Safari Season 2012

As my time in Botswana is coming to a close, I wanted to reflect on this past safari season. We started out in May with the Furman group. As part of a May X program (a three week, two credit course) called “Botswana: Paradox and Profession”, the main question I wanted to address was, “Why does a country that has done everything “right” when it comes to HIV/AIDS still have the second highest rate in the world?”

As a medical sociologist, for the past 5 years, I have been reading everything I can and learning as much as possible about this topic. After three days of preparation on campus, 19 students, one faculty colleague and a staff person from the Office of International Education and Study Away and I headed off to Botswana for two weeks. We spent the first week in the capital, Gaborone, talking to an array of individuals and organizations about the topic of HIV/AIDS in Botswana.

We visited everyone from the US Embassy to the Center for Disease Control, Peace Corp and USAID to Harvard University’s labs and Baylor University’s Teen Club. We also had the opportunity to meet with some local organizations like BONELA – Botswana Network on Ethics, Law and HIV/AIDS, researchers like Bagele Chilisa at the University of Botswana and Unity Dow whose book, Saturday is for Funerals, we read. One of the most exciting moments occurred when one of the students asked Unity, “So you’ve written both fiction and non-fiction books, served as a High Court Judge, helped change laws to advocate for the rights of women…now what do you plan to do?” To which she responded, without missing a beat,  “I’m going to be the next President of Botswana.” We were impressed and she certainly would have the support of our group (if we could vote!). 

Group with Bagele Chilisa at University of Botswana

 

Group outside of Harvard Labs after our tour

Group with Unity Dow at her house in Udi

It was an action packed week of learning about HIV/AIDS and many of the US based outreach programs trying to help as well as getting the perspectives from locals about some of the most pressing issues. Students did a great job preparing us for these visits by doing research on the organizations/individuals while on campus and then doing presentations for the entire class the night before our visits. For the first time through, I think the program worked quite well.

Rhino at Khama Rhino Sanctuary

Our second week we spent in the bush seeing some of the beautiful animals and landscapes of Botswana and exploring questions of vocation and calling. We visited Khama Rhino Sanctuary, “bush” camped along the Boteti River (with an unexpected night of lion calls all around us!), and visited the Khwai River area before flying out of Maun and back to the States for a few final days of class to wrap things up (I stayed here, while my faculty colleague and staff from the Office of International Education and Study Away escorted the group safely back to the States). 

Group at Mokolodi Game Reserve, Gaborone

Dr. Nocks and group in front of game viewing vehicle

 

 

 

Ellies in the Khwai River

We had a quick turnaround for our second safari of the season and this one had a Furman tie as well. You might call this a “reunion tour” as a student from the 2007 trip (the trip I met Paul on) and her father came for a ten day safari. This was a “Best of Botswana” tour starting in the Central Kalahari Game Reserve (CKGR) and working our way up through Moremi Game Reserve, then onto Savuti and ultimately the Chobe River front with a day trip to Victoria Falls. This is really one of the best routes offered by Kalahari Skies as I think it gives you a taste of all that Botswana has to offer from desert to delta to river front.

Ellie playing in the Chobe River

Young ellie - thinks he's a tough guy!

Aardwolf in the Central Kalahari

We had a beautiful trip with seasonably nice weather for late May-early June. Days were pleasantly warm and evenings were not too frigid (it can get down to freezing at night during the winter!). We had some unique sightings (like a caracal and aardwolf in the Central Kalahari – both pretty rare to see) but unfortunately couldn’t find a lion to save our lives (despite our best efforts including over a 10-hour day of trying on their last day). I think I’ve talked about “lion anxiety” before and we definitely had it (that is the stress that builds up when you’ve been on safari for a few days and haven’t seen a lion and all you want to do is see a cat!!).

We also ran into a bit of mechanical difficulties when the central barring of one of the tires on the kitchen trailer blew out and we had to scramble to get it fixed. It’s called “making a plan” - Rush clients to river cruise so that we could search for parts. Put them up in a lodge so we could drive back to repair the trailer with what parts we could find. Switch day trip to Zimbabwe to see Victoria Falls to complete repair. It was a bit of madness but it all worked out. I ended up having to escort the clients to Zim (since Paul had to work on the trailer) and nearly had a heart attack as I watched them both clients fearlessly bungee jump off the bridge between Zambia and Zimbabwe (let’s be clear - NO, I WILL NEVER DO THAT!).

A classic African sunset keeps people coming back for more.

View from the Cliff Trail

Our third and final safari came at the end of June (after a quick trip to Copenhagen to meet Paul’s six month old grandson Arthur – who is, by the way, super cute!). We met an interesting couple who is spending their retirement traveling around the world. We had the opportunity to take them to Tsodilo Hills to look at some rock art. We hiked for two full days and were able to do the Cliff, Rhino and Lion trails. We had beautiful blue skies and clear nights with a full moon rising over the hills. Quite lovely! We also got to see the resident dog of Tsodilo Hills - last time we saw him he was pretty beat up so I was glad to see him in good shape. And he was glad to see us (and our leftovers). 

Lion painting, namesake of the Lion Trail

Moon Rise over the Male Hill

Resident Tsodilo Dog

Sadly, given the economy, that was all we had for safaris this season. While we were supposed to be out this week in the Central Kalahari with a Spanish group (one we had done for several years in a row), it didn’t “make” this year (the reality of all the international news you’re hearing about “bail outs” and “austerity measures”). We’ll head off one more time for a couple of star shows in the CKGR this weekend and then I fly back to the States on August 10. 

Things I’ve learned this summer (winter)…

First, my apologies for not writing as much this summer (winter) as I usually do. I think Botswana’s recent rating as the “unhappiest place on earth” (of 151 countries surveyed by the New Economics Foundation’s Happy Planet Index) may have rubbed off on me a bit. The question is - what’s happening over here?

In the limited amount of time I’ve been coming to Botswana (on and off for the past five years), I’ve noticed a change. In an effort to “modernize” or perhaps “become more developed”, Botswana has become more and more bureaucratic to the point that it seems to be almost “strangling itself in its own bureaucracy.” Even the simplest tasks seem to take on a level of absurdity that is hard to ignore.

Paul’s continuing attempt to deal with BURS (Botswana Unified Revenue Service, comparable to the USA’s IRS) feels like a Sisyphean task (you remember Sisyphus – the Greek king punished by being forced to roll an immense boulder up a hill, only to watch it roll back down, and to repeat this action FOREVER!).  Or a better yet, dealing with BURS is like a scene from the movie “Groundhog Day.” You may recall that 1993 movie where Bill Murray keeps waking up to find himself living the same day over and over again. Well that’s what it feels like when trying to deal with accounts and taxes here. Paul is on his fifth (or maybe sixth - I’ve lost count) book keeper in the time I’ve been here. His accountants are a disaster that are not only slow (they have had his year end accounts for 2010-11 since last July and they STILL are not finished!), but incompetent! To make matters worse, they not only routinely make mistakes, but then they charge for the time it takes them to fix those mistakes. Unfortunately, Paul is not alone in this book keeping/accounting nightmare. Just about everyone we talk to struggles with both. The only positive news about this, is evidence it provides for Paul’s eternal optimism - we are currently “test driving” some new accountants and Paul is convinced they are going to be wonderful! The glass is always half full! (Thankfully)

IF one can successfully gets through a financial year with records intact, you must then deal with BURS to try to get the infamous “tax certificate clearance” (imagine a choir of angels singing in the background to signal its importance). This coveted document is necessary for any government contracts (e.g. if Paul wants to make maps for any government office, he has to have a “tax certificate clearance” for his company). My favorite story regarding this took place in 2009 when Paul went in to get his “tax certificate clearance” (aaaaahhhh) for the year. Upon arrival to the office with year-end financials in hand, he was told that they couldn’t issue a clearance because he had a problem with his 2007 taxes. When he explained that the he had a clearance from 2007 which was necessary for the clearance he got in 2008, and asked how there could now be a problem in 2007 affecting 2009, he was told by the woman working in the office that, since she hadn’t actually issued the 2007 clearance herself, she didn’t know what had happened in 2008 but certainly 2009 was not coming from her! What’s the point of having a “clearance” if you’re not really “cleared”?

The absurdity continues when looking at the licensing of one of Paul’s businesses. Paul’s main work (in addition to the safari company and internet business) involves map making, printing (large format on a plotter/printer), laminating, copying, and more recently the development of guidebooks (like the “Maun Guide” – maps, advertising, and a directory of Maun). About a year and half ago, local government officials showed up at his office asking if he could make copies for him. When he said yes, and went on to say all the other things he could do for them, they informed him that he was operating a business illegally (tricky huh?) and that the “miscellaneous” license he was operating under was no longer available and he would have to get a new license. After much wrangling they decided the closest thing to what he was doing was a “bookstore and internet café” (what? He neither sells books nor offers internet services???). Later, when the health inspector came to do a sight inspection she asked, “Where’s the bookstore and internet café?” Ut oh! Fortunately, when he explained the situation, she signed off on the paperwork. I’m pretty sure it is only a matter of time before there’s a knock on the door informing him that he’s operating illegally again since he neither sells books nor runs an internet café. What kind of craziness is this?

The latest point of unhappiness among the expat community in Botswana is the new “point system” being used to get work and residency permits. While it is not completely clear what the rules are (except that you get 10 points for speaking English and must achieve 85% of all points in order to be granted your permits), there’s a lot of concern that long term residents of Botswana, people who have made lives here and been active members of the community, may not be granted “permission” to stay. Large financial investments and employment of many Batswana citizens seem to be key factors to approval. While I appreciate the desire of the government to help its citizens, this new approach seems to really be making it difficult for people who have been here for years to continue to live and work in Botswana. Even a co-worker, who is married to a Motswana (the term for an individual from Botswana), is concerned about getting the appropriate approval. If he can’t get permission to work, he can get approval for residency as the spouse of a citizen (like I have) but isn’t this worse? Wouldn’t the government rather have him work than simply live here? This is certainly contributing to widespread unhappiness.

And, as if you needed another example, recently in order to renew Paul’s PRDP license (needed to be a safari guide) he had to not only have a physical (certifying he wasn’t crazy, that’s right in a 10 minute encounter with a doctor they can certify that) but he had to be “re-fingerprinted” to make sure he hadn’t committed any crimes. When Paul queried as to why he had to be finger printed again (since his finger prints were already on file with the police) they responded by explaining that this was to see if he’s committed any crimes recently. Apparently they don’t review finger prints on file when crimes are committed?

Fortunately, I’ve been here long enough that there are moments that I can simply embrace the absurdity. The other day, for example, we were in the store buying wine. After being escorted to the “alcohol area”, a separate glassed-in room that you can’t enter on your own, we selected our bottles and proceeded to the checkout area. Our assistant put each of the bottles up on the counter and she scanned them into the computer to get their prices. After scanning one of the bottles, the attendant informed us that it was “out of stock” (mind you, this is as she holds the bottle in her hand??). Paul tries to ask how that could be possible given we had just pulled it off the shelf and she still currently had it in her hand. She insists, “This one is out of stock. You cannot have it.” Paul continues to try to argue with her (he really likes this particular brand) at which point I interject, “What she means is, it is here but is it not here, so we cannot have it.” And she replies, “Yes.”

Despite all this, I have learned a few things on this visit and I thought I’d share them with you:

1.     The air conditioner units Paul installed in his house on my first summer visit in 2007 (hoping I would not overheat and might ultimately return), are also heaters! This past April Paul had to have the units serviced, because they weren’t cooling as much as they used to, and in the process of checking the units, the service man switched it over to heat and tested that too. Paul says, “What are you doing?” The service man replies, “Checking the heaters.” Paul inquires, “We have heaters?” To think that we froze during the last five winters, huddling around the tiny space heater in the living room is quite funny! (FYI – most houses in Botswana don’t have central heating or air conditioning.) I guess this is a case of “better late than never” and we’ve enjoyed some mighty toasty mornings this year.

2.    After years of observation I’ve come to the conclusion that, when driving you need to worry about some birds flying into your windscreen (what we would call “windshield”) but not others. Horn bills, francolins, lilac breasted rollers, and guinea fowl - all risky and not to be trusted as they might fly out in front of you in suicidal ways. Doves, starlings, and plovers all safe – while they may be flying toward you they will likely get out of the way before they smash your windscreen. Unfortunately, I didn’t come up with this categorization until after a francolin took a suicidal leap into our windscreen on the way to Johannesburg to catch our flight to Copenhagen earlier in June. We spent most of my birthday getting it replaced before we flew out to Dubai.

3.    I like being “in the bush” much more than I like being “in the office” (which we’ve been doing a lot of lately). Wait, I already knew that one...

In addition to learning a few things, there have also been some new bright spots in Maun as it develops. A new art center, Motsana, now shows movies every other Thursday night. Given my love for movies, this is pretty exciting. We’ve seen “Iron Lady”, “We Need to Talk about Kevin”, “Sherlock Holmes” and last night “The Artist”. Maun is feeling quite cosmopolitan these days. Also, our Woolworth’s store has moved and expanded its food section (it is primarily a clothing store). This small annex off the side of the main clothing section of the store now offers us fruits and vegetables that don’t look like they should be thrown away, a variety of breads (some of which may include whole grain wheat) and chicken cutlets that are tender and juicy (as opposed to the texture of shoe leather, which most chicken tastes like around here). While there is no deli or bakery (that would be asking too much), what is available has definitely improved the quality of my life and helped to counter some of the unhappiness that seems to be hanging over Botswana these days.

Wild Dog’s Breakfast

On our recent trip to the Khwai Community campsites, just outside of the Moremi Game Reserve, we showed up, uninvited, to…a wild dog’s breakfast.

Escaping the office and Maun for the long four-day President’s weekend we head north about two hours from home into the bush. On our first morning we stay in the tent a bit later than one should, if you want to be out looking for cats, but the night was windy and the grass munching hippos were loud and I found myself up a good part of the night. This is not an uncommon pattern; Paul sleeps like the dead when we’re in the bush and I stay up at night… listening. There are lots of sounds to hear. On this particular night it was the wind (I feared our tent might collapse on us) and grazing hippos (which sounded like they were right outside our tent chewing away). On our second morning we woke to find spoor (foot prints) of both a hyena and a honey badger just inches from the corner or our tent - -where our heads were! Fortunately, I was so tired from not sleeping the first night that I slept right through it…

In any case, on this particular morning we stay in the tent a little longer, not only because I haven’t slept much but also because a cold front has come in with the strong winds from the south and it is ice cold. I mean ski hat and gloves, sleep in your thermal underwear cold! Still in our evening “warms” (what your warm clothes are called here…FYI pants are called “longs”), we begin driving around the sand tracks to see what we can see. This particular area has tons of elephants, hippos and impala but as we round one corner I see three wild dogs on an impala kill. This is very exciting as wild dogs are quite elusive -- I’ve probably had less than half a dozen sightings in the five years I’ve been here.

When the Furman group was here in May we saw a pack of four very close to where we were on this past trip. Even from our viewing point in May, across the Khwai River,  we could see that one had a recently broken leg (the lower part of the left front leg was simply dangling and the poor dog couldn’t put any weight on it at all and had to hobble on the remaining three). Interestingly, the other three dogs seemed to be caring/watching out for the injured dog; nudging her to get up when they were leaving, sticking close to her when she was lying down.

As we watch this pack of three on the impala kill I notice that one of them is limping a little and seems to have an injury to the left front leg. We’re convinced it must be the same injured dog we saw two months earlier. While she can now put weight on the leg and seems to getting along quite well, when given the opportunity she lies down to get off of it.

They take turns eating, pulling and tugging at what is left of the impala carcass (the innards sit in a bloody ball about four yards away from the rest of the body). We are so early on the kill that vultures begin to arrive as we watch (typically when you come onto a kill you know where it is by the abundance of vultures in the trees overhead). There is a pecking order to eating at a kill and the vultures are the last in line. As scavengers they have to wait for the hunters to finish first.

 

Apparently exactly “when” they are allowed to eat is not clear, as over the course of the morning they inch closer and closer to the kill only to be chased off by one of the wild dogs when they’ve passed some invisible line. The dogs themselves seem to have set up a system wherein one will eat while another chases off vultures. 

Interestingly the chasing looks more playful than aggressive. It’s as if it is a game. He elongates his body into a perfectly straightly line parallel to the ground – nose pointing out forward, large rounded ears down flat, white fluffy tale out straight… and then he springs into action, running into the flock of vultures sending them flapping into the air with their long wings crashing into each other as they try to take flight. From the safety of their perch they wait for another opportunity to stealthily land on the ground and inch closer to the kill, hoping for a bite. 

 

 

At one point, a group of vultures gets brave enough to go for the innards. The literally pick up the ball of yuck and transport it to the other side of a log. While the guarding dog takes a run at them, followed by a leap into the air, he doesn’t pursue them too far as he’s not interested in this part of the kill. Instantly a mass of vultures descend. All we see is a flurry of wings and dust and pulling and what’s been discarded by the dogs is gone in seconds!

Pregnant dog with wounded leg

We watch for an hour or more as the dogs take turns eating. They rip what’s left of the carcass in two and continue to eat. They intermittently rest, eat, chase vultures. Their stomachs are bloated with meat, we notice however, that the wounded dog’s stomach is more bloated and in fact conclude that she must be pregnant. This is a little late in the season for pregnancy and she looks like she could be due any day.

As more safari vehicles begin to descend on the kill (like vultures…by the end there are six vehicles total) the wild dogs decide they’ve had their fill and head off down the road. In moments, what is left of the carcass is covered in vultures. I now understand why their necks are so long. Their wings look like hiked up shoulder blades banging and crashing into their neighbors’ as a mass of vultures try to stretch their necks into the cluster to get a little bite! From our perspective it is all dust and wings and elbowing for position.

When we pass by the area later in the day, all that is left is the impala’s head and neck. That certainly was a “dog’s breakfast”.*

 

We spend three nights in Khwai before heading to a friend of Paul’s wild dog research camp. We are excited to share our story with the researchers and they are anxious to see if they can identify the dogs. While, to us, they simply look like beautiful mixes of black, tan, and white (sometimes called “African painted wolves”), to the researchers, they have a whole system of dog identification from our pictures. From what I can gather they look for distinguishing white marks. Our wounded dog is identified as “Ellen” (I’m not sure this is better than what I’ve been calling her, which is “Miss Booboo Leg”, but it seems there were a rash of talk show host names used to identify dogs for a period of time).

She is known by a distinguishing white check mark on her side. She’s actually been sited (in the past) all the way in Zimbabwe and the two males she is currently with are not dogs that the researchers know (suggesting she’s picked them up somewhere along her way). They agree that she is pregnant and will probably “den down” in about a week (in preparation for the arrival of her litter – typically 8-10 pups). They’ve seen her recently with another pregnant female who they suspect has already gone underground (so to speak). The typical gestation period is 60-73 days so she was fairly recently impregnated back in May when we saw her with her freshly wounded leg. We learn that she is an older female who has had previous litters. The researchers explain that it is not uncommon to see packs of dogs collaborate to care for a wounded dog... a happy ending to what we feared might be a life ending injury in May.

*Note: In Southern Africa there is a phrase used to describe things as a “dog’s breakfast”. While I’m not completely sure of its meaning, the context it is used in seems to describe a situation that is a complete mess. This certainly was the case for the impala on this morning.

Why I’d like to be a wildebeest

Of all the animals I see,

the one I would most like to be,

is the wildebeest.

While some may look at them and scoff, when I see them I just smile and laugh.

When I think of their funny array of leftover parts, it brings a warm feeling right into my heart.

 Horse like tail and punk rocker mane, with their mismatch of parts, they don’t seem to complain.

They are, in fact, quite cute when they’re small,  with a slightly lighter brown color to their fur overall.

Their side flanks, while they look dirty,

are actually “brindled” with two shades of furry.

With a rocking horse gait they can pick up some speed, and don’t get in their way if they start a stampede.

 

But the main reason I like them the most,

is that they seem to join any herd, no matter the host.

They simply blend with whomever they come upon,

whether impala or gemsbok they just tag along.

 

The most gregarious of creatures,

they simply disregard their features.

Back haunches too small for their larger front legs,

Wouldn’t you like to be a wildebeest too?

I think the question begs…

Cuba – A Global Health Miracle?

 When one thinks of Cuba, if you’re like most Americans, a flood of preconceived notions of the Cuban revolution, cigars, the missile crisis, classic cars, Fidel Castro and socialism probably come to mind. For those of us who study global health, another image comes of what is sometimes called the “Cuban health miracle.” This image is bolstered by the fact that, despite its limited financial resources (further constrained by the US embargo or “blockade” depending on which side you are evaluating it from) Cuba has health statistics that are comparable, if not superior, to the USA and other developed countries. Cubans live as long as Americans, fewer of their babies die in their first year of life and they do it all at a tiny fraction of what the US spends on health care. The big questions is – how do they do it?

Since learning about this phenomenon five years ago when I started studying global health, I have been anxious to see firsthand what is actually going on in Cuba when it comes to health care. Fortunately, when President Obama was elected he changed the visitation regulations so that educational groups were allowed to go to Cuba, so I was able to travel with a group of Furman students for two and a half weeks as part of Furman’s Latin America Study Away program. On this trip, unlike Africa, I was not directing but simply one of the “parachute professors” teaching the students on campus in January and April and “parachuting in” to join them in Cuba in March during their two months of travel around Latin America (including Nicaragua, Guatemala and El Salvador).

To say I was excited would be an understatement. We planned for months, attempting to coordinate visits to all three “tiers” of the Cuban health care delivery system including: consultarios (family doctors located in neighborhoods where they are responsible for the all families in the area), polyclinics (the next level up which includes some specialists) and hospitals (where people are referred to from polyclinics if their cases are more complicated). We also scheduled a visit to their medical school where they train doctors from all over the world (for free) who are committed to returning to underserved areas to practice. We learned about their medical internationalism program where they send doctors all over the world to provide health care to those in need. In the end, we managed to coordinate a rich academic program to help us better assess Cuban health care.

Run down buildings

Overall I’d say, some of what I expected to see in Cuba I saw. I expected to see classic cars, buildings from the colonial era, dancing in the street, mojitos, images of Ernest Hemingway and the sounds of the Buena Vista Social Club. On the other hand, there was much I didn’t expect. What I didn’t expect was the warm and welcoming nature of the people in Cuba who, after asking us if we were Canadian and finding out we were American, unilaterally stated that they liked Americans but not our government policies (namely the embargo). I’ve traveled to lots of places and have, at times, encountered hostilities towards Americans. I expected it in Cuba, given the long history of political tensions, but didn’t receive it. I also didn’t expect to see the run down nature of buildings (Sherwin Williams could make a fortune down there as most buildings are in need of a new coat of paint) or the ever present image of Che Guevara – young charismatic revolutionary.

 

 

 

Even more interesting was what we didn’t see – namely images of Fidel or Raul Castro. And academically, what we weren’t allowed to see: namely the inside of a hospital. While I requested a hospital and polyclinic tour, we were denied access to both. We were offered a couple of explanations. One was that, because of the opening of the borders to Americans they simply were receiving too many requests (I don’t buy that one) or that two, they were embarrassed to show us their deteriorating facilities and lack of resources. The latter seems more likely.

So, what are some of the key ingredients of Cuban health care that make it a success?

Close Neighborhood Surveillance

1.     A focus on primary care and prevention – With limited resources, the focus is on preventing illness as opposed to treating it. All doctors are trained as Primary Care Physicians first and the bulk of doctors in the country are not specialists (like in the US) but family doctors who live and work in the local community. By keeping their population healthy, they avoid the very expensive costs of treating people who are seriously sick. Avoiding diabetes, high blood pressure, high cholesterol or maintaining it within reasonable limits, is less expensive then treating it once something disastrous happens.

2.    Close surveillance and monitoring (perhaps some coercion) – With family doctors in each neighborhood responsible for the families in their area, there is close monitoring and surveillance of potential health issues. Our translator, for example, told us that when her sister turned 25 they received a knock on their door from the family doctor reminding her that it was time for a routine PAP smear. In the office of the family doctor we visited, there were carefully up-to-date records of who in the neighborhood suffered from what illnesses (# of case of diabetes, etc.). With this type of close monitoring, few health problems go undetected or untreated.

3.    Providing for basic needs  - By prioritizing education and health care (two things we know produce better health outcomes) and providing basic food rations, Cuba has reduced the amount of abject poverty which is good for overall health. 

Food Ration Store

4.    Reducing Inequality – There is a huge body of academic research that focuses on the relationship between inequality and health outcomes. Basically, the more unequal a society is, the worse their health outcomes; the more equal a society is, the better the health outcomes (some point to Japan as evidence of this – a fairly equal society with the best health outcomes in the world; other use this to at least partially explain why the US, despite the fact that it spends more on health care than anyone else in the world, does not have the best health outcomes). With the government control of just about everything in Cuba, and a goal of producing a rather egalitarian society, some point to the lack of inequality as a reason for better health outcomes.

So, what’s the down side?

1.     Limited resources and supplies – When we were able to visit a doctor’s office and a pharmacy the lack of supplies was very evident. Additionally, other researchers have documented a vibrant black market that has arisen to fill this gap and a strong network of “socios” that provide preferential service to their friends (although we did not have firsthand experience with this). Contributing to this lack of supplies, of course, is the US embargo which, while it allows food stuffs to be exported to Cuba because it would be inhumane not to, they have not made a similar exception for medical supplies (for reasons that I don’t fully understand – why would you allow food for humanitarian reasons but not medical supplies?).

2.    Compromises to patient autonomy – One of the issues my students struggled with the most were allegations of compromises to patient autonomy. While we saw no evidence of this firsthand (we were not allowed to witness any doctor patient relationships ) some of our readings for the program suggested that patients are not always the final decision makers when it comes to their health. Specifically, we read that a pregnant woman with a nonviable or fragile fetus may be told by her doctor to have an abortion. On the one hand, if you have limited resources and your goal is better infant mortality rates, this makes complete sense. Fragile fetuses are quite expensive and often don’t have good health outcomes. On the other hand, this doesn’t leave much control in the hands of the patient.

So are these allegations we read about true? We had mixed responses when we tried to ask. Some doctors responded by saying very clearly that the patient always made the final decision regarding their health. Others indicated that, “Of course the doctor makes the final choice. The doctor knows best.” This paternalism certainly rubbed our individualistic-focused American students a bit wrong. I think the thing that is difficult to assess is how a patient, who has lived their entire life in a society that values the community over the individual, feels about this. Perhaps they don’t question it as much as we would?

Veradero Beach

In short, it was an amazing trip to a beautiful island with breathtaking beaches, temperate climate and warm friendly people. In terms of the question of if Cuban health care is really a “miracle” – I would say in some ways yes. By focusing on prevention and primary care, by perhaps stepping on people’s individual freedoms a bit to produce better health outcomes, and by providing for many of the basic needs that we know produce good health outcomes and reducing the amount of poverty and inequality, I think they have achieved miraculous health outcomes with very limited resources. 

I think we could all learn a few lessons from our scrappy neighbor next store. Prevention is cheaper than treatment. Closely administered primary care can effectively manage disease. Providing for the basic needs of citizens reduces abject poverty. Reducing abject poverty improves health. Investing in health care and education, as basic human rights, produces long term positive outcomes for the entire community.