The Risks and Insecurity of Being a Doctor in Cuba

In training sessions, doctors are warned about publishing images that could slander the health system. (flickr)

14ymedio bigger14ymedio, Cynthia de la Cantera, Havana, June 23, 2020 — Ernesto is considered an “old dog” in his profession as a primary doctor. However, he still remembers how he and his colleagues were “tattooed with fire” after the authorities warned them during a training session about Covid-19 protocols. “Be careful about publishing a photo or information that doesn’t agree with what is official, because notice will be taken at the highest level of what is said.”

The “inappropriate” photo or information refers, in his opinion, to the precariousness of the health system and the working conditions for medical personnel. The polyclinics don’t have bathrooms or rooms in a condition where doctors, who dedicate seven days a week to their jobs for barely 1,600 pesos a month, can rest, and this hampers the performance of all health measures. In addition, once they leave the hospital, the doctors encounter the same problems as the rest of the population: shortages and lines.

Access to medical sources and hospital centers in Cuba requires permission from the Ministry of Public Health, which already has been denied to the independent press under normal conditions. Now that health personnel are at the center of media attention, a public statement with the author’s identity can propitiate a sanction or expulsion from the health system, depending on the seriousness of the offense.

Ernesto, who uses a pseudonym, explains how his day usually goes. It begins at 7:00 in the morning in an apartment with three rooms, one for a nurse and two for consultations. “We don’t have water in the bathroom; nor in the sinks or the toilet. We have to get it in buckets.”

His first job is to fill out a sheet of paper, writing down the names of patients who are waiting by “medical groups,” a system of categories implemented by the Ministry to classify the population according to risks and vulnerabilities. “I have to see a minimum of 20 patients a day. If I don’t, my work isn’t considered productive.”

At 9:00 am, the medical students arrive and perform their surveys. Ernesto distributes forms and they must visit all the houses to learn how many people live there, their ages and symptoms. This system is based on the epidemiological vigilance that already was done for zika and dengue.

“After the first weeks the neighbors were calling me because the students weren’t coming by every day (as they were supposed to), but they were still handing in daily reports. Falsifying them is easy: first they fill out a complete questionnaire, well done, with all the data, and before handing it in, they take a photo. Then they use this as a template and visit the houses only a couple of times per week,” he laments.

Ernest tried to rotate the students to avoid the trap, but the faculty agreed that they should investigate in fixed areas to get to know their patients, with a maximum of 40 homes. “As you might understand, there are times they go and times they don’t,” he says.

Since the beginning of the pandemic, the number of Ernesto’s patients has gone down, and he is already beginning to note the return to normality. “Most are older adults who come for prescriptions. They request the same thing two or three times, because there is a lack of medication and their prescription expires.” The doctor complains that the authorities haven’t approved extensions for prescriptions as they have for other things. “If I haven’t written 100 expired prescriptions, I haven’t written any. It’s a waste of time and incalculable resources since this country is so poor,” he complains.

Among the most requested medicines are analgesics like dipyrone and naproxen, antibiotics like gentamicin and triamcinolone, and sedatives like lorazepam, which aren’t available.

After lunch, Ernesto visits nearby patients who live alone and those who have declared symptoms to visitors or by the mobile application. “With these last, I have gone by and sometimes arrive and they tell me there’s nothing wrong with them, they’re bored, or they only wanted to see if the application really worked. Almost all are elderly adults. I ask them to imagine how it would be if they really needed me and I was visiting another person that falsified symptoms,” he says, although the application itself indicates that giving false information is subject to sanctions imposed by the law.

When he finishes his paperwork in the polyclinic, he concludes his day and lingers with his colleagues, chatting during the hour or hour and a half he spends waiting for the bus that drops off the medical personnel. Some of them, according to the municipality where they live, must wait for two or three hours.

Ernesto thinks he contracted coronavirus a couple of months ago after coming into contact with an Italian woman from Bologna. One week later, he was at the polyclinic with fever, a headache and fatigue, and they sent him to the Luis Díaz Soto military hospital in Havana. “The doctor looked at me and said, with a straight face, ‘What you have is tonsillitis. Go home’. He knew that I was a doctor because of the referral. The following day they disinfected my house, and I spent 21 days in quarantine. They didn’t do an analysis; I never knew what I had.”

The doctor believes that cases like his allow them to improve the statistics, although he says he doesn’t know of other cases of apparent omission of registering someone contaminated by the virus. “I don’t like to speak about politics, because everything is always misinterpreted, but the way they have of defending the system is by saying ‘look how we are managing the pandemic’.”

In this country they have already reported two outbreaks of contagion in hospital centers, both in Mantanzas. A local media gave details about the working conditions and lack of hygiene, and the scarcity of protective equipment that contributed to the outbreak in the Comandante Faustino Pérez hospital. The floor where the focal point originated had lacked water from more than a year. In addition, with all the personnel isolated in the hospital to avoid new contagion, the number of doctors available in the province was reduced, and the workload of the rest was increased, until a brigade from Mayabque had to be sent to help.

Milena is a medical student, in her last year, and she practices on the front line, but she fears for her pregnancy. “It really gets ugly when you begin to count between 25 and 30 ambulances a day that bring in patients with respiratory symptoms. They authorize specific consultations for them, so they enter on the other side of the hospital. They put me in the emergency room, but still, occasionally, suspicious cases arrive that way, and you have to examine them to do a pre-diagnosis.”

The young woman notes the influence of the international missions on the loss of professionals in Cuba. The Government maintains personnel in 59 countries, 3,300 in the 29 nations where they participate in the struggle against Covid-19, adding up to a reduction of some 29,000 health workers in Cuba.

“They formed groups to go relieve them. The intensive care specialists, internists, gynecologists and pediatricians were obligated to go, but the rest of them went voluntarily. After they took doctors for the missions they had to create more groups because there weren’t enough. No one knew what was going to happen,” she remembers.

“I was really afraid because the security measures weren’t great. They only gave you one cloth mask, the green kind, for the whole shift of 24 hours. They didn’t give out gowns or caps, not even eyeglasses. Only after the donations [of the Chinese Government] did things improve a bit. But still we were worried that some patient would arrive who didn’t have symptoms, coming for something else, and that one of us would get infected,” she says. She brings from home four or five masks, two protective suits, a pair of gloves and a surgical cap.

The Ministry of Health retired personnel over 60 years old with 60% of their salary because they were a group at risk, but not anyone pregnant, since it hasn’t been determined that the virus causes anomalies or severe complications, but Milena is afraid because the immune system is depressed during gestation. “In the case of Covid-19, you can have pneumonia or bronchial pneumonia, which is very dangerous for the life of the mother and the baby,” she says.

These fears have led some health workers who still haven’t reached their second trimester to present medical certificates that permit them to be absent until their due date. Then they extend them to week 34, when they can benefit from paid leave. But Milena had to go back after the first expiration date because she’s a student. “If I don’t fulfill the requirement of 80% attendance, I lose the right to my diploma,” she explains.

Mariela, a family doctor who practices in the Havana municipality of Revolution Plaza, is worried about the Program of Infant Maternal Attention. “The pregnant and lactating women take a series of courses each trimester, a level of monitoring that is one of the most exhausting there is.” This means more tests, more consults, more follow-ups, more information and reports. There’s no rest.

Before she was working from Monday to Friday and Saturdays until 12:00, but now she also has to work on Sundays, for the daily surveys. “No one expected this. And it’s not considered overtime. If we don’t do it like that, cases occur. But from my point of view, you get exhausted, because it’s not just Covid-19. You have a population with other diseases and follow-up programs. In addition, there are medical emergencies, the elderly, those who live alone, the following of contacts and those whom you have to see every day,” she says.

When health workers are tired, Mariela points out, they stop fulfilling the protocols with the same rigor, and now she can only rest in the days following emergencies in the polyclinic, four times a month.

“Have they told you when you could officially rest?”

‘No, I don’t know; I suppose it’s when all this ends.”

Francisco Durán, the head of the Department of Epidemiology of the Ministry of Public Health, has explained that the epidemic would be considered concluded 28 days after the last positive case, the time that corresponds to two periods of incubation of the new virus.

Meanwhile, Havana is full of posters that highlight the triumphant battle against the pandemic. Some include photographs of Fidel Castro and José Martí. There is one where several doctors appear with green masks keeping a distance; the first of them holds a Cuban flag.

It’s very probable that the photo was taken at the time of farewell for a medical brigade leaving on their mission. The text says: “For Cuba, together we will win.” The message is repeated in the State media to remind us that they are our heroes: those who wear the white coats. And really they are, but not for their unconditional support and discipline, but rather because they work without adequate means, without pay for extra hours, without days of rest and without being able to enjoy their families.

Translated by Regina Anavy


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