Also:  A Resident's MEDICC Rotation in Cuba:
Ethan David Loeb, MD |
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From the Front Lines:
Miguel Salinas, MD
By Gail Reed |
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ur "cover photo" this issue pictures Dr. Miguel Salinas, family physician with 82-year-old José Manuel Larrondo, one of the patients that Dr. Salinas and nurse Regla Berragarza attend to in Havana's central Plaza Municipality. A total of 140 families are in their care, 415 people in all. This family doctor-and-nurse team works out of a
converted first-floor apartment, where they counsel and treat patients. The waiting room is full of hand-lettered posters and murals on the importance of breast-feeding, household
hygiene and exercise. The day I interviewed Miguel—as he's called by everybody in the neighborhood—the mobile mammography unit had pulled up in front of the office to screen
several community women due for annual mammograms. Regla had already gone personally to the homes of each one to make sure they would be on time for their
appointments; and Miguel was just finishing up with a toddler who was running a high fever."Yes, if I were to choose again," he told me, "I would choose medicine. Maybe it's my
altruism, because there's no doubt that being a family doctor takes complete devotion. The hours are long, it's stressful and sometimes frustrating. But I'm left at the end of the day
with the satisfaction that I'm doing something important, that I didn't pass through this life for nothing, that I've served the people around me."
He and Regla have been in this neighborhood four years now. But Miguel's first experience as a family doctor came in his residency years, when he served in the remote
coffee-growing mountains of Guantánamo Province, eastern Cuba. It was in the settlement of El Chote de Caugerí where he first practiced on his own, without electricity and far from
city comforts, in a small white home-office on the hillside. "I attended 110 local families, but their houses were scattered all across the mountains in the area," he recalls. Those
were the worst years of Cuba's economic crisis of the nineties, and the kerosene-powered electric plant was without fuel most of the two years Miguel spent in the mountains.
Miguel was 24 in 1990, when he became the third family doctor to serve in the zone, where infectious diseases and parasitism were as common in his patients' clinical histories as
noncommunicable chronic conditions such as hypertension and asthma. His first challenge was to integrate himself into the community. "I've always had the same approach," he
explains. "And that is, right from the start, to share in people's lives as much as possible. The good times and the bad. If they needed extra hands to weed the coffee groves, I
picked up a machete and left the office to help. If they were celebrating, I'd take my chances with the locally-produced moonshine." "There isn't any other way, as far as I'm concerned," he says. "Because until you can
identify with people, and they with you, they will keep their distance, especially in these rural communities. The doctor, the teacher, anyone who comes from the city, isn't trusted at first."
Miguel Salinas says he went to the mountains confident in his clinical skills, honed as they were for several years in a medical school program that emphasizes practical training
throughout. But he did have his share of emergencies—a 2am knock on the door brought in from a raging thunderstorm a distraught young man whose wife was already in labor.
Miguel and his nurse delivered a healthy baby girl two hours later by lamplight. "I remember we had no aspirator," he comments, "so the nurse just sucked the mucous out of
the baby's nose, so she could start normal breathing. It was something." Miguel's second assignment came in a far different community: the highly urban
neighborhood known as La Timba, adjacent to Havana's Revolution Square. "The main health problems we faced there," he says, "were related to the poor habits of the
population. La Timba is a very diverse community: you can find scientists and engineers, but also out-of-work and unmotivated young people who've done a stint in prison for
stealing. So we faced social and psychological problems as well." Miguel was La Timba's first experience with a family doctor, and he recalls that most of his
time in the two years he spent there was devoted to very patient efforts at health education. "Forty percent of the women in La Timba weren't getting Pap smears, and by the end of
my term there, we had managed to convince over 90% of the women in the neighborhood to come in for the test. One hundred percent of the children were vaccinated; and we had no infant or maternal mortalities."
Introducing Miguel Salinas, MD Born and raised in
Manzanillo, Granma Province (eastern Cuba), his father is a construction worker and his mother a housewife. Miguel decided to become a doctor in his last year of high school, when a call went out for
more young people to study medicine. "It's a career that brings you close to people, that breaks down barriers," he comments today.Miguel received his MD in 1990 from the Higher Institute of Medical
Sciences in Havana, and went on to do his residency in Comprehensive General Medicine (Family Medicine). He has one sister, currently enrolled in medical school herself, who shares Miguel's small apartment
above his doctor's offices in Havana.  |
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The impact of the Cuban economic crisis was also acutely felt in La Timba, where nutritional and hygiene conditions had
seriously deteriorated. "Our main job was to prevent a decline in health standards: we worked more with people in their homes than in our office. We managed to help young people find jobs; they in turn began
to confide in us to help them with STDs, to trust in our discretion." Teenage pregnancy was one health problem not entirely solved by the time Miguel left La Timba in 1994: "We began working in an
integrated team of family doctor, psychologist, OB-GYN, and family nurse. But this is a long process, convincing young men and women to use effective contraception, since you have to
overcome their psychological barriers, their prejudices. And at first, by the time a young woman realized the benefits of using contraception, she had already had several children she hadn't planned on." So, the
daily job of convincing goes on with La Timba's new family doctor-and-nurse team.There are currently over 28,000 family doctors in Cuba, living in the communities they
serve, and covering over 98% of the Cuban population. This primary care model has been widely credited for keeping Cuba's health indicators steady—and in some cases improving
them—even during the worst of the island's economic crisis. I asked Miguel Salinas how indeed he explained such results. "Take the national maternal-child program," he said. "As
a national guide, it is designed to prioritize the health of women and children. But it is through the family doctor program that the preventive aspects of the program—which are
the most important over the long run--have been given a real chance. Like our efforts to reduce infant mortality, where our results not only depend on making sure that each
expectant mother comes in for her monthly exams and lab tests, but most especially on our ability to ensure that the woman is healthy before she becomes pregnant. That is the only
way to guarantee a healthy mother and newborn. And that is the beauty of working in health education: although it may be less glamorous, it's where effective health
care starts."
Above:  From the Front Lines:
Miguel Salinas, MD |
A Resident's MEDICC Rotation in Cuba
Ethan David Loeb, MD
 he first day he made a house call. "Now that was
an experience I had never had in the States", comments Ethan Loeb, saying visits to patients' homes was a highlight of his four-week rotation in internal and family medicine. "I went with Alex, the family doctor I
worked with, to look in on an 86-year-old diabetic woman with hypertension, who lives with her husband but no other family members. We talked with her about her diet, how she is cooking, if she is using oil or
lard. Then we walked to another house to check on a boy with an earache—we had changed his antibiotic at the doctor's office in the morning, and wanted to make sure he was responding to the new one."
Dr. Loeb, finishing a fellowship at the Scripp's Clinic in California, came to Cuba in May for a MEDICC rotation that took him into the heart of Havana and also to western Pinar
del Río province, an agricultural region best known for its tobacco crop. But that had not been his original idea: "I thought I would get to see alot of tropical diseases that I might not
have seen before," he comments. "But those diseases just don't exist in Cuba." During the week in Pinar del Río, where he worked with Cuban residents in a hospital emergency
room, he says "I saw my first case of leptospirosis". But other than that, he found that patterns of illness in Cuba resemble those of the United States more than they do of other developing countries.
The real surprise came in community medicine: "Cuba has a tremendous amount to teach in terms of primary care, prevention and integration of health services.....not to mention the
culture and the music! I was left wishing I had been able to see more of the innovative programs throughout the country." The Plaza Polyclinic itself is the "incubator" for some of
these programs, since it is the national reference center for primary care and is headed by one of Cuba's pioneers in family medicine, Dr. Cosme Ordoñez.
Dr. Loeb—known simply as David at the polyclinic--has practiced in Spanish-speaking community settings in the United States, including an outpatient clinic in San Diego. He also
lived in East Harlem, New York, and spent his senior year of medical school in Puerto Rico, where his mother was born. In the fall, he goes to New Orleans for a second
specialty in tropical medicine and travelers' medicine. His hope is to continue traveling, and later work in a dual capacity: with immigrants to the USA and travelers going abroad.
On a personal note: "The first day at the Plaza Polyclinic, I sat in on a 'jornada científica' where physicians presented their research in primary care...but after the day's discussions
were over, they wound up with a tremendous party. I've never seen a group of doctors have so much fun in my life!" |
