Nicaragua
Cubans Still Keep Bluefields Alive
Envío team
As Tomás Linton Barrera came up the steps of the two-story white house on Bluefields' main street, he was speaking Creole English to the pregnant woman at his side. Tall and dark-skinned, he could have been taken for an Atlantic Coast native himself. But Dr. Linton is Cuban; the oval Colombian Consulate plaque still beside the building's front door belies the fact that it houses the Cuban volunteer medical brigade he directs.
This is Cuba's seventh such brigade to come to Bluefields since the program began in 1980. "At that time," Dr. Linton explained, "Bluefields had virtually no general practitioners. Today it has enough generalists to meet its needs, but it still has no specialists, so we fill the gap." From a peak of 16, the team is currently down to 12; 2 of them generalists and the remainder surgeons, gynecologists, pediatricians, internal specialists and one anesthesiologist. Linton himself studied internal medicine, then specialized in health organizing.
A Taxing PostUntil last year the Cuban volunteers did two-year stints at the hospital in the coast's largest port city, broken up by a 15-day vacation in Cuba every 6 months. But due to the economic effects of changes in Eastern Europe, this luxury has been cut from Cuba's program. "Now we work here for a full year, then go home for 30 days," Dr. Linton explained. "When we get back, we do the second year in Managua, Granada or Masaya, the three other Nicaraguan cities where our medical brigade program is still functioning."
Why shift to the Pacific for the second year? "We wouldn't hold up here for two years with only one break," Linton said with a chuckle. His candor reaped a poorly-veiled look of surprise. Given that thousands of Cuban medics and teachers who have come to Nicaragua over the past decade earned justified fame by volunteering for remote areas of the country to which their native counterparts balked at going, Bluefields does not give the first impression of being a hardship post. Admittedly the water supply in this city of over 44,000 inhabitants is contaminated and its intermittent energy supply threatens to become altogether nonexistent if the obsolete power plant isn’t modernized by the end of the year. But it has a modern hospital, built only a couple of years before the hurricane that flattened the city in October 1988. Even the damage to the hospital was quickly repaired with international help. And unlike in the first years of the revolution, there are now a few public health centers in Bluefields and even doctors in some outlying villages, all of which takes some pressure off the hospital.
As Linton drew a picture of the brigade's working conditions, surprise gave way to comprehension. He considers the hospital's resources and equipment "quite good," and said he has heard that it is the cleanest and best maintained hospital of any the Cubans are working in, but he stressed that the general conditions in the coast are much more taxing than in other regions: "The geography here is special and there's a lot of rain [12 to 18 feet a year]; as a consequence, transportation is bad. Sometimes the boats and planes can't travel, or you can't risk moving a critical patient such a long distance for special treatment in Managua." Under these conditions, the hospital in Bluefields effectively becomes a terminal hospital for the whole region. "Highly qualified doctors are thus key—we have to be able to respond to any contingency," Linton said. "We have to work very carefully."
As the region's only specialists, the Cubans are on 24-hour-a-day call for the whole year they are in Bluefields. "Even if we want to go to the beach and relax for a few hours, we have to leave a message saying where we can be found."
Sylvia Byers, the Ministry of Health delegate in this coastal region, has recommended to her bosses in Managua that the Bluefields brigade be expanded. "The Cuban doctors work better here than Nicaraguan doctors," she says. "They come ready to work, and aren't demanding about the conditions. Our own specialists from Managua want conditions that are beyond our means." Byers hopes that in the future Cuban medics will go out to the communities, and that several will be sent to the mini-hospital planned for Corn Island.
Making Medical HistoryThere is no tally of how many lives these doctors have saved, but two particular cases made national news and Nicaraguan medical history—and both were in Bluefields. The first was a young man with a gunshot wound who required open heart surgery last year. Newspaper reports of the emergency operation say it was Nicaragua's first open heart surgery. "It was certainly Bluefields' first," Linton said modestly.
The second historical operation took place earlier this year—the removal of a 25-pound fibroid tumor from the uterus of a middle-aged woman. The operation was performed in Bluefields because the patient had returned to die in her home after Managua doctors were unable even to tell her whether the tumor was benign or malignant. "It was an extremely delicate and difficult operation. The tumor was so large that its fibers had also become attached to a number of other organs—her kidneys, lower intestines and so on. The operation took 4 hours and 20 minutes, and the whole team participated. She's fine now." The surgeon who headed the operation was given a Nicaraguan award.
Nicaragua is not the only place Cuban medicine has made breakthroughs. Back home medical researchers have discovered a hepatitis-A vaccine; a vaccine against the meningococcus bacterium, which causes cerebrospinal meningitis; and a medicine to lower a body's cholesterol level. Cuba, he said, is also working on an AIDS cure.
On a 1985 visit to Cuba, an envío delegation had an opportunity to see another Cuban medical invention, called an external fastening device. Visiting Nicaraguans in a Havana hospital, they met one man whose lower leg bones had been shattered in a motorcycle accident. Since the treatment exceeded Nicaraguan skills, the man had been rushed to Cuba, where he was operated on three times, completely free of charge. His leg was not in plaster, but simply caged within a series of large metal rings attached to each other by adjustable rods and to his leg by metal pins that held the mending bones in place the way spokes of a wheel hold the hub. Minute expansion of the distance between the rings over time prevented bone shrinkage. When the man returned to Nicaragua after five months, he did not even limp.
Comparing Medical SystemsDr. Linton said that in 1959, the year of the Cuban revolution, that country's public health system was as bad or worse than Nicaragua's. While the private system was good, the flight of doctors who disagreed with the new order soon left only 1,200 medical personnel in the whole country. For the first few years, he said, the revolution was forced to train nurses in only one year. Health centers, or what Cuba calls polyclinics, were created to provide primary care and take some stress off the hospitals. Linton recalled an article in the Ministry of Public Health journal comparing 1959 with 1970 that demonstrated a complete shift in Cuba's health picture in only 10 years. In particular, there were significant decreases in the incidence of typical, and often unnecessarily fatal, third-world medical problems such as diarrhea and tuberculosis.
The health system the Cubans encountered in the Atlantic Coast in 1991, Linton said, has a different concept than Cuba's. "In Cuba we give the greatest emphasis to primary care, to the clinics and family doctors where the vast majority of people have their first contact with the health system." While Nicaragua has a primary care system too, it is much weaker than Cuba's; most of Nicaragua's health centers have no equipment and no specialists, whereas Cuba's polyclinics have both. In Cuba there is a family doctor for every 125 families (roughly 700 people); here the ratio is much greater.
Another point of contrast Dr. Linton mentioned is that in Cuba doctors do what they call "integral" work, spending one day in the clinic and the next making systematic visits to homes or workplaces in their zone. Here that does not exist.
In Cuba, as in Nicaragua throughout most of the Sandinista administration, public health care is free. By 1988 the Nicaraguan government had to start charging a subsidized price for medicines, which Linton said Cuba is now also being forced to consider. With Nicaragua's new UNO government, most medicines have been turned over to the private sector and are dispensed at international market prices in all but state clinics and hospitals; in the past year small, privately owned drug stores have burgeoned in Managua neighborhoods. Even though people feel psychologically better knowing there is no longer a scarcity of medicinal supplies, they are beyond the reach of poor families.
As in Nicaragua, there are still private doctors in Cuba, but Linton says they are only those who remained in Cuba after its revolution—literally a dying breed. To be expected, Linton disagrees with the classic capitalist argument—and practice—that a competitive private medical system is necessary to stimulate excellence and medical advances. "Some are surprised to see that we Cuban doctors are stimulated by the service we offer society, by a good operation or a medical discovery. It would be utopian for me to deny that personal motivations can also produce results, but humane motivations are just as effective." He added that he is paid well enough that, together with Cuba's strong social benefit program, all his needs are covered. "Why would I need more money?"
He believes that a public health system need not deteriorate under capitalism, and offered Sweden as an example. "All that's needed is willingness," he stated flatly, implying that capitalist governments committed to a private health system usually lack that ingredient. Since they view the public health component as merely an obligation to the country's "indigent" population and not as a right of the entire population, it is understaffed and under-financed.
Asked if Cuba's medical profession encourages women at all levels, Dr. Linton claimed that there is no machismo in this field. Skirting a more categorical answer to a question of whether women are encouraged at all levels of medicine, he proudly gave the example of Hilda Molina, head of Cuba's National Neurotransplant Program. He added that, whereas women in Japan earn 60% of what men in the same job are paid, in Cuba women earn the same as men and have the same rights.
Cuba's Brigade ProgramHumane consciousness is the motivating factor in Cuba's international medical brigade program as much as in its domestic health system. The program has existed for 20 years and is completely voluntary. Some never register for it and others only do so once, depending on their commitment level and personal circumstances. "Some don't want to leave their family," Dr. Linton said, noting that the period is always two years and families are not relocated along with the volunteer.
He said Nicaragua is the fourth stint for a surgeon and a pediatrician on his brigade—both have been in Angola and one or the other has gone to Guinea, Mozambique and Ethiopia. Often, he said, medics return to Cuba for a while, to "recharge their batteries," then sign up to go out again.
All medical schools maintain a list by specialization of those interested, and people are contacted when a country asks for a particular specialist. "We don't charge anything for our services," explained Dr. Linton. "Most of our basic needs are paid for by our Embassy, and part [housing, etc.] is provided by the host government."
Those who will form the brigade in a given country spend at least a week learning about that country's culture, tradition, characteristics, habits and health picture. Those coming to Nicaragua's Atlantic Coast learned not only about the country as a whole, but about its two distinct halves, each of which has its own historical tradition, different ethnic profiles and very different ways of thinking and acting. They each also have their own health profile.
Bluefields Through Cuban Eyes"This has been an important experience for me since I'm Caribbean too," Dr. Linton began. Born in the eastern province of Las Tunas, he lived in Havana before coming to Bluefields in February 1991.
"What will stay in my computer after I go home? Well, let's begin with culture, then talk about health. First of all, I've really been struck with the Caribbean influence in the music here. I've learned how the region was formed, and about the important influence of music in Bluefields."
The next cultural element Dr. Linton mentioned was food, which formed a natural bridge to a discussion of health. "Most of it is very like Cuba's food, except that they use coconut milk in their gallo pinto [rice and beans] and in rundown [a traditional coast dish of meat or fish stewed in coconut milk with root vegetables]."
Stepping onto the bridge, he said, "I like the diet here because they use oil and not lard, as we do; compared with Cuba they have very few cardiovascular problems. They also eat a lot more vegetables than we do—green peppers, tomatoes—and also fish, which we don't. All of that is very good for your health. We eat too much pork and not enough fish, even though we're an island. Regrettably, we don't have very good eating habits. We're working on a major education campaign about this in Cuba right now. It's in all the media, but I don't know what effect it's having, whether the message is getting across."
That comment led naturally to a discussion of health campaigns in the Atlantic Coast, particularly the current cholera campaign. A sea-level jungle region with many rivers and two port towns open to the Caribbean Sea, the coast is a likely point of entry for the cholera virus, whether borne by water or infected visitors. With few latrines in most villages and a regional capital lacking a decent sewage disposal system, it is a breeding ground in which the deadly virus could reach epidemic proportions in a very short time.
The coast region, as the rest of the country, has prevention programs such as vaccination campaigns for a number of diseases, but preventing cholera depends largely on personal hygiene education, not on vaccines. "Preventive measures could have a useful effect, but the education programs need to be more systematic," says Dr. Linton, "as in Costa Rica." Because Bluefields does not receive TV signals from Managua and only has one local channel, Linton, like most Bluefields residents, watches a lot of Costa Rican programming.
"There's an immense difference between the two countries' health campaigns," he said. "Every afternoon there are public service announcements on how to recognize symptoms of different diseases, when to go to the doctor, etc.; it's very systematic, particularly regarding cholera. A lot of commercials are also linked to cholera, and the other day the Costa Rican President was on a long program with the minister of health talking about it in detail; it's a great campaign."
In Nicaragua, he said, a series of programs are in place to be implemented when the epidemic arrives, but he does not believe most people yet understand the gravity of the problem. As with Cuba's dietary change campaign, the difficulty is getting people to take the message seriously. "It's a question of changing people's attitudes, and that's a hard psychological problem. The older people are, the less likely they are to change their habits. I personally think you have to try to reach the younger members of the family."
The medical brigade is not Cuba's only contribution to the coast's preventive health efforts. When Nicaragua's new government did not ratify Cuba's agreement with the Sandinista government to build 1,000 new houses in Bluefields, work on the houses stopped and the construction brigade went home. But the heavy equipment is all still housed at the huge Cuban construction compound on a hill overlooking Bluefields bay, maintained by a rotating skeleton crew of three construction workers. Anticipating the cholera epidemic, the crew has volunteered the equipment and their labor to the mayor's office for free. As a result, Cubans are now in charge of cleaning Bluefields' streets and—at least for the duration of the heavy rainy season, when the city's only two garbage trucks cannot slough through the deeply rutted and muddy streets—they are using their tractor-trailers to collect and dump solid waste.
From Anti-Communism to Genuine GratitudeWhen it was time for the construction team to rotate recently, official and unofficial goodbye parties for the departing workers went on for days. Most of the farewell speeches were more than protocol; they expressed heartfelt gratitude. It’s quite a change from 1980, when Bluefields erupted in a massive demonstration against the Cuban presence.
The region's deeply rooted anti-communism did not die easily; in fact, in the north, the large Cuban medical brigade pulled out of Puerto Cabezas a week after the February 1990 elections because virulent anti-Cuban campaigning by some Miskito candidates convinced them that the new regional government could not guarantee their security. In the same week in Bluefields, in contrast, an ad hoc committee of civic leaders formed to assure the brigade there that it was appreciated and safe.
Many people peg Hurricane Joan as the turning point in peoples' attitudes in Bluefields. While the population reeled from the days-old devastation, Cuban doctors tirelessly attended the victims and Cuban planes were the first to land on the rubble-strewn runway with emergency supplies. For those not won over even by those examples of Cuba's international solidarity, the hundred or so attractive cement houses finished before the construction brigade left are mute reminders of ideological shortsightedness. When the new central government failed to ratify the contract, Alvin Guthrie, the UNO governor in the newly autonomous southern region, assured those attending one of the first meetings of the Regional Council not to worry because the United States was going to build 5,000 houses. There is as yet no evidence that his promise was true.
The continued presence of Cuban medical brigades in four Nicaraguan cities is generally attributed to the greater open-mindedness of Dr. Ernesto Salmerón, Nicaragua's new health minister. He and most of his ministry team refer to the Cubans with warmth and great respect. Sylvia Byers says there is no problem in Bluefields; the Cubans are now fully accepted by the people.
Even so, the bilateral agreement for the medical brigades has still not been ratified and their presence could end at any moment. Dr. Linton is certain that if the Cuban team leaves, another with its skill level will be needed, but he is determined not to react to such an advent with hard feelings. "We're far from our families and are here because we can provide services to the population. We doctors aren't interested in the political system; it doesn't matter if the new government thanks us or not. The rich here in Bluefields can go to Managua, but the poor can't. Those we can help the most and cure the easiest are the humble people; this is what makes us happy."
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