Report by the Fundación Amistad Delegation
to Cuba on the Current Status of Women and Children
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Table of Contents
Message from President of Fundación Amistad
Delegation Participants’ List
Education/Child Care in Cuba
Pediatric Health and Adolescent Mental Health
Non-Governmental Organizations (NGO’s)
Status of Women
Next Steps for Fundación Amistad
People And Places in Cuba
Mission Statement of Fundación Amistad
The Fundación Amistad is a 501 (C) (3) corporation established to arrange exhibits, seminars, and conferences designed to increase U.S. persons’ awareness of Cuban history, culture and society and to coordinate ways to improve life in Cuba.
Its president and founder, Maria de Lourdes Duke (Luly), a Cuban American. She is also Vice President of The Harbor for Boys and Girls, a sixty year old nonprofit in New York City that provides education and counseling services to inner-city children and young people. [ top ]
Message from the President of Fundación Amistad
In my role as President of Fundación Amistad, and as an officer, supporter and long time consultant with The Harbor for Boys and Girls of East Harlem, it was extremely interesting for me to see first-hand the services in Cuba offered to women and children. And it was of great personal satisfaction to bring together an outstanding group of individuals, eight women and one man, to add their own professional opinions and expertise to the visit.
The delegation had three main purposes:
The delegation to Cuba, March 8-15, l998, began an assessment of the condition of a representative sample of Cuban women and children, in the areas of health care, social services, women’s studies programs, and education.
Education and the mental health needs of children and adolescents was also a target priority. In addition the delegation devoted special attention to the issues of infant and child health care, reproductive and prevention services, vaccination programs for childhood diseases, average daily diet and national nutrition needs for children and pregnant women.
Our timing was intended to occur after the historic visit of the Pope, to see if the enormous press coverage and actual changes brought about in Cuba for his visit would provide more lasting and substantive changes in the way of humanitarian concerns.
Throughout our visit, we observed Cuban pride, its sense of its own rich cultural history, and a deep concern for women and children. But the absence or lack of up-to-date equipment and supplies struck us all as being both a problem for and a detractor to efficient handling of the needs of so many women and children of Cuba. Despite the remarkable emphasis of the Cuban government on the needs of young children, the lack of supplies hinders the philosophy greatly.
The children themselves were alert and displayed all kinds of abilities, and quickly took advantage of the small gifts and supplies we brought to the centers. The teachers of personnel were deeply appreciative and literally begged our group “not to forget us — your visit gives us strength” and not to fail to send along additional needed items such as children’s Tylenol.
This kind of personal contact at such a professional level can only enhance good will and practical relationships between groups from the United States and Cuba. The negative stereotypes between both groups are ameliorated by such personal visits, and particularly those visitors who bring vitally needed materials at this critical time in Cuba.
Luly Duke, President
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With extensive subsidies from the Soviet Union, the Cuban government has invested heavily in a system of free and available education and health care since 1960. There are 11 million Cuba today, and 60,000 doctors, or one doctor for every 150 people. Even today, the small island nation compares favorably in these areas to most developed countries. The infant mortality rate is low, literacy rates impressively high and the maladies that effect both the developing and developed nations, (death by curable disease, extreme poverty, crime, and drug abuse) remain diminished.
However, with the collapse of the Soviet Union, the eastern block was no longer in a position to buoy Cuba's economy and Cuba found itself suddenly bereft. Reduced resources now make it impossible for a Cuban citizen to live for a month from a month's supply of government rationed food. In order for the average person to survive, extras must now be procured from the black market which operates mostly in dollars. With the peso now hovering at around 25 to the dollar, the average professor's wage works out at about $10 a month. Aside from those fortunate enough to work in Cuba’s tourism industry (waitresses, bell hops, cleaners, taxi drivers, etc.) everyone we met who was willing to discuss the issue had been forced to take on a second career. Hence university professors become cake bakers by evening, research scientists become taxi drivers; and almost everyone with a room big enough -- film makers, teachers, engineers and scientists — become amateur restaurateurs.
With the recognition of the American dollar as legitimate currency, monies sent from family members and friends of native Cubans in the States have helped to ameliorate the sinking standard of living of the average Cuban citizen. Some even suggest that such personal subsidies provided the single largest block of hard currency to the Cuban government with estimates ranging up to $800 million per annum. As one professor-turned-baker with no foreign based relatives told us one afternoon: "The American money helps not just the families who receive it, but all of us. When I bake a cake, I sell it only for dollars. Most often the cake is bought by families with money from the states. I then spend that money in the black market in exchange for soap or cooking oil. In this way the money passes from hand to hand and helps many more people to live than the initial relatives themselves."
However, the scarcity of basic items such as food, medicines, clothing, paper and cleaning materials means that black market prices remain almost unattainably high to the average Cuban citizen. One eighty nine year old woman told us that she couldn't remember the last time she had seen a piece of fruit. Then she quickly corrected herself and added: "Well, I have seen them of course, but I have not been able to eat them because of the price. Dollars are very expensive."
Lack of basic materials is also inflicting damage to Cuba’s social and academic infrastructure. Though it is still illegal to be unemployed in Cuba, guaranteed employment is a thing of the past, and as the Cuban people are left increasingly to fend for themselves, so the once vaunted advances in education, and health care are begin to deteriorate. Already many university professors, doctors and scientists have left the country. Others are leaving their jobs for the more profitable tourist oriented trades. University places are shrinking, medical technology is in danger of becoming redundant and the once grand general educational system -- whose students are forced to share long out of date text books and scraps of recovered paper -- is in danger, quite literally, of crumbling. It is our opinion that a well educated work force can not last much beyond a generation under the current circumstances. As Cuba’s highly skilled work force is a genuine and legitimate national recourse we feel that dramatic changes need to occur to prevent further disintegration.
Members of the delegation noted the following as a result of its visit:
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Delegation Participants’ List
Maria de Lourdes Duke (Luly): President of Fundación Amistad, a nonprofit designed to increase US awareness of Cuban history, culture and society, and to discuss ways to improve life in Cuba. Also Vice President of The Harbor for Boys and Girls in New York City.
Gail Furman, Ph.D: child psychologist. Chair of the Children’s Task Force of the Women’s Commission for Refugee Women and Children. Clinical Professor of Child Psychology, Child Study Center, NYU Medical School. Member of several boards focusing on educational/emotional needs of children.
Ruth Frazier: educational consultant in community organizing .Former President of Futures for Children, a nonprofit in New Mexico doing community work with American Indians; established independent community educational organizations in Colombia, Honduras, Costa Rica and Mexico.
Nancy Lublin: founder and President of Dress for Success in New York City providing clothing and training for women returning to work force. Author of book on the history of women’s reproductive rights. Active in women’s issues.
Cristina Rathbone: journalist specializing in youth issues, urban poverty, and education. Author of On the Outside Looking In: A Year at an Inner City High School.
Eileen Stern: Director of the National Child Care Program for the General Services Administration, oversees all federal day care programs.
Mary Ann Schwalbe: consultant to the International Rescue Committee and Save the Children, US. Former director and current Board member of Women’s Commission for Refugee Women and Children. Extensive work in secondary and post-secondary education.
Clifford Tepper, MD: pediatrician, Professor of Pediatrics, Albany Medical College. Chief of Allergy Division, Ellis Hospital .Co-Founder of Physicians for Social Responsibility.
Lindsay Thompson, MD: pediatrics resident at Dartmouth Hitchcock Medical Center in New Hampshire. Extensive work with homeless adolescents in NYC
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Education/Child Care in Cuba
Children are of utmost importance in Cuban society. They are considered national treasures and are given priorities throughout their young lives. Child care is one of those priorities. There currently exists a three tier system for the delivery of child care services in Cuba: Formal; Informal; and Familial. There are tremendous variations in the quality of care in each of these systems. We visited four formal “circulo infantile” child care centers, three just to walk through and one for a more comprehensive visit.
In the early 60’s, the State began to build facilities with a capacity of 120 young children and no infants. These centers are still operating; while we were told there were perhaps 200 centers like this built, the actual number was just a guess. During the mid 70’s, the State built an additional 200 centers for approximately 200 children each, this time including infants. In 1989, an additional 50 new child care centers were constructed, for infants through preschoolers. While all of the other centers were of similar physical construction, each of these centers .were unique in terms of size and shape but they were all large (175-200) capacity.
There are approximately 135,000 - 150,000 births a year in Cuba. Since all family members now must work, about 500,000 child care slots are needed. There is an extreme shortage of slots in the State-run formal system; some say only 20% of actual needed space exists. This shortage forced a change in the system: child care services used to be provided from age three months to six years. Now care starts at six months. Mothers get up to one year maternity leave but only three months is paid leaving a gap of three months for all parents, whether in formal or in informal settings - to find care for their children. Anecdotal evidence suggests such a severe shortage that it is now necessary for both parents to bring letters to the circulo infantile stating that they are working and specifically that the mother is working in an education or health related field.
It is anticipated that there will be a decrease in the already low (less than 1%) birth rate. This is a very highly educated population with total access to birth control that is faced with harsh economic circumstances and severe housing shortages. This group will postpone beginning or increasing families’ size for as long as possible in anticipation of some change. Most families live in multi-generational settings with women retiring early to take care of their grandchildren so that their daughters and/or daughters -in-law can continue to work. This system will work for this generation, but probably not after that since the women in question will be at the height of their careers and the leaders in their fields when their children need child care.
There currently exists an outstanding infrastructure within the formal network of child care centers. The staff was extremely well educated and undergoes continual training. The class room supervisory ratios were extraordinary, and there exists age appropriate groupings of children in warm, friendly environments. The health practices were excellent with both doctors and nurses on site; this health care is integrated into the local primary health care system. Hearing, eye, and dental exams were overseen by the medical staff at the child care center site. There were outstanding classroom health practices: including, individual toothbrushes, individual personal towels, individual potties, showers in the bathroom areas. The center provides clothing for all of the children; they change into these clothes upon arrival and all clothes worn by the children in the center were washed every day. Meals were served in family style.
There were, however, some very severe problems including a lack of very basic materials - both sanitary and program related. There was no toothpaste, no hand-washing soap, no toilet paper, no mops, sponges, etc. There was very limited food, even though the children get priorities. They were totally without any teaching materials: books, paper, pencils, paints, toys, etc. The teachers hold up old flash cards in front of the classroom to teach colors and shapes. The physical plant was deteriorating. There were no light bulbs and overcrowded rooms. Despite a strong on-site medical presence, there was no sick child care.
This fee for this type care is based on income and ranges from 40 pesos per month (about $1.50), which is what most people pay, to a maximum of 80 pesos a month. The fee was standard regardless of the age of the child, and includes food and diapers.
This system resembles an unlicensed version of our family day care system in that several children were cared for by a woman in her home. There was no regulation or licensing by the State (which was, in and of itself, amazing since everything else was totally regulated). The homes were usually much too small to accommodate any additional children as several generations of one family were usually already crowded into a few small rooms. In general, there was no specialized equipment or educational materials. Since there was no regulation by the State, this becomes the parents’ problem. This type of care costs approximately 80-100 pesos a month, plus food and diapers, for each child.
Since there was no licensing, the provider pays no taxes and is able to keep all of the money which is a real incentive to keep this system unregulated. However, in an effort to upgrade the quality of care provided in these type settings, the nearest circulo infantile often sends a team of teachers and health care professionals to these homes to provide some training materials and basic guidance to the parent in charge. This is done on an informal basis.
This system was exactly what it implies -- a relative or close friend or neighbor watches the child while the parent works. It may or may not involve some form of payment. There was a facility within each community for use as a resource for these care givers. This facility has a playroom and some professional staff who can offer advise and assistance.
DETAILS OF VISIT
What follows is a summary of our visit to the Circulo Infantile los Ninos, “Suenos del Che”, established in 1989. The Director was Rodolfina Varna. The center serves 193 children from six months to six years and was open from 6a.m. to 6p.m. five days a week. There were 24 teachers and educators; 15 support staff (cleaning staff, laundresses, cooks); 1 doctor and 2 nurses. The Director has 28 years experience, 9 in this center. Each classroom was headed by a teacher with a university degree who earns 300 pesos a month. The assistant teachers earn 150 pesos monthly. The Director earns a little more than the head teachers. Secondary school students who were interested in pursuing degrees in early childhood education can intern in a center for a full month during their last year as well as part of each school week. There were no male teachers working in any child care center in Cuba. (There were male primary school teachers, however.)
The State provides two snacks and lunch each day. The Director claims they were short of protein but on the day we visited, they seem only to be missing animal protein, which Cubans believe is essential. There were outstanding medical health records on site and a total integration of the school and family health system.
The age groupings of the children were: 6 months to 1 year; 12-24 months; 2, 3, 4, and 5 years. Immediately on arrival, each child changed into clothing owned by the center and back into their own clothes when they left. The center’s clothing was washed every day. This system may not still exist in all centers as there was now an extreme shortage of clothing. Cloth diapers were provided and washed on site as well.
The bathrooms were old but very well laid out, with each including two small showering areas for the children. In addition to pediatric toilets, each child had a personal potty for toilet training, as well as a clearly identified toothbrush and towel. For those children who were too young to read, easily recognizable symbols or pictures were used. There were few toys and they were clearly inadequate for the number of children and many were broken or missing parts.
The classrooms were sparsely furnished and the furniture that was there was well worn and occasionally broken. The walls had some commercial pictures up, but no projects made by the children were visible. The physical layout was problematic with possible head entrapment area in the rooftop outdoor play yard fencing. Termites had eaten the large wooden doors that covered entire sides of the classrooms and so the rooms were open onto an indoor play area and therefore quite noisy. There were no play structures inside or out and cement floors throughout the entire area. There were no soft areas anywhere.
Despite the fact that there were severe shortages of all consumable goods:( no paper, pens, crayons, linens, bandages, soaps, etc). the staff was highly motivated and doing an excellent job without any materials. The children seemed engaged and friendly and there was an outstanding teacher to child ratio. At times it was amazing how many adults were in each classroom. Students on work-study made up many of the personnel. This compensated somewhat for the physical limitations of the facility and the lack of materials in the classrooms as well as contributing to the positive interactions in the classrooms.
PRIMARY AND SECONDARY EDUCATION
Our delegation visited several education centers, including one of the most selective and demanding secondary schools in the country.
Children in a child care setting get a good start on their elementary school education both from the socialization that exists for young children and from the professionals under whose care they are included. The songs they learn, the group activities, and the sharing of even the limited number of toys and learning tools have already helped them for future learning.
The primary school that was visited --Hermanas Giral — was in a building that had been a magnificent private home before the revolution. Now there were 392 children in this school in 13 classrooms. Primary school children wear red pants or skirts, white blouses or at least white collars, and a blue scarf. Children between the ages of 5 and 15 were called Pioneers. The 1st grade classroom in which we spent much of our time had 36 children and only one teacher. She had their total attention, and though they were crowded into this classroom (ideal circumstances would have held no more than 18 children), there was no problem of discipline or learning. All these children can read by the middle of their first year. A look at their writing and writing books showed that their letters were clearer than most 3rd grade students in this country. They were fully focused on their work. If any child was having problems with writing, the classroom teacher worked with that student individually after school.
At the request of the child psychologist in our group, each child was asked to draw what he or she wanted to be as a grown-up. The response was instant. Each child began drawing with fervor. Ballerinas, baseball players, astronauts, and teachers were the favorite occupations with very imaginative drawings. Children told what their mothers did— mostly professionals such as doctors, dentists and teachers. The children loved the drawing project, particularly when left with additional paper and crayons and pens for their own uses.
There was an active Parents Council at the school and one of the mothers chairs the Council. It meets monthly. There were health professionals at the school and a dentist comes on a regular basis. The students begin learning English at this school in the 5th and 6th grades, the last two years of elementary schooling. Other schools now start English earlier. Until the breakdown of the Soviet Union, Russian was the other language taught. The phonic method for reading was the one recommended, but teachers were allowed to use any method that works for them and the children. They learn to read first and then to write. There are no standardized tests in the school until the 6th grade when students are tested in Math and Language for placement in their new schools.
One of the interesting teaching philosophies, at least at this school, was that the same teacher stays with a class from kindergarten through the fourth grade. This may explain why the children seem so comfortable with their teachers and also why they were reading and writing so well at an early age. As more specialized subjects are introduced in the 5th and 6th grades, children are less likely to have the same teachers at that point in their development.
Classes begin at 8:10a.m. and were 45 minutes long. If mothers are at home, children go home for lunch. If mothers are working, children stay at school and are given lunch. They all bring snacks. For working mothers, there was someone at the school every day from 7:00a.m. until 7:00p.m. Evening hours were spent playing and in group activities. Every two months there was a parent-teacher conference. Hermanas Giral school has only four computers (very old ones using ancient tv’s as monitors), and computer classes don’t start until the 5th grade.
The library was pitiful. It has almost no books, and those it has were very old. The children, nonetheless, love to come and check the books out. They were encouraged to do this but could be much more so if more books were available. The staff at the school seemed excellent, thoroughly professional, proud of the school and their students, and happy to be working in a school.
We also visited the Lenin School for Science and Technology, a 3 year boarding school for extremely advanced students. It was a highly selective school which takes only the brightest and best from the Havana district. Entrance was based on tests in Language and Math and on prior school records. Only one in three applicants makes the cutoff. There were 3048 students currently, 300 teachers and 600 staff. The students were bussed to and from the school every week. One week they were there from Monday morning to Friday night and the next week until Saturday night. There were two girls for every boy in the school, and the main subjects taught were math, chemistry, biology and physics. There is one school like this in each of the 14 provinces, but the Lenin school was the most prestigious, although the students are also from the most privileged families.. Most of the students go on to universities and many into professional life. The school year starts on September 1 and goes till the end of June. If a student fails a class, it is made up in July. There was a hospital close to the campus with 6 doctors and psychologists available to the students. There was an 86% retention rate, with a goal to improve this figure. Students get up at 6:00a.m and lights are out at 10p.m. As at the elementary school, parents were active and meet with teachers every two months. Half the day for students was spent in the classroom, and an equal amount of time was spent working and doing chores. We observed a group of students painting cabinets for an exhibit in their natural history library. The chores vary from cleaning to working in the fields surrounding the school and students rotate their chores.
In the past 24 years, the Lenin School has had over 20,000 students. Of the medical students in Cuba, 85 to 90% come from here. Some of the graduates have come back to teach and many come back to visit. We met with two leaders of the Student Council. These boys were very impressive. We asked one if he would consider politics and he adamantly said “no.” We found this interesting, later, when we discovered he was the son of a high ranking government official. The boys described the Student Federation which has three units, one for each grade. When asked what they liked best about their school, they mentioned their teachers, the quality of their education, living with the other students, and the challenges of the work. When asked what they liked least, they missed homes and families, disliked the food, and said there were some behavior problems with students. There was an enormous amount of pressure their final year in terms of testing for the university level, but the school helps prepare them all semester, so it was easier when they finally take the tests.
There were only a few very old computers at the school. In spite of this, the Lenin team has won at the Computer Olympics. Each student was given one pencil a month and textbooks have to be shared among ten students. There were usually 33 students in a class. While athletic teams for both sexes were very popular, sports equipment was very scarce, and there was an enormous need for baseballs, bats, and soccer balls.
As in the elementary school, the motivation and dedication of administrators, faculty and students seemed superb. The principal of the school has been there many years and was proud of his students and his faculty, and very willing and candid to answer questions.
COMMENTS AND RECOMMENDATIONS
It was clear that the educational system was outstanding, given the lack of equipment and supplies. No one has paper, so even if there were Xerox machines, there would not be the possibility of copying anything. We learned that there were special schools for other subject areas, but it did seem that science and math were the most competitive areas of the schools. Others outside the schools talked about their own educational experiences and that of their children. Though the classes we saw were mostly teacher led from the front of the classroom, we were told that cooperative learning exists and was very much part of the learning scheme.
In order to make any recommendations on educational philosophy and pedagogy, one would have to spend much more time in a school than we had during our visit. We have no recommendations to make on a philosophical level. We do feel that these teachers and students need to have adequate materials with which to work. We believe that this country should contribute and coordinate efforts through an international organization to get supplies and textbooks to Cuba.
Though class sizes were large, they were not any larger than in many schools in other countries. The delegation congratulates the Ministry of Education on the rate of literacy in the country (over 95%) and on the ability of teachers to teach and students to learn in far from ideal situations.
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Pediatric Health and Adolescent Mental Health
“Cubans in their first year of life get medical treatment like those in the First World. Those older, like 20-year-olds, are treated as if they live in the Fourth World.” An anonymous physician
Cuban health care is a system of free and accessible medical attention for every citizen. Since 1992 the quality of their health care delivery has been severely compromised by the fall of the Soviet Union, the Cuba Democracy Act (CDA) and the Helms-Burton Act. The CDA provides for the sale of food and medicines to Cuba, but under conditions so strict as to de facto prohibit them. The Helms Burton Act prohibits U.S. suppliers from attempting to trade medical equipment with Cuba.
The country is still able to report some of the best indices of health in a setting where obtaining the most basic medicines can be a challenge. The Cuban government has made health care a nationwide priority by increasing its spending from 10% of the GNP to 15%, according to the Ministry of Health, since the reduction in Soviet aid. Despite efforts to ration precious resources to the populations most in need, Cuba suffers from a lack of food, medicines and access to medical information. A unique dichotomy exists between a well designed health care system, and a miserable scarcity of resources. The situation demands a rereviewuation of the economic forces that are compromising the health of the Cuban people.
Despite an excellent infrastructure in place to provide health care, which includes a surplus of educated doctors and accessible providers, Cuban doctors have few pharmaceutical options for treatment of diseases. State officials claim that they can access medicines in moments of dire need. All the doctors, however, to whom we spoke cited shortages of antibiotics, steroids (basic treatment for asthma), chemotherapeuticals (for cancer), and technological equipment. Because of the embargo, we were told, medicines cost 300-500% more than they would if they were directly traded with US companies due to increased licensing and transportation costs. For example, a drug called prostaglandin, a life-saving drug for newborn infants with heart disease, costs about $50 per dose in the US, but $250 in Cuba. Thus the government is not able to afford to keep newborns with these conditions alive. The government demonstrates interest to buy the medicines, but over 90% of all medicines available worldwide are manufactured in the US, and the Cuban economy cannot afford these costs. To control costs, Cuba has learned to make its own medicines, and they are able to manufacture 92% of the medicines available within Cuba. Despite this, they cannot make sufficient quantities, especially since they can no longer obtain the raw materials from the Soviets.
Because pharmacies are bare, patients and doctors turn to humanitarian donations for support, but this is a fluctuating and unreliable source. One week a simple urinary tract infection may be cured by outpatient management with antibiotics, whereas the same disease a week later may be fatal. Likewise, the Helms Burton Act prohibits the country from obtaining medical supplies and parts for equipment. Some intensive care units are well stocked with many ventilators, but they lack critical parts that cannot be replaced. Children and adults cannot maintain adequate health in a setting that cannot provide basic medicines. Cuba has many highly educated doctors who want to help, but they are unable to practice the medicine that they were trained to do. One doctor lamented “we are able to diagnose most problems, but are powerless to provide the simple medicine to help cure.”
Nutrition is another aspect of health that has been dramatically affected by the Cuban Democracy Act. The Cuban government, unable to trade with old allies or nearby neighbors, has responded to this crisis by preferentially providing better quality food to those with the highest need. For example, only pregnant women, breast feeding mothers, and children under seven can get milk. Likewise, sources of protein and iron are scarce, as their ration cards afford no red meat or leafy vegetables, and contain little soy. According to OXFAM, the average caloric intake has fallen from 3100 calories per day to 1800 over the past five years. Furthermore, an epidemic of neuropathy, with resulting temporary blindness, in 50,000 adults was documented between 1992-3 that was due to a lack of B vitamins and sulfur-containing amino acids. As Dr. Francisco Valdes Lazo, the Director of Maternal and Child Health, bluntly stated, “the country is starving."
Maintenance of a clean water supply has become a major problem. The equipment used to chlorinate and purify drinking water is breaking down for lack of spare parts which can only be obtained in the US. The result is a marked increase in water borne diseases, dysentery, parasitic disease and hepatitis.
Information is another scarce resource. Because of the profound lack of supplies and its political isolation, Cuba cannot exchange critical medical knowledge with the rest of the medical world. Internet access, a standard of care in modern medical facilities, is just being introduced in a few hospitals and polyclinics. Distribution of internet access may be slowed by both dollar and political reasons. Confounding the problem, Cuba lacks a fundamental product -- paper — to print or photocopy materials. One doctor showed a torn and faded document on Pediatric Intensive Care that he claims doctors around the country beg him to borrow for one hour. The doctors are isolated from new advances and experimental therapies.
Conversely, the US and the rest of the world cannot benefit from the knowledge and research the Cuban doctors perform. For example, almost all Cuban babies are born in hospitals, and the placentas are then used in experiments for therapies and medicines for skin diseases, a technique not used in this country. This could provide the medical world with valuable information. Also, at least 15,000 children from the Ukraine, exposed to radiation from Chernobyl, have flown to Cuba to receive treatments for diseases ranging from leukemia to vitilligo. The Cuban doctors have not been able to publish any of this critical data, again because of a lack of resources.
PEDIATRIC AND ADOLESCENT MENTAL HEALTH
The delegation visited the Adolescent Mental Health Clinic in Havana, for children and teens. This self-standing facility established in l975 is unique in Cuba, as mental health services are usually attached to the pediatric/adolescent wings of provincial hospitals. A plan for proliferating the Adolescent Mental Health Clinic model in every province has not been realized due to a lack of funds. The Clinic is an inpatient and outpatient facility, taking cases from Havana and its immediate environs as well as difficult cases that cannot be handled at the local level. While we learned a great deal about the Cuban psychiatric system from the doctors at the clinic, it should be made clear that we did not visit any other facilities or investigate adult psychiatric care.
Although there is a deep knowledge and respect for Freud and other prominent theorists, the philosophy informing child and adolescent mental health is largely practical, eclectic, and quite sophisticated in its varied approaches. The Cuban system, as we saw it and heard it discussed, can be described as community psychiatry at its best. The Mental Health Clinic we saw is inventive and adaptive with the treatment it offers. Both individual and group therapy, as well as drug therapy, are used. In addition, academic tutoring and parent counseling are generally included in each protocol. The Clinic is highly attuned to learning disabilities and sees a child’s mental health as closely tied with how he or she performs in school.
The Clinic cultivates a comfortable and caring atmosphere. Children’s artwork is hung on the walls. Music and sports programs supplement treatment. There are no locks on the doors. Staff, parents, and patients show kindness and respect to one another. The three professionals we met, Drs. Frank, Resell and Gutierrez were open, intelligent, and clearly devoted to their work. Visits to schools and inclusions of other community support systems are common.
In the inpatient facility, there are twenty-four beds and twenty-four day beds. Fifty patients can be accommodated during the day, but only twenty-two at night. Parents sleep in rocking chairs next to a child’s bed. The average inpatient stay is 45 days. There is a comprehensive 24-hour intake process, with a professional on site at all times.
With outpatients, the staff of the clinic works in teams, assigning a doctor, a social worker, and teachers to a case. A team approaches a case multilaterally, combining nursing, occupational and rehabilitation therapy, neurophysical examination and treatment, alternative medicines, and speech therapy, when needed.
Throughout the Cuban system, work with parents is deemed critical and is a core treatment support. The doctors we spoke with were quick to cite a recent research project in which three treatment methods were studied: working with a child in isolation, working with parents in isolation, and working with parents and children together. The final group had the greatest rate of success. At the clinic, parents are required to accompany their child through the outpatient and inpatient process. (It should be noted that any parent of a hospitalized child is paid the his/her employer to take time from work to be with the youngster.) Social workers also work with patients beyond the walls of the clinic. They travel to a patient’s home, school, neighborhood, and to the work center of the patient’s parents. These outreach efforts on behalf of families and treatment providers form deep connections between them, which is extremely beneficial to the child under their care.
Knowledge of psychopharmacological treatment is very sophisticated among the clinic’s staff. Everyone, however, we spoke to was frustrated by the devastating lack of access to medications and current research. There are no medicines such as Prozac or Zoloft. Ritalin, Dexedrin, injectable valium, and anti-psychotics are unavailable.
Everyone we spoke with at the clinic felt that the stress of the economic situation in Cuba was contributing to greater familial stress and more mental health problems among children, adolescents and families. Low salaries, poor living conditions, and difficulty of transportation all put pressure on parents that is easily projected onto their children. Divorce and alcoholism, both associated with economic stress, directly affect the mental health of children and teenagers, and are on the rise.
Many types of pathology seen at the clinic are indicative of the economic hardships faced in the country. Depression, conduct problems, prostitution, and teenage alcoholism are all on the increase. These social disorders are treated with a community approach, involving a patient’s parents, school, and neighborhood, but one can see the beginning of a crumbling of the community/family as the economic pressures increase.
COMMENTS AND RECOMMENDATIONS
In sum, Cuba, like no other country in the world, lives under such restrictions against medicines and food, even Iraq, an openly aggressive country with weapons of mass destruction. The other major communist country, China, enjoys an extraordinary trade with the US. Cuba poses no credible threat to American security or American interests. American actions, inappropriately continued from an era of rabid anti-communism, are causing severe human hardships in Cuba. There must be an end to the Cuban Democracy Act for humanitarian reasons so that Cubans can access adequate goods, medicines and medical equipment to end this hardship. Furthermore, scientific and cultural exchanges need to increase to provide an international understanding of the country and the scientific knowledge Cubans have to offer. Finally, because the future health of the population is precarious, we recommend continuous observations of indices of mortality and nutritional status.
The professionals met at the Adolescent Mental Health clinic were highly motivated, intelligent and dedicated individuals who espouse a multifaceted, sophisticated approach to child and adolescent mental health. Unfortunately, the economic conditions have made it extremely difficult to implement the mental health system to its potential. A lack of access to medication, research, and basic materials like paper and bed sheets, as well as exceedingly low pay for professionals have all been damaging. Lifting the embargo would not only allow for the trade of materials, but of intellectual currency as well. There are many ways mental health professionals in our country can support the Cuban mental health community and much that our mental health professionals can learn from their Cuban counterparts.
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Non-Governmental Organizations (NGO’s)
We were interested in visiting those non-governmental organizations, both indigenous to Cuba and those whose funding comes from outside Cuba, to assess the type of services available to women and children.
Non Cuban NGO’s are seen by the government as a threat and a way to undermine the political system if they have as a stated purpose to develop civil societies, a very common goal of many NGO’S. Thus, foreign NGO’s must tread delicately in their work. They are not encouraged to have conferences together, nor was there much provided them in the way of offices and staffs. Health service NGO’s, for example, must not be too narrowly focused in their approach, but must be general and in compliance with State initiatives.
One of the oldest Cuban NGO’s is the Federation of Women, founded in l960 to involve women in the revolution, funded by the State. It was to be the channel to have women considered at the highest levels for their economic and political considerations. We were told that the Women’s Federation was the voice for the struggle for women’s equality, and while it has not produced a perfect product, it was one that was just.
“Women comprise 40% of the labor force in Cuba, 27% of parliament, 30% of the leadership in labor, and 65% of the skilled labor force,” said the director of foreign relations at the Federation. Women are charged $.25 per month to belong to the Federation. In addition to its political role, the Federation helps women with family and social problems.
In 1990 the Federation began a series of community centers, called Houses of Guidance for Women and Children. They provide legal and social services for women and training, but are not battered women’s facilities, which don’t exist. They are staffed largely by volunteers in the community. A visit to one found the disconnect surprising between what the expressed philosophy is behind the centers, and the reality of the situation. All teaching is theoretical, for example, and done without supplies. Computer skills are learned not on computers, but from instructions written on blackboards.
The delegation was told that a group of young women had come to learn better grooming and hair-dressing skills for their own edification. The women, however, told us they were really there to learn to do hair-dressing and fixing nails from their own homes as quiet and small businesses.
Caritas Cuba is one of the most influential and effective of the local NGO’s. It exists in 3000 communities with as many volunteers from its Catholic Bishops Dioceses, and has a working staff of 30 full-time personnel. It distributes $4- 6 million a year in humanitarian aid which comes from Catholic Relief Services in other countries, particularly the US. Caritas works carefully through the Ministry of Public Health which warehouses its donated supplies, doesn’t tax them, and delivers them where Caritas instructs.
Caritas helps rebuild houses damaged during hurricane emergencies, and helps rehabilitate farm lands. Caritas also develops services for the elderly, and collaborated with government programs for a “Slips and Bloomers” program to provide undergarments, a program which can be used to assess other needs of the elderly.
Because of crowded living conditions, children are often left to the streets to play and socialize. NGO’s cannot work inside the schools, nor can avowed Catholics teach in schools. Caritas has started after- school programs for 5-12 year olds. They also work with women on sewing projects, despite a pitiful lack of supplies. Caritas was proud to report that it will receive 72 boxes of baseball equipment from the Baltimore Orioles, but will have to negotiate with the ministry for distribution of this much needed equipment.
“For NGO’s to be successful in Cuba,” said Rolando Suarez, the director, “they must make decisions based on a knowledge of Cuba.”
A new NGO with just such a knowledge base is MEDICC, Medical Education Cooperation with Cuba, a program of the American Association for World Health. As of April, l998, MEDICC has begun to offer US medical students the opportunity to team up with Cuban health professionals in direct contact with patients. Courses are also offered for graduate students in Public Health and Midwife Practitioners.
OXFAM US, Canada and UK has a presence in Cuba with support to Cuban groups actively engaged in organic methods of food production. It also promotes urban rehabilitation and development through community initiatives and the use of sustainable and ecological approaches to food production. One sees lovely urban gardens flourishing throughout Havana and many of these have been funded by OXFAM’s efforts.
UNICEF also walks the fine line to cooperate with existing governmental programs. It is heavily involved with water purification projects, which is also a high priority of the Ministry of Public Health. Two thousand rural communities have either obsolete or non-existent water systems, and water is delivered by the State in trucks. UNICEF has partnered with the State to develop a National Hydraulic Institute which provides a simple technological system of PVC pipes to get underground water at low cost. An installation for more than a thousand people costs only $8-9 thousand for a complete water system. UNICEF also provided two desalination programs in Guantanamo and Bayamo.
In addition UNICEF created a major program to encourage breast-feeding and is also a major supplier of the twelve required vaccines for infants and children. UNICEF is also trying to expand the internet system called Infomed to outlying areas for much better communication by and training of medical personnel.
“A strategic target of all UNICEF’s”, said its director, Luis Zuniga, “is not to be only around with material things, but with ideas.”
COMMENTS AND RECOMMENDATIONS
NGO’s are an effective and efficient source of supplies, training and a link for Cuba for grassroots development methodologies. In order to continue to help the people of Cuba in their daily struggle, effective NGO’s such as Caritas, UNICEF, and the new work of the Fundación Amistad must be supported and funded.
Links need to be made between NGO’s to streamline efficiency and increase communication about findings to develop new programs and enhance existing ones. Simple gatherings of like-minded NGO’s to exchange information would be a first step.
Congress has two bills in process which would lift the ban on the sale of US food and medicine to Cuba. We
Most are young women who hold regular jobs during the day, and who desire visits to nightclubs, gifts of clothes, drinks, food and access to restaurants, which otherwise are inaccessible to Cuban citizens, male or female. Many of the prostitutes are under sixteen. Some are encouraged by their families in their pursuits, even to marry foreigners. Such marriages must be made with the assistance of the state which charges a fee for each ceremony performed. Prostitution is not illegal in Cuba through recently, pimping as well as less formal encouragements to prostitution have been made illegal.
With the increase in tourism to Cuba, there will be more of an opportunity for small, women-owned businesses to produce and sell products and services with great success. Enterprises such as hairdressing and baking not only require few resources and elementary training, but they are also occupations well suited to women of all ages and various family responsibilities. Supplies should be made as widely available as possible.
The importance of sports to develop girls as confident, healthy, equal members of society is well known in the US. Many people in Cuba explained that there is a lack of organized activity for children beyond the school day. While baseball is the national sport, it is predominantly for boys, as is soccer.
There are many “girls” sports which require little space and equipment such as double- dutch jump roping, cheerleading, dancing and running. Such sports have a beginning, middle and end each year and require little in the way of resources. Local NGO’s already initiating such programs should be supported.
There is an intellectual isolation in Cuba due to a lack of books and paper with which to publish. Libraries have hourly lending limitations. Only one or two copies of a particular book exist in the entire country. The delegation urges a greater supply of books and journals to be sent through the University of Havana.
Create a Journal of Cuban Women’s issues. Follow the US law journal format, where students apply and are selected to become part of the journal staff. Duke University or other university students could select articles (from a pool submitted by both Cuban and non-Cuban women), assist in the editing and fact-checking process, publish and market the journal.
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Next Steps for Fundación Amistad
As a result of the delegation’s observations on its trip, the Fundación Amistad recommends the following as opportunities for additional support of the women and children of Cuba.
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Persons and Places in Cuba
Cuban Federation of Women
The House for Women and Children
Gonzalez Coro Hospital
Policlinico 5th de Septiembre
William Soler Pediatric Hospital
Hospital Hermanos Almejeras
Adolescent Mental Health Clinic
Dr. Elsa Gutierrez
Dr. Michelle Frank
Dr. Jose Baudillo Jardines, Vice Minister of Public Health
Carlos Fernandez de Cossio, Foreign Ministry (Minrex)
Circulo Infantil: Suenos del Che Daycare Center
The Lenin School for Science
University of Havana: Women’s Studies Program
Dr. Jose R. Mendez
Dr. Marta Nunez
Dr. Alberto Prieto
Escuela Hermanas Giral
Elsie Casaros, Director
Ester Hernandez, Subdirector
Rolando Suarez, Director
Luis Zuniga Zarate, Director
United States Interest Section of the Embassy of Switzerland
John S. Boardman
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Fundación Amistad (The Friendship Foundation) is a 501(c)(3), not for profit organization created in 1997.