I just spent a week in Cuba where I was given access to unique individuals. These individuals are residents of Cuba who shared their stories. They allowed me to attend their medical appointments to enter the hospitals. There are few modern myths that have been debunked as frequently yet have been accepted as incredulously as the idea that Cuba has a superior (or even adequate) health care system. Articles have been written since the 1960s debunking the nonsensical claims about health care in Cuba and yet it is invariably the issue that is trotted out to show how socialism can actually be effective.  These appointments I attended were heartbreaking.

If you get sick on a cruise ship or are an American in Cuba, who gets sick, your health care experience is distinct.  These are hospitals that the regular Cuban citizens are not permitted to go to, only foreigners can. For foreigners, who can pay with hard currency.  In Havana can receive pretty decent healthcare. However, if you need any advanced imaging you will have to take a flight to Mexico to do so. Many medical device manufactures have donated  MRI, CT and other devices to the hospitals. However, they are boat anchors now. There is no money to service them so they sit rotting in their suites. A primary selling point of socialism is that everyone is treated equally regardless of class or ability to pay. But in reality, socialism keeps the inequality of capitalist systems and merely spreads the misery to more people. Outside of Havana, the hospital conditions are inhuman.

In America doctors are well compensated for their years of training and experience. Although the pay varies based on such factors as specialty and region of the country, the average physician in the US earns $472,000 a year. In most countries, of course, doctors are not paid nearly as well. In Hungary doctors earn an  annual income of $12,000, while in many regions of China the salary is half that amount, about $5,000 a year.

But, Cuba is near the bottom of the least when it comes to compensating health care professionals. Doctors in Cuba earn somewhere between $30 and $50 a month ($360 to $600 a year). At the high end, doctors with two specialties can earn as much as $67 per month.

These salaries do not match the cost of living in Cuba. It’s quite expensive to live in Cuba.  A young doctor would have to work for more than a week just to afford a gallon of milk (average cost is $7).  If he doesn’t have such expensive taste he can go forgo the dairy for cheaper fare: a pound of potatoes only cost about one day’s wage (90 cents). Physicians have a territory, like a paperboy. They are assigned a neighborhood to knock on doors to go and see families. They go in and give vaccines (Cuba is ahead of many countries as it pertains to vaccines), give prescriptions and assess the overall health of the community, proactively.

In Cuba, medication for hospitalized patients is free, but all outpatient medications have to be paid for out-of-pocket. And all medications (even aspirin) require a prescription. There are also no private pharmacies (except on the black market) so you have to get your Tylenol at a state-run pharmacy. That is, if you can find one.  With a population of 11 million, and more than 2 million in Havana, there are only 2pharmacies presumably located on the island.

The first was situated in a residential neighborhood in Havana. It was large yet incredibility rundown, just like its surrounding area. The narrow shelves lining the pharmacy were bare bones, giving the impression that the store was going out of business. The space focused strictly on pharmaceuticals; there were no cosmetic, greeting card, health and wellness, or candy aisles.

In comparison, the second farmacia we visited near the Ciengage de Zapata Biosphere Reserve—a 3-hour bus ride from Havana—was no larger than a backyard storage shed. Dressed in a white lab jacket, a female pharmacist manned the Dutch-door prescription window, counseling a patient who stood on the sidewalk. Her female assistant sat at a card table with a cardboard box containing filled prescriptions.

Not surprisingly, the shortages allow health care workers to supplement their income on the black market. Some doctors, nurses and cleaning staff smuggle the medicine out of the hospitals in a bid to make extra cash.

The doctors are underpaid, the system is unequal, and the hospitals are horrific. But at least they can take credit for having a low infant mortality rate, right? Actually, there’s more to be said for that statistic.

You might suspect a story behind this respectability — and you are right. The regime is very keen on keeping infant mortality down, knowing that the world looks to this statistic as an indicator of the general health of a country. Cuban doctors are instructed to pay particular attention to prenatal and infant care. A woman’s pregnancy is closely monitored. There are numerous maternity only hospitals all over the country. They are significantly run down and close to inhuman conditions.  The regime manages to make the necessary equipment available.  And if there is any sign of abnormality, any reason for concern — the pregnancy is “interrupted.” That is the going euphemism for abortion. The abortion rate in Cuba is sky-high, perversely keeping the infant-mortality rate down.  Cuba's annual induced abortion rate persistently ranks among the highest in the world, and abortion plays a prominent role in Cuban fertility regulation despite widespread contraceptive prevalence and state promotion of modern.

There is one aspect of Cuba’s health care system that seems to produce results: preventive care. The foundation of Cuba’s preventative health care model is for family doctors to oversee the health of those in their neighborhoods. But there’s a catch.

In Cuba when you hear “The doctor will see you now” it often means in your own home. And you don’t have a choice about it.

Imagine your doctor knocking at your door to give, not just you, but your whole family an annual health check-up.  As well as taking blood pressure, checking hearts and asking all sorts of questions about your job and your lifestyle, this doctor is also taking careful note of the state of your home, assessing anything which could be affecting the health of you and your family. These doctors are assigned a territory in the town, like a paper route.

Chances are the doctor is not just checking to see if you’re hiding Twinkies in the pantry, but will be reporting other findings to the local magistrates.

Cuba has a thriving Black market in medicine.  Friendships are carefully maintained with several doctors so a seller will have no problems obtaining enough prescriptions to support their  business.

People will sell medications at vastly inflated prices, but shortages in state-run pharmacies mean that many people have no choice but to turn to black market entrepreneurs.  Massive corruption throughout the Cuban health system means that this double-tier system is common across the country.

Although medicines are officially sold only through government pharmacies, prescriptions are routinely siphoned off to obtain remedies that are then resold on the streets for far higher prices.

As doctors are only paid up to 1,600 Cuban pesos (65 US dollars) each month  - barely a living wage - most need to find some way to subsidise their income. All Cubans know that doctors have thousands of needs and life challenges corrupt even the most honest. You may even find your physician driving a rickshaw or cab to make ends meet.

The best selling medicines on the street are salbutamol inhalers for treating asthma, the tranquiliser meprobamate, the painkiller ibuprofen and vitamin C in tablet form.

Topical treatments such as the anti-bacterial ointment gentamicin, skin cream triamcinolone and antifungal lotion clotrimazole are also in high demand.

Products such as these officially cost 0.65 Cuban pesos but are sold for ten pesos on the black market.

Beta-blockers such as atenolol and the anti-inflammatory analgesic dipyrone were in particularly high demand on the black market. A strip of dipyrone is sold in a pharmacy for 0.70 Cuban pesos; on the street it costs five Cuban pesos.

This year 60 medicines were affected by problems with raw materials and the withdrawal of some suppliers. Other medicines are sourced from far away, leading to production delays.

Of the 857 medicines that make up the state’s basic medicine supplies, 269 are imported from different countries, primarily from very distant markets like China, India and some European countries, and have a supply procurement cycle of between 60 and 90 days.

Last November, the minister of public health announced new control measures to try and stamp out the illicit sales.

All doctors were limited to issuing 100 prescriptions a day, each identified by a numeric code.

To prescribe a medicine a physician must see the patient and give them a prescription. Now no one can have blank prescriptions that haven’t been filled in which could be taken to a pharmacy falsifying the doctor’s name and the medicine.

In addition, the doctor’s name and signature on the prescription must be legible and accompanied with instructions on how to take the medicine.

But the practice is proving hard to end, considering that the black market involves all levels of health care staff, from pharmacy workers up to doctors. Worst affected are people who rely on these medicines, mostly of whom are elderly people. When we went to see the family doctor and he prescribed a family member a cortisol cream. We went to buy it at the pharmacy and were told that there wasn’t any.  This is the normal thing that happens.  However, in the corner of the pharmacy there was a man selling it for ten Cuban pesos. The same thing happened when a family took their child to the doctors to have their eyes tested. It was identified that he needed glasses. They were told that no glass was available to male the glasses. However, if they paid them 10 CUC they would meet them on the corner in an hour and would have the eye glasses. I don’t understand why the government doesn’t have enough for people´s needs but there are people selling it outside.

 Want some paprika-infused chorizo sausage? How about a bit of buffalo mozzarella? Or maybe you just need more cooking oil this month, or a homemade soft drink you can afford on paltry wages. Perhaps you are looking for something more precious, such as an imported air conditioner or some hand-rolled cigars at a fraction of the official price.

In a Marxist country where virtually, all economic activity is regulated, and where supermarkets and ration shops run out of such basics as sugar, eggs and toilet paper, you can get nearly anything on Cuba’s thriving black market — if you have a “friend,” or the right telephone number.

A raft of economic changes introduced over the past year by President Raul Castro, including the right to work for oneself in 178 approved jobs, has been billed as a wide new opening for entrepreneurship, on an island of 11 million people where the state employs more than four in five workers and controls virtually all means of production.

In reality, many of the new jobs, everything from food vendor to wedding photographer, manicurist to construction worker, have existed for years in the informal economy, and many of those seeking work licenses were already offering the same services under the table.

And while the black market in developed countries might be dominated by drugs, bootleg DVDs and prostitution, in Cuba it literally can cover anything. One man drives his car into Havana each day with links of handmade sausage stuffed under the passenger seat. A woman sells skintight spandex miniskirts and gaudy, patterned blouses from behind a flowery curtain in her ramshackle apartment.

Economists, and Cubans themselves, say nearly everyone on the island is in on it.

“Everyone with a job robs something. The guy who works in the sugar industry steals sugar so he can resell it. The women who work with textiles steal thread so they can make their own clothes.

Some make their living as a “mule,” ferrying clothes from Europe to Havana for sale at three underground stores. These people end up in jail for his activities.

Merchandise flows into the informal market from overseas, but also from the river of goods that disappear in pockets, backpacks, even trucks from state-owned warehouses, factories, supermarkets and offices.

There are no official government statistics on how much is stolen each year, though petty thievery is routinely denounced in the official press. On June 21, Communist party newspaper Granma reported that efforts to stop theft at state-run enterprises in the capital had “taken a step back” in recent months. It blamed managers for lax oversight after an initial surge of compliance with Castro’s exhortations to stop the pilfering.

Criminal and corrupt acts have gone up because of a lack of internal control. An extensive study by Canadian economist Archibald Ritter in 2005 examined the myriad ways Cubans augment salaries of just $20 a month through illegal trade — everything from a woman selling stolen spaghetti door-to-door, to a bartender at a tourist hot spot replacing high-quality rum with his own moonshine, to a bicycle repairman selling spare parts out the back door. He and several others who study the Cuban economy said it was impossible to estimate the dollar value of the black market.

One could probably say that 95 percent or more of the population participates in the underground economy in one way or another. It’s tremendously widespread.  Stealing from the state, for Cubans, is like taking firewood from the forest, or picking blueberries in the wild. It’s considered public property that wouldn’t otherwise be used productively, so one helps oneself.

Cubans even have a term for obtaining the things they need, legally or illegally: “resolver,” which loosely translates as solving a problem. Over the decades it has lost its negative connotations and is now taken as a necessity of survival.

Turning to the black market and informal sector for nearly everything is so common that it has become the norm, with little or no thought of legality or morality. When legal options are limited or nonexistent, then everyone breaks the law, and when everyone breaks the law, the law loses its legitimacy and essentially ceases to exist.

There is evidence, however, that Castro is persuading at least some black market operators to play by the rules and pay taxes. In the last seven months, more than 220,000 Cubans have received licenses to work for themselves, joining about 100,000 who have legally worked independently since the 1990s. Of those, some 68 percent were officially “unemployed” when they took out their license, 16 percent had a state job and another 16 percent were listed as “retired,” according to statistics on the government Web site Cubadebate.

Many of these jobless and nominally retired people were likely making ends meet by working in the informal market, and even the former government workers were probably connected in one way or another.

You have to find a way to survive.  A Cuban residents  monthly government ration card plus their meager salaries only covered two weeks’ worth of food. They often sit in the pa and think, ‘What can I do?’”

Some will even begin bicycling around town on Sundays, renting out bootleg DVDs of the latest Hollywood films, which others had downloaded from the Internet.  They defend their decisions to turn to the black market to put food on the table.

Physicians are required to stay in their roles for a minimum of two years. IT is only then that they can migrate to another higher paying job, such as a cab driver, shoe shiner, etc.

How do we help them?