Urban Renaissance Institute

Lawrence Solomon
National Post
January 18, 2003

The shelves in the neighbourhood pharmacy, like those in the other neighbourhood pharmacies I had seen in Havana, were half empty and full of dust, the small selection of medicines on display arranged in lonely rows of old-fashioned little bottles. Customers were as scarce as the medicines.

One bottle on a shelf contained a fungicide, another aloe ointment. A third countered diarrhea. The odds of finding a specific medicine to treat a particular malady were vanishingly small. “What is this bottle for?” I asked the woman behind the counter. “Memory,” she said. “It’s good for memory and for circulation.”

“Do you have Aspirin,” I asked, wondering if average Cubans could obtain the world’s most familiar pharmaceutical staple. The answer was no. Her pharmacy only stocked drugs manufactured in Cuba and available for purchase in pesos, the currency used by Cuba’s poor. “For Aspirin, you must go there,” she said, pointing to a nearby hotel that housed a pharmacy for customers able to pay in dollars.

The “dollar pharmacy” did indeed have aspirin, along with other pain killers, cough medicines, syringes, Band-Aids, Alka-Seltzer and all the other common medicinal products familiar to Westerners. Its shelves were piled high – literally to the ceiling – with some 500 items, including tampons, disposable diapers, and other drug store items that were more conveniences than necessities. Pesos – the national currency and all that most poor have access to – bought nothing in this government-run establishment. The dollar pharmacy only welcomed dollars, and those who carried them.

Earlier in the day, a Cuban had stopped me on the street, pulled out his asthmatic child’s puffer, and asked for help in getting it refilled. He could not get the drug, he explained, but I, as a tourist, could. Begging for medicines is common in Havana – next to begging for money to feed children, it is the most common plea – because the government won’t use its scarce foreign exchange to import basic drugs that the populace needs. Doctors won’t even prescribe drugs for the poor that aren’t available in the local pharmacies – the state frowns upon that – but many will write the name of the drug that’s needed on a scrap of paper.

“This is what you need,” the doctors will tell desperate patients, in effect sending them out into the streets on a mission of what can amount to life or death for themselves or their children. Cubans with access to dollars – typically those in the tourist industry who receive tips in dollars – can obtain the drugs they need. Others have relatives in the United States who can ship them. The rest – middle class Cubans included – must resort to begging, the black market or, increasingly, to prostitution.

Cuba is renowned for having a universal health-care system and, in fact, doctors are plentiful and doctor visits are free. But without access to antibiotics, insulin, heart drugs and other life-saving medicines, doctors cannot perform their duties. Too often, for lack of medicine, doctors have no choice but to amputate limbs, or to put patients through painful therapies without painkillers. In one celebrated case, Dr. Hilda Molina, the founder of Havana’s International Center for Neurological Restoration, returned the medals that Fidel Castro had awarded her for her work and resigned in protest, outraged that Cubans were denied critical care in order to treat foreigners.

Byron (not his real name) is a 30-year-old doctor in Cuba, a former medical student from Africa who came to Cuba on a Commonwealth country scholarship. Because he speaks fluent English and French, and understands three other European languages, the government assigns him to treating tourists whom, he confirms, lack for nothing in Cuba. The tourist hospitals are excellent, the quality of care delivered to a high standard, as high as any you will find in any Western country, he says. The hospital pharmacies provide whatever drugs tourists require.

Care for top government officials and those in the military is also excellent. “They also lack for nothing,” Byron said. But after providing for the needs of tourists and the top government officials, the health system has little left for the general public. I asked Byron about a man I had seen sitting on the pavement, wrapping raw lesions on his foot with filthy rags. The care with which he was tending his gaping holes made an impression on me, and made me wonder why he lacked proper care.

Byron identified the man’s malady – a disease that slaves had brought to Cuba from Africa 400 years ago – as one easily treated, but not with the medicines available in the peso pharmacies.

“The government doesn’t give a shit about the poor,” he stated matter-of-factly. “The poor have no medicines, no painkillers, no nothing.”

Before Castro seized power in his 1959 Revolution, Cuba had one of the world’s best medical systems, its ratio of one physician per 960 patients ranked 10th by the World Health Organization (England, in contrast, had one physician per 1,200 people, Mexico one physician per 2,400 people). Cuba had Latin America’s lowest infant mortality rate, comparable to Canada’s and better than France’s, Japan’s and Italy’s. Its population was well fed, with a per capita food consumption that was the third highest in Latin America.

Today, Cuba ranks last in Latin American per capita food consumption – cereals and especially meat and milk consumption are down dramatically – but it has not lost its medical capabilities. Instead, Cuba has reoriented its medical system to the task of earning foreign exchange. To do this, Cuba pioneered “health tourism” through agencies such as Servimed, which markets medical services abroad. Cuba is “the ideal destination for your health,” it boasts, frankly admitting to being “a tourist subsystem.”

With an annual growth rate of 20% in health tourism, Servimed has done well in its task of marrying health and tourism. Many Italians now couple their annual vacations to Cuba with their annual dental work, while others come for cut-rate knee replacements or eye surgery. But perhaps Cuba’s most popular medical service, and the one it heavily promotes to tourists abroad, is cosmetic surgery. Cuban doctors have become expert at breast implants, tummy tucks, liposuction and nose jobs, giving some doctors international reputations while letting them serve the Revolution as one of the country’s best earners of foreign exchange.

It’s a “win” for the elite doctors and a “win” for privileged patients, who benefit from what has become the world’s most extreme two-tiered medical system. It’s also a “win” for the Cuban elite, from Castro on down, whom Byron describes as participating in a fitness culture. “When I treat tourists of 75 years of age, I am treating fit people with many healthy years ahead of them,” he said. This is also the case with members of the Cuban elite. “Castro is fit, the others at the top in government, at age 75, are fit. They take care of themselves.

“But an ordinary Cuban of 63 or 64 years is already feeble, an old man.” For the poor, beaten down by the system and denied basic medical care, the medical system is all “lose.”

Related articles by Lawrence Solomon :

Castro’s dupes
Fidel Batista!
Cuba’s cruel joke
Triumph of freedom

Lawrence Solomon
National Post
January 11, 2003

“Can I have your bones?” the old woman asked my eight-year-old daughter, pointing to the gnawed remains of the chicken leg that had been her lunch. Seeing that my daughter was perplexed, the old woman displayed a box of chicken bones that she had collected from other customers at the lunch counter of the department store, a respectable establishment frequented by locals in Old Havana’s main shopping street. My daughter provided the bones after the lunch counter staff gave its consent – the old woman was evidently a regular at the lunch counter, and this was how she earned her supper.

Welcome to Cuba, 44 years into the Revolution that was to industrialize the economy, eradicate hunger and eliminate the gap between rich and poor in this island nation, previously the most prosperous in the Caribbean. Today, the once-muscular Cuban economy is in tatters and its much lauded social safety net a cruel joke. The poor, in reality, are bled to support the lifestyles of the government elite, which lives in luxury – the driveways of the Havana honchos sport Mercedes – while its populace goes hungry.

Some Cubans outside government – increasingly those who obtain patronage positions in the tourist industry, where they receive tips and other payments in U.S. dollars – manage comfortable, if meagre, existences. With dollars, they can shop in the many “dollar” shops, where they can obtain some of the consumer goods, medicines and dairy products that most Cubans, prior to the Revolution, could readily obtain.

The great majority of Cubans, however, are left to fend for themselves in a pitiless system. Most must “do business” to survive, as Cubans put it, because most cannot subsist on the typical wages – the equivalent of about 50 cents a day – that the government sets for them. The old woman at the lunch counter begged for food; other Cubans beg for old clothes or for medicine, or sell peanuts on street corners. Young men sell cigars and other goods in the burgeoning black market; young women sell their bodies in the burgeoning sex trade.

Without dollars, life is grim. People line up at dimly lit government distribution centres, ration books in hand – libretas, the government calls them – for their monthly allocation. The books, which were established in 1962 to “guarantee the equitable distribution of food without privileges for a few,” entitle Cubans to 2.5 kilograms of rice, 1 kilogram of fish, 1/2 kilogram of beans, 14 eggs and sundry other basics at subsidized prices. Through the libreta, each Cuban also gets one bread roll a day. Every two months, a Cuban is entitled to one bar of hand soap and one bar of laundry soap. Fresh fruits and vegetables come infrequently; meat might come once or twice a year. Until the mid-1990s, children under seven were entitled to fresh milk, but fresh milk, like butter, cheese and other dairy products, is now off the shelves. Before the revolution, two litres of fresh milk cost 15 U.S. cents, well within the means of the poor.

Cuba, a country with a coffee culture, produces fine beans in its Oriente province, but not for average Cubans. The good stuff is sold to tourists and exported to earn dollars, or reserved for the Cuban elite, while the government imports cheaper beans, grinds them, mixes them with ground chickpeas, and doles out 28 grams per month – less than one ounce – to Cuban citizens. The government also exports high quality Cuban rice for dollars while importing a low-grade rice from Vietnam for its citizens. It exports 90% of its fresh fruits, directing much of the rest to tourists and others who can pay in dollars.

Nowhere in the world does the Almighty Buck more separate the haves from the have-nots. The Cuban government has adopted the U.S. dollar as an official currency that co-exists along with the peso and cleverly keeps the poor in their place. The multinationals operating in the country – Cuba now courts them to earn dollars – are forbidden to pay their Cuban workers directly in dollars. Instead, they must turn over the workers’ wages to a government agency which pockets most of the money and gives the workers a pittance in pesos. Cuba’s communists have perfected the Double Currency Standard, and the double standard: One currency for the rich, another for the poor, and the rich determine the means of exchange.

Cuba’s poor are also squeezed in the other necessities of life. Even in central Havana, people commonly carry water by bucket from standpipes in the street to their homes, and then lift the buckets by rope to the higher floors, because their buildings’ broken water pipes go unrepaired. Those lucky enough to have working water pipes can get water at the tap – but only at certain times. In one dense urban neighbourhood that I visited, the water flowed from 7 p.m. to 10 p.m., during which time families scrambled to fill pots and pans inside their homes for drinking water, and former oil drums outside their homes for washing. About the time that the water came on, the electricity went off – it, too, is rationed by daily blackouts.

In buildings where one or two families might have once lived, today live many. The inner courtyards of Cuba’s residences have become miniature shanty towns, cinder block housing units or other improvisations piled on top of one another. The units – often two small rooms totalling 200 square feet – can house an extended family of seven, 10 or even 12. The rooms are often windowless or near-windowless, the ceilings low and oppressive. Among these buildings packed with people lie many identical buildings, but appropriated for government use. In the space that might house 50 or 100 people will sit one government functionary, bored and idle at a desk, the premises otherwise near-empty.

“For the first time in the history of our country, both the state and the government left aside the rich side and joined the poor side,” Fidel Castro proclaimed after assuming power in 1959. Forty-four years after the Revolution, the poor side are talking of another revolution, in which the government will do much, much more for its people by doing much, much less.

Related articles by Lawrence Solomon :

Castro’s dupes
Fidel Batista!
Triumph of freedom