Posted Friday, May 1, 1998, at 3:30 AM ET
A joke making the rounds in Cuba:
Q: What are the three greatest accomplishments of Fidel's revolution?
A: Health, education, and sports.
Q: What are the three greatest failures of Fidel's revolution?
A: Breakfast, lunch, and dinner.
On a recent trip to Cuba, I walked through Havana's crumbling neighborhoods to the Hospital Nacional Hermanos Ameijeiras. I found myself in a modern lobby with the size and feel of a new airport terminal and, with my feeble Spanish, talked my way into meeting some fellow surgeons. I asked them to show me around. I was interested, I said, in what they could do. But what I really wanted to see was what they couldn't do--and why.
For 36 years, the United States has resolutely tightened the screws on trade with Cuba in an effort to topple Castro's regime. However, in the weeks since the pope spoke in Havana against the U.S. embargo, the pressure seems to have lessened. Not long after the papal visit, Clinton allowed humanitarian flights and the sending of money to Cuban relatives. Congressional legislation to end bans on the sale of food and medical supplies is gathering bipartisan support, and a Senate vote is expected this spring. Embargo defenders, however, say the harm is more rhetorical than real. Cuba can get supplies elsewhere, they argue, and trading with a dictator is immoral. Here I had a chance to see the effects for myself.
The hospital, one of Havana's best, was impressive. It has 900 beds and 39 specialties and offers the services of a top U.S. hospital. Its surgeons perform microsurgery, neurosurgery, and organ transplants. And ordinary Cubans seem to have no trouble getting access to this care. Later on my trip, for example, I met a woman who had no special connections but had been sent here after she developed frightening stomach pains. One gets a sense of the priorities in Cuba: A teacher who couldn't put meat on her table (what little she finds she gives to her son) was able to obtain a full medical work-up including endoscopy and biopsy of her stomach. A parasite from the drinking water had invaded her stomach lining.
Still, for all the resources Castro provides, the system founders from an unreliable supply of materials. Dr. Nilo Rodriguez, a cardiac surgeon, told me, "We can do any kind of surgery, but not always."
Rodriguez appeared to be in his 50s. His office was spacious, but his bookshelf was bare except for a single textbook (American), a few patient files, and some knickknacks. Like the other doctors I met, he was quick to brag about his high-tech accomplishments. He described the heart transplants and complicated valve replacements he performed. But I wondered how he, a surgeon, could spend an hour meeting with me at the spur of the moment. He admitted that, for all he was capable of doing, he operated on only five patients per week.
Was the problem getting time in busy operating rooms? No. Rooms were free as we spoke. Was it a lack of patients? He laughed and said that he had over a hundred patients with failing hearts in the hospital awaiting surgery. The problem was the constant struggle for supplies. Yes, they were costly, but that wasn't the biggest issue. Even if Cubans lacked for meat, Rodriguez would have money for ventilators and heart valves. The problem, he said, was the embargo.
Cardiac surgery, like every surgery, is a series of interlocking steps, each requiring specialized materials. You need anesthetic agents, IV tubing, blades for the bone saw, and so on. Every week, Rodriguez must halt surgery because he can't get one or another material through the embargo. Among the sickest patients waiting were some 12 who needed new heart valves. He had been able to get some Chinese-made replacement valves. They are not that reliable, he told me, but they get the job done. Sometimes he can get American valves sold illegally through third parties at inflated prices. "Your CarboMedics valve," he said, his eyes shining, "is beautiful." That week, however, he didn't have the suture he needed to sew in the valves. And a lack of perfusion fluid to prime the heart bypass machine had held up all his operations.
Rodriguez was reluctant to admit anyone would die waiting. We are strong people, he told me. But "maybe sometimes" it happens.
Once home, I learned the United States cuts off supplies in two ways. First, sale of goods with U.S.-made or patented parts--which include most new drugs and medical devices--is embargoed under the Trading With the Enemy Act. As U.S. companies merge with foreign competitors, the ban covers more and more. For example, according to the Washington Post, U.S. acquisitions removed Cuba's suppliers for pacemakers and several chemotherapy agents. Companies can seek a permit for medical sales, but hardly any have because of the unmanageable requirements.
Second, the 1992 Torricelli Act cut European supplies by prohibiting ships that dock in Cuba from entering U.S. ports for six months. Few shippers are willing to lose access to the world's largest market for the sake of this tiny country. The act also outlawed food sales to Cuba. Only Libya faces a similar ban. (Iraq and North Korea can at least barter for food.)
It's disingenuous to argue that the embargo doesn't actually hurt many people. After all, the point of the ever-tighter provisions is to cut off goods--including food and medicine. But imposing suffering can be justified if it averts greater suffering or serves a larger good. And the embargo once served worthwhile purposes--forcing the Soviet Union to spend resources propping up Castro and denying Cuba resources to foment revolution elsewhere. Now, however, Cuba poses no threat to anyone.
It's conceivable we could justify continuing to cause pain and death if the embargo fueled enough discontent to cause Castro's overthrow. But it shows no sign of doing so. The relationship between political freedom and economic conditions seems far more complicated than advocates of free trade or the embargo seem willing to admit. I doubt that either policy can bring Castro down. Meanwhile the embargo continues to exact its human costs.
The names of patients waiting for surgery at Rodriguez's hospital are kept on a computerized list. The sickest patients are at the top. When supplies are obtained, they get surgery first. On a walk through the hospital, Rodriguez was unwilling to take me to the intensive care unit to see these patients. He claimed he was too busy, and by the end of our conversation, he had grown reticent. At one point he admitted that he feared he had said too much, that I could use the information to write anti-Cuban propaganda. He steered me to a young woman with a new valve and a vigorous man recovering from a heart transplant. We finished walking the wards and shook hands as medical colleagues. Then we parted ways, the list of the sick scrolling through my head.
Atul Gawande, M.D., writes a regular column on science and policy for Slate.Article URL: http://www.slate.com/id/2674/
No comments:
Post a Comment