In spite of reports of human rights abuses, the forty-year-old U.S. economic embargo against Cuba, and endless shortages of food, medicines, and other necessities after the 1989 collapse of the Soviet Union, the island nation has managed to control the AIDS epidemic more effectively than any other country in Latin America. Screening virtually all of its high-risk population and the island’s blood supply also helps control the disease, and all infected Cubans receive care. The nation manufactures its own HIV medications with technology pirated from U.S. patent-protected formulas. While fewer than four thousand of Cuba’s population of 11 million are HIV positive, its neighbor to the south, Haiti, struggles with an epidemic among more than two hundred thousand of its 7 million people.

What Cuba lacks in resources it makes up for in resourcefulness. All Cubans receive free, accessible healthcare. The system intricately weaves public health and medicine, emphasizing community-wide health promotion and prevention. Priority care goes to vulnerable groups, such as children, mothers, and the elderly. Patients are able to see specialists in the nation’s 444 multipurpose “polyclinics.” In a nationwide network of family physician-nurse consultorios (thirty or forty to every polyclinic), each neighborhood-based team serves a population of six hundred to eight hundred. The family physicians are on call twenty-four hours a day; they spend mornings seeing patients in the clinic and afternoons visiting them at home.

“The family doctors must be scientists, counselors, epidemiologists, administrators, educators, and team members,” says Claribel Presno, president of the Cuban Society of Family Medicine, who hosted the students during much of the trip this spring.

Statistics bear out Cuba’s success. Last year the nation’s infant mortality rate was 6.2 per 100,000 live births (the U.S. average is 8 per 100,000). Deaths per 1,000 are 7, compared to 9 in the U.S.; life expectancy is 75 (77 in the U.S. and 79 in Canada). Infectious diseases that were leading causes of death before the 1959 revolution (such as malaria, parasites, and tuberculosis) have been virtually eradicated.

And Cuba has busily grown its ranks of doctors. Before the revolution that swept Castro to power, six thousand physicians served the island, which had but one medical school. Today, the nation counts twenty-one medical schools and more than thirty thousand doctors (all of whom are required to do a three-year residency as a family physician)–so many that Cuba routinely exports them to work abroad.

Such accomplishments have caught the collective eye of the international medical and academic communities, and the Cuban system has been praised in American medical publications such as the Journal of Family Practice. During his historic visit to Cuba just two months after the Rollins students, former U.S. President Jimmy Carter also walked the grounds of the Los Cocos Sanitorium. In his speech from the University of Havana, Carter praised the Cuban healthcare system as “superb,” while acknowledging that the U.S. has “stuggled unsuccessfully” to provide universal healthcare.

Growing numbers of American medical students are flocking to Cuba to study the system through an Emory nursing-school-based organization called Medical Education Cooperation with Cuba (MEDICC), which organized the March Rollins trip as well as a visit of a group of Emory nursing students earlier this year. Established in 1998, MEDICC works in close cooperation with Cuba’s National School of Public Health.

One of the trip’s many lessons was how Cuba has met its challenges by reconsidering medical approaches it had earlier rejected. While the country has a small biotechnology industry, medical and pharmaceutical necessities are in short supply. By official sanction, “traditional” or “natural” medicine has been integrated into mainstream, conventional healthcare in order to fill the gap. Maria Theresa Pons (left), a family physician in Havana, showed the students her medicinal herb garden behind her modest, three-room consultorio, which is also her home. She broke a sprig off a shrub and held it out to one of the students. “This is salvia,” she said. “It’s good for treating hepatitis.”

Tai Chi, acupressure, homeopathy, and other unconventional methods also come into play in treating pain and are taught in the general medicine curriculum. Only trained physicians are permitted to practice the techniques. They are used to complement Western medicine, so that a patient may receive pain medications at a clinic and then a few hours later receive acupuncture. Juventino Acosta Mier, director of the Center for Natural and Traditional Medicine in Matanzas, told the students, “The fight against the pharmaceutical industry is difficult because the problem at its center is not a health problem but an economic one.”

Mier focuses much of his efforts on prevention, especially among children. A class of eleven year olds recites a litany he has taught them: eat a healthy diet, stand up straight and speak slowly, don’t smoke, strive to balance yin and yang. Ultimately, he hopes, his teachings will reduce hypertension, acquired diabetes, and other preventable illnesses that are leading causes of death in Cuba.

The Emory students also witnessed the problems that continue to dog Cuba’s healthcare system. While many physicians insist that they now accept the alternative techniques because they have seen “scientific support” for them, that support mainly consists of clinical outcome data–not the years of costly study and carefully controlled trials that would be required in the United States. A visit to a medical school led to warm and thoughtful exchanges between the American and Cuban students, but it also revealed the host institution’s poor, ill-equipped facilities. Presno acknowledges some distribution problems with the fifty-two medical journals in Cuba and recognizes that not every doctor has immediate access to the Internet, but she says the nation’s medical information network is gradually growing.

“Giving away thirty thousand computers to doctors is not an economic priority when children need cancer treatment,” she says. “It’s not a perfect system, but we work every day to make it better. ”

The nation’s greatest challenge is its own economic recovery. Facing a starving population, in the late 1990s a desperate Cuban government legalized the U.S. dollar and accelerated investment in tourism. Tourist hotels built during Havana’s 1950s heyday as a gambling and resort destination for North Americans were renovated and the glorious historic architecture of Old Havana restored, while the rest of the city continued to crumble. Vacationers mostly from Europe and Canada poured in, leaving their dollars, jump-starting the economy, and creating new and troubling social disparities. Cubans who work in the tourism industry (as maids in the posh hotels, as taxi drivers, and as hustlers and prostitutes) have access to U.S. dollars and the “dollar stores” that have sprung up, offering goods in quantity and variety unseen in the Cuban peso stores. By contrast, those who work state jobs, including the highly educated professionals who make up university faculty and the medical profession, bring in only a fraction in pesos of the amount of those earning dollars. Consequently, many professionals–among them doctors and engineers–moonlight as cab drivers or hotel doormen, or they abandon their state jobs altogether.

Unlike many other healthcare-focused trips to “developing” nations, the Rollins students didn’t go to Cuba to help provide care. As Audrey Lenhart ’02PH, one of the students on the trip, says, “Cuba’s doing pretty well on its own. It’s not like they have a shortage of doctors so they need medical students to go down there and pick up the slack.”

What Cuba needs, says Presno, is the students’ understanding. “Relations between the U.S. and Cuba don’t really allow them to know the reality of what is going on. It’s important to us that they go through a transformation while they are here.”

That kind of transformation is the mark of an emerging kind of student travel, Lenhart adds. “Many short-term service trips, like alternative spring breaks, are usually focused on some element of service–renovating a school in Harlem, building a clinic in Honduras. Rather than coming in as an equal and just listening to what they have to say, the mentality is, I see you have this problem, and I’m going to fix it. Sure, these communities are going to have a lot of problems, but a bunch of North American students is not the solution. It can have the effect of absolving people of their responsibility, once they come back to the university, because they can say they did something to help. But really helping would be coming back and advocating for policy changes that would create systemic, long-term solutions.”

A better model, Lenhart says, is “to go just seeking information, to genuinely learn about an unfamiliar situation, rather than having some kind of preordained project. Then you can educate people in your university around the issue. Cuba was a great opportunity to show people how the policies of our country influence the lives of others. Our goal was just to learn about the healthcare system. We weren’t there to fix any problems.”

Allison O. Adams ’00G, editor of the Academic Exchange, accompanied a group of Rollins School of Public Health students to Cuba in March.




© 2002 Emory University