-Experience of Cuban Medical Brigade to Sri Lanka in the 80’s
Authors: MCs , Mrs Olga Chamero Trías*
Dr. Guillermo Mesa Ridel, MPhil**
Dr, Carlos Felipe Domínguez Ejiaek***
A new chapter was opened in Cuba-Sri Lanka Relations in 1986 with the signing of an agreement on Scientific and Technical Cooperation between the two countries, following the visit of late President J. R. Jayawardena in 1985. Consequent to the signing of this agreement, preparations were made to begin the Cuban medical collaboration in the Democratic Socialist Republic of Sri Lanka. As result, arrangements were made in Cuba in consultation with other agencies to send the first eight-member brigade in specialities of General Surgery, Pediatrics, Internal Medicine, Genecology and Obstetrics, Anaesthesia and resuscitation, Pathological Anatomy, Hygiene and Epidemiology to be stationed to work in rural hospitals in Sri Lanka.
The selected team consisted of four doctors from Provincial Health Directorates, three from Cienfuegos, two from the city of Havana, two from Santiago de Cuba and one from Granma province. They had to undergo a rigorous preparation programme covering meetings with officials of MINSAP (Ministry of Public Health), CUBATECNICA (Cuban Company, exporter of professional and technical services), ICAP (Cuban Institute of Friendship with the Peoples) and the Central Committee of the (Communist) Party, who laid foundations with information about the country where the team was expected to serve in next few years. This together with the degree of professional training given to the team consequently contributed immensely for successfully performing of their duties as pioneers of the medical collaboration in the brother country.
During the preparation period in Cuba, the team had to face many challenges. It was a high responsibility given to us by our country due to the recognition already earned with medical collaboration with other countries began in 1961. At the same time, it was a challenge to understand and worked in a country faced with internal conflict on national scale for several years. Even though, it was the political responsibility of everyone in the team, we were informed that it was a personal commitment by Commander in Chief Fidel Castro to the Sri Lankan people.
While preparations were ongoing, for the team to leave in September 1986 postponement came resulting a five-month delay. As a result the team returned to their normal works until a new call for service.
On 22nd February 1987, with a high patriotic pride and representing the true expression of the Cuban people´s spirit team of seven Cuban doctors embarked on a thirty-hour flight from the “Jose Marti” Airport towards unknown eastern world. At that moment, we realized that the two women selected to be in the team would not travel with us, and later another colleague would join us.
A stopover in Shannon, Ireland and another in Moscow, Russia completed the first stage of the long journey. A few hours later in the evening we continued the course to Bombay, India to end the journey in the so called “Island of the smile”.
Although we were fatigued due to the long travel, during the trip Cuban solidarity and humour did not fail among the team who later shared their lives for the first time in a new land. The hilarious “errors” causing laughter among ourselves due to misunderstandings of those who had never travelled before also help us to keep up in high spirit. There also anxiety of the “passage to the unknown” land and nausea and vomit that unhappily accompanied with the only woman in the group is well remembered.
The arrival in Colombo and welcome was particularly warm, and we received the first signal of the great hospitality in the country. An unexpected and emotional encounter with the Chief of Mission of the Cuban Embassy and the CUBATECNICA Representative at the steps of the plane was such a “full-blooded” Cuban meeting. This was accompanied by a warm welcome kiss and a bouquet of flowers leaving in all of us an indelible mark that represented the first “fighting order”.
The tight initial programme had several indications aimed at the adaptation of the new time zone that would rule our biological clocks for twenty five months. Afterwards, we received an updating about the situation in the country, work organization, the good Cuban music that exalts the soul and the participation of the Brigade in a welcome cocktail hosted by the Solidarity with Cuba Committee.
After the meticulous preparatory work where all members of the Diplomatic Mission were involved as tutors, we were sent to two of the cities where our services were mostly needed. These were General Hospital in Ampara – located about 320 kilometres from the capital – where professionals of the clinical and surgical areas would work, while the pathologist was assigned to the General Hospital in the city of Anuradhapura, sharing her location with the hygienist. The Head of the Brigade and the Epidemiologist were located in a regional hospital of the same city, around 260 km from Colombo. A specialist in Internal Medicine joined the team a month later.
We must acknowledge that the first challenge faced made by the Medical Brigade while in Sri Lanka was to learn local habits and customs. We did not know about the Sri Lankan custom of moving the head side to side and say “OHH” means something affirmative. In one incident where a team member visited a restaurant and after reading the menu asked for chicken: the first “OH” from the waiter the team member interpreted it as “they did not have”, then he asked for a steak receiving the same response, he was about to get restless thinking that they did not have what he wanted to eat. Then he saw the waiter bringing all food items together. Of course, he could not eat it.
Particularly millennial, rich and unknown food culture of the country played us a bad turn. The traditional food showed strong and extravagant aroma “in the Oriental style” and it basically consisted of chicken marinated with garlic, onion and cinnamon, in addition to much spicy curry powder and chilli, which would move tears of those daring to savour it, meanwhile, our hosts thought it was because they miss their families in Cuba. There was even some who tried serve Tamil coffee with added cardamom, the same aromatic seed used to flavour sweets and puddings.
We learnt about the living conditions of the rural population, the development challenges in its cruellest phase, misery, illiteracy, malnutrition, poor health education and vandalism. We were able to see that lack of understanding as a source for the poor health.
We heard that Cuban cigars were known through commercial companies and aircrafts flying to the country. However, we learnt that ancestors used betel leaves with a mixture of calcium and other seeds, causing excessive salivation and a permanent sweet breath, while several reddish spots dropped on the ground -as expelling salivation residues- similar to effluvium from patients with tuberculosis. This practice is still commonly assumed by population that does not know its close relation with oral cancer, upper gastrointestinal tract cancer and the high rate of mortality due to cardiovascular diseases, which in turn, is exacerbated by the high levels of cholesterol, arterial hypertension and the continued stress caused by conflicts and economic problems.
We found that peoples in cities where we worked were located in areas of conflicts between Government forces an armed groups. These cities were moderately populated, with a long and paved main street. Some places had a tower clock with small shops where typical aroma of fish, curry and coconut oil converged and mixed up. The latter was one of the flavours which our palates was never adapted.
Given the number of dialects and languages, our work initially became very difficult, to the point of imposing another great challenge to the team and their professional performance. Those who thought that they knew English realised that preparation was poor. Even though, our own performance and the decision to fulfil the mission entrusted to us, led medical professionals to improve the English language skills (adapted to each locality), including technical terminology required by each case and even to begin learning words, complete phrases and short conversations in Sinhala language, the most commonly spoken by average population.
There were occasions where patients were assisted by local physicians with translation from Sinhala or Tamil to English. But most of us had to learn the hard way to speak the native language. In the meanwhile those displayed their abilities were able to make themselves understood and understand the answers.
Going further step we even compiled a dictionary of common medical phrases and their pronunciation in local language and leaving them behind in writing for the benefit of doctors that succeeded us. Unfortunately, we did not have a vision to keep it until the present day for a timely publication.
All this favoured us in our professional performance while at the same time setting guidelines for a true interrelation with the local community.
We also learnt that even in a country in conflict, our solidarity assistance was recognised by the most progressive groups, regardless their nationality or social group, despite the dismay clearly expressed by the National Medical Council in Sri Lanka.
One example of this was in Ampara, where our team was always admired and protected by the most important parties, as it was an assistance to their people. Even in moments of most confrontation, members of the Government and Tamil groups came together at the same time around to the team member houses to make sure nothing would happen. Only once we were alerted that a kidnapping of a surgeon was suspected. This was reasonable, as a guerrilla always needs a doctor, even more, a surgeon. Fortunately nothing had happened.
In Anuradhapura a member of the Communist Party mysteriously turned up at the house of one of the team members to offer help if required.
This way we learnt to love the noble people of Sri Lanka to whom we offered our humanitarian service and love. They rewarded us with the most sensitive tokens of friendship and brotherhood.
To mention some of the remarkable results obtained from the technical and professional point of view, it is worth stressing the work done in the field of surgery by its team leader who is no longer with us. The surgeon of the brigade was the most charismatic person who fulfilled four international missions before, including the role of personal doctor to President Zamora Machel, but above all with an excellent technical preparation and enviable surgical skills, apart from the surgeon, he was also the orthopaedist, angiologist, proctologist and neurosurgeon. If he did not do more, it was because of lack of resources to treat medical pathologies at that health facility,
Once a patient suffering a skin tumour weighing over 25 pounds came to see him. Doctor said “I dare it”. The patient and her families did not know how to express their appreciation to the doctor when she was released from hospital. On top of that, he was able to improve the hospital conditions and due to his insistence, a new operating room with better conditions was built by a candidate for mayorship office with new beds, fans and isolation room for serious cases, among other things.
Work in the internal medicine room was actually exhausting. Treating diseases that had never been seen in our country. Health system suffered from the lack of necessary conditions and, besides working harder, further education was necessary. A consultation for cases of tuberculosis was implemented, disease that was very common and could be seen in all its clinical forms, however, the verification of the diagnosis was very improbable, due to lack of resources, although an important preventive work was done with families.
Malaria was the most common disease. Almost 50% of cases daily admitted and most of deaths were due to this disease. Number of medical consultations and cases treated was surpassed, previous records in one year of work.
The pathological anatomy service of the Anuradhapura Hospital, which was closed for several years as there was no specialist revitalised, facilitating quality assurance of diagnosis and medical treatment, also representing considerable savings in costs. The service was extended to the Ampara Hospital with arrangements to send slides and results by post from one city to another.
High suicide rate was a curious. Most of them due to passionless reasons, as well as, influenced by the long war combined with economic problems arising in a vicious circle. Patients often used pesticides. Among them only few could be saved. but those who survived were sentenced or imprisoned or had to pay a fine. It was a contradiction to us to see that patient had to pay to continue living, especially when reasons were economic. Our preventive efforts for that matter failed to achieve the elimination of the penalty (as they were laws), but we do achieve an agreement with the police station by making influence on the form of payment which had always been excessive or to charge with cleaning materials for the hospital, which was scarce. With this a concrete social contribution was made for the alleged crime of taking their own lives.
Once a young adult was admitted in the Medical Ward with the diagnosis of pneumonia. The accompanying diarrhoeal episodes and neuropsychiatric manifestations made us think of an entity called “Legionnaires’ disease”, emerging disease transmitted by air conditioners or showers in bathrooms. After few minutes new cases were received, all of them from a military cell, and we were able to take actions and began to correctly treat patients. There was one fatality, but if we had not thought of it, the number of fatalities would have been higher.
Hospital birth rate in the area was also increased and, accordingly, infant mortality also considerably decreased. Although, statistics were not properly maintained, we remember that, in the hospital, there was only one maternal death diagnosed with cerebral malaria and not due to an obstetric complication. Considerably reduction of the hospital postoperative infection rate was achieved upon building relations with sanitation labours of the surgery room. Local staff and even patients, some of them with no proper habits of cleanliness when entering the operating room.
In Paediatrics, some basic practices were achieved, such as to keep the ward always clean, and as in the other medical specialities, diagnosis was frequently clinical due to lack of the most indispensable auxiliary means in a hospitalization room. It was also achieved to influence the importance of breastfeeding within women during the postpartum period, weaning process habits of children under one year of age and contributed to significantly reduce mortality among children below the age of five. A UNICEF recognition was given to specialists of Anaesthesia and Obstetrics to favour family planning of the Region through surgical ligations. This consisted with a cash award which was used to improve the general living conditions of collaborators.
A deserved recognition was also given to Hygiene and Epidemiology as epidemiological studies were conducted for two of the most lethal diseases affecting the population of the Anuradhapura region (Japanese encephalitis B and Malaria) which significantly contributed to acquire knowledge of both health problems and the decision-making process in health sector.
In the case of Malaria, we found the weaknesses of the Health System to the test due to impossibility of prevention and its effective control, which was expressed by a senior official of the agency to specialists that worked on it. Similarly, both specialists faced the study and control of a Xerophthalmia outbreak, illness caused by vitamin A deficit, in elementary school children, whose poor health and hygiene conditions favoured the outbreak. This led to actions taken by the Government and international organizations with free medications for the control of the illness.
An idea blossomed from the continued interdisciplinary teamwork of the brigade flourished during the assignment. The poisonous-snake-bite infection rate in the country was high due to farming population mainly working in the field going barefoot, sleeping on the floor due to economic reasons or local customs. At least one patient per day was suffering from this serious issue. We devoted ourselves to study the therapeutic possibilities and there was an anti-ophidic serum manufactured in India which often was not available at a pharmacies. When patients came on time and serum was available, they were saved. In other cases they came too late or did not wake up due to bites while sleeping. Sometimes, with an inadequate treatment, with excessive ligature in the limbs or incisions made to “drain” poison. They did not die due to the bite, but they do due to gangrene. We met professionals of Traditional Medicine, listened to their experiences, which together with those we had acquainted, allowed us to begin health education talks.
In the light of the epidemiological situation, we wrote a monograph on the clinical-epidemiological aspects and treatments for poisonous snake bites, which later became a publication of articles and presentation of the subject in an international Congress. We left copies for future brigades and, thereinafter in Cuba for several consecutive years, this subject was taught in courses of Tropical Medicine for future international students.
Support given to the team by the Cuban diplomatic mission in Colombo was a genuine expression of brotherhood and patriotic sentiments created a work spirit within the team. During occasional visits to Colombo the Medical Brigade cooperated with the Embassy staff in diplomatic and cultural activities. The team was recognised for its support to diplomatic tasks of the mission. One of them was a dinner hosted by the Cuban Ambassador to the President of the Sri Lanka, where expressions of culture, music, dance and the multifaceted nature of Cubans were offered. Participation of the Medical Brigade in Cuban exhibition, with members of Friendship Societies with Cuba in Sri Lanka, were always a pleasure while in our cities of work or while in Colombo.
The visit to Yahalakele estate was particularly emotional for all of us, as it was one of the places visited by Che Guevara, during his visit to Sri Lanka on the location of the signing of the document for the Establishment of Diplomatic Relations between the two countries, in 1959, leaving his imprint in a tree hi planted at that State. Were we all gather to take photographs.
One of the most far-reaching achievements of our mission was the continued and permanent political and ideological relations established within the Brigade. Psychologists often state that a group achieves a true sense of belonging when adopting phrases symbolising the feeling and acting of its members. Our slogan replicated by all at any time was: “to return to the motherland being healthy, sane and prestigious”. It was 100% accomplished.
There were many examples of the personalised attention to the team by the Cuban Diplomatic Mission. This was especially evident when a team member suffered a neurological disease with no known cause. Until his total recovery he was in Colombo by the care of members of the diplomat Mission, every guidance and briefing to update us on the political situation; every telephone call to give guidance or provide encouragement; also the expected newspaper by post, as well as up-to-date materials; lending of electrical appliances to enjoy during free time and so on, we could enumerate many other actions showing the interest for making the group´s slogan a reality.
The Cuban diplomats used to fulfil a systematic programme of visits to places where team was assigned and there were rich exchanges and timely making-decision processes, It is clear that such visits were always accompanied by reasons to celebrate historical dates and cultural activities, recall Cuban leisure activities, casino dance and the traditional Cuban food, usually followed by a good coffee.
From links established by the Cuban Mission with the national health authorities and the Government authorities of regions in collaboration, the whole Medical Brigade used to enjoy an-all-expense-paid week at the capital every six months. There were periods away from work were mostly used to finalise arrangement and details for scientific symposiums and to undertake analysis of the work performed by the Medical Brigade. We never forget assistance provided and kindness shown to us by the Sri Lankan Minister of Health Dr Ranjitt Attapattu.
We must say that the good interpersonal relations developed during the collaboration period and the effective psycho-emotional support shared by the Cuban Diplomatic Mission staff with the team, also involved local employees of the Embassy and residences. And all these actions have a decisive impact on exemplariness shown by medical collaborators during the developments of November and December 1988, period in which the country was almost totally paralysed due to internal conflicts and, in spite of the total lack of communication, they show an exemplary attitude with complete disposal to fulfil any task, even the most difficult ones.
The solid links between members of the Medical Brigade and collaborators from other sectors, was a very singular experience. Such were the cases of Culture, Hydraulic Resources and sport coaches, who joined the tasks in which the medical team was working on, promoting a very fraternal and comradeship atmosphere. All this made us grow as professionals, as human beings; we became more revolutionary, more patriotic, more communist, and made us love motherland even more.
Medical collaboration substantially increased over time and obtained positive indicators, in comprehensive care and hygienic-epidemiological control with high degree of satisfaction of the attended population, which was acknowledged by local health professionals and technicians with whom they worked.
All this was really possible due to the solid bonds of comradeship and brotherhood that, as time went by developed. The support and care giving to us by the Health authorities of the Government of Sri Lanka, and the special attention we also received also by President J.R. Jayawardene, played a decisive factor in the accomplishment of our mission.
We have had the privilege of being pioneers and active protagonists of the medical collaboration in the Democratic Socialist Republic of Sri Lanka, while fortunate to have shared precious time with our srilankan friends. We never forget their kindness and their support.
Farewell was truly sad. The anecdote of those in Ampara describes it as follows: “The new collaborators who arrived few days before were still afraid at the house gate. The surprised look on “Pucha”, the dog´s face ¨suspecting that something was happening, but its brain could not understand.
Population was both sides of the path leading to the road to Colombo. They were really emotional and threw flowers to the leaving members of the Medical Brigade
We recall with love ours nurse of the OPDs (Outside Patient Department), the laboratory and administrative staff, and the daughter of the first serious patient we treated for a heart attack, all were taking the typical bow of placing a hand on the heart and lowed the head. Some were throwing wild flowers, while others cried.
We are satisfied that we were able to contribute to enhance the well-earned internationalist prestige of our people, fact acknowledged by the Central Unit of Medical Cooperation of the Ministry of Public Health of Cuba, the Epidemiological Unit and the Health Secretariat of Sri Lanka, the Health Service Regional Division in Anuradhapura in Sri Lanka and the President´s Office.
To our dearest Commandant in Chief, we thank him for giving us the opportunity to participate in such an important mission and for having placed his trust on us.
