Few things in Cuba are easy. Most countries faced with what Cuba has lived with for more than half a century would be failed states. Cuba keeps going, with hardship and sacrifice, but a shared vision.
The reputation of Cuba’s health service – providing rich-country outcomes on a poor-country budget – attracts interest from politically aware medical students. But arranging an elective there, well, no es fácil. Fidel Castro’s Escuela Latinoamericana de Medicina provides medical training for poor students from other countries, but few people in Cuba’s health service are aware that medical training worldwide often includes an elective. Only the occasional foreign student managed to penetrate the indifference, the bureaucracy, the lack of information and the limitations of Cuba’s IT, and arrange an elective.
I was fortunate to meet a Cuban doctor with the imagination to think outside the restrictive Cuban box. He had welcomed one such applicant. We discussed the practicalities of an elective programme, and in 2010 I started Cuba Medical Link, a UK registered charity with a website to help students arrange electives in Cuba. Eight years, 400 students from 20 countries later, I have closed this programme.
No es fácil, an elective in Cuba. Foreign students are in Cuba on Cuba’s terms. They pay substantial fees for their tuition. They have to speak Spanish. They learn alongside Cuban medical students, they live as paying guests with Cuban families. Being Cuban no es fácil, and students gain an insight into the difficulties of everyday life under the USA’s economic blockade. They acquire a first-hand experience of the Cuban health system and of the social sacrifices and restrictions of political freedom which underpin it.
Once they have surmounted the hurdles of registering in Cuba and donned a bata blanca (white coat) elective students enter a world of shared knowledge of the human body and its infirmities. Cuban doctors are generally welcoming and keen to teach. But practising in Cuba no es fácil. Buildings may be in need of basic repairs, and doctors may have only a thin, shabby towel to dry their hands. But the commitment to patients is the same. Cuban ingenuity keeps antiquated CT scanners working 24/7 and every stroke patient is scanned in A&E – an objective few British hospitals achieve.
Back home, students probably don’t think much about the patient’s diagnosis till they have the results of a battery of investigations. Cuban students have to learn to make a diagnosis without technology, and elective students have to try to do the same. As one British student said, “I felt like an amateur compared to their seemingly vast clinical skills!”
Some differences can be startling. Interactions with patients can sometimes be uncomfortably brusque. And in a country in which people live in each others’ pockets, confidentiality isn’t a consideration. It can be a shock to find two doctors consulting in the same small room and all available space crammed with patients’ relatives and friends, nurses, medical students and even the next patient who has wandered in through the open door.
In many countries preventative health care is given only lip service, or responsibility is devolved to public health departments. Visiting students see how in Cuba it is everyone’s responsibility, and they make the connection with Cuba’s impressive health statistics. They may even take part: a Japanese student was proud to give a talk about reducing their risk of heart disease to a group of abuelos (elderly) at their exercise class. As another student observed “The primary care doctor in Cuba is part shaman, part confessor and this demonstrates both their medical and social roles and how it is difficult, and probably inappropriate, to try to see one without the other.”
Students go to the beach, play football, go dancing with their fellow Cuban students. Cuban doctors teach them to interpret X-rays and to make a mojito, and most welcome the opportunity to find out how medicine is practiced in the students’ home country. Students put the world to rights and go to meditation classes with their Cuban casa hosts.
For one student his elective fulfilled a childhood ambition. When he was 14 his mother agreed to buy him a Che Guevara t-shirt on condition that he read Che’s biography, and he became fascinated by Cuba.
For Cubans the students open a window on a different world. The Indian parents of one British student came to visit during her elective. “We had a big dinner with the two families which was a mixture of Cuban, English and Indian food with a healthy amount of Cuban rum afterwards. Our hostess is fascinated by Indian culture but will probably never see the real India. I like to think in some way our visit allowed her and her family to understand a little more about other cultures as much as it helped us to do so.“
Almost every student report was positive; for some it was a life-changing experience. But the barriers to setting up and running a functional programme were substantial and the process was exhausting.
Cuban medical school authorities were full of goodwill, but they face huge obstacles. They may share a computer with several colleagues, it may work erratically, and probably struggles to download a one-page document. Most Cubans have no experience of the way other countries do things, and some found it hard to understand the need to keep students informed. Some applications sat in piles in an office while the students’ deadline for confirming their electives expired. One Cuban official was frustrated that forms from medical schools around the world aren’t all the same, as forms are in Cuba.
Only one independent-minded official answered emails promptly, didn’t ignore sensitive questions, and understood that students have to change their plans if they fail their exams or break a leg.
And he did his best to be flexible. Cubans may be agile and inventive on the dance floor, but these are not qualities which get you very far up the ladder in a totalitarian state. And Cuba is very suspicious of foreign intervention – with reason. So the programme began, like most start-ups, under the radar. It took some years to get an appointment with someone in MINSAP – the Ministry of Health. Though official recognition didn’t make a lot of difference.
They do things differently in Cuba. In one centre, the woman responsible for dealing with students’ electives went on holiday for three weeks and no-one looked at her emails, or, apparently, knew she was away. The government closed the bank account through which students paid their fees without notice, throwing electives in doubt. It took time before alternative arrangements were made. At one point some remote bureaucratic action abruptly doubled tuition fees and imposed an impossible Kafkaesque system of accrediting documents. The programme was on the edge of collapse until we achieved a reprieve.
Administration was onerous and unremunerated. It took time to sift from the five hundred or so enquiries I received each year the 40 or 50 students with a genuine interest, adequate Spanish and money to pay the fees. And sorting out the bureaucratic problems they encountered in dealing with Cuba never got easier.
Over the years I sought a sustainable future for the programme. No era fácil. In fact, imposible. Medical schools were interested, but only for their own students. The government’s Department for International Trade accompanies the RCGP on trips to China, but isn’t interested in a country with very limited investment opportunities. No charity was interested in sponsorship. No business, NGO, Global Health department, student elective organisation, wanted to take on unremunerated work. The logical place for the administration is Cuba, but that clearly is not feasible. I couldn’t carry on, so had no option but to close the programme.
I am puzzled and disappointed that so few students – only 10% – gave me any feedback. Not even clicking reply to my welcome home email to offer one tip for future students. Those that did send reports gave vivid pictures of the reality of Cuba’s health service, something no tourist or visiting official ever sees. I just hope that all the students take into their careers some of the lessons they learnt in Cuba.
Around 400 students had an unforgettable experience, forged friendships, and had their horizons broadened and their assumptions tested. Where else can you get a political education while enjoying sun, sand and salsa?
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum and an LMC chair. She started a charity which for nine years enabled medical students to go to Cuba for their electives.
Judith is a long-time supporter of NASGP and has been providing regular articles for The Sessional GP for over 12 years, her reflections ranging widely on practical, ethical and cultural aspects of health and medicine.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…