The Coffee-stained Pages: An Elective in Cuba and Peru: Cuba

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used.

I did two weeks of General Surgery rotation in Hospital Manuel Fajardo and two weeks Obstetrics in Hospital Gineco-Obstetrico Ramon Gonzalez Coro. As expected, the biggest problem I had during my time in Cuba was the language barrier. Even though I could understand basic Spanish, the Cubans spoke at a breakneck pace and with a strong accent, which made it almost impossible for me to take a history from the patients. However, there were more surprises for me apart from the language barrier.

The Lack of Resources

When my General Surgery supervisor brought me to the theatre changing room on my first day, I was surprised to be offered reusable surgical masks and head covers made of cotton fabrics. When I was changing into my surgical shoes which I brought from home, the other doctors were surprised to see the odd looking ‘flip-flops’ and offered me a pair of cotton shoe covers. I was at loss of how to use those covers until a nurse showed me how to tie them over my shoes. When I arrived outside a theatre room, a registrar told me to scrub in. ‘What is a Hibiscrub?’ she asked when I asked her where can I could get Hibiscrub from, a soap ubiquitous in Addenbrooke’s Hospital. She proceeded to show me how to scrub: first, by using a bar of regular soap for 5 minutes; after rinsing, apply an alcohol mix, which left strange white residues on my hands and caused the skin on my palm to peel.

The equipment in the theatre was all reusable: from cotton surgical gowns to the enormous pieces of green cotton fabric used as drapes, to the metal yankeur suction tube. The only things which were disposable were the swabs and sutures. The waste they had after any surgery was a little 2L plastic bag, as compared to the 2-3 large garbage bags we had in the UK. While in the General Surgical Ward, instead of the usual surgical site drainage bags we have in the UK, a white surgical glove connected to a plastic drainage tube with duct tapes was used in place of a drainage system.

Apart from disposable items, the hospitals lacked laboratory-based investigations, imaging equipment and medications. This used to be the reason why Cuban doctors were so good at diagnosing based on the clinical picture alone, instead of relying on imaging. However, I also witnessed the harsh reality of not having X-ray machines, CT and MRI scans readily available in clinical practice. An 80-year-old lady with painless jaundice was admitted during my placement. Although the doctors suspected that she had pancreatic cancer, they were unable to offer her CT scans to check for metastases. The only thing they could offer her was a staging laparotomy. I secretly hoped a palliative care doctor was referred for her, but judging from the lack of a CT machine, I wondered about the availability of palliative care here. During the laparotomy, they found multiple metastases and a blocked duodenum. She deteriorated rapidly after the surgery and died the next day.

Due to the economic sanctions, the Cuban surgeons had few disposable items and imaging equipment at their disposal. Although I was at awe with the creativity of the surgeons, there is a limit to their improvisation skill. After the death of patient with jaundice, I became more aware of our reliance on technologies in our daily practice in the NHS. These experiences made me realised the luxury we have always enjoyed in the NHS, both as a doctor and as a patient. For example, as a junior doctor, I would be able to order any investigations just with a few clicks on the computer without actually considering the costs behind them, and I can be sure that the results will return me soon. These experiences revealed to me the real costs of these investigations and treatment. Thus, I should be more mindful when using the resources available, using them only when there is a valid clinical reasoning behind each investigation, instead of doing it ‘just as a baseline’.

The evidence-based practice?

Since the beginning of medical school, I learned about the importance of evidence-based medicine and how a simple study like Ignaz Semmelweis’ comparison of the mortality rates in obstetric wards cared by doctors and those cared by midwives had spared countless women and newborns from agonising deaths. As medical students, we were all told to wash our hands numerous times since day one of our clinical years to prevent spreading pathogens to our patients and ourselves. Despite so, I often washed my hands in the wards with the sole intention of avoiding reprimands from the infectious control nurses. In Cuba, I witnessed the consequences of not adopting this simple yet effective evidence-based practice. Due to the lack of proper hand-washing facilities nor gloves in the clinics and wards, I often witnessed doctors examining patients, one after another, without washing their hands in-between. As a result, surgical wound infections, wound dehiscence and large surgical hernias were familiar sights. It was strange to see these iatrogenic pathologies every day, yet no measures were adopted to improve the situation. It was even more strange to see patients keep coming back to the same doctor to seek help and even thanking the doctor for his willingness to treat their complications! This would have earned the doctors lawsuits in the UK!

The lack of resources might have curtailed any effort to do audits or research to improve the situation. However, I believe there is another factor dampening the research culture – the constant use of socialist-based propaganda to reassure themselves and the public of the current state of the healthcare system. After Fidel Castro’s successful use of propaganda to unite the Cubans in the Cuban Revolution, the government maintained an intricate propaganda machine, including all broadcasting facilities and publishing houses. The culture of using propaganda to unite the Cubans seemed to infiltrate the medical field. When asked about their health system, the Cuban doctors have only the highest praises and nothing less. Their unacceptance towards criticism was evident when a Colombian trainee doctor lamented about the state of the system to one of the elective students. The doctor later received very disapproving comments from his colleagues. Besides, as elective students, we were not allowed to conduct audits too. This surprised me as I learned from another elective student who was at the same time as I did that each primary care centre has a statistician and they were obsessed with collecting data! Several African medical students studying in Cuba told me that they were not taught to conduct any audits, partly due to the lack of resources, and partly since all statistics were heavily monitored by the government. The doctors were pressured to produce favourable statistics to protect the international ranking of Cuba healthcare system and Cuba hardly ever allow independent verification of its statistics. I have also witnessed how clerking sheets and observation sheets were completed in the hospital. The doctors filled in clerking sheets, which in theory would aid in taking an extremely comprehensive history and examination, without having interacted with their patients for more than 2 minutes; the 4-hour-post-partum observation sheets were filled in within the first hour postpartum. Although I would not generalise these actions to the culture of the whole system, they provoked my scepticism towards the stellar statistics reported to international organisations from Cuba.

Furthermore, Cuba is also a country with an inadequate and heavily-censored internet connection. Although I was unsure if this was due to the US embargo or it was part of the government’s effort to prevent Cubans from assessing outside culture and information, I witnessed how their healthcare system suffered from their isolation from the international medical community. During my four weeks in both hospitals, I have attended several teaching sessions and teaching ward rounds with the local medical students. However, during those sessions, I did not see any professors quoting any evidence from any scientific journal during their teaching. When questioned about their clinical reasoning, anecdotal pieces of evidence were often used to justify their actions. However, how are the Cuban doctors supposed to assess the latest NEJM when the internet costs USD 1.50 per hour, but an average Cuban doctor earns merely USD 60 per month? Besides, most Cubans who have never been outside of the country were unable to understand simple conversational English.

Throughout my time there, I worried about the quality care received by the patients and at times, secretly blamed the doctors who did not wash their hands for the infected surgical wounds. On hindsight, perhaps the cause of those infected surgical wounds was more than the bacteria on the doctors’ hands, rather a cumulative consequence of the environment they were in.