The shelves in the neighbourhood pharmacy, like those in the other neighbourhood pharmacies I had seen in Havana, were half empty and full of dust, the small selection of medicines on display arranged in lonely rows of old-fashioned little bottles. Customers were as scarce as the medicines.

One bottle on a shelf contained a fungicide, another aloe ointment. A third countered diarrhea. The odds of finding a specific medicine to treat a particular malady were vanishingly small. "What is this bottle for?" I asked the woman behind the counter. "Memory," she said. "It's good for memory and for circulation."

"Do you have Aspirin," I asked, wondering if average Cubans could obtain the world's most familiar pharmaceutical staple. The answer was no. Her pharmacy only stocked drugs manufactured in Cuba and available for purchase in pesos, the currency used by Cuba's poor. "For Aspirin, you must go there," she said, pointing to a nearby hotel that housed a pharmacy for customers able to pay in dollars.

The "dollar pharmacy" did indeed have aspirin, along with other pain killers, cough medicines, syringes, Band-Aids, Alka-Seltzer and all the other common medicinal products familiar to Westerners. Its shelves were piled high - literally to the ceiling - with some 500 items, including tampons, disposable diapers, and other drug store items that were more conveniences than necessities. Pesos - the national currency and all that most poor have access to - bought nothing in this government-run establishment. The dollar pharmacy only welcomed dollars, and those who carried them.

Earlier in the day, a Cuban had stopped me on the street, pulled out his asthmatic child's puffer, and asked for help in getting it refilled. He could not get the drug, he explained, but I, as a tourist, could. Begging for medicines is common in Havana - next to begging for money to feed children, it is the most common plea - because the government won't use its scarce foreign exchange to import basic drugs that the populace needs. Doctors won't even prescribe drugs for the poor that aren't available in the local pharmacies - the state frowns upon that - but many will write the name of the drug that's needed on a scrap of paper.

"This is what you need," the doctors will tell desperate patients, in effect sending them out into the streets on a mission of what can amount to life or death for themselves or their children. Cubans with access to dollars - typically those in the tourist industry who receive tips in dollars - can obtain the drugs they need. Others have relatives in the United States who can ship them. The rest - middle class Cubans included - must resort to begging, the black market or, increasingly, to prostitution.

Cuba is renowned for having a universal health-care system and, in fact, doctors are plentiful and doctor visits are free. But without access to antibiotics, insulin, heart drugs and other life-saving medicines, doctors cannot perform their duties. Too often, for lack of medicine, doctors have no choice but to amputate limbs, or to put patients through painful therapies without painkillers. In one celebrated case, Dr. Hilda Molina, the founder of Havana's International Center for Neurological Restoration, returned the medals that Fidel Castro had awarded her for her work and resigned in protest, outraged that Cubans were denied critical care in order to treat foreigners.

Byron (not his real name) is a 30-year-old doctor in Cuba, a former medical student from Africa who came to Cuba on a Commonwealth country scholarship. Because he speaks fluent English and French, and understands three other European languages, the government assigns him to treating tourists whom, he confirms, lack for nothing in Cuba. The tourist hospitals are excellent, the quality of care delivered to a high standard, as high as any you will find in any Western country, he says. The hospital pharmacies provide whatever drugs tourists require.

Care for top government officials and those in the military is also excellent. "They also lack for nothing," Byron said. But after providing for the needs of tourists and the top government officials, the health system has little left for the general public. I asked Byron about a man I had seen sitting on the pavement, wrapping raw lesions on his foot with filthy rags. The care with which he was tending his gaping holes made an impression on me, and made me wonder why he lacked proper care.

Byron identified the man's malady - a disease that slaves had brought to Cuba from Africa 400 years ago - as one easily treated, but not with the medicines available in the peso pharmacies.

"The government doesn't give a shit about the poor," he stated matter-of-factly. "The poor have no medicines, no painkillers, no nothing."

Before Castro seized power in his 1959 Revolution, Cuba had one of the world's best medical systems, its ratio of one physician per 960 patients ranked 10th by the World Health Organization (England, in contrast, had one physician per 1,200 people, Mexico one physician per 2,400 people). Cuba had Latin America's lowest infant mortality rate, comparable to Canada's and better than France's, Japan's and Italy's. Its population was well fed, with a per capita food consumption that was the third highest in Latin America.

Today, Cuba ranks last in Latin American per capita food consumption - cereals and especially meat and milk consumption are down dramatically - but it has not lost its medical capabilities. Instead, Cuba has reoriented its medical system to the task of earning foreign exchange. To do this, Cuba pioneered "health tourism" through agencies such as Servimed, which markets medical services abroad. Cuba is "the ideal destination for your health," it boasts, frankly admitting to being "a tourist subsystem."

With an annual growth rate of 20% in health tourism, Servimed has done well in its task of marrying health and tourism. Many Italians now couple their annual vacations to Cuba with their annual dental work, while others come for cut-rate knee replacements or eye surgery. But perhaps Cuba's most popular medical service, and the one it heavily promotes to tourists abroad, is cosmetic surgery. Cuban doctors have become expert at breast implants, tummy tucks, liposuction and nose jobs, giving some doctors international reputations while letting them serve the Revolution as one of the country's best earners of foreign exchange.

It's a "win" for the elite doctors and a "win" for privileged patients, who benefit from what has become the world's most extreme two-tiered medical system. It's also a "win" for the Cuban elite, from Castro on down, whom Byron describes as participating in a fitness culture. "When I treat tourists of 75 years of age, I am treating fit people with many healthy years ahead of them," he said. This is also the case with members of the Cuban elite. "Castro is fit, the others at the top in government, at age 75, are fit. They take care of themselves.

"But an ordinary Cuban of 63 or 64 years is already feeble, an old man." For the poor, beaten down by the system and denied basic medical care, the medical system is all "lose."

http://www.capmag.com/article.asp?ID=2538