Not Feminist, but Not Bad: Cuba's Surprisingly Pro-Woman Health System

by Eileen Schnitger and Christina Romero

In April, Women's Health Specialists sent two representatives to Cuba to explore health care and other aspects of everyday life for women there. As a feminist organization that strives to empower women to make their own medical decisions, we would seem an unlikely match for a country whose policies are famously top-down, with little tolerance for decision-making at the individual level. But we were impressed by much of what we saw.

Over the course of 10 days, in talking with and observing health professionals and ordinary Cubans in several cities, we saw a country that manages to provide free health services to everyone and that places a high value on prenatal care and breast-feeding. We didn't research hard data to verify what we saw and were told, but as American women we relished being able to viscerally experience a culture that has no stigma on abortion or birth control, that allows women and girls to live without fear of sexual violence, that teaches sex education at an early age and embraces sexuality as normal.

Coordinated Health Care Delivery

The Cuban health system coordinates three points of health care delivery: a family doctor in each neighborhood (one for every 150 people), a 24-hour "polyclinic" for urgent care and a hospital, including separate maternity hospitals for births and abortions. When a Cuban hasn't been to the doctor for more than six months, his or her family doctor—who knows every person individually— makes a house call regardless of whether the person has a known health problem. The system emphasizes preventive care for children, with the result that nine of 10 one-year-olds are fully vaccinated.

Health education and prevention are consistent and integral. Each of the three classes of providers communicates with the other two about every individual's needs, and the three then develop an integrated care plan that includes health education and prevention. The doctor can prescribe drugs, vitamins, homeopathic remedies and herbs, and pharmacies fill the prescriptions. The use of herbs has expanded greatly since 1992, when the fall of the Soviet Union created a scarcity of drugs that still exists in Cuba. Unlike the situation in the U.S., drug companies do not market directly to consumers or fuel the education of Cuban doctors. It will be interesting to see what Cuba does if the U.S. embargo ends and western drug companies are allowed a bigger presence.

Policies on education and health care are implemented from the top down, with the Cuban Ministry of Health controlling physician training and medical protocols. For example, we brought cervical caps on our visit, thinking they might not be available in Cuba. They weren't, so we gave them to the medical director of a polyclinic. He said he would share them with the Ministry of Health, which, if it chose to do a study, would write a protocol and implement cervical caps nationally after six months. We explained to the medical director that in the U.S., cervical self-exam is part of the cap-fitting visit. He said this may be ideal, but it was not going to happen there. Cuba's top-down approach makes for consistent medical practice nationwide but does nothing to put women's health care in their own hands. It also prohibits doctors from trying new approaches on their own.

Sexism

Gender equality is still a goal in Cuba, and sexism does exist. While Cuban women occupy slightly more than half of all professional positions nationally all the medical directors we met with were men and all nursing directors were women. Only 30 percent of local officials are female, black or young, and women are far more likely than men to take care of children and elder family members.

Social Mores and Sexuality

Sex education is an. integral part of the Cuban educational system, reaching all children, adolescents and adults through schools, television and family doctors. We saw no evidence of stigma against birth control, abortion, birth and parenting, or heterosexual expressions of sexuality, and people we met spoke easily about these matters. The Castro regime has admitted past mistakes, including quarantining people with AIDS. Cubans have challenged the government's homophobia, but we did not hear of policies to promote equality of sexual orientation, as there are policies to eliminate gender differences and racism. For what it's worth, we did see two drag queens walking together one afternoon. Nobody seemed to notice or give them special attention.

There appears to be no shame attached to women's sexuality in general. Cuban women of all ages and sizes wear snug clothing and high heels, and often walk with a sway in their hips. On one occasion, we saw 13-year-old girls dancing in a sexy, confident way—shaking their hips, pushing out their breasts, rubbing their bodies in a provocative way. All the while, elderly neighbor women were clapping and smiling. The only disapproval we witnessed came from a man in our travel group, an American in his 30s. Sexual Violence

Sexual violence is rare in Cuba, as is crime overall. Citizens are prohibited against owning guns, and neighbors are urged to get involved if they see or hear signs of violence or abuse. The status of women generally seems higher than in the U.S., and respect for women is taught to boys in school. The threat of punishment is also a strong deterrent: rape and child sexual abuse are capital crimes, and domestic violence is punishable by time in jail.

In our own experience, we noted that most of the Cubans out at night were men, along with some couples. We saw Cuban women standing solo on the roadside waiting for a ride from a passing car—apparently a normal and safe mode of transportation. Men who approached us on the street left us alone if we just said goodnight and kept walking. They were respectful and not threatening.

Birth Control and Birthing Practices

Cuba's family planning policy is implemented through education designed to limit the number of children to two per woman in the city, and three or four in the countryside. The actual birth rate is just 1.6 children per woman, according to the World Health Organization.

Birth control is available to all. Most of the women we met were on the pill or depo-provera injections, called la vacuna (vaccine). Since vaccines are seen as important for health and are widely provided in Cuba, we interpreted the term la vacuna as a recommendation of sorts. Condoms are easy to purchase, and safer sex is taught in schools and doctors offices. We saw condom education posters in both of the clinics we visited as well as in pharmacies. Doctors have diaphragms but seem to recommend hormonal methods more often. We met two people who were intent to learn about fertility awareness, including a waiter who asked us how to conceive a boy.

Sterilization is an option for men and women. One doctor told us that women must be over 30 and have three children to be sterilized, but he noted that the procedure is not very common. Several Cubans told us that abortion is readily available between seven and nine weeks under a general anesthesia in the hospital. Early aspirations, called menstrual regulation, are done under local anesthetic at the polyclinics. Later abortions are performed from 12 to 26 weeks by inducing labor with oxytocin, but only with the health commission's approval. Repeat abortions are said to be rare. One hospital administrator insisted that women are counseled about birth control after an abortion, so multiple abortions just don't happen.

All births take place in a maternity hospital under the care of an obstetrician, followed by a two- or three-day stay. One hospital we visited had broken windows and birds flying throughout, but it was clean and had separate areas for diabetes care, high-risk pregnancies, post-delivery care and post-cesarean recovery. Women who give birth by cesarean—30 percent of all births—stay in the hospital for eight days. We wondered if the surprisingly high cesarean rate reflects the fact that births are managed exclusively by doctors. There are no midwives or doulas. Hospitals actively promote breast-feeding and claim that all mothers nurse at least initially.

Prior to giving birth, pregnant women may elect to stay in maternity houses that provide respite, better food and health screening. Adoption is difficult and rare but available through a health commission. Child-care centers are open to all from 6 a.m. until 6 p.m. and cost just 10 Cuban pesos (approximately 40 cents) a month.

Menopause and Conclusion

Cubans regard menopause as normal and do not treat it medically. However, one doctor explained that some postmenopausal women have psychological problems that may require counseling or hormonal treatment. We asked if doctors discussed the recent Women's Health Initiative, and one doctor told us Cuban practitioners use hormones very judiciously on a case-by-case basis. Cuba has more than its share of problems, and its harsh treatment of dissidents and slow progress embracing gays and lesbians indicate the shortcomings of the state-run system. But Castro's regime has confronted some of its past mistakes and changed its policies as a result. And although there is no woman-controlled health care in Cuba—not that we saw, at least—we as feminists had to admire the success of its top-down system in fostering values that support and respect women. Certainly, Cuban women never "won" these by wielding equal power in the system. It's an interesting contrast to the battle we continue to wage in this country.

Eileen Schnitger is development director of Women's Health Specialists (www. womenshealthspecialists.org), originally the Feminist Women's Health Center, in Chico, California. Christina Romero is the organization's clinical administrator.