Castro's Clinic: Making Housecalls in Havana
Opinion / Editorial
By Jeanne Parr Lemkau
Courtesy of WorldView Magazine
and the National Peace Corps Association
May, 2004
On a Saturday morning, Dr. Félix Sanso and several students from the Medical School at the University of Havana were leading neighborhood children in dancing and games at the central park of Cerro, a poor section of Havana where he practices medicine. The occasion was a health fair for youth, and for the event the young doctor wore jeans and a gray T-shirt imprinted with a picture of José Martí and the words Ciencias Médicas Anti-Imperialistas. Salsa music pulsed from two amplifiers as a mass of children and teenagers danced with their family doctor. When Félix smiled, his dark brown eyes sparkled, and a crooked front tooth lent him a mischievous air. He looked like the picture of health.
Nearby, an elderly gentleman looking on the scene with pleasure remarked, "This is fundamental for us – children and young people."
After an hour or so of pure play, Sanso turned down the music and announced that anyone interested in adolescent sexuality could gather at one of the park benches where an expert would talk with them and answer their questions. As the young people gathered, the expert, a handsome young medical student, opened a box of condoms and began talking about sex. He asked for a volunteer and demonstrated how to put a condom on the young man's two fingers. A few small children pushed forward for a better look. The expert explained that mouth-genital contact also needed protection, and his audience stood in a tight circle around him as he showed them how he could put a condom on a pair of his own fingers using his mouth. The children wanted to try, leaning up against one another, arms around each other, all eyes and hands and condoms. A barely pubescent girl in Lycra snatched a condom and stuck it under her waistband. The young doctor ended the session by offering three condoms each to all who had stayed around for the bench-side session and blew several up into balloons for the smaller children to play with.
"I've only had one adolescent who became a mother this past year," Sanso explained as the youthful cluster dispersed. "Of course, there have been some abortions but mostly, it is this," he said, gesturing to the spot where the young people had just been.
Félix Sanso is a family doctor in Cerro, one of the oldest neighborhoods in Havana. His patients are of all ages and even his pediatric patients call him Félix when they greet him on the street. He is committed to preventing as well as treating illness. As the doctor explains, he is responsible "not for health care in the community, but for the health of the community."
Throughout Cuba doctor and nurse teams attend to geographically defined populations through neighborhood consultorios. Often, like Félix, they live in modest apartments that adjoin their clinics. These teams work proactively to identify and address risks to the health of the families they serve. A more specialized polyclinic serves a group of consultorios. Félix's consultorio is one of 32 affiliated with the Plaza de la Revolución Polyclinic. Pediatricians, epidemiologists, and other specialists visit Félix's consultorio regularly to consult on health and community issues. In turn, he sends patients to the polyclinic for specialized consultations and laboratory tests and relies on polyclinic staff for assistance executing programs of prevention and education.
Félix has lived in and practiced medicine in Cerro since 1994, when the Ministry of Health sent his predecessor to work in South Africa. Cerro is not a popular medical assignment. With the exception of Old Havana, the neighborhood has the greatest concentration of buildings from the colonial period in the city and residents suffer from the humidity, poor ventilation and social problems that go with deteriorating housing. "If we had class in Cuba – which we don't – Cerro would be considered low class," he said.
A buzzing sound interrupted our conversation. The noise, remarkably similar to that of a mosquito in one's ear, was that of fumigators, sent by the state in response to a recent dengue outbreak. They were charged with assisting each consultorio in the war against the Aedes aegypti mosquito.
The entrance to the barrio is on Calzada del Cerro, a broad street flanked by adjoined one-story homes with red-tiled roofs, front porches and columns that look like old teeth that had long ago lost their enamel. The boulevard gives way to side streets that open onto the small central park where a group of elders, a Círculo de Abuelos, gather every morning to do calisthenics. Félix, 36, and his wife, Aidelis, 28, a nurse at another consultorio, share a second-floor apartment above his consultorio which is around the corner and up a hill and a concrete staircase from the park. From there, Havana's urban landscape stretches toward the Plaza of the Revolution, and I could see the government offices of El Comman-dante Fidel Castro, and a monument to poet and national hero José Martí. Félix once explained, "Fidel made real the dreams of Martí. It was Martí who said that the best medicine is not that which cures but that which prevents."
I first met Félix last year at the Hotel Nacional, where he gave a presentation on his work as part of a Cuban team of 36 doctors, nurses and epidemiologists sent to El Salvador three years earlier to help combat a year-long epidemic of dengue fever. He described walking door to door in that war-ravaged country, talking with villagers about mosquito control, paying no attention to their political allegiances. In 10 weeks, using a strategy introduced by the Cuban team, the epidemic was brought under control. El Salvador is one of many countries that have benefited from Cuba's medical system. Since the Communist revolution in 1959, over 130,000 Cuban health professionals have served in more than 80 countries.
Now, in addition to his duties at the consultorio in Cerro, Félix teaches at his alma mater, the medical school of the University of Havana. Cuba's health care system, like its public education, is greatly respected for what it has achieved. According to the World Health Organization, Cuban longevity and infant mortality rates are equivalent to those of the United States, in spite of more than four decades of economic blockade by the U.S. government. But Cuban doctors are not paid well. Physicians earn more than most people, but typically the equivalent of $30 or $40 a month. And their salaries are in pesos in an economy where access to dollars has become essential for more than subsistence living. The state provides Félix with his modestly furnished apartment but he has no telephone in either his office or his apartment; he uses his neighbor's phone when he needs to make a call. He does not own a car and, like his patients, he depends on his ration book for state-subsidized food.
One day we shared a meal at his usual lunching spot, the cafeteria of a nearby shoe factory. We ate small helpings of yellow rice, thin slices of watery tomato and tiny bits of meat on aluminum plates. Félix seemed apologetic. "Sometimes there is more food when I get here earlier," he said, adding, "We are a country of shared poverty but not misery."
During one of my visits, Félix spent the morning attending to patients in his office and the afternoon making house calls. The waiting room of his consultorio is furnished with hard wooden chairs. A wall poster profiles the health of his barrio of 200 families and the families are divided into four categories: healthy; at risk; acutely or chronically ill; and disabled. Cancer and cardiac disease are listed as the two leading causes of death, as they are in the United States.
Approximately 40 percent of Cerro homes are considered structurally good or better. Seven percent of his patients have difficulty meeting basic needs, including food, shelter, recreation and companionship. These data were gathered as part of a detailed analysis of community health that Félix conducts each year. Beyond the waiting room are two consulting rooms. One is used by his nurse, Bárbara Gomez, and contains the medical charts. There is a small bathroom but the plumbing is broken. The consulting room where Félix sees patients is about 12 feet square. Fluorescent lights hang over a desk, a chair, a filing cabinet and an examination table. There is a sink in the corner. Three posters decorate the walls. One promotes preservation of the ozone layer. A second extols the health benefits of a mother cuddling her baby. The third shows a stretch of Varadero Beach in blues and greens, colors Félix believes will relax his patients.
At 8 a.m., even before seeing any of his patients, Félix walked to a nearby consultorio to discuss medical issues with colleagues from other nearby practices. This was a daily meeting that he attended with about 15 other doctors, nurses, and students in his equipo de trabajo, one of three work teams associated with his polyclinic. They sat crowded into a small waiting room, sometimes two to a chair, as Félix raised questions about the diagnosis of a child with pneumonia. In the Socratic tradition, he began by questioning the nurses and medical students and then the more expert physicians. With caution, he offered his own thoughts, adding, "My experience is not as important as evidence." He shared material gleaned from an ask-the-expert section of a website maintained as a nation-wide resource for medical personnel, and ended by reviewing guidelines for treating children with acute respiratory tract infections.
His return to see patients was delayed by the group of elderly women in the park who had just finished their exercises. They laughed and greeted him warmly. One statuesque woman in a white blouse reached toward Félix with outstretched arms and recited lines from a poem by Nicolás Guillén. Félix listened politely, and then excused himself.
The morning patients were mostly women. They came in a steady stream from 9 in the morning until 1:30 in the afternoon and presented Félix with the same garden-variety complaints that keep a clinic busy in Yellow Springs, Ohio. No childhood diarrhea, no infectious diseases, no parasitic infestations, no malnutrition, no patients with advanced untreated illnesses or preventable diseases who crowd into medical clinics in less-developed countries.
He admonished a teen-aged girl with acne on her cheeks to wash her hands with soap and praised her when she scrubbed up at the sink in his office. A young man about to begin working as a lifeguard needed an employment physical. Félix said he would screen him for sexually transmitted diseases. He advised him on monogamous relations and the use of condoms, then, grinning, he offered a final caution. "Be careful," he advised. "Girls pretend to drown and then want you to give mouth-to-mouth." The young man flushed with embarrassment. A middle-aged woman sought a referral for her fifth abortion. Félix reminded her that the pregnancy could have been prevented by regular condom use. The woman sighed, "No es fácil," she said. It's not easy. He wrote an order for her to receive a first-trimester suction abortion at the hospital.
Between patients, Félix showed me their medical charts. Where lab results should have been, there were notes that read "N/R," indicating "No hay reactivos." Reagents necessary for many routine laboratory tests to assess kidney function or cholesterol are often unavailable. Since the early1990s it had been hard to get glycerinated hemoglobin tests for diagnosing and monitoring diabetes. Doctors are often forced to rely on the clinical exam alone. The results are sometimes devastating. Félix attributed the shortages to the ongoing U.S. embargo of Cuba and to difficult economic conditions on the island. "Over the years," Félix said, "more Cubans have died from El Bloqueo than all the people who died in 9/11."
As a plump and pretty teenager sat down to complain of a persistent headache and a painful belly, the nurse interrupted to announce that the fumigators were going to spray his apartment. Félix tossed her the key to his quarters, and began to examine the patient. He told her that she was probably experiencing pre-menstrual stress and possibly sinusitis. He wrote orders for sinus X-rays and a pelvic ultrasound that she would receive at the polyclinic. "Is your father still smoking?" he asked. "If he is we'll have to start a campaign to get him to stop." As she left, she kissed him on the cheek.
A woman suffering arm pain brought in an X-ray that had been taken the day before at the polyclinic. The film for X-rays and chemicals for their development are also in short supply. Often only small film plates are available, making diagnoses of complex problems difficult. "Resolve and invent are the verbs we use most," he explained wistfully. He held the patient's film up to the light-box and noted degenerative changes and a narrowing of the spaces in her cervical spine. He recommended physical therapy and traction but cautioned that the problem would be chronic.
His final patient of the morning was a pretty young woman with mild chest pain. Félix listened to her heart, assured her that it was fine, and suggested that the problem was muscular and possibly aggravated by stress. She should do more aerobic exercise, take an anti-inflammatory and rub a Chinese pomade on her chest where it hurts. She would be able to find both the anti-inflammatory and the Chinese pomade at her neighborhood pharmacy that carried "green medicines" as well as manufactured pharmaceuticals.
The morning passed quickly. The doctor had seen a half-dozen patients, spending about 20 minutes with each of them. He usually sees more. After a quick lunch at the shoe factory, Félix pulled cards out of a file box to organize his afternoon house calls. He had developed the tarjetas, pre-printed cards used to track family visits and consultations, and his system has been adopted for national use. The frequency of home visits depends on the health of family members, but every family receives at least one visit a year. "Home visits are the best way to know what people need as opposed to what people ask for," he told me. With tarjetas in his pocket and his medical bag in hand, Félix stepped off the narrow sidewalk into the street. "In Cerro, people still walk in the middle of the street as they did before there were cars." We claimed our prerogative and the occasional car accommodated us.
Félix knocked on the door of a modest stucco house, where an attractive woman with short white hair lived with her husband, her 10-year-old grandson named Julio and a yippy little dog. Julio's father had been a balsero, one of hundreds of Cubans who left Cuban shores in home-made rafts during the 1990s. The grandmother worried because Julio, who was playing at a table, often asked about his father. She was concerned that his absence was damaging to the boy. Félix reassured her that the love Julio shared with his family was the most important thing. He examined Julio's school notebook. There the boy had written, "When I grow up I will be an athlete so that I can travel to other countries with the gold medal." Félix smiled and advised Julio to write a letter to his father, now living in Florida.
He took the grandmother's blood pressure, which was higher than on previous visits, now borderline hypertensive at 140 over 90. He recommended that she exercise more by joining the Círculo de Abuelos, advised her to cut down on the use of salt and come to the consultorio for blood pressure checks. Her husband, a smoker, poked his head into the room. Félix scolded him. "If you have to smoke," he said firmly, "go up on the roof so that you at least protect your wife and grandson. We are all breathing your last cigarette right now."
As we left, we could hear the buzz of the fumigation sprayers down the street. We walked less than a block before a grey-haired man in a white T-shirt invited us inside his home for peach popsicles his wife had just made.
The next patient was a 45-year-old diabetic in the care of his elderly mother. Cigarettes, alcohol and illness had devastated him, and, although he had stopped smoking and drinking, he looked to be 60. He was propped up in bed with a pile of medicine bottles on the table next to him. His left leg had recently been amputated. Félix talked with the man about his medicines, diet and physical rehabilitation. "How much did the operation cost you?" Félix asked. The man looked startled until he realized that the question was being asked for my benefit. "Nada," he replied. His prosthetic leg, however, cost 27 pesos, or about $2.
His next patients were an older couple who lived alone. The woman was hypertensive and had been his seventh patient within the year to be treated for an infection caused by giardia, a water-borne protozoan parasite. Because chemicals for water treatment and replacement parts for aging plumbing are hard to come by, water-borne illnesses occasionally occur. Although he advises people to boil their water, many can't afford the kerosene to do so. Since the woman's blood pressure was still elevated, he suggested an increase in her anti-hypertensive medicine and more exercise. If she didn't want to join the Círculo de Abuelos, he said, she could watch them through her front window and exercise along with them in the privacy of her home. He advised her to go to the consultorio in three weeks so that he could check her blood pressure again and give her a tetanus shot that was due.
Félix shifted his attention to her husband who boasted that he had cut down on his cigarette smoking, and could now walk a block without getting winded. On his doctor's recommendation, he had started taking Policosanol, an anti-cholesterol drug developed in Cuba from sugar cane. "It's a popular drug," Félix said, turning to me with a half wink. "It has Viagra-like side effects."
His last house call was to a family that had recently weathered a crisis. At the doorway stood a woman whose husband had threatened to leave her and their children. He wasn't home, but his wife reported that their situation had improved since her husband had followed Félix's advice and seen a psychiatrist at the polyclinic. Félix and the woman chatted until he felt it was time to leave. "I'll stop by another time to talk with your husband," Félix reassured her as we made our departure. Once out of the earshot of his patient, he shook his head and sighed. "El médico de familia esta en todo." The family doctor is involved in everything. From family therapy to fumigation, I thought, as a tall slender man approached us. He had a sprayer strapped to his back and was wearing a red "Special Detachment" T-shirt that marked him as an emissary of the anti-dengue campaign. He was accompanied by the nurse who had spent the afternoon walking house to house talking with families about the importance of eliminating standing water and garbage and allowing the fumigators to spray. The four of us (the doctor, the nurse, the fumigator, and I) together climbed the hill leading back to the consultorio.
At the home of his neighbor, Félix paused. The proud mother sitting by the front door was eager for us to appreciate her precocious three-year-old, a plump little girl who peeked up at us and mumbled softly into her mother's skirts. "See," the mother said, "She can already say 'Aedes aegypti'!"
It was almost six o'clock when we reached his apartment. Félix had invited a family medicine resident to eat with him and his wife so they could talk shop. Then he would leave for a meeting with colleagues. At 9:30 when he returned, a mother would bring a septic child to his home and he would arrange for his hospitalization.
In my last visit to see Félix in his consultorio, I gave him a supply of analgesics and vitamins from the States. As I handed him the bottles, Félix carefully read each label and placed them in rows in the metal cabinet where he kept pharmaceutical supplies for his patients. When he came to a large bottle of B vitamins, he smiled and declared, "This bottle is for the doctor!" Back in his apartment, over papaya refrescos prepared by his wife, he explained why he had kept the vitamins for himself.
He spread a photo album open before me, full of snapshots from his two years of social service in the early 1990s. When Félix graduated from the medical school of the University of Havana, the state was placing its top graduates, Félix among them, in the neediest rural communities for their internships. Among subsistence farmers in a rural community between Santiago de Cuba and Holguín provinces Félix provided medical care on horseback to a dispersed rural population of about 200 people. The pictures showed a young man gaunt and pale, but looking content. "There was one week when I didn't even have shoes," he laughed, as he flipped to a picture of himself seated at a table, barefoot, leaning forward and listening to a patient.
When the Soviet Union collapsed, the abrupt termination of subsidies and trade ushered in what was called the Special Period, a stretch of severe food shortages and economic hardship, unrelieved by foreign aid from the United States. Where Félix was working, coffee was the only cash crop and everyone was dependent on government rations for food. When food shortages worsened, Félix and his patients resorted to eating wild herbs to quell their hunger. Over several months, he lost weight and developed strange sensations in his limbs. Then, one morning, he realized that he could not see his horse although he knew that the animal was tied up close by. He had lost central vision. Later, in Havana, he was diagnosed as suffering from serious Vitamin B deficiency. Félix was one of thousands of people throughout Cuba who suffered neurological problems from food shortages during the Special Period. With vitamin supplementation and improved nutrition, his visual problems gradually resolved, but residual neurological problems persist. Sometimes, he said, while he visits patients on the streets of Cerro, he is bothered by tingling and cramps in his limbs. But he expressed no bitterness, just pleasure, as he reminisced over the photographs.
"All physicians should have to serve in the countryside," he said. "Medical school taught me about medicine, but the mountains taught me about community. The community is the center of my life."
Jeanne Parr Lemkau is a professor of psychology at Wright State University School of Medicine
