Footnotes – part one by Pamela Johnson

On a visit to Cuba in 2015 Pamela Johnson had an accident requiring emergency treatment. Friends back home remarked how lucky to be in Cuba – ‘they have so many doctors, such amazing healthcare.’ In this excerpt from a work in progress, she revisits the experience and reflects on why the pursuit of healthcare is central to the island’s history

Sunday 6 December, 2015

The bus to Havana isn’t due until nine-thirty.  Last night I packed my suitcase so there’s nothing to be done but, at seven, I get up anyway. I want to savour one last outdoor shower in the tropical air of Cayo Santa Maria. David, my husband, dozes on.

We’ve no idea what the hotel in Havana will be like or even if the booking is confirmed; this might be my last shower before home. As it turns out, I won’t have another shower for two months. I head for the tiled area open to the sky. With slatted fencing all around and tropical vegetation on the other side, it’s entirely private and makes perfect sense in this climate.

Enjoying the play of water over my skin as I rinse shampoo suds, I study a line of ants marching up the yellow tiles. They navigate a route that carefully avoids my splashes.

It’s hard to believe it’s winter and only three weeks until Christmas. I’ve not even thought of cards or presents let alone bought any. There’s nothing to buy here apart from rum, cigars or cigar boxes and t-shirts displaying the image of Ché Guevara. There are no shops full of glitter and gifts.

Two weeks ago, en route to catch the Gatwick Express, a minicab zoomed us along Oxford Street at five-thirty a.m. With no crowds on the pavements we had an unimpeded view of the decorated storefronts. The excess of Christmas-stacked windows in the dawn light was unsettling. All that stuff.  It was a relief to be lifted out of the festive frenzy to focus instead on this beautiful, complicated island; to visit its sites of revolutionary history; to attempt to compare first-hand present-day Cuba with my vivid childhood memories of the missiles crisis.

October 1962. There I am washing my hands in cold water that streams from the solid brass tap, trying to get some lather from the block of pink carbolic soap.  Alone in the girls’ toilets in the basement of Bolton County Grammar School where six weeks ago I arrived in the first year, excited by the potential that lay ahead. I’m alone because my period came mid-lesson; alone with time to think about the news of ships heading for Cuba loaded with nuclear missiles. Everyone is talking about it; about a clock that is ticking. If the ships don’t turn back – Wooosh! A mushroom cloud. No one survives. If I’m going to die I want to be at home with Mum. President Kennedy has been on the news for days talking about the man with a big beard and soldier boots. Castro, everyone says, is a dangerous man, in league with bald Mr Khrushchev, who must be dangerous because he is Russian. Handsome President Kennedy will have no choice. If anyone can, he will save us.

So I’m given to understand and I believed it then, though, growing up and growing in political awareness I came to understand it had been more complicated. Still, the memory of that terrified child surfaced often during our two-week tour, especially at the start in Havana, at the Plaza de la Revolucíon where we’d stood opposite The Ministry of Defence, an unassuming slab of a tower block, site of 1962 operations. I wished I could have sent a message back to my eleven-year-old self as I listened to the Cuban version of the events that led to the unforgettable stand-off.

‘Always it was meant to be a green not a red revolution,’ explained Raul, our guide. ‘Cuba wanted nothing to do with USSR at the start. Ernesto Ché Guevara made a speech here in this place,’ he said pointing to the ground. Raul always referred to the revolutionary hero in this way. Never simply Ché. 

In 1960 Ché said: Are we or are we not struggling to be a free nation among free nations, without belonging to any military bloc, without having to consult the embassy of any great power on earth?[i]

‘After Bay of Pigs, no choice,’ our guide continued, explaining how, in 1960, the CIA had plotted to invade the island having trained fifteen hundred Cuban exiles in Miami.

‘They even painted an American bomber in Cuban airforce colours! Kennedy didn’t want the world to know he’s behind it. He thought Cubans here would join his side.’ When the exiles landed at The Bay of Pigs, on the south coast, Castro had the Cuban air force ready, along with 20,000 ground troops. Over 1000 exiles were captured and imprisoned.

 ‘What did Castro do?’ Raul paused for effect. ‘He traded the prisoners for 50 million dollars worth of baby food and medicines,’[ii] he said with pride, to prove that, even after this affront, the welfare of the population remained a primary concern.

 Following those events Cuba became piggy-in-the-middle of the Cold War.  If the Revolution was to be about social justice – healthcare, education, housing – Cuba could not afford to spend already scant resources on defending a small island against a super power.

‘That’s why Castro agreed to missile bases on Cuba – self-defence.  Did you know that the USA had secretly placed nuclear missiles along the Turkish border directed at Moscow before 1962? Self defence. Not aggression.’

When the crisis was averted Kennedy agreed to dismantle the missiles in Turkey but only if that fact was not made public.  ‘Kennedy did not want to been known to the world as an aggressor.’ And he made sure it was kept that way so it was decades before the facts of USA missiles in Europe became widely known.

As I turn off the shower, I’m well aware that the floor is flooded and there’s no bathmat. Don’t step on wet tiles. I say to myself. I’m being cautious, as I had been round the pot-holes of Havana, the cobbles in the historic town of Trinidad and the showers in all the Casa Particulares where we’d stayed these last two weeks. 

cobbles in the historic town of Trinidad

Recently recovered from torn ligaments in my left ankle, I know how easy it is to fall.  The skin of my left foot is still purple from the bruising.  

I reach for the beach towel that I’d hung to dry over the fence, fold it in half, the better to absorb the water, and lay it over the wet patch. Carefully, I step onto it, right foot first.

My heel skids as the layers of fabric separate and slide away from each other.

I’m falling. Falling. Falling backwards.

My head, my back

I picture either or both taking a crack on the tiles. I wait for the impact. But there is no blow to the head, no pain. I’m on the floor. Relief!  I’m not unconscious. I turn my attention towards my splayed legs. My right foot flops inwards, as if it will fall off my leg. And what is that raised red patch, that bulge, on my ankle? It’s a bone pushing against flesh, says a calm voice in my head. Keep still. A Girl Guide knowledge of not moving the injured surfaces. At the same time another part of my mind, the bit that’s still falling, hasn’t caught up, says, this isn’t happening. It’s doing a rewind, mentally fixing the foot back onto the leg, does not want anything to do with my hidden anatomy asserting itself.

How can it be broken?  There is no pain, discomfort, yes, a clicking of shifting bones if I move any part of me but it’s nothing like the searing, out-of-body pain when I tore the ligaments on my other ankle. I’m amazed by this but also concerned. If I move will the bone protrude? Two thoughts: 1. If I can get a cast put on we might still be in time to catch the bus to Havana. 2. Bang goes the Christmas shopping and I certainly won’t be able to cook a turkey.

 ‘David,’ I call calmly. ‘Can you bring the first aid-kit? I need the crepe bandage.’ Though I already know that no amount of half-remembered Girl Guide crisscross strapping will be enough. How will I get up off the floor, never mind back to England?

In the last two weeks we have learned much about the health service in Cuba. Now I’m about to experience it first-hand, I try to recall another of Raul’s talks.

It’s easy to see why healthcare became central to the Revolution. The Cuban war of Independence in the 1890s might have seen off Spanish colonialism but not without some US backing. Although the Republic of Cuba existed from the early twentieth century America retained a prevailing influence.  In the 1920s, Prohibition brought the Mob to Havana. Lucky Luciano controlled many casinos through which to launder money and trade cocaine. A few wealthy Cubans in the capital benefited while the majority of the population outside the city was illiterate, undernourished and in poor health. There was a high rate of infant mortality. 

It was against this background that, in 1960, Ché Guevara gave his address, On Revolutionary Medicine. He described children he’d seen in the Sierra Maestra as ‘offspring of hunger and misery,’ who, ‘appeared to be eight or nine years old, yet almost all of whom are thirteen or fourteen.’  His vision was clear as he urged, ‘Our task now is to orient the creative abilities of all medical professionals towards social medicine … to find out what have been chronic miseries for years…The work entrusted to the Ministry of Health is to provide public health services for the greatest possible number of persons, institute a programme of preventive medicine … If we make war preparations the centre of our concern, we will not be able to devote ourselves to creative work,’ that being the health of the nation.

Five hundred, I remember from Raul’s talk, 500 polyclinics throughout the island, free primary healthcare for all with a doctor in even the smallest community. But we are on a far-flung archipelago off the north coast. We are forty-five minutes from the main island. The only way off here is via a causeway, flanked on either side by sea and mangrove. Will there be a clinic out here? If the main function of the polyclinic is primary, preventative care will they have A & E facilities? 

Undisputedly I am in Cuba but I also inhabit a strange hinterland, the place-where-this-has-happened. In that place, I’m still naked and wet; my mind is still willing my foot back on to my leg and I need the loo.

David hauls me upright onto my left foot. Too shaken to hop, supported by him, I manage a swivelling movement into the bathroom. David is as shocked as I am and still half asleep.

‘Call Alex,’ I say. She’s an English woman on the tour who befriended us, a dentist also trained in facial fractures who regularly works in her local A&E.  Over mojitos the other night she’d described how she had reconstructed the cheekbone of some high-up in the Air Force. In return he’d given her a ride in a Chinook helicopter. ‘Alex will know what to do.’

Alex’s arrives and her voice reaches me in my hinterland. She’s calming David.  Now she’s encouraging me to raise my leg as she piles towels on the bidet which becomes a foot rest.  She administers ibuprofen. I tell her I have no pain.

‘For the swelling,’ she says.

I can hear her on the phone talking to reception, asking them to call an ambulance, to bring ice and a member of staff to accompany us in the ambulance. She is calm, clear, polite, softly spoken yet authoritative. She brings me a t-shirt dress, slides it over my head. Putting on underwear is too complicated. It involves disturbing the clicking bones.

How will I get down the steps – there are at least six to ground level?

Now a man in a white medical coat appears with another man in a t-shirt. And there is Belkis, a member of the hotel staff. They are weighing up the options for a route out of the room. Several arms raise and support me on to one leg. The injured leg clicks uncomfortably as it dangles. I’m scooped into strong arms, carried down the steps to a waiting trolley, then fed into a white van. Apart from me on the trolley and the man in a white coat, nothing about the van says this is an ambulance.

‘Carlos,’ the man in the white coat introduces himself. He is a doctor. He lays a reassuring hand on my shoulder. ‘We go International Clinic,’ Carlos says and Belkis nods and smiles. This clinic is 7 km away. It sounds promising.

I wince as the van bumps over potholes, mainly at the fear of further damage rather than pain.

‘I find solution,’ says Carlos pointing to my foot, ‘I always find solution for my patients.’

Belkis smiles and nods and David explains to me that there is, indeed, a clinic out here on the Cayo. I silently give thanks to Ernesto Ché Guevara. Soon we are pulling up beneath a huge portico of what looks like a new building, the van parks beneath it. It protects us from the warm rain that has begun to fall as they slide me from van to clinic, which, a sign proclaims, is Clinica Internacional Cayo santa Maria.

The grandeur of the entrance disappears once inside. It is bare, as if not yet furnished, as if uninhabited. Then into a room in which there is a cumbersome machine that takes up most of the space. Nothing else except for a medical couch. Discussions in Spanish and broken English. I’m not to be lifted onto the couch. Instead, an awkward maneuvering of the trolley until they can swing the arm of the machine over my foot. Everyone leaves the room as the x-ray is taken. I can see David in the corridor on his phone, calling up the medical emergency service that comes with our travel insurance. I’m wondering, since Dr Carlos is now facilitating a ‘solution’ if a precious phone connection might be better spent alerting the tour company that, though not today, we will be in Havana in time for our flight tomorrow.

Once it emerges, several people gather round to discuss the x-ray; an almost two-foot square sheet of negative is held up to the light. Urgent talk in Spanish.

‘Santa Clara. Santa Clara,’ I hear mentioned several times. Santa Clara means a big town, possibly with a big hospital; it means a bumpy two-hour road journey; it means the site of the final defeat of Batista’s troops in 1959, the site where the Revolution was won by the derailing of a consignment of US-Supplied arms coming from Havana and meant to defeat the rebels. Loyal followers of Ché whispered along the track, sent word to say which train and at what time it was expected. A crowbar loosened the points, a yellow Caterpillar bulldozer slung across the track for good measure. The derailed carriages still lie where they fell, now house a small museum to this victory, the crowbar proudly displayed, and at the entrance to the site the bulldozer sits on a plinth – Este monumento a los combatients de la batalla de Santa Clara.

Now my personal derailment is going to send me back there. It’s thanks to the bulldozer and the crowbar that there will be a medical facility where I can be repaired. I steel myself for two hours of foot jiggling, bones clicking. Trying to ignore the fact that, though Dr Carlos, David and Belkis are all putting on a positive face, something in the mood has changed.

I begin to understand we are not going to Santa Clara, though I’m not sure where we are going only that it is much nearer.

‘Half an hour,’ says Belkis. 

We are on the causeway, the road that skims the shallow sea, towards the main island. Through a grubby window I catch glimpses of mangrove, bits of sky, sea. Lying flat on my trolley, I feel as if I’m the one skimming the water.

Dr Carlos continues to smile and press a comforting hand on my shoulder each time I wince as we hit a bump.  It’s not pain so much, rather the disturbing thought of bones set loose. I can’t bear the sound, the unnatural clicking, from a foot I can’t control, that no longer has any relationship to the leg to which it’s meant to be fixed.

Click, click, click. 

It is not my foot, and I am not me.

 ‘Soon,’ Carlos says, ‘soon find solution.’

Solution? This could mean: amputation, death or, at the very least, surgery. The kind of surgery Tricia had last May. Oh, yes. Tricia. The woman I walked and talked with just 12 days ago as we toured the eco village of Les Terrazaz at Viñales.  I push away thoughts of the image she’d shown me on her mobile phone. An x-ray of her repaired ankle – her fibula with its metal plate pinned in place, the tip of her tibia held secure by a stainless steel screw.

 ‘This is worse than the pavements in Havana,’ she’d said having spotted me being super-cautious over uneven ground.

‘Yea, you really need to concentrate.’

We’d stopped for a rest on a low wall. I’d rambled on about my left foot.

‘A nasty sprain, six weeks ago. Still purple, it swells in this heat,’ I held up my foot to demonstrate. That’s when she pulled out the image, trumped my sprain with her break. Walking in Wales she’d stumbled into a hole in the ground and a rock had fallen on to her ankle.

‘So easily done,’ she’d said. She’d been left to sit in the waiting room at A&E for several hours. Her ankle had swelled so much she needed ten days in hospital with her leg elevated for the swelling to reduce enough to make surgery possible. Surgery. Weeks in a wheelchair. Months of physio. No. This won’t happen to me. I have no pain, only clicking. No rock fell on me.

When he’s not reassuring me Dr Carlos is making hasty calls on his mobile. Belkis explains that the person we need is on his day off. Of course, it’s Sunday. We must collect him from his home. I pick up a tone, a look, the sense of an apology, that this is the only way they can help me, that this is some kind of makeshift option, which on the bright side means it can’t involve surgery.

At last we are off the causeway and turning round a roundabout on which sits a giant concrete crab – through its massive pincers I see its bulging eyes. We are on the main island at the small town of Caibarién on the Atlantic coast.  

We had commented on this crab, four days ago. And the blocks of flats on the edge of the town built in the 1960s. Once state-of-the-art homes, now in need of repair. They were built for workers in the sugar factory and the small harbour from which sugar was once exported, but no more.

Today, we keep stopping to ask directions. Carlos is not clear where our man lives.  In this jumble of tracks, criss-crossed by wires sagging from telegraph poles, it can’t be easy to follow instructions. We drive along streets of much older, colonial style, one-storey houses, with crumbling porticos and faded, peeling paint in every shade: turquoise, yellow, pink.  

Eventually, we pull up at one of these and into the van climbs a man in paint-spattered jeans and t-shirt.  He has a two-day beard and large hands with which he’s been doing up his home, happily engaged in DIY, until we arrive.  He smiles a reluctant sort of smile and Carlos tells me this man has no English. I don’t catch his name and begin to think of him as Dr DIY. He now directs the van to the clinic.

A crowd gathers, a woman holding a baby, children. It’s stopped raining and the sun shines right into the van. I try not to think of my lack of underwear as they lift me out. A horse and cart clip-clops past, hens scratch around the pavement. The kerb is broken; they must lift the trolley to a position where it can be wheeled into the clinic. I notice the words Policlinico II stencilled on the blue-washed wall. Thank you, Ernesto Ché Guevara. No chance of surgery at a primary healthcare centre. Whatever’s happened to my foot can’t be that bad. 

There are colourful walls in the waiting room and many rows of chairs but only one woman waiting. There is a blackboard with a chalked handwritten list that seems to relate to today. I’m wheeled into a room off this waiting area. Along the far wall a sink unit and surface all white tiled but not clean. Above it a window barely covered with a tattered curtain.

Dr DIY finds a bucket and begins to mix what I take to be, hope is, plaster of Paris and try to block out the fact that I have an urgent need to pee. Instead, I begin believe this means an end is in sight – I have a broken bone and Dr DIY’s cast is the solution! He works swiftly, but what he puts on my leg is only half of a plaster cast.

‘Back slab,’ explains Carlos, ‘to hold foot in place.’ In this firm gutter my leg can rest, my foot will be restricted in its movement but clearly, and I see it on Carlos’s face, this not a solution

Nobody has named the injury or explained the protruding bone or said how routine this might be or how serious. But it’s becoming clearer by the minute that treating what they’d seen on the x-ray is beyond this facility.

‘When plaster is set, he will bandage, make secure,’ explains Dr Carlos. Clearly Dr DIY is not an orthopaedic surgeon. He may not even be a doctor but a maker of plaster casts. Will there be a hospital in Santa Clara or Havana that can properly set the bone? With the right expertise bones can be manipulated into a cast, can’t they? What do I know – I’ve never broken a bone before. And, could I make a ten-hour flight with a tight cast on my leg?

I don’t want to be a nuisance but I’ve needed to pee since they wheeled me in.  Now it’s urgent. I don’t want the indignity of peeing all over their trolley but, equally, I don’t want to make more demands. In the end I figure getting me to a toilet is less trouble than cleaning up after me.

‘Toilet? Is possible?’ I venture.

‘Soon.’ Dr Carlos puts a hand on my shoulder and points to Dr DIY preparing to swathe the plaster gutter in lint and bandages.  He leaves the room as the last of the bandage is taped into place, returns with a shiny stainless steel bedpan. Relief.

Back in the van, there are rapid discussions in Spanish between Belkis, Carlos and DIY.  I listen out for the words, Santa Clara. No. This is about money. I have the sense that my treatment has been unofficial. At the first clinic it was agreed we’d pay the hotel with a credit card and they would settle the account. The polyclinic is a place for free primary, preventative healthcare for Cubans not A&E for pesky tourists. Out of kindness they have brought me here rather than schlepped me all the way to Santa Clara. Out of kindness Dr DIY agreed to help.

As it’s our last day we are running low on Cuban currency. David counts all the CUCs[iii] we have and offers the notes to Dr DIY. We’ve been told a CUC is worth 25 times more than the local currency, the CUP. We can only hope the amount we give isn’t insulting.  Dr DIY looks hesitant, awkward, pauses before he takes it. Why? Because it’s unofficial, because it’s too much, not enough?

For the first time he speaks. Pointing to my pristine plaster says:

‘You go your country. See doctor. Soon.’

Dr Carlos looks disappointed but has to agree.

When we pull up outside DIY’s place. He gestures for me to sit up, points towards his house and encourages me to wave to his wife. There, in the doorway, of a modest home that is under substantial repair, sits a smiling woman with a child on her lap. The child is all uncoordinated movement, limbs everywhere, severely disabled. I wave, and his wife waves back.

On the return journey to the hotel, back through the sea, Dr Carlos, with some translation from Belkis, explains that Dr DIY works very long hours. His wife finds it hard to cope on her own with the child and often calls him to come home. And I have taken precious time from his day off, time with his family.

I would like to know more – does Dr DIY work at the other clinics, does Carlos sometimes work at the polyclinic? Clearly they know each other well. Clearly both are committed to caring but are working with scant equipment, doing what they can with so little. I can’t ask complicated questions because I don’t have the Spanish. Even if I did I’m not sure I trust myself to speak because, after all, this isn’t really happening. 

‘What time is it?’ Eventually I try out words that do seem to come from me.  

‘Eleven-thirty.’

Over four hours since something unpleasant happened in the shower. Two hours since the bus left for Havana without us. Now, it seems we are travelling backwards, skimming through sea to the cayo and, hopefully, through time where I may unslip in the shower, watch as the foot realigns with my leg, climb back into bed to start Sunday again.  In reality, as it’s December, high season, with hotels all fully booked, we will arrive at the hotel we should have checked out of to find our electronic room key no longer recognises us.

Part 2 of Footnotes will be published on Thursday 31 December 2021

You can download part 1 here …

© Pamela Johnson, 2021

Pamela Johnson is the author of three novels Under Construction, Deep Blue Silence and Taking In Water, which was supported by an Arts Council Writers’ Award.  Her poems appear in magazines and anthologies. She has also published short stories, art criticism and journalism. 

From 2002-2018 she taught fiction on the MA in Creative & Life Writing, Goldsmiths, University of London, and has devised writing workshops in a range of contexts: schools, community groups, U3A, residential courses for The Arvon Foundation.


[i] On Revolutionary Medicine, Ernesto Guevara, originally spoken August 19, 1960 to the Cuban Militia. Online version at Ché Guevara Internet Archive, 1999, translated by Beth Kurti

[ii] https://www.bbc.co.uk/news/world-latin-america-13066561

[iii] back in 2015 Cuba operated a dual currency system. Tourists use Cuban Convertible Peso (CUC), locals use the Cuban Peso (CUP). The CUP is worth much less than the CUC; US dollars aren’t accepted as legal tender. From January 2021 this system is now being phased out.

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