By Dr. Babette BeckerPsychotherapist, Geriatric Care Manager, Writer
I visited Cuba for 18 days to learn about the physical and mental health care and the response to the social and familial needs of the elderly. As a practicing psychotherapist and geriatric care manager in New York City, this trip was to be a preliminary attempt to see what I could learn, with whom I might be able to talk, and what sites I would be given permission to visit.
I put together a list of questions that I hoped would be flexible enough to include the range of health care professionals I wanted to interview and/or the sites I hoped to visit. My next task was to find out whom I had to see to secure the permission(s). Once I started interviewing, I revised my list of questions a few times to more appropriately reflect the Cuban health care system as I learned more about it.
My questions were as follows:
1. What is the overall design of the health care system?
a. Physical health
b. Mental health
c. Psychosocial and familial health
2. Does it differ from one province to another; between cities?
a. How do the various styles and extent of care differ between cities, towns, rural area?
b. Is it harder to find good care in the towns and rural areas than in the cities?
3. What is available in the community or from hospitals for elderly who are homebound?
a. Are there different agencies that deliver different forms of care and services to the homebound?
b. What part do family members play in the care and services of their elders?
4. Are there costs for medicines, x-rays/MRIs, various tests/scans and procedures for elderly living in the community who are receiving services and care? Are there costs for these things for persons who are hospitalized?
5. Is there any equivalent in Cuba of a Geriatric Care Manager or Consultant?
6. What is the response to alcoholism, drug/medicine abuse, abandoned/abused elderly, malnourished elderly, depression and other mental health issues?
7. Are there senior centers? What part do they play in the lives of elders?
8. Is there any equivalent to Assisted Living Facilities? Are there nursing homes? Who can go there? What is the admission system?
9. What is the prevalence of Alzheimers in Cuba, and where and how are they cared for?
After my first couple of interviews with professionals in the community, learned that the model of health care and delivery is replicated throughout every province regardless of whether the area is rural or urban, and that I would learn what I needed to know about the broader model of health care in Cuba by concentrating in Havana alone. Havana is very large and spread-out, with several “boroughs” or neighborhoods (La Lira, Playa, Miramar, Buena Vista, Vedado, Centro, Habana Vieja, San Miguel de Padron, Guanabacao, Cerro, Santo Suarez to name a few), and each of these neighborhoods has its own distinct characteristics and population distribution. It wasn’t clear that I would be able to receive permission to visit the facilities during this visit, so I decided to concentrate my research with professionals in community health care.
Even though many professionals were only at specific sites a few days or hours per week, were busy with appointments, or had to take care of numerous crises that arose, I was able to interview five doctors, four psychologists, four social workers and four nurses who worked in the community settings. They were all either members of community teams that I visited in Consultorios, or attached to Casas de los Abuelos (equivalent to Senior Centers). Some of the health care professionals worked in a setting called El Centro Rehabilitación Geriatrico, which is the only large community facility that is specifically for the elderly in Cuba. It has its own physician specialists, occupational and physical therapy, pharmacy, psychologists and social workers.
People in all the sites greeted me warmly once I introduced myself as a fellow practitioner. The professionals were eager to share findings, types of approaches, special issues and common problems. I spent time in several Casas de los Abuelos and in some I joined their programs. I talked with several elderly persons attending the different Casas.
While my spoken Spanish is good, my understanding is less fluent. No one spoke English with the exception of a couple of the elderly who had either been in the United States or who worked with people from the United States before the Revolution. They were very excited to have the opportunity to speak with me, either to explain things they thought I might not understand, or just to practice English. Mariana, from the Casa de los Abuelos, “La Felicidad,” gave me a large and very old picture of Mariana Grajales, an important woman in the Revolution, with the caption, “Madre de la Patria,” that was published in one of the newspapers, probably 60 years ago. She explained that she too had worked for a radio station, was quite vocal and a fighter for the Revolution as well. She obviously admired Grajales and kept that photograph for many years. She also told me stories of her days as a singer and composer of national anthems for the children to learn. The article was pasted on a piece of red cardboard, and on the other side she wrote a long note telling me about her own university degrees, her work in radio, and about her son who is a Babalao (a high counselor/priest in Santeria). She gave me her home address and said she hoped that I would visit.
Many persons in the Casas were eager to tell me how many relatives they had, or other people they knew in the United States. I was treated like a celebrity and urged to participate in their programs. I led some movement and exercise classes in two Casas. In another one I gave each person in the group three minutes to tell the group something about themselves that they felt was important to share. They all seemed to enjoy the classes. In fact, they all seem to enjoy participating in the activities, which varied a lot depending upon the number attending and the general health and abilities of the members.
In Cuba, probably close to 90% of the elderly live with or close to their families. In fact, if there is any family at all, the family members must be responsible for and take care of their elderly. Despite this, there are certainly feelings of loneliness, depression, abandonment and uselessness, even with close family ties and frequently shared living quarters. While Cuban culture tends to respect the elderly more than they are in the United States, they also find themselves in the middle of all the issues and problems that are going on within the family.
The Model and Construction of Health Care in Cuba
The Cuban health care model is a public health/holistic one. In other words, health care includes the whole person; the physiological, psychological, emotional, social (including family relationships), and environmental aspects of the person. The services are distributed in a public health triage model. If ten people are waiting to be served, rather than be seen on a first-come-first-serve basis, they are taken in the order of need.
The first stop for the elderly is to participate in a Casa de los Abuelos in their community. Of course not everyone does – some are too sick, some too occupied with more active lives. The Casas’ function is primarily to provide a social setting so that elders who so often feel isolated can meet others and share activities. They are given breakfast, a midday snack, and lunch. They often have some kind of arts and crafts, story-telling, book sharing, and some level of exercise. The actual activities during the course of the day depend very much on the number of attendees, the range of their interests and the health of the attendees. Many of the directors social workers or nurses. Whether they are or not, they have a social worker, nurse and/or psychologist visit a couple days per week to deal with various individual, marital or family issues that come up. If the director or visiting professional thinks there is any abuse, depression or alcoholism in the family, he/she can call the family in for a consultation. If someone clearly has a medical or mental health problem the director can suggest that they be seen by the community team. The Casas, in essence, are a kind of watch-dog organization, in addition to providing a social setting for the elderly. The Casas are open five days per week from 8:00am to 6:00pm.
The first level for medical, nursing or on-going psychological care in the community is the Consultorio, which is the home base of the community team. The team is composed of doctors – generalists and some specialists - nurses, psychologists and social workers who live in their working community. The Consultorio teams each serve a population of anywhere from 600 to 900 people of all ages who live in that community. People can go to the Consultorio, or to any one of the team any time. A member of the team can see someone in their home if for any reason the person is unable to leave, such as the homebound elderly. The Consultorios keep all their patients’ medical records. They also have a proactive approach to helping people make lifestyle changes, such as, smoking cessation, diet, sanitation issues, post-partum care.
There are also dental clinics throughout the city; some of them specialize or have special units, such as children’s dentistry.
The second level for certain types of care or a referral from the community team is the Policlinicos. Each Policlinico can serve up to 6000 patients and is the next level support for 9 to11 Consultorios. The Policlinicos have a full range of medical/psycho/social staff, often with separate divisions for children, maternity, oncology, geriatrics, and other specialties. They also provide emergency care and will stabilize a patient for transport to a hospital. They do have a few beds for patients to stay overnight if they need to provide a higher level of care for someone who does not need hospitalization but is not quite ready to go home.
Elders from anywhere in Cuba can be referred to El Centro Rehabilitacion Geriatrico for more extensive care. The people who go to this rehab center must have a prescription from their community doctor, or team professional, for a specific health-related reason. The mornings I was at the center when it opened there were at least 25-30 people waiting. Within the first half hour there were another 15-20 elderly with prescriptions for appointments. The head nurse was amazing. She not only had each person’s name down and which service or doctor each was to see, but she got them all playing various verbal/circle games, talking to each other, telling jokes to keep things organized, and keep the folks from getting edgy/feeling pain/angry, while they were waiting. Waiting is a big part of all services in Cuba.
Doctors in the United States tend to prescribe a plethora of tests, scans, and procedures, as well as too often over-prescribing medications. In fact, doctors often do not ask what other medications a person is taking, and too many elderly are given prescriptions that are counter-indicated with other drugs they have already been prescribed. Because of the scarcity of new modern equipment and the perpetual scarcity of prescription drugs in Cuba, doctors have to be very cautious as to what they prescribe. Elderly can get drugs without cost if they are in the hospital, but as soon as they are discharged, they are responsible for purchasing their prescriptions. There are also frequently two levels of medications, one far more effective than the other and can only be bought (for a higher price) in the international pharmacies. The international pharmacies do not take Cuban pesos -- the salary payment form for Cubans – they only take CUCs – the exchange currency for tourists and people living in Cuba from other countries. Some of these medications are made in the USA, but due to the embargo have to be sent to another country before they can be sent to Cuba causing the purchase price to be much higher than it would be if they could be purchased directly from the USA.
The third level is the hospitals, which both specialize, (e.g. the maternity hospital, children’s hospital) or have divisions like any hospital here. There are hospice areas in the hospitals, but Cuba has no type of advance directives, living wills, or health care proxies. They believe that the family and the attending doctor should make any terminal decisions, based on the wishes of the patient. Medications are free during a stay in the hospital, but cost once back in the community.
Families must play a major part in the care of their family members. As one becomes more dependent, or is homebound, it is up to the family to provide food, personal care, help with activities of daily living, and all care within the home. If the elderly family member can get out at all, however difficult, they must be brought by a family member to whatever service the person needs.
In Cuba, poor living conditions are rampant. It is not unusual to see several family members of different generations living together, often in very small apartments. The elders very often live with one of their children and his/her spouse, grandkids and even great grandkids. In the apartment building where I rent an apartment when I am in Cuba -- a third floor walkup with very high ceilings -- there are two couples on my floor that are well into their 80s who climb the stairs several times daily.
The Functional Ability of Health Care in Cuba
The public health care model, built on a triage system, works amazingly well. It is built on careful planning, real attention to the broadest definition of health care of the Cuban population. It is a holistic concept in which the biopsychosocial is intrinsically welded together at each level of care. Although virtually all the hospitals and health related buildings are in need of repair and paint, and the doctors and technicians are often working with older equipment, everyone eventually gets seen. Waiting time, sometimes many hours, is expected. El Centro de Rehabilitacion Geriatrico serves 80-150 people daily. The model emphasizes preventive care and an aggressive approach to treatment.
In answer to my last question, while I saw a wide spectrum of elderly care needs, I saw few persons with dementia or suffering from mid-to more severe level Alzheimer’s. When I asked at the different health care sites, I was told they are mostly homebound or in some of the hospitals, but that for some unknown reason, Holguin, a city toward the Eastern End of the country, has statistically the largest percentage of Alzheimer’s patients in Cuba. Holguin is also the center for all the Alzheimer’s research.
The medical educational system is excellent. Once Cuban students have finished their education, whether in medicine, dentistry, nursing or any of the technical lab fields they all are required to practice medicine in the “Interior” – in small towns or rural areas – for a minimum of two years. There is considerable medical and biological research being conducted in Cuba.
I thoroughly enjoyed the time I spent with all the people in all the sites I visited. I found everyone informed, eager to share and exchange information, and amazingly available given their rigorous daily schedules. I found the elders in the Casas delightful and eager to talk and participate with me. On my next visit, I will continue my study of the health and medical care of the elderly in facilities–and since I did not get the chance to visit the policlinics and couldn’t visit the hospitals or Hogares Ancianos (similar to nursing homes, but with very different entrance and stay requirements), without a permission letter, I will be certain to arrange to receive it before I return to continue my study
List of the Casas de los Abuelos in La Habana
Abel Santa Maria, 240 y 247 Avenida Santa Maria 645-3595
Celia Sanchez, Lindero #25, Cojiman 766-0818
Corazones Alegres, Calle C #2505, Altihabana 643-0303
Guanabacoa, I. Clementa, y Catt V. Maria D’Beche 797-4142
La Felicidad, San Rafael #415 Centro Habana 862-4941
Gracias a la Visa, Paz #74, Tamarindo 640-0193
Los Caguaranes, Calle182 #37911, Mulgoba 683-9673
Playa, Avenida 19 #7012, Playa 202-1830
Playa, Avenida 11 #700, Vedado 830-8079
San Augustin 232 y Avenida 35A, San Augustin 831-3592, 265-8846
Santa Maria, 36 y 101 Santa Maria del Rosario 682-7014
Solde Oraño, Consulado #24, Centro Habana 863-2477
Tamaro Bunke, M. Gomez #57, Vieja Habana 862-1217
14 de junio,Merced #213, Vieja Habana 862-8264
15 y 18 Calle 13 #1958, Vedado 830-2525
El Centro Rehabilitación Geriatrico, Oficio #280 e/ Muralla y Sol, Vieja Habana 062-4578
List of Hogares Ancienos (equivalent to Nursing Homes) in La Habana
Adorattices de la Preciosa Sangre, Calzada de Cerro #1357, Cerro 870-5246, 879-1991
Alfredo Gomez Gendra, Avenida de Bolivar #409, Centro Habana 862-7095
Bautista Toro de Gómez, Fro de junio #14114, Obrero 698-5190
Celia Sánchez, S. Gil y Angela, Célimar 765-6276
Chung Wah, Beltran #19320 691-0350
Complego Atención al Adulto Mayor, Avenida 39A #4408, Playa 203-5324 203-5356
Christiano Matodita Calle 58 #4306, Playa 209-1765
General Francisco Peraza, Augustina y San Miguel, Vedado 641-1020
José M. Lazo de la Vega, Avenida 51 #22022, La Lisa 271-5979
Madres Teresa Jamel, Calzada de Cerro #1357, Cerro 878-5963
Maria Imaculada, Calzada de Cerro #1239, Cerro 870-3190
Nacional Masonico Llasó, Calzada de Bejucal Km 9, A Narajo 644-1732
Para Empezar a Vivir Calle 284 y Avenida 5ta, Santa Fé 209-7220
San Francisco de Paula, M. Rodriguez y Espadero, 640-9463
San José, Carr de Guanabo y C de Berroa, Santa Fé 797-7111
Santa Susana, Fca La Magnolia #130, Rincon 683-3300
Santavenia, Calzada del Cerro #1424, Cerro 870-6449. 879-6072
Sierras de San José, Calle 12 #102, Playa 209-3409
Williams Booth Calle 84 #5525, Mnao 267-1328, 260-1118
13 de Marzo, Versales y C. Garcia, Guanabacoa 797-9518
24 de Febrero Calzada 10 de Octubre #429, Lux 641-5277
28 de Enero Avenida C Cienfuegas #575, Lawton 696-7145, 696-7478
Ancianos, Avenida 31 y Maricano 265-1452
Benjamin Moreno, Avenida 51 #7405, Marinao 260-9781, 267-1146
Benjamin Moreno, Avenida 51 y 78 265-1463
Discapacitsdos, Santa Catalina #720, Vlb 648-7378
Impedidos Fisicos, Avenida 11 #609, Playa 203-1252, 203-1257
La Castellana, Calzada 10 de Octubre y Rivera A. Apolo 643-8274, 643-8742
Pequito Gonzalez Cuero, Avenida 51 #11202, Mnao 267-1132, 267-1551
Victoria de Laredo, Santa Catalina #720 Jibora 648-7379
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