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Cuba - Winter 2013

Stories From Cuba -- eight days understanding public health in Cuba

"Eight Days in Cuba" -- The Video!


Day One       Day Two       Day Three      Day Four      Day Five/Six     Day Seven      Day Eight

Pictured above - the students were merry and bright at LAX as they waited to board their flight to Miami on the first leg of the amazing eight day journey. Later, they used the long layover in Miami to store up energy for the upcoming adventure.

In early December, 17 Nursing School Students, along with Dr. Adey Nyamathi, Dr. Maria Elena Ruiz and Dr. Inese Verzemnieks, spent 8 days in Cuba.  During that time, they were able to visit and interact with key physicians, nurses, plus some patients and city residents; health support personnel,  educators, community leaders from various organizations, etc; including visits to the Pan American Health Association (PAHO), a Policlinic, Maternity Hospital, Community Sex Education Center, Senior Home, Nursing School, the international Medical School, and various other places. During the next several weeks, we will be sharing their amazing experiences! 

Day One - Arrival in Havana

It was a long journey - six hour flight to Miami, four hour layover then a one hour flight to Cuba. One student noted:

"Arriving at Jose Marti International Airport was an experience. There were people crowded, speaking in this beautiful foreign language with one of the most extravagant accents I've heard thus far known as Cuban. The luggage they brought in from the states was wrapped tightly in saran wrap that included tables, TV, strollers, etc. This made me wonder why such products had to be imported from the states. As I stepped out of the airport, I almost tripped over the broken concave pavement. But this did not stop me from enjoying the sweet yet somewhat smoggy smell in the air."

From the Airport, the group checked in at their hotel and then went on to Old Havana Palacio DE Artensania for their welcoming dinner "Our lovely unforgettable experience at Palacio de Artesania was such an enchanting experience including: salsa music/dancing, romantic with trumpet, cigar tasting, authentic Cuban cuisine, and our first great immersion into the beautifully passionate culture."  

Day Two - Exploring Cuba


It is said that to truly treat the individual, you need to understand the culture. So, Day 2 saw the students taking in the culture and history of Cuba in preparation for the upcoming health care activities.

Dr. Maria Elena Ruiz sets the stage: Day 2 in Cuba; our first full day enjoying the warmth in Old Havana. Our group of 17 students; 3 faculty, 1 tour guide, 1 "guide in training," were chauffeured by a cheerful and young at heart bus driver Fernando. We begin the day with our usual breakfast of scrambled eggs, cheese slices, fruit juice and coffee. We board our tour bus, arrive in Old Havana, where we view the historic buildings weathered with varying signs of decay, while others are undergoing renovation with fresh coats of bright blues, pink, green, and pink colors.

From Leslie Ling, 2nd Year MECN: In broad daylight, Cuba was a marvelous sight to behold. As we rode into Old Havana, we all marveled at the rustic establishments of churches and monuments of Jose Marti.

The narrow streets were lined with colorful buildings where we often peaked into the open courtyards and marveled at the gardens and fountains. The streets were also filled with colorful people: children playing soccer, couples holding hands in the park, vendors selling snacks and books, and musicians playing a beautiful tune.

The town was alive, full of music and voices. We then traveled to the Revolution Museum and learned about the timeline of the revolution, as well as the individuals involved. All across the city, we noticed graffiti art of Che Guevara and slogans about the revolution.

From Gaiane Doubinina, FNP: As we experienced Havana with a walking tour, we bought old unique Cuban books and post cards sold in the city square. We came upon this old rustic church that defined Cuban classic architecture. It felt like we were walking through Cuban history. There were children freely playing on the streets, music everywhere, old dogs roaming without collars, and women dressed in Cuban traditional wear taking photos with tourists from all over the world. I saw paint stripping off building walls, many windows broken from frequent hurricanes, clothes hanging from balconies, and small streets made for travel by horse carriages back in the early 1900s. It was a scene from an old movie, beautiful and unique in its own sense.


Two other students shared these observations related to culture and health:

For me, the most significant aspect so far was learning about the Revolution Museum and the revolution; it started with the interactions we had with a gentleman who was travelling from the states back to Cuba, he was bringing supplies to his mother (including some adult protection products, or Depend products). ...I now wonder what are the feelings of the people living in Cuba? It seems unfair that a taxi driver makes more than a doctor (here). Understanding this is essential...as understanding that the underserved deserve adequate health care. 

People were smoking everywhere...Physical injuries were also high, no wonder...the cars were driving fast and pedestrians don' have the right of way...and the streets were so bumpy I wondered how disabled people would walk around the streets safely.

 Day Three: Travel from Havana to Matanzas

Matanzas (literary translated as "the killings or massacre"), refers to events of the Spanish American war of 1896.

Matanzas was our opportunity to get out of the bustle of tourism in Havana, to see the countryside, and to spend time with rural folks. Using a standardized "windshield/walking" guide, the students had a list of questions to guide their observations and interactions with residents.  Our 1.5 hour bus ride took us east, providing a beautiful view of slow rolling hills and magnificent bridges that allow us to traverse rivers that flow into the Bay of Matanzas.  We were surprised to see several group groups of Cubans waving along the highways, asking for rides from anyone driving by.  Automobiles, as well as any type of motorized transportation, is limited and a luxury  We learned that anyone with space in their auto/bus would stop for residents --even tour buses with tourists -- as residents have learned to depend on the kindness of travelers.

We were fortunate to visit Ediciones Vigia, a unique workshop and publishing house where workers write, stencil, bind, and produce handmade paper, and collector's books. A great place to shop for one-of-a-kind books and observe working conditions

Next was the Museo Farmaceutico (Pharmaceutical Museum, 1832), a beautiful building where we browsed through some of the first pharmacy books, antique scales and syringes, an EKG machine, antique medical instruments, hand painted porcelain jars, potions, herbs, recipes for home remedies, scorpion oil, arsenic, etc. The pharmaceutical museum allowed students to see how Spain, France, and the Afro Cuban culture have influenced Cuba's health system, and how they've managed to integrate western, herbal and folk medicine.


For many, a highlight was the zocalo, or central park, where we interacted with Cuban families; mainly the teenagers and seniors who gather, and openly share stories and welcome tourists.

As one student noted: "people are very visible in every community; age ranges vary from children to elderly but babies are not visible.  Most residents are of average weight - not too thin or overweight." 

Becoming immersed and interacting with individuals in Havana and now Matanzas was a first step in gaining a public health perspective.    In the evening, the student spent time with their assigned public health readings, and documenting their experiences in clinical logs and reflective pieces.



 Day Four: The Student Experience

On day 4, students visited Medical University in Matanza, participated in a workshop on the Cuban Health Care System, visited a policlinic, and interacted with physicians, nurses, physical and occupational therapists, patients, as well as medical and nursing students.  The students quickly demonstrated their observational skills, as they asked tough questions about infection rates, adherence to universal precautions, reusing of "disposable" equipment (disposable by US standards), and the physician/nursing educational system-especially as the medical and nursing students we interacted with all looked very young.   We learned, students are identified for medical and nursing careers beginning in high school, and family practice and a doctor-nurse team approach is the key model in Cuba.
At the end of the day, students participated in the required post conference; where they again compared and contrasted the US and the Cuban health care systems. 


For many of the MECN students, the older equipment, open displays of medicines and injectables, plus limited supplies and sanitary practices brought up many questions.  For the seasoned faculty, the older equipment and sterilization practices stirred memories from nursing in the "older days" (pre 1970s).   By the evening, the students shared how the workshops challenged them to return home with new ideas for public health and health policy changes.

Mario Chavez, one of our FNP Students Wrote:
"One of my favorite experiences was visiting the Policlinic. We got to tour all the services that these clinics provide but my favorite was walking into their emergency room: a three-bed department with one doctor and one nurse. The doctor was writing her notes and orders on paper while the nurse was at the bedside treating the patient.  There were two patients:  one a student (status post epilepticus, and a gentleman in DKA). Both diagnoses are commonly seen in the emergency rooms where I work in Los Angeles.  What was great to see is how healthcare was provided before I became an RN. The metal needles are autoclaved for repeated use because disposable angiocath needles are not an option. How dull do you think this needle may be after repeated use? How skilled do the nurses have to be? The large O2 tanks are used to provide oxygen. But not the in wall units I am used to. All medications are in glass vials. Do you think they use filter needles to draw up those medications?  A defibrillator was present which I am pretty sure is a bit dated.  So what did I get out of this? One we are a privileged country, be thankful. The second and most important, learn the skill of talk and touch. It is constantly ingrained in school and being in Cuba showed me how important these skills are as a practitioner. "

From MECN student Jessica Lee:
I was very impressed that the Cuban health care system follows Jose Marti's motif "Real medicine is not to treat, it is to prevent" which shows a strong emphasis for the primary care. Before the revolution, Cuban health system's focus was tertiary care in private clinics. After the revolution, the Cuban health care system changed to universal care with emphasis to primary and prevention care. Together with universal health, Cuba also provided more education opportunities for the Cubans which eventually led to decrease in illiteracy level, helping Cuban to be able to read and understand the health related information better.

In every Cuban community, there is a 'consultorio'. The residents are divided into three classifications. The first level includes healthy or apparently healthy individuals. They are mandatory to come see the doctor at the 'consultorio' at least once a year. The second classified population is those who are in risks. They are required to see the doctor at least twice a year. The third group includes those who are sick and have health diseases. They are required to come see the doctor at least 3 times a year. The doctors would also do home visits if the individuals were not able to come into the 'consultorio'. Cuban health care starts from this community based 'consultorio' where the health care access is free and open all the time.

Day Five and Six: The Student Experience

On days 5 and 6, the group gained increased exposure to the Cuban public health/primary care model and observed health promotion through various integrated facilities, including a Maternity Home, the Pan American Health Association district office, and a prominent Sex Education Center.
Cara Williams, a MECN student, sets the stage for visiting the Maternity Home:

In this 60-bed maternity home in the province of Mantanzas, women of all ages are housed for anything considered a "high risk" pregnancy. The most common "high risk" pregnancies include multiple births, bleeding, and young maternal age. At the time of our visit, the youngest patient being housed was 12 years of age and the oldest was 42 years of age, pregnant with twins. All women carrying twins move into the maternity home at 20 weeks gestation. One reason for the increasing number of multiple births is the increasing use of In vitro fertilization in Cuba.
Women in Cuba cannot choose whether or not they want to have a natural birth or C-section. The need for a C-section is determined by the doctor, otherwise it is expected the woman will have a natural birth. Similarly, the use of anesthesia is determined by the anesthesiologist and not offered as an option to the delivering mothers.   
The Student Comments:
Casey Rodriquez commented: Visiting the maternity home was a great experience. In Cuba, if woman has a high risk pregnancy, then she will live in the maternity with other high risk pregnant women. A team of consisting of a doctor, nurses, and other staff take care of the women until they give birth. It was amazing to hear how Cuba has a low infant mortality rate, in addition to placing an emphasis on prenatal care and giving families an extended maternity leave. Although these women are away from their families for long period of time, there is a strong sense of community with the women and the staff in the maternity home. It was also good to hear that the families of the women are taken care of while they are living in the maternity home
APN Student:  The maternity home made me feel as if the US does not appreciate pregnancy as much as Cuba does.  Providing care for at-risk twin pregnancies, placenta previa, and adolescent pregnancy is an important part of the government health policy.  I though how sad it was that they were in a ward for anything from 1-5 months, away from their homes, lives and independence.  But the fact that infant mortality rates were low made me feel like they were doing something right.  The way the doctor interacted with his patients and his staff was touching.  The breastfeeding and bonding with the baby is something that the US truly needs to embrace.
APN Student: While someone mentioned during the post conference that the maternity home was depressing-realistically, imagine the environmental stressors that were removed from your home and family.  I believe the Dr. and nurses create healthy relationships with the expectant mothers.  A beautiful experience.  Visiting the maternity home was breathtaking.
MECN Student: I find it contradictory that there are some rights and freedoms such as sex reassignments respected but women could not choose to stay home is she was pregnant with twins.  It's contradictory that women can choose to abort a baby, but cannot choose if she want to deliver her baby at home.
MECN Student:  The maternity home was overall disconcerting to me, especially as classifying some pregnant women as "high risk" only because they were pregnant with twins seemed a bit drastic.  I am continually surprised by how patient privacy is viewed in Cuba; also, when we strolled through the women's rooms, they had very little reaction. I was also very unhappy with the discussion that took place about the various risks in pregnancy right in front of some patients.
Next, the discussions at PAHO and the Sex Education Center tested our public health knowledge, as vital statistics, morbidity and mortality, early integration of sex education; respect for sexual orientation and targeted intervention at the community level were integrated to the systems model.  Guided by the assigned readings and the western model of care, students posed challenging questions in these workshops, questioning the good-bad health outcomes. The student reactions continued into the faculty led post conferences, as students continued challenging the data, including the rising rates for cancer, cardiovascular conditions, and maternal infections. As the logs and reflective notes demonstrated, these students are savvy global health nursing representatives, as they interweaved issues of community, ethics, culture, politics and medicine with social justice - all public health core functions.

Visiting the PAHO
APN Student: PAHO was my favorite part of the day.  It was very resourceful -- providing unbiased information re: health rates and outcomes.  The packet they put together reinforced the statistics we have been reading about. 
MECN Student: The exchange provided great statistics.  I wondered what is being done about chronic diseases and the aging population.  It was interesting to hear about the dietary changes affecting health and how the changing economy is affecting the availability of unhealthy food. 




The Sex Education Experience
MECN Student : Seeing what's normal in sexual health in Cuba, I am seeing the foundation I wish we had in America...one that wasn't influenced by religion.
I asked about the percentage of families that accepted their LGBT kids...I was corrected in my choice of words; that acceptance and tolerance connote power, or rather a power dynamic.  Instead, the speaker talked about "respect" and how that's what CENESEX tries to teach.  To have a governmental agency speak about tolerance, respect, solidarity and anti-homophobia is something very new and a breath of fresh air.  It is something that I will take back with me to the states.

 Day Seven: The Student Experience even

Exchanges with the Nursing School in Havana, Infomed, and the International School of Medicine (ELAM)

The School of Nursing-Havana
We had the opportunity to visit one of the major nursing universities in Havana; there are a total of 12 nursing schools in all of Cuba. In an open exchange with the Vice Dean for nursing research and two nursing faculty, we quickly learned of the various nursing degrees available. These include how the BS program (5 years) is more focused on clinical nursing care, while the Masters and PhD programs are more research focused. In one classroom, students were learning the fundamentals of nursing, with one mannequin to practice skills, and one textbook dated from the 1990s.
Exemplar (APN student)
In the School of Nursing, I noticed the lack of available resources, no computers or printers, and only several old books. Despite this lack of resources, the school works with whatever is available and teaches the students the value of good assessment for diagnosis rather than focusing on technology. In the US, we tend to overuse technology. Their focus on primary care is what maintains this third-world country above many modernized countries.  This reinforces the importance of providing free healthcare and the need to maintain citizens health-thus preventing costly tertiary care. This is something the U.S. healthcare undervalues.
Exemplar (MECN student)
The Dean of the Nursing School highlighted their core principles: health promotion and prevention with community health, an emphasis on humanitarian work and solidarity.  There is a belief that technology takes away from providing nursing care, so the emphasis is on providing basic nursing care. I wonder if perhaps we do not need all the advanced technology (in the US), resources, and tools in order to take care of ill people.  The nurses in Cuba were using paper charts, cone shaped fetal stethoscopes, and reusing some materials sterilizing these.  When I go back to the US, I want to keep to their principles: "Back to basic, humanism, solidarity and prevention."
Exemplar (MECN student)
The visit to the School of Nursing impressed me with how rigorous the Cuban nursing educations system is. I felt envious for their experiences, as each nurse is expected to have a student with them in the hospital.  I wondered if the clinical education was a more positive experience for Cuban students compared with the US.  We were able to see a classroom; instead of simply lecturing from a PowerPoint presentation, the professor was demonstrating the skill on a mannequin.  Even though the mannequin was primitive, I found myself feeling jealous.  We also learned that students spend five hours in class and then five hours in the hospital setting starting the first year of the program. I believe that this idea way of "learning through working" is very important and should be used in the US.
Visit to Infomed
Infomed is the national information portal, or virtual technology that links a vast electronic network with medical information, research, education, and other resources.  One Infomed office in Havana services the country.
Exemplar (MECN student)
Learning that the 70,000 institutions in Cuba only have 16 megabytes to split between them blew me away.  It has been an experience not having access to the Internet at night and at our fingertips, but it has also been very refreshing having to rely on face-to-face conversations.  It makes me want to go home and cancel my Facebook account because Cuba has proven that none of the things we rely on are actually necessary.
Exemplar (MECN student)
What struck me the most was that most materials are not printed out because they cannot afford ink.  I also thought about the potential for waste reduction, given that the health care system cannot continue to print out patient handouts, etc.  In Cuba, they must rely on their ability to teach patients effectively, relying mostly on verbal communication.
Visit to the International Medical School (ELAM)
The school, established in 1999, is in a beautiful garden-like setting, in an old naval academy site, with the ocean in the background.  Students in the school come from over 50 countries outside of Cuba; the Cuban government provides mostly free tuition, housing and resources for all students.  The primary mission is the prepare students from the neediest countries, as well as students from underserved areas in the US.  In return, the graduates are expected to return to their home country, and thus provide services in the neediest communities.
Exemplar (MECN student)
It's hard to fathom how a government can take care of all educational expenses, not only for its own citizens, but also for international students.  I wish I had known that this option existed.  Unfortunately, I've passed the cut off age of 25.
Exemplar (MECN student)
I was so surprised to learn that 114 US students are studying there.  It was incredible as we got to meet 2 of them; they expressed how much they love studying in Cuba.
Exemplar (MECN student)
I was surprised to learn that the school accepted American students and largely funded their education.  I feel that if medical education were financed in the US, we would not have nearly the numbers of underserved people.

Day Eight: The Student Experience

Exemplars From Student Logs; The Senior Home-Havana

This is our final full day in Cuba.  Everyone is starting to feel melancholy; we're starting to miss the new friends and colleagues we have made on this trip.
The bus could hardly make it down some of the narrow streets in a small residential area; we finally arrive and look at a small gated house-this can't be the Senior Home, as it looks like a private home.
The Medical Director and a nurse come out to welcome us, as they open the chain link fence and we talk for over an hour. The students jumped at the opportunity to ask some tough questions: does Cuba have Advanced Directives, how does the staff handle end of life choices, who funds services for seniors, how is the aging population taken care of, and who are the caretakers?
We learned that the family and community continue to bear primary responsibility for care of aging family members; the government intercedes only when family is not available or unable to provide care; the government finances senior services; they are not familiar with Advanced Directives (Sandy Wang, an APN student does a good job of explaining this concept)., etc.  So many of our Western based concepts seem unnecessary to health providers in Cuba.
This has been a fast paced program, structured to provide global public health experiences that meet curricular objectives.  We started off with getting the students immersed in urban and rural communities, introduced the PHN Practice Model, windshield assessments, moved to evidence based research and internet support, learned of epidemiology and health data from WHO/PAHO, interacted with medical and nursing leaders in educational settings/organizations, conducted post conferences, visited clinics, a maternity home, and ended with a visit to senior care facility.
Who would have thought that the last day at this Senior Care Home would end up being one of the student's favorite activities!


                                                                                                                           FROM STUDENT LOGS
APN student: This was the most significant day for me.   Interacting at the nursing home reminded me of why nursing is such a significant important field.  Seeing how the residents reacted to the group was very emotional; I was teary eyed and overwhelmed.  I personally have a strong bond with my family and I can strongly relate with the Cuban family focus.
APN student: I realized the quality of life for elders is preserved through these services.  It is all so amazing how all of these services we have encountered are free of cost for the Cuban population.
APN student: The Cuban trip was simply amazing and educational.  I cannot explain the feeling it left in my heart.  It made me realize that there is a lot that I can take back with me; there is a lot I can do to improve the health care system in the US.
MECN student: I wasn't surprised to learn that senior care is largely free and there are mechanisms in place for some elderly Cubans to be taken care of in their homes.  I was sad to realize the huge discrepancy between the Cuban long-term care system and the American system.  Although the facility we visited was very basic in terms of technology, it was clean and a lot of the residents smiled.  That is more than I can say about a lot of the facilities that I have visited in the US.  I did see residents that didn't smile.  I'm under no illusion that an elderly person wants to be removed from their home and placed into group living-regardless of nationality.
MECN student: I was very touched when the medical director said that no one is abandoned at the home, because she takes care of everyone as if they were her family.  She thinks of them all as someone's father and mother.
MECN student: When we first saw the home, I was taken aback by the condition of the facility. They genuinely care for each person as if they were their own family members. I was brought to tears when Yohan told one of the women that she was beautiful and she began crying.  I could not hold it together!  I have to say that we have an amazing group of caring and compassionate future nurses, and I feel so privileged to be among them.

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