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In Situ

Issue 1 In Situ 2016 Article 2

5-14-2016 Guantanamera: Healthcare Delivery to Women in Ivana Kohut University of Pennsylvania

This paper is posted at ScholarlyCommons. http://repository.upenn.edu/insitu/vol5/iss1/2 For more information, please contact [email protected]. Guantanamera: Healthcare Delivery to

Cover Page Footnote Ivana Kohut, Anthrofest 2016

This article is available in In Situ: http://repository.upenn.edu/insitu/vol5/iss1/2 Kohut: Guantanamera: Healthcare Delivery to Women in Cuba Guantanamera: Healthcare Delivery to America, and is deemed the “healthcare model” Women in Cuba for many countries (Paul Farmer). In addition, “at approximately nine deaths per Ivana Kohut every one thousand newborns” (Randal), Cuba On December 17, 2014, President Obama has one of the lowest rates in the stated that, “In the most significant changes in world. The study was developed in order to ex- our policy in more than fifty years, we will end an amine how Cuba translates written health policy outdated approach […] and we will begin to nor- into practice. Logistically, how does the Cuban malize relations between [Cuba and the United government explicitly protect women’s health in States]. Through these changes, we intend to terms of services and broader systems? In turn, create more opportunities for the American and how are these systems accessed by the average Cuban people, and begin a new chapter among Cuban on a daily basis? What makes the the nations of the Americas.” The political state- current system practical and impractical? That is, ment has and most likely will continue to inspire the research studies the effectiveness of the cur- change, notably change pertaining to travel and rent, general health system for women through qualitative interviewing procedures. A total of trade restrictions. The of America’s 1 desire for a new relationship with Cuba has more- 89 interviews were conducted in 9 provinces over created an intense fascination, a unique (Pinar del Rio, Artemisa, La Habana, Mayabe- Cuba Locura, in USA media. Travel agencies, que, , , Villa Clara, Sancti as an example, paint Cuba as unique due to its Spíritus, and Ciego de Ávila) with an average of scenic beaches and greenery. The rich architec- about 8-10 interviews per province. Interviewees ture in Old La Habana and cobblestoned streets were categorized into three cohorts (ages 18-32, frequented by cars that would make any collector ages 33-69, ages 70 plus) so as to assess the green with envy, are strong pieces of evidence to healthcare system’s delivery at various stages of the fact that Cuba has been frozen in time. And development. The collected data evaluates which primary, reproductive, and geriatric care services though these qualities are uniquely Cuban, they 2 are by no means the only characteristics that are delivered effectively. Access to , set Cuba apart from other Caribbean and even to , and to health information were Latin American countries. Universal access to analyzed when measuring effectiveness. healthcare, and an explicit prioritization of wom- Availability of general practitioners, free en’s health during pregnancy, constitute a unique of charge, constitutes a defining quality of the facet of the Cuban healthcare and policy. Cuba primary care system. The Consultorio Médico de boasts one of the highest doctor- ratios, a la Familia (CMF, the Family Doctor Consultation statement that separates the country from many Center) is an establishment supported by the Cu- others in the Western hemisphere. The Cuban ban government to increase access to physicians state has likewise implemented many resources (in both urban and rural areas). A CMF is spe- to revolutionize healthcare so that the right to cific to each town, city, or community equivalent health is as fundamental as any other right up- (based on location boundaries, such as in more held by the state. rural areas). The CMF is a two-floored structure The Hassenfeld Family Social Impact in which a general practitioner sees on Foundation through the Center for Undergraduate the ground level and lives permanently in the Research and Fellowships (CURF) at the Uni- center on the second level. The state encourages versity of Pennsylvania, funded my three-week these physicians to live in the CMF for an extend- research opportunity to Cuba in the summer of ed period of time (a decade or more) so as to 2015. The study I conducted aims to analyze truly get to know and understand the community the unique and renowned Cuban healthcare 1 84 valid interviews. system currently in practice. With impressively 2 Note that the only healthcare system made low TB, AIDS and malaria mortality rates, Cuba available to Cuban citizens is the government provid- is the frontrunner for healthcare delivery in Latin ed care. Published by ScholarlyCommons, 2016 3 1 In Situ, Vol. 5, Iss. 1 [2016], Art. 2 that s/he serves. The program fosters stronger the Maternity Law, a woman’s employer must patient-doctor relationships in which the doctor grant her paid leave of absence post-partum. quite literally serves the community as a doctor of The law states that a woman is permitted up to a the people (a concept inspired by the health sys- year of paid leave after the birth of her child.5 The tems in the former USSR). As a result, the doctor paid leave of absence is furthermore flexible. For becomes family-like within a town, and in this instance, if the woman gives birth to multiple chil- way practices her/his profession better since s/ dren, to a child with disabilities, or to a child born he gains the trust, and in many cases the love, of prematurely, she is automatically eligible to re- the greater community. The CMF system hence quest more paid time off from work. In some cas- reduces the lab coat boundaries between doctors es, women can also be eligible for a paid leave of and patients for the better. absence up to two weeks prior to her due date. This is especially the case if the woman has had The CMF system additionally facilitates a difficult or high-risk pregnancy. The state largely a more logistical access to the . As an supports paid leave for these women and protec- interviewee stated, “Here in Cuba, a child can be tion for pregnant , so that without shoes but never without .” Again, women do not have to choose between being the CMF enables such an incredible feat consid- professionals (and being active participants in the ering that through this institution, the doctor is Revolution thereof) versus being . made available, is trusted, and is able to firsthand observe the community and act according to the The state additionally provides Hogares health needs s/he witnesses as not just a doc- Maternos (Homes for Mothers) for women who tor but as a community member. For instance, experience a high-risk pregnancy. (These preg- 88.10% of the interviewees stated that they have nancies can be deemed “high-risk” based on the easy access to a doctor because of their local medical health, emotional health, and or domestic CMF.3 The CMF doctor is most often a gener- circumstance of the .) These homes are al practitioner considering that the CMF rarely fully staffed with medical personnel 24/7 and are houses specialists. Even so, the only specialist environments that offer a strong, reliable commu- who frequently visits the CMF is the OBGYN nity for women during a vulnerable time. Again, specialist. The CMF physician is obligated to re- her stay in the Hogar Materno is fully funded by port any pregnancies that occur in her/his vicinity the state. and to contact an OBGYN specialist to visit her/ Likewise, in the event that a woman gives his CMF. The pregnant woman then meets the birth to a child prematurely, the state offers her specialist in the CMF of the district she lives in.4 If the opportunity to stay with her child in the hospi- the pregnant woman consistently refuses to keep tal. This hospital stay is fully funded by the state her appointments with the OBGYN specialist, the so that the mother can: a) learn how to care for specialist is legally obligated to visit her in her the child and b) breastfeed her child regularly. home and conduct the tests there (even if she The concept of breastfeeding is interestingly a does not want to undergo examination). This ex- recurring theme in the interviews. One hundred treme measure ensures not only her own health percent of the women interviewed stated that during pregnancy, but also the health of her child. they breastfeed/fed their children (the average is All of which contributes to impressively low infant a period of 1-2 years post-partum). According to and mother mortality rates in childbirth. many of the interviewed women, the state en- Through health policy, notably the Materni- courages breastfeeding so that mothers can nur- ty Law, women’s reproductive health is designed ture a relationship with their children and because to protect all women (medically and in the work- access to infant formula is incredibly limited. force) before, during and after pregnancy. Under Under the current healthcare system, the 3 Access here is defined in terms of walking state also ensures that most women have access distance. 4 In some cases, she can meet appoint- 5 Details concerning pay are ultimately de- ments in a polyclinic or hospital. termined by the employer. http://repository.upenn.edu/insitu/vol5/iss1/2 4 2 Kohut: Guantanamera: Healthcare Delivery to Women in Cuba to contraceptives. Correspondingly, 60.71% of retired to have increased physical activity the women who participated in the study stated while socializing with peers. that they have/had access to contraceptives. Another unique aspect of the care policy Often, such access is made available through the includes the distribution of health information to CMF, polyclinics,6 and schools. Similarly, infertility citizens. Access to Internet is difficult considering treatment is funded by the state under the health- that the few servers present on the island are not care. currently equipped for the ever growing demand. Comparatively, the state healthcare sup- Consequently, when a woman or man has a med- ports geriatric health specifically through care ical question in Cuba, finding an answer is not as centers intended for aging populations. In the easy as emailing a nurse or searching WebMD. field, I came across various full time care cen- As a result, the state financially supports Medi- ters (nursing home equivalents) throughout the cal Information Centers. These centers are often provinces visited. However, when speaking with separate wings in polyclinics or separate build- the women, I found that culturally many women ings (not associated with the CMF in any way). considered taking care of aging relatives at home The purpose of the Medical Information Center more acceptable than sending them to a nurs- is to provide a space where citizens can ask ing home. That is, sending one’s aging relatives medical professionals questions about a health or friends away to be taken care of in their ad- disorder, concern, etcetera. These centers do not vanced years is ubiquitously considered culturally treat nor admit patients, but rather were created taboo. In many cases, the elderly live together so that people have uniform access to medical in the same house but are constantly “checked” information. In addition to Medical Information upon by relatives, neighbors or close friends. Centers, the state designs and implements health Full time care centers are truly, only utilized if an courses in schools (elementary and secondary elderly individual has a severe medical circum- schools). Lastly, through television programs and stance. Another less taboo and more utilized the cooperative efforts of the CDR (Communist service includes Círculos de los Abuelos. This Defense of the Revolution, which is analogous phrase quite literally translates to “Grandparent to USA town governments or councils) with the Nursery.” The center is open for a few hours ev- CMF, the state promotes ways in which citizens ery few days and serves as a place for the elderly can stay healthy, particularly during flu or cold to socialize, dance, and exercise. There are no seasons, on community levels. actual doctors or health professionals present Though the current health system has in- since the center is not meant for admissions credible benefits for Cuban women, there seems or check-ups of any kind. It is simply a way for to be a general deficiency of doctors domestical- 6 A health center that is modeled off of the ly in hospitals and polyclinics due to the state’s polyclinics in the former USSR. Polyclinics are tendencies towards Health Diplomacy. Cuba designed to: promote preventative care, treat “boasts more than 30,000 physicians [Cuba also when necessary, and care for the body as a has the most medical schools than any other holistic entity. 58.33% of the women interviewed country in the world], yielding one of the high- stated that there are salient differences between est doctor-patient ratios in the world” (Randal). a polyclinic and a hospital. These women stated However, many of these doctors and specialists that a hospital is: bigger, cleaner, attends bet- are exported to countries like Brazil, Haiti, and ter (staff is more mannered), has a significantly Angola. In return, Cuba gains political alliances shorter wait period, has better technology, has and economic benefits (receives money, products more seasoned doctors, treats major such as toothpaste, and so on). Ultimately, how- and illnesses (i.e. cancers), generally has more ever, less specialists are present at home to take staff and greater staff variation, is significantly care of the Cuban people. As a result, the provid- more specialized, and is designed for admis- ed healthcare in polyclinics and smaller hospitals sions. tends to be inefficient because of the general lack of medical specialists (i.e. long waiting periods, Published by ScholarlyCommons, 2016 5 3 In Situ, Vol. 5, Iss. 1 [2016], Art. 2 fewer technicians that can operate machinery for was finally called to be seen by the surgeon, she specialized tests, etcetera). entered a room with six other patients who had also been waiting. There was no privacy in the I witnessed the lack of accessibility to room; the doctor and multiple patients were pres- medical specialists firsthand in the field. While in ent as the woman offered her medical history and a small town in central Cuba, I met a woman who was examined by the surgeon. The physician needed a copy of her prescription for glasses assured the elderly woman that she was indeed since the original was misplaced. Unfortunately, a good candidate for surgery, but that it was first her local polyclinic and CMF do not offer ophthal- necessary for the ophthalmological to be com- mological services and do not maintain a copy of pleted. Unfortunately, the woman had to wait until such records. It became necessary for the elder- the equipment was in working order. ly woman to travel 21 kilometers to the polyclinic where she had her initial evaluation. Transpor- This ethnographic account supports anoth- tation, particularly for the elderly in rural environ- er recurring theme in the interviews. When asked ments, is very challenging since it often involves how long the average wait-period is in a polyclinic riding in the back of trucks where the passenger or hospital, 89.29% stated that they wait over 3 must remain standing and balance as best as hours before seeing the health professional. The possible. This particular elderly woman ambulat- political tendency towards Health Diplomacy is ed with the use of a cane and had the beginning one factor that can explain long wait periods in of Parkinson’s, which limits her transportation hospitals and polyclinics in spite of the high doc- options. The woman had to wait until a relative tor-patient ratio. who had access to a vehicle visited her so that Access to emergency transportation and she could be driven to the polyclinic. Upon arrival care is likewise not as meticulously delivered nor to the polyclinic, the woman was informed that made accessible to women universally. In Cuba, records of previous exams were not kept and the SIUM (Servicios Intensivos de Urgencia that she must have another examination. How- Médica, intensive urgent medical services) is the ever, the equipment in the polyclinic was out of equivalent of an ambulatory service. When an in- order and the staff did not know when it would be dividual needs urgent ambulatory care (cases of repaired. It was suggested that the woman travel strokes, heart attacks, major accidents, etcetera), an additional 49 kilometers to the nearest poly- the SIUM transports the individual to an emer- clinic where the examination may be completed. gency room. However, 15.48% of the women Eventually the woman decided to return home interviewed stated that in the case of an emer- since she was aware that there would be no gency, they do not make use of the SIUM but of assurance that she would be seen. Later on that the “other” option. “Other” included the following: week, her relative transported her to the poly- personal car, flagging down drivers on highways clinic that could complete the examination. This or roads, a friend/neighbor’s vehicle, a military polyclinic was approximately 70 kilometers away vehicle (respondent’s son is in the military), from her home. When the woman arrived at the “whatever you find”, street car, bus, or a polyclin- polyclinic, the staff informed her that she would ic’s car (if the individual had already arrived at not be able to have the exam performed on that the polyclinic and needed to be transferred from particular day. Even so, she would be examined the polyclinic to the hospital). For women in rural by an eye surgeon who would provide a prescrip- areas particularly, the SIUM has been known tion for the examination. As the woman waited for to never arrive or to be severely delayed in the her turn to see the specialist, she spoke with the transportation process, especially if called at an other patients who were also waiting to be seen odd hour (such as nighttime). Therefore, although by physicians. Through conversation, it became everyone can have access to emergency care, apparent that it was not unusual for patients to logistically the SIUM is not made readily avail- wait five hours or more to see the specialist (es- able to everyone, especially to women from rural pecially if the specialist had a reputation of being areas. an excellent surgeon). When the elderly woman http://repository.upenn.edu/insitu/vol5/iss1/2 6 4

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Kohut: Guantanamera: Healthcare Delivery to Women in Cuba Similarly, the current health system ications purchased in pharmacies) and over-the- demonstrates a need for improvement concern- counter products (such as feminine care products ing the availability of non-prescription and over- and toothpaste). Some women also stated that the-counter products. In the field, 71.43% of the their orthodontic work is not included in the 08 women interviewed stated that they had easy healthcare and must be paid for out of pocket.8 Fall access to prescription medications. However, this Generally the healthcare costs are assumed by number essentially flips when asked if women the state, but the state prioritizes equal, financial had access to non-prescription medications. For access to more expensive forms of in instance, 75% of the women interviewed stated comparison to minor ones. that they do not have easy access to non-pre- Cuba’s healthcare policies and the result- scription medication or over-the-counter prod- ing healthcare systems prove distinctive primarily ucts. Examples include the following: band-aids, because of the uniform and meticulous delivery feminine care products, non-prescription pain of medical care regardless of financial, racial, medications (Advil, Tylenol, Aspirin, or any other or gender bias. The fulcrum of the state’s health equivalent), medications for hemorrhoids, diabe- policy is to uphold the promise of protecting a tes test strips (and in some cases insulin), and person’s health as a human right, especially antacids.7 Subsequently, many interviewed wom- for women during pregnancy. This fundamental en identified that the doctors in Cuba are excel- promise of healthcare access to the best of the lent because they know “how to do so much, how state’s abilities has accelerated life-expectancy to truly help a person heal, with very few devices to an impressive 76 years of age (Randal). Even and medications” (including prescription and so, a lack of access to emergency transport, long non-prescription products). wait periods in medical facilities (notably hospitals At first glance, lack of access to such and polyclinics), and the scarcity of more minor medical products could be explained by a lack medications and medical products are significant of access to pharmacies. However, 92.86% of setbacks. As geopolitical relationships between the women stated that they have a pharmacy the United States of America and Cuba become within walking distance. When further attempting more open, crucial changes to healthcare sys- to explain the lack of access to such products, tems and health resources will be inevitable (no- many of the women I spoke to stated it is a nega- tably changes in the access of non-prescription tive consequence of the embargo. Several wom- products, of specialized care, and even of ambu- en explained that because of the embargo, it is latory care). With these changes, ethnographic difficult to find goods since pharmacies are sim- studies will grow increasingly more important so ply poorly stocked. Even so, some claimed that that the voices of the Cuban people can be re- medications or products from China and Brazil corded and amplified—so that a conversation can are more readily obtained since these countries occur between two forces that have been oppos- share political and economic ties with Cuba. ing each other for nearly half a century. Through ethnography combined with qualitative inter- Lastly, though no one personally pays for viewing, conversations about will , fine lines to such a statement become people-centered, truly Cuba-centered, exist. For instance, 100% of the women inter- so that successes of the system can be voiced viewed stated that they do not pay their doctor in tandem with the areas for improvement. Such nor do they pay to be admitted nor seen in health a centering will hopefully promote peaceful dia- centers (chiefly hospitals, Hogares Maternos, logue between the two countries on the accounts polyclinics, mental health institutions, Grand- of healthcare, but also on more difficult topics parent Nurseries, the CMF). These women also such as politics. With time and true understand- stated that they generally do not pay for very ex- ing, the dialogue has potential to mature into a pensive treatments that are administered in these mutualistic relationship in which Cuban medical health facilities. However, these women are ex- pected to pay for medications (prescription med- 8 However, costs for teeth pulling are as- 7 This list is not exhaustive. sumed by the state. Published by ScholarlyCommons, 2016 7 5

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In Situ, Vol. 5, Iss. 1 [2016], Art. 2 needs can be met through the United States of America, and even vice-versa. Acknowledgements 08 I thank Dr. Guadalupe and Dr. Petryna for their Fall support and academic guidance. Because of them, the study is what it has become today. I thank CURF and the Hassenfeld Family for making my research trip possible. I also thank Dr. Spooner and the UPenn Anthropology Depart- ment for the opportunity to continue to explore the world through research. And as always, I thank my family and friends for their unending encouragement. Works Referenced “Health Education in the USSR.” World Health Organization, 1963. Web. 1 Dec. 2015. Holt-Seeland, Inger. Women of Cuba. Westport: L. Hill, 1982. Print. Huish, Robert. “Why does Cuba ‘care’ so much?” Oxford Journals 7.3 (2002): 261-276. Ethics. Oxford Journals. Web. 20 Oct. 2015. Kidder, Tracy. Mountains beyond Mountains. New York: Random House, 2003. Print. Obama, Barack. “Statement by the President on Cuba Policy Changes.” The White House. The White House, 17 Dec. 2014. Web. 1 Dec. 2015 Randal, Judith. “Does the U.S. Embargo affect Cuban Healthcare?” Oxford Journals 92.12 (2007): 963. Journal of the National Cancer Insti- tute. Oxford Journals. Web. 27 Oct. 2015. Randall, Margaret. Women in Cuba: Twenty Years Later. Smyrna, 1981. Print.

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