From Havana with love: A day in the life of a Cuban doctor in a county hospital

When Aselerera Korea, a family physician from Cuba, arrives at the Mandera County Referral Hospital at 8am, there are 15 patients in line waiting for him.

Taken aback, he greets them and apologises for being late. In the consultation room is a mother and her child, one of more than 20 that he treats every day.

As he puts on his white coat and fishes out his notebook, he makes faces at the baby, who hides her face in her mother’s lap. Then, gradually, she giggles, laughs and starts to play with him.

“I’m sorry to have kept you waiting; did you wait for long?” Dr Korea asks the mother, who doesn’t respond.

“Who is sick? You or the baby?” he tries again, and again no response. Instead, the room is engulfed by awkward silence, which he breaks with a sigh and calls out for a translator. Fifteen minutes later, the mother and child are sent for an x-ray.

TREATMENT

In Nyamira County, Edy Cordero Suco, a cardiologist, enters the office of the medical superintendent, clutching a notebook. These are not his medical notes, but the place where he notes down words in Ekegusii. He wants to learn the language and communicate with his patients more smoothly.

At the door, Dr Suco and the head nurse joke about his communication challenges, which his Kenyan colleagues help with by stepping in to translate.

Dr Suco is accompanied by his compatriot, family physician Yunia Puebla Ricardo. They are on their way home from work, but are passing by Dr Sam Ombati’s office, to check on the progress of the house the county is constructing for them, so that they can move out of Borabu Hotel, where they are currently housed.

With dramatic gestures and explanation, Dr Ombati assures them that he is doing everything in his power to have the houses ready.

As the Cubans leave his office, screams from the hospital’s reception rend the air. A woman just brought in her unconscious son, who is also in shock (lack of oxygen in the body’s vital organs) and dropped him into the arms of a nurse.

The nurse takes the boy to the adjacent emergency theatre and a crowd gathers outside the entrance, trading hushed opinions about the wailing mother.

Dr Suco, Dr Ricardo and two Kenyan health workers rush into the theatre, and the door is shut, locking out prying eyes.

“Hao wazungu hawataacha mtoto wake akufe tu hivyo … ukiona ameenda, ni vile walikuwa wamejaribu ikakataa kabisa(The white doctors will not let the child die; if he dies they must have tried their very best and failed),” says one bystander.

She echoes an observation in many of the counties visited, where patients preferred being treated by the Cubans rather than by their Kenyan counterparts.

In Mandera County, Adan Mohamed Adan, a patient who described local health workers as lazy, toldHealthy Nationthat he travelled from Takaba, 300 kilometres away, just to be treated by Hassel Herrera (general physician) or Landy Rodriguez (surgeon), the “white doctors” at the Mandera County Referral Hospital.

At the hospital, after their bodyguard left them to their work, consultation looked like something out of a miming class as doctor and patient strove to understand each other. Amidst the gestures, medical notes were taken and a prescription filled.

“They pay attention to what you say,” Mr Adan explained his preference.

In Migori County, patients say that kidney expert Pedro Machural and family doctor Norys Calzada do not allow patients to “jump the queue.”

“They treat everybody equally and they believe all patients deserve quality attention,” said George Owino, a patient.

RESISTANCE

Similar sentiments were echoed in Tana River County, where patients who “know someone” in the hospital or who have more money are attended to faster and given better treatment than other patients.

It is not clear whether the doctors’ popularity is from sheer curiosity or the fact that the doctors seem present whenever the patients need them, but they seem to have earned the public’s trust and confidence.

Yet, just four months ago, before the Cubans came into the country, there was controversy over their coming to offer specialised services following a bilateral agreement between Kenya and Cuba, that first came to light in 2017.

Just before that, the Ministry of Health had announced a plan to import doctors from Tanzania to solve an acute shortage of health workers, but that announcement was met with a lot of resistance and the plan was shelved.

When the government revived the agenda of importing doctors, this time from Cuba, after signing a deal with the Cuban government in April, and a memorandum of understanding with the Council of Governors in May, the plan was still met with resistance, up to the very final stretches when a court case sought to have the Cuban medics barred from practising in Kenya.

Local doctors argued that they had not been consulted, that the process to hire them was not competitive and that Kenya did not have a shortage of specialist doctors to warrant importing them from Cuba.

The presiding judge dismissed the case, saying that the applicants had not proved that local doctors had the same skills as the Cuban medics; he added that young specialists were not willing to work upcountry, where the Cubans would be posted.

FAMILY DOCTORS

Oblivious to the bickering around their presence, months after they were deployed to the counties, the Cubans celebrate little medical victories in their WhatsApp group where they occasionally seek second opinions from each other.

This is not the first time they have worked overseas, something they have been prepared for since graduation from medical school back home.

Global health diplomacy expert Julie Feinsilver, who has written extensively on Cuba’s health internationalism, wrote in her paper50 Years of Cuba’s Medical Diplomacythat health occupies a powerful position in government policies in Cuba.

In 1961, the people’s Health Commission placed people at the heart of healthcare and in 1975, “health as a basic right” became a tenet on which Cubans judged the efficacy of their government.

Monitoring what could be maximised for the country’s benefit, Cuba began training family doctors in large numbers, and by 2001, there were 58 family doctors for every 10,000 Cubans, far above the 28 and 16 for every 10,000 people in the United Kingdom and the United States respectively, countries which are richer. In Kenya, the rate is 1.5 doctors per 10,000 people.

By 2008, there were 185,000 Cuban doctors serving in more than 103 countries, with 1,034 working in African countries, including The Gambia, Angola, Botswana, Zimbabwe and Ivory Coast, according to data from the WHO.

In June 2018, Kenya got 53 family doctors and 47 specialists, who included cardiologists, nephrologists (kidney), radiologists, plastic and reconstructive surgeons, orthopaedic surgeons, trauma specialists, general surgeons, neurologists, urologists, neurosurgeons, anaesthetists, endocrinologists (hormones) a maxillofacial surgeon, dermatologist (skin), ophthalmologist (eye) and gastroenterologist.

Each county got at least two specialists, a boon for regions like Mandera, Vihiga, Marsabit and Wajir, which had no single specialist before the Cubans were posted there.

QUALITY CARE

Besides serving patients, the Ministry of Health said that the Cuban healthcare workers would also train local doctors to offer the same kind of quality care available in their country.

In Cuba, family doctors occupy the first layer of healthcare, which also comprises nurses, all charged with providing basic healthcare. These doctors work in neighbourhoods, making house calls, especially to the elderly and children and other patients who may have mobility challenges.

In this first level of healthcare are also gynaecologists, paediatricians and other specialist healthcare workers — called a group health team — who provide comprehensive and holistic treatment.

On the second level are more specialised health workers who provide care in health facilities, and refer patients to the third level of care for highly advanced investigations and treatment if necessary.

After working in this system for more than a decade, family doctor Yunia Puebla Ricardo, who is based in Nyamira, wants to replicate the primary care system from her homeland by splitting her time to spend more of it in the villages. The county has agreed to support her to make visits to smaller health facilities and villages.

“We need to spend more time educating the people to prevent the diseases that I am seeing here,” she toldHealthy Nation.

At her station in the county referral hospital, she has also requested for a bench for mothers with children to sit on and a water dispenser for the patients, and the county is responsive to her requests.

Her colleague, Edy Cordero Suco, a cardiologist, has practised medicine for two decades in Cuba and abroad, and notes that the risk factors for the chronic diseases he has seen so far are similar to what he has seen in Cuba and other countries. He also emphasises the need for preventive healthcare.

“An educated population can ease the pressure on primary healthcare. We can win the war against chronic diseases with more awareness,” he toldHealthy Nation.

In Busia, family physician David Rodrigues and kidney expert Sorangel offered to report to duty before 10am, when their specialist clinics begin to do some ward rounds and shoulder some of the work load of their Kenyan colleagues who step in to translate when they battle communication challenges.

And in turn, the counties have not spared anything for the Cubans.

In Nyamira, where the County Executive for Health Douglas Bosire, said, “we want them to be comfortable,” in reference to the Cuban doctors, the county shoulders the costs of taking the doctors to the neighbouring Kisii and Kisumu counties to “show them around so they can enjoy the beauty of our country.”

While Kenya bends over backward to make the Cuban medics comfortable, observations in 15 counties showed that there are no formal plans in place to ensure that once the Cubans leave after two years, they will have transferred the skills and knowledge that makes them sought after to local health workers. At least not just yet.

Additional reporting by Elizabeth Ojina, Ruth Mbula, Elisha Otieno, Benson Amadala, Gaitano Pessa, Derick Luvega, Fadhili Fredrick, Stephen Oduor, Manase Otsialo, Angela Oketch, Irene Mwendwa and Lucy Mkanyika

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Is Cuba the answer to Kenya's health worker shortage?

Kenya has a shortage of 42,800 health workers. There are 63,000 health workers, including 20,981 nurses, 3,284 clinical officers, 2,286 medical officers, 405 dentists, 1,104 pharmacists, 293 radiologists and 22 radiation protection workers.

To meet the World Health Organisation recommendation for 23 workers for every 10,000 people, Kenya would need 105,800 health workers.

Previously, health Cabinet Secretary Sicily Kariuki said that addressing the health workforce gap would require “scaling up recruitment, reviewing health workers’ salaries and benefits and strengthening human resource policies and practices.”

Healthcare worker challenges are particularly prevalent in the counties, with the Kenya Healthcare Workforce Report noting that five counties held more than half of healthcare workers in Kenya, as the rest struggled to attract and retain medical officers and specialists.

Nairobi has 9.5 doctors per 10,000, followed by Machakos, Mombasa, Kiambu, and Uasin Gishu. Counties like Turkana, Mandera, Garissa and others suffered chronic doctor shortage, having less than one doctor for every 10,000 people.

Harsh working conditions, especially in arid counties, have been blamed for the shortage of medics in some areas, and the government has done little to allay local doctors’ fears on security, hardships and to help them adjust to their new environments.

To solve the issue of healthcare worker shortage, the Ministry of Health had proposed deployment of medics from Nairobi to serve far-flung counties such as Lamu and Tana River and Mandera that were unable to attract and retain medics.

In a rare display of concern for its doctors, the Turkana County government would pay rent, meals and transport for newly deployed doctors, making them the envy of their colleagues, who had been left to their own devices in other regions.

When the doctors in Turkana participated in the national doctors’ strike, the county withdrew the relocation support services.

The persistent shortage of doctors, and especially specialists, in the counties, is what informed the government’s decision to bring in Cubans to plug the deficit. Each county was to get at least two doctors from Cuba, depending on their needs, in what was meant to improve access to specialist medical services and reduce dependence on the few referral hospitals in the country.

The Cuban doctors are also expected to train health workers in Level 4 and 5 county hospitals, and 50 Kenyan doctors — at least one from each county — are to receive specialist training in family medicine in Cuba, as part of the deal between Kenya and Havana.

Starting with a two-week induction programme on the Kenyan health system and local heritage, when they arrived in the country in June, the government promised the Cubans all the support they would need to discharge their duties without difficulty.

The counties provide the doctors with accommodation, security and transport while the national government caters for their salaries and airfare to and from Cuba during their 30-day annual leave.

Benjamin Tsofa, a health policy and systems expert based at KEMRI Wellcome Trust, has studied health systems, including contractual agreements such as Cuba’s. Dr Tsofa says that in such cases, countries judge that it would not be cheaper to have medics trained elsewhere to run the country’s healthcare.

In that case, the country does the math to answer questions like “Is this cheaper and value for money in the long term?” “Is this the range of medical expertise that we need?”

— Verah Okeyo