In the valley of Viñales, Cuba’s finest tobacco is grown, nurtured by the climate and rich red soil that make Cuban cigars the best in the world. Vitamin-rich fruits and vegetables are sold at roadside stands.

This lush valley also is the setting for 10 consultorios, neighborhood clinics that have formed the backbone of the Cuban health care system since they were established more than a decade ago.

At one small consultorio on Calle del Cementerio (Cemetery Street), a mother brings in her 7-month-old baby to be weighed. She is warmly greeted by Nadilia Ramos Bernal, RN, a general nurse who has staffed the consultorio for 11 years, side by side with the neighborhood physician. Nurse and patient, longtime neighbors, catch up on news while the infant is weighed.

Ramos Bernal, 41, has worked in nursing for 23 years. After pursuing a three-year course of study from ages 16 to 19, she began her career in a hospital in Pinar del Rio, a city in the province of the same name, working in intensive care, burns, maternity and pediatrics.

"I came back to Viñales polyclinic in emergency, working here until the system of consultorios was begun back in ’89 or ’90," she said, explaining that a polyclinic falls in a category between a hospital and a consultorio.

"My hours are 8 to 12 and 1 to 5, but our services are available on demand 24 hours a day. We have people drop in, and we go to the homes of patients daily."

The main health issues Ramos Bernal sees at the consultorio are hypertension, diabetes, parasitic disease and hepatitis. "We have only two AIDS patients, and they’re treated like others," she said. "Educating them to live safely with their condition is a priority."

Short on supplies
As elsewhere in Cuba, medications are in short supply, especially for asthma. To the many American visitors who come to Cuba bringing medical supplies cut off by the U.S. embargo, she makes a heartfelt plea:

"Tell visitors to bring asthma medicines here, to consultorio No.6 in Viñales, where we have more shortages than in the city," Ramos Bernal said.

Antibiotics and even Band-Aids are in short supply. "We don’t even have enough disposable syringes, so we have to sterilize them and reserve them for HIV patients and for those with hepatitis B and C." Residents are more aware and better educated about AIDS in the municipalities, such as Viñales. In the cities, more people contract HIV because of tourism.

Ramos Bernal, who was drawn to health care as a child, especially likes to work with children and the elderly. Because she feels that education and public health are well-respected professions in Cuba, Ramos Bernal takes pride in her work.

"Our primary focus is on preventive medicine, which is the logical response to our country’s economic reality, as well as a sensible foundation for any health care system."

Every patient has access to care, with a diagnostic every three years that includes a cell check and blood tests, as well as immunizations every 10 years, Ramos Bernal said. A diagnostic test for breast cancer is available and women are taught to do monthly breast self-exams.

The consultorios provide extensive prenatal education that includes classes on nutrition and breast-feeding benefits. For those at high risk, maternity homes with eight beds to a room focus on rest and nutrition.

Cuba’s low infant mortality rate—7.2 deaths per 1,000 births—reflects the country’s policy of preventive health care during prenatal, postpartum and infancy, along with breast-feeding for at least four months, in accordance with World Health Organization guidelines, said Joan Edelstein, DrPH, MSN, RN, a professor of nursing at San Jose State University.

Baby-friendly policies
Edelstein, who also is an integrated perinatal education coordinator at Kaiser Permanente Hayward in California, said that Cuba is one of 10 countries in the world that top breast-feeding rates. "Of Cuba’s 57 maternity hospitals, 52 have earned "baby-friendly" certification, and the other five have filed certificates of intent to become certified."

The Baby-friendly Hospital Initiative, launched in 1991 by WHO and UNICEF, is a global network whose goal is to give every baby the best start in life by creating a health care environment where breast-feeding is the norm, thus helping to reduce the levels of infant morbidity and mortality in each country.

On a recent Health and Healing trip to Cuba sponsored by Global Exchange, a human rights organization based in San Francisco, Edelstein visited a neonatal intensive care unit at America Arias, an ob/gyn hospital in Cuba’s capital, Havana.

Babies are given no artificial formula, only breast milk, which is hand-expressed by the mother because there are no electric or manual pumps in Cuba.

Edelstein also observed the nurse-to-patient ratio and found it comparable to the United States.

America Arias holds about 200 patients and delivers about 400 babies per month. A typical hospital stay is between two and three days, five for birth by cesarean. In comparison, a 200-bed general hospital in Northern California would have 250 deliveries in a month, a one- to two-day stay for normal deliveries and three days for cesarean.

Edelstein did note the unsanitary conditions at several hospitals brought about by a lack of resources—basic items such as soap, towels, toilet paper and toilet seats, and sometimes even running water. In the worst circumstances, buckets of water must be hauled from the street.

Traditions live on
Nurses in Cuba still wear white uniforms and caps that identify their levels of experience and authority, such as charge nurse or supervisor, even at the psychiatric hospitals, Edelstein said.

There’s no nursing shortage in Cuba, where the system of education for health professionals is excellent and free. A two-tier program for nurses who follow a three- or five-year course of study is available, but there is no transition between the two, Edelstein said.

Those who complete the three-year program and want to advance to the next level must start over again, for a total of eight years. That’s not much different, she said, than in the United States in the early ’70s, which was why Edelstein pursued a baccalaureate degree in psychology rather than nursing.

Prisca Esther Miranda Hernandez, RN, head of nursing in the senior unit at Miguel Enriques Hospital in Havana, where she has worked for 38 years, continues to take special technical nursing courses to keep her skills up-to-date and supplement the three-year nursing degree she initially completed.

She is one of six nurses and five doctors who work in the outpatient unit that serves mainly mental patients. Like all nurses in Cuba, she earns 300 pesos, about $15 a month.

Physicians earn 525 pesos, or $26 a month. This reflects a recent wage increase for both professions.

"The salary is low, but we arrange our lives and try to buy what we need because much is free, including medical care. What hurts us greatly are the shortages in medical necessities," Miranda Hernandez said.

Her typical workday is from 8 a.m. to 4:30 p.m. Monday through Saturday, with 15 days of vacation twice a year. The typical retirement age is 55 for women, 60 for men. She’s 69 and still going strong.

"As long as my mind is clear, I’ll continue to work," she said. "This is my house, my specialty and my commitment to my country."