Cuba Up Close

A death brings loss and insight into a country that is lacking.

By Alex Marshall

I had not expected to find myself in Cuba in a hospital that looked like a run-down suburban elementary school. But that’s what happened when a friend unexpectedly died.

Three of us had been bicycling between the cities of Santa Clara and Remedios, and I was excited about the material I was collecting for this story, which was supposed to be about my impressions of the country as my companions and I biked through its cities and countryside. Suddenly my friend Steve, 57 and apparently healthy, collapsed into the roadway. It was a shock, to say the least. Very shortly, we were hustling his body into a passing taxi, with a helpful driver.

In about 15 minutes, I would be at the door of the “new” hospital in Santa Clara, trying to get a medic’s attention. The experience, while traumatic, would take me into places difficult for a foreigner to reach, like the inside of a hospital examining room, a state-owned funeral home, a hearse, and a forensic institute. The autopsy report said that Steve had died of a heart attack.

What I saw that day added to the impressions I had already had: Here was a country that was shockingly primitive. The medical attention my friend received was rudimentary, in facilities that were skeletal. The infrastructure of the country, from transportation to the Internet, was rudimentary at best. I saw an absence of physical and technological resources in a nation that lacks a fully convertible currency, and so persists by barter and self-sufficiency in an age of global trade. I saw people whose lives were lived in very small circles.

This is not to say the country or its people were without their charms or joys. Overall, the nation still resembled the Cuba I’d visited 25 years ago, on a reporting trip. Classic American cars — Packards, Edsels, Chevies, and Studebakers that were antiques a generation ago — still cruised streets lined with glorious, crumbling historic buildings. The people, while lacking employment options, had a lot of time for conversation, dancing, and the arts. It’s also true I did not see the visible hunger or disease evident in Haiti or parts of Africa. I did see worn faces, often with a calm stoicism blended with frustration.

What was new was the addition of a thin veneer of tourism, with its own currency, called “convertibles” or CUCs, that are spent (mostly by tourists) in a separate system of shops, restaurants, and even infrastructure, including a bus system. This influx of tourists also means a new influx of cash for the government, and to some degree regular citizens as well.

The past is present

By most standards, Cuba is still a ThirdWorld nation. This was brought home to me again and again. One of my first “aha” moments had come on our first full day of bicycling, in Cienfuegos, a city founded in the 1800s whose crumbling buildings lined the broad, tree-lined streets. It could have been an aging city in France or Spain, if either country had fallen on hard times. The city sits on an oval-shaped, hill-ringed bay that empties into the Caribbean.

Bicycling through the streets at 9 a.m. during a weekday rush hour, I was surprised to be surrounded by horse-drawn carts that accommodated six or eight people at a time. It turned out that this was the go-to form of mass transit here and in other towns we would bike through, though not in Havana.

The extensive use of horse-drawn carts as people movers meant Cuba’s transportation system had reverted to the 19th century, when horse-drawn streetcars were common in the U.S. and elsewhere.

By American standards, the traffic here was light. But it was amazingly diverse, mixing horse-drawn vehicles with cars, as well as bicyclists and even people on foot. The buses seemed cobbled together from various remnants. Once I saw a Mercedes cab-style truck pulling a giant, rusty metal container with passengers inside. These sorts of vehicles contrasted with the clean new conventional buses that tourists used in the “Viazul” system, a network of modern buses and stations that is accessible only to those who have CUCs to spend.

My trip into the country’s health and police system simply deepened my impression of a nation sorely lacking resources.

Cuba has a reputation for excellent health care. So in my unexpected journey into its medical system, I expected to be impressed. Instead I was shocked at the worn, run-down hospital corridors and the appearance of staff simply standing around, doing nothing. When our car pulled up at the emergency room entrance, I had to work to get anyone’s attention and eventually had to help remove the body myself.

This sort of thing happened repeatedly. Hours after we arrived, the mortuary drivers nonchalantly asked my help in lifting my friend’s body off a hospital gurney, into a body bag, and then into the back of a hearse. Was this the communal nature of the society? I didn’t know.

What was clear was the bare-bones nature of the place. I had heard how well trained Cuba’s doctors were, and I saw nothing to contradict this. But a lack of resources must impact their skills eventually. At one point during what would be a very long day, I sat down in “the library,” apparently reserved for off-duty doctors. One of the resources was a box with worn, dog-eared index cards, referencing journal articles from years past. There were no computers in sight.

Parts of the hospital were dirty. To cite one vivid example: Directly across from the examining room where doctors tried to revive my friend was a bathroom with an overflowing toilet and broken sink; there was no place for visitors to wash their hands.

I am often critical of American health care, on a variety of grounds. But things occurred in Cuba that would never happen in an American hospital. After my friend Steve had been declared dead, I asked the doctor his name, a routine question in a hospital in the U.S.

“Why do you want to know?” he asked. I explained that I was keeping a record of things so I could explain to my friend’s family what had occurred. The doctor reluctantly gave his name. A similar exchange occurred later the same day. This time the doctor would only give her first name. What did these doctors fear?

As the day progressed, it was as if I was being given a tour of the country’s meager resources. In the later afternoon it was decided I should accompany the body to a state-owned mortuary home, and then to Havana, where an autopsy would be performed. As the person in our group who spoke the best Spanish, I was the most likely candidate for these tasks.

From the hospital, the two attendants and I loaded my friend’s body into a Chinese-made truck or station wagon that bore the name “Great Wall” on the steering wheel. It had been converted into a hearse. On the side were the words Funeraria Las Villas, a state-owned funeral service, I was told.

When we got to the funeral home, I was again greeted with worn hallways and a general decrepitude. I asked for a place to wash my hands, which I hadn’t done in some hours. At first I was shown a bathroom, but again the sink was broken. Finally I was led out into a courtyard, where an ancient faucet emptied into a stone basin in the yard. Someone dug up a sliver of soap for me.

Eventually, a mortuary attendant and I made our way in the hearse to Havana, a journey of about 175 miles, where an autopsy would be performed at the Instituto de Medicina Legal — the forensic medicine center, which occupied another worn cluster of one-story buildings. The police had decided that an autopsy needed to be done that day. We didn’t arrive until late that night, after hours spent searching for the institute. The driver had never been there before.

On the road

Once on the highway, my perspective shifted from medicine to the state of Cuban transportation. The country does have a few interstate-style, grade-separated, limited-access highways and we took one of those, A1, to Havana. It was deserted.

Often I would only see one other car, far in the distance, on this long, straight road. It was quite a contrast to congested American freeways. The driver said this was typical. So light was the traffic that this would have been a very safe place to bicycle, in contrast to the crowded intercity roads we had taken. It would have been boring, though, with many miles between exits as in the U.S. and nothing much to look at along the way.

“The country’s transportation infrastructure is indeed a pending and major problem and challenge,” says Rainer G. Schultz, a doctoral student in Cuban Studies at the David Rockefeller Center for Latin American Studies at Harvard. “There has been some recent investment and changes in road security; legal-administrative change; railway, air, and urban transport, etc., but it is still far from sufficient.”

In this case, though, the problem was not a lack of highways, but of cars to fill them. The national, intercity train system, which I got glimpses of, was even more decrepit. Havana’s once impressive central station was a wreck, with ancient locomotives and railroad cars creeping out along a few lines to a few cities.

The state of the state

Among the responsibilities of a government are education, public health, food, and public safety. By those measures, Cuba does pretty well. Life expectancy matches that of the U.S., according to United Nations statistics. While the hospital facilities I saw were worn, public health specialists I interviewed in the U.S. said Cuba excels at primary care, including things like clean water, vaccinations, and neonatal care. And in such a heavily policed state, there is little conventional crime.

Then there’s education. According to UNICEF, the country has a 100 percent literacy rate, and 85 percent of the population attends high school, matching or exceeding rates in the U.S. I have some distrust of official statistics, but my travels bore out the country’s emphasis on learning, including in the arts.

Cuba Facts

Slightly smaller than Pennsylvania: Pop. 11,061,886 (July 2013 est.) 6.4 physicians/1,000 people (2007) Source: The World Factbook 2013–14

One day after arriving in Santa Clara, before my friend’s death, I took the opportunity to bicycle to the University of Santa Clara. It was a campus built about seven miles outside the city, from the looks of it in the 1960s. It was a complex of oblong, modernist-style buildings, scattered across a large campus and to my mind set too far apart, making walking difficult. The students seemed like typical college students.

One professor of social sciences I spoke to, Carlos, defended the country’s university system by noting its advantages. “We are a Third World country,” said Carlos, who was dressed in a T-shirt and sweated in the heat while he waited at a bus stop across from the main campus. “But … look at those students [as he gestured to the campus across the street]. All of them are attending without paying a cent. It’s true you have to do without many things, things your family might want. But what is important in life? Culture and learning. You can have that here and live a rich life, rich in culture.”

Later that same day, in Santa Clara’s central plaza, I saw a gaggle of elementary or junior high school students coming out of dance classes that were held in one of the historic buildings on the main square.

Despite good overall health and education, however, the country seems to fail in providing fuller lives for its citizens, including the opportunity to participate meaningfully in their own government. Cuba is still ruled by the Communist party, whose membership is very limited. But much as representative democracy might be important to me, few Cubans I spoke with put it on their list of priorities.

“No hay carne de res,” said one taxi driver, complaining about the lack of beef. I heard this several times. Cubans are fond of beef dishes like ropa vieja, but it’s difficult to obtain because most of it goes to tourists in restaurants that Cubans can’t afford. To the extent they have meat at all, Cubans eat pork and chicken.

One man I spoke to, a retired doctor, said that after more than 50 years of service, he now lived on his pension of $9 a month. He had been invited to a conference in Washington some years ago, but the government would not let him go. He spoke to me from an ancient building, built in 1825, he said, with timbered ceilings that were beautiful but falling down around him.

One owner of a tourist-related business, a muscular man with bulging forearms, noted that Raul Castro, the de facto leader of the country since his brother Fidel Castro fell ill, was opening the country up to both more market activity and overall freedom, including foreign travel and the sale of private property. This was evident. I saw many “for-sale” signs on apartments, a strange sight in Cuba.

Uncertain future?

Speculation about Cuba’s future has been rampant for a half-century. But Cuba has continued as it was, its streets still filled with antique cars and a Castro still at the helm.

Imagining myself an urban designer, I couldn’t help contemplating what I would do to Cuba if given a free hand and a hefty sum of money, say from a European Union pot of infrastructure development funds. My first thought was to avoid the whole era of postwar American sprawl, and redevelop the country around high-speed or at least vastly improved rail service.

As an island roughly 700 miles long and less than 100 miles wide in most parts, Cuba could make most of its cities and towns easily accessible by rail. You could have a central high-speed rail line down the center of the island, with branches accessing coastal cities. I’m afraid, though, that the populace might demand more private cars and better roads first, and embrace a Cuban version of suburban cul-de-sacs.

Julio Cesar Perez, a Cuban architect and urban planner who is currently a visiting professor at Harvard, said my idea for development based around rail was not so crazy. In an exchange of e-mails, Perez noted that his own Master Plan for the 21st Century Havana, a set of plans for the renewal of that city and intended as a model the entire country, revolves around improving the train service and using it as a vehicle for development.

“This has a historic background” that any such plan could build on, Perez wrote in an e-mail. “Cuba was the fifth country in the world to start a railroad system, back in 1837, even before Spain, despite being a Spanish colony then.”

But when and how quickly faster development comes to Cuba is anyone’s guess. Certainly a key factor is how long the U.S. maintains its virtually complete economic embargo. The Obama administration has loosened travel restrictions to the extent it can. Right now family members, full-time journalists, and officially organized tours can all travel legally from the U.S. If travel were truly opened — and this would mean Congress repealing or altering the 1996 Helms-Burton Act, which maintains the economic embargo — the country would be transformed simply by the flood of American tourists. I’m glad I had a chance to see it again before this happens.

One potential area of appeal is the country’s historic architecture. Ironically, because of communism, which halted capitalism’s merciless mill, very little has been torn down or built since Fidel Castro took power in 1959. Thus, the country is a preservationist’s dream. It is not unusual in Cuban towns and cities to see a profusion of styles and histories. Within one block you might see a colonial-era building from the 1600s or 1700s, with columns carved from coral, next to an ornate 19th century Beaux Arts building, followed by crisp-lined midcentury modernism.

Cuba seems to have particularly embraced modernism before Castro’s revolution. You find a profusion of chrome railings and cantilevered, butterfly-winged porticos, and curving concrete balconies.

Many groups in the U.S. have noticed Cuba’s treasure trove of historic architecture, as well as its decaying infrastructure. They are motivated by a mixture of ideology, future profit, historical interest, and nationalism. Institutions include the Cuban Transition Project at the University of Miami, the Center for Cuban Studies in New York, and many others.

Until Cuba’s leadership changes dramatically, or its leaders make different decisions, this island of about 11 million people will continue on a path remarkably different from the rest of the world. Those on the outside who care about the country are still relegated to the status of interested observers.

Alex Marshall, a writer and journalist for 25 years, is the author of The Surprising Design of Market Economies and How Cities Work. He is a senior fellow at the Regional Plan Association in New York City.

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Images: Top — Without the merciless mill of capitalism, Havana looks lost in time: an architectural treasure trove. Photo by Lyman Labry. Middle — Jerry-built trucks, classic American cars, bicycles, pedestrians, and even horsecarts share the streets in Cienfuegos, Cuba. Photo by Alex Marshall. Bottom — This aging hospital in Santa Clara looked grim and deserted. Photo by Alex Marshall.