Cuba is doing more than any other country in the world to reverse medical "brain drain." Higher pay in English speaking countries lures medical graduates from India (10.6 percent of doctors), Pakistan (11.7 percent), Sri Lanka (27.5 percent), and Jamaica (41.7 percent). Only 50 of 600 doctors trained in Zambia remained there after independence. A physician who leaves Sierra Leone for South Africa can earn 20 times as much.
The Cuban alternative is the 11-year-old ELAM program (Latin American School of Medicine). With educational costs covered by Cuba, students focus on returning as doctors to underserved communities in their countries. The 21,000 medical students in Cuba receive more than a free education—they are participating in a project to build a new type of medicine. ELAM students learn the Cuban model of Medicina General Integral (MGI), which focuses on public health and primary care. MGI emphasizes the wholeness of biology, sociology, economics, and politics in establishing the context of health and disease. Cuban efforts to improve health care are based on creating a new medical awareness.
This article describes how ELAM affects the medical consciousness of 13 of its students. Several themes run through these stories. All students show a desire to provide medical care to people who otherwise might not receive it. Absent is any discussion of becoming wealthy, a highly unlikely outcome for an ELAM graduate. The MGI Cuban medical model emphasizes family practice as the foundation of holistic medicine. The excellent level of care which Cubans receive is attributed to the high number of family doctors in neighborhood consultorios. Yet a majority of students had thought about a specialty. This may appear to be a contradiction between the Cuban school preaching general medicine and its students practicing specialties. It is not. In many of the countries students come from there is a shortage of specialists that needs to be met.
Many students had decided early in their lives that they wanted to be doctors and then discovered ELAM. Others did not even consider the possibility of becoming a doctor until they heard of ELAM. The African students were the youngest and the Americans the oldest. U.S. students had completed undergraduate studies while students from Latin America and Africa often go directly from high school to medical school. Methods which countries use to select students for ELAM vary enormously. In some, political affiliations and recommendations are critical. In others, it is purely on the basis of grades.
While most countries are eager to have Cuban graduates, some are hostile, but most students would be unable to attend medical school without ELAM. This indicates that the shortage of doctors in impoverished areas has nothing to do with a shortage of young people willing and capable of going to medical school in order to serve those communities, due to the unwillingness of governments, especially in rich countries, to provide adequate medical training.
Discussions were designed to capture a wide range of experiences and were not intended to be representative of students at ELAM. However, the 7 discussions with women and 6 with men approximates the gender breakdown of ELAM students in Havana, which includes 4,807 women and 4,868 men.
There are 3,406 pre-med first-year and second-year students living at the main ELAM campus near Havana and 6,169 third- through sixth-year students in the Havana area, for a total of 9,675 non-Cuban students from 100 countries. Cuban and non-Cuban students at campuses in other provinces number 11,343, for a total of 21,018 medical students enrolled in Cuba in April 2010.
Though Africa has the highest number of countries (36) represented at ELAM, the 7,777 Latin American students from 15 countries comprise over 80 percent of students. Africa is next with 9.1 percent of students, followed by the Caribbean with 7.3 percent. A much smaller portion is from Asia (0.7 percent), Europe (0.1 percent), the Middle East (0.5 percent), Canada/U.S. (1.2 percent), and the Pacific Islands (0.7 percent).
Exa is the only student I met over the Gulf of Mexico. Exa was sitting next to me on the plane as I told her of my hassles getting to Cuba to visit my daughter at ELAM. She replied, "I'm a sixth-year student there." Exa is from the town of La Paz in Baja California, Mexico. Both of her parents have been active in the Partido de Trabajo (PT, Workers Party). In 2001, Exa and her parents went on two trips to Cuba with the Friendship between Cuba and Mexico group. In high school, Exa was interested in art and took courses in film. She had always been interested in helping people and knew that Cuba had sent hurricane relief doctors to Central America. On her second trip, Fidel Castro described ELAM to her delegation. That changed her life. She decided that the best way to fulfill her childhood goal would be to become a doctor. When she entered ELAM right after high school at 19, Exa spent several months studying biology and chemistry in pre-med. She described her first year at ELAM as her sad year, when she found herself in a culture very different from Mexico and felt so alone that she wanted to leave. With her mother's encouragement, she decided to stay and when we spoke, Exa was completing her final year.
Anmnol (21) was waiting outside the Consultorio Médico No. 17-2 in Havana with ELAM students from the U.S., Chile, Brazil, and Venezuela when he told me of life in Honduras. His entire family was affected by the June 2009 coup against President Zelaya. Anmnol's 17-year-old brother planned to study engineering in Venezuela, but those hopes were dashed as the new Honduran regime showed its hostility to Chavez. Anmnol had long wanted to be a doctor, but the expense was out of the question. After studying to be a teacher, he heard of ELAM. According to Anmnol, Honduran students are selected for ELAM by a mixed system of exam scores, lottery selection, and recommendations. Exam scores gained Anmnol approval to attend ELAM in 2006. Not having the money to fly to Cuba, he had to work for a year.
Under Zelaya, Cuban-trained doctors worked in Honduras and ELAM graduates had begun a clinic to offer free medical care, but they were shut down after the coup and thugs attacked the medical students and doctors. Honduran doctors tend not to want to work in areas which have the greatest need. The Honduran Colegio Médico (analogous to the American Medical Association) supports the coup and would like to privatize government-based medical care. There is a danger that it will not recognize Cuban-trained doctors so it may be necessary for ELAM graduates to form their own medical association. After graduating Anmnol would like to study cardiology in Spain before returning to poor areas of Honduras.
Ivan Angulo Torres
In 2002, Ivan (28) was studying technical hotel administration in Lima, Peru. He said it would have been crazy for him to even think of studying medicine. Only 100 students per year there are admitted to medical school and even with his father being director of a secondary school, his family could not afford it. His father is a member of the Socialist Revolutionary Party (PSR), one of the left parties that can nominate young people to attend ELAM. Ivan became the first PSR-recommended student. Ivan just completed ELAM's six-year program. New Peruvian doctors must work for a year in rural areas where there is a shortage of all services, including medical care. He hopes to study orthopedics and practice in either Peru's jungles or in the province where his family lives. He expects his Cuban degree to be treated as if it were from any other country.
Ivan Gomes de Assis
Ivan Gomes (23) is a second-year student from Salvador City in Brazil. After finishing his studies, he taught math in high school. His father is a lawyer and Ivan's family helped people to receive medical care despite their inability to pay. When Ivan was 20, he learned of ELAM through the Internet and was impressed that the school did not turn out wealthy doctors. He decided that practicing medicine would be the best way to work with Brazil's poor. Brazilians are typically admitted to ELAM through left parties. Ivan had no history with the left, but the Cuban embassy staff endorsed him. When he finishes medical school, he would like to study orthopedics and practice in rural areas of Brazil where there are few specialists. Ivan finds school at ELAM difficult, partly because the U.S. blockade makes it hard to access the Internet. He feels ELAM is a great school, but prefers to study independently and does not like making a lower grade if he skips classes. Ivan is concerned about the way Brazilian doctors fit into the country's corruption and gross inequality and that the Brazilian medical association does not want doctors trained in Cuba to receive certification in Brazil.
Walter (23) is a second-year student from São Paulo, Brazil who dreams of creating Cuban-type community medicine in Brazil. Walter always wanted a career in medicine. Since progressive parties in Brazil recommend students, he realized that his activism with the Brazilian Communist Party could be important. Walter was also active in student groups working in solidarity with the Landless Workers' Movement (MST). Walter found an enormous difference between political environments at ELAM and in Brazil. Seeing that Cubans survive with very little by having the necessities of life helps ELAM students envision how they could change their own countries. When he gets his degree, Walter would like to return to his community to practice general medicine and then study psychiatry. But the Brazilian Colegio Médico (Medical Association) is rich, elitist, and does not recognize Cuban degrees. For Walter, building a new medical system in Brazil is a necessity.
Amanda (26) explains that, "Cuba gives people like me an opportunity to study medicine that we would never have anywhere else." Her father is a taxi driver and her mother is a food vendor. Amanda is a first-year student from St. Lucia, a Caribbean island with 165,000 inhabitants. She graduated high school in 2000, went to community college, and then taught integrated sciences and chemistry. When Amanda learned that the maximum age for admission to ELAM was 25, she applied right away. Though she was a youth organizer in St. Lucia, her political and social work did not count toward admission. Her school grades were the most important factor. After receiving her medical degree, Amanda would like to focus on kidney disorders. She reported that there are enough general practitioners in St. Lucia, but only one oncologist and one ear, nose, and throat doctor.
Students from St. Lucia will have no trouble with their medical degree being recognized, but Amanda will have to work for the government for five years to pay for her transportation and incidental funds. Though St. Lucia physicians think that a degree from Cuba is not as good as other schools, Amanda thinks it is better: "Here, they give us more hands on work with patients at the consultorios [neighborhood medical offices] and polyclinics."
Cassandra Cusack Curbelo
Cassandra (31) is one of the few Cuban Americans at ELAM. Cassandra is from Hialeah, near Miami, Florida. Her mother was born in Cuba and came to the U.S. with Cassandra's grandparents shortly after the 1959 revolution due to misinformation. Her grandparents soon felt tricked. They are strong supporters of the revolution. Cassandra's grandmother only had third grade schooling in Cuba and her mother had to struggle hard to get her education. They would both like to visit Cuba, which puts them in conflict with most Cuban Americans. Cassandra feels that the dictatorship which existed before the Cuban revolution now exists in Miami. She finds that young people are far less hostile towards the Cuban government, despite the flood of horror stories.
Cassandra decided to go to medical school sometime between her trips to Cuba in 1996 and 2006. In school she studied film and then social work. Before coming to ELAM, she was actively involved in anti-war coalitions, immigrant rights, animal rights, and anti-WTO efforts. She applied for admission to ELAM when she approached the age limit of 30 for U.S. students. Cassandra is finishing her first year. Though she could have gone directly into medical school, she took a year of pre-med to improve her science skills. Cassandra's work with ELAM's student government helped add a course on popular education, with topics such as Chinese medicine as an elective for the second year.
Cassandra feels a strong obligation to return to the U.S. to practice a Cuban model of medicine which emphasizes family medicine and gynecology. When she first came to Cuba after high school, she saw how people do not need a lot of material possessions, but need a sense of belonging and safety, which they can find on the island. Living with thousands of people from the Americas has been the most tremendous experience of her life. "It doesn't feel like we are from two continents, but more like we are one people who share a common history and a common struggle."
When I met Ketia (30), she was working on the Ghana Project. Medical brain drain is so bad in Ghana that the country has only 1 doctor for every 45,000 residents. The Ghana Project is one of the many efforts designated as Brigadas Estudiantiles por la Salud (BES, Student Health Brigades) that ELAM students design and carry out themselves during summer vacation. It emphasizes traditional forms of medicine taught at ELAM and widely practiced in Africa. The 2010 phase of the Ghana Project plans to begin with ELAM students traveling to Ghana to meet with Cuban-trained doctors already there. If successful, the Project hopes to create an internship so that sixth-year ELAM students can complete their medical training in Ghana. A student from California, Ketia first heard of ELAM in 2003. She wanted to go to medical school, but not in the U.S. because of her public health interest. ELAM was a perfect match. Ketia had been teaching high school so, after getting her degree, she would like to continue working with high school students and open a wellness clinic emphasizing the changes people need to make in their lives. "ELAM is the revolution realized," Ketia told me. "It is a reflection of what can be done with medicine." She strongly believes that, "We must attempt to have a revolutionary project in a capitalist world." She sees ELAM as such a project.
Dennis (26) lived the first 13 years of his life in Bo, Sierra Leone. When civil war ripped the country apart and his cousins were killed, his family made its way to neighboring Guinea in 1997. In 2001 they moved to Jonesboro, Georgia where his brother had been living. Medicine had been in Dennis's mind for years, but he couldn't bear the thought of graduating with a huge debt. In 2006, he looked up ELAM on the web. He applied in 2007 and began his studies in 2008. He took Spanish during his pre-med year. Dennis is currently finishing his second year at ELAM. He would like to take board exams in the U.S. after graduating, but spend most of his time in Sierra Leone. Most communities are underserved in Sierra Leone, which has a national health care system that controls the hospitals even though there is simultaneous private practice. Sierra Leone has a good relationship with Cuba and Dennis feels he will have no trouble practicing medicine there. He would like to combine health education, pediatrics, and internal medicine.
Lorine (18) is a pre-med student from Kisumu in western Kenya. Her family has to pay for her transportation so she can only visit them once during six years. Before graduating, she may get to spend a summer in Ghana with the Organization of African Doctors. Lorine speaks Swahili, English, and Spanish and had long wanted to be a doctor. In high school she read an advertisement about ELAM and applied to the Kenyan Education Ministry. Kenyan students are selected for study in ELAM by the government without involvement of political parties. The Kenyan government gives students loans for medical school, which are reimbursed by paycheck deductions when they become doctors. When she graduates, Lorine would like to specialize in orthopedics and psychiatry. Lorine thinks that ELAM gives a better medical education than she would have gotten in Kenya. Professors often cannot see all the students and rarely have multi-media presentations. The private university in Kenya is good, but far too expensive for her. At ELAM, she can hear what professors are saying, she can ask them questions, and they often call on students in class.
Yell is from Trinidade, a city in the African island country of São Tome Principe. He speaks Portuguese and is learning Spanish during his pre-med year at ELAM. When he was 18, the government told him that, based on his grades and exam scores, he was accepted for medical school, but they could not tell him where. Shortly before leaving home he learned that he would be coming to Cuba. At ELAM, he finds it a struggle to master the pre-med science courses. Since there are plenty of general practitioners in São Tome Principe, he plans to study a medical specialty, but he is not sure what it will be. Yell reports that he will be required to work for three years in a government job to pay back the cost of his transportation to and from Cuba.
Keitumetse Joyce Letsiela
Joyce (18) is a first-year student from rural Lesotho. After talking with a doctor she knew and seeing an advertisement for ELAM, she applied during her last year of high school. The Lesotho government loans her money for transportation which Joyce must pay back after graduating. Joyce speaks Sesotho and English, but found ELAM hard at the beginning because she had to learn Spanish. She misses home, but is becoming used to Cuba after getting to know Lesotho students and other friends. What she likes best about ELAM is meeting people from all over the world. She sees ELAM students as independent and serious. Cuba was Joyce's first choice for medical school. Since there is no medical school in Lesotho, the main option is studying in South Africa. But very few go because of the cost. Joyce says there are only two doctors in the public hospital near her home. She would like to choose a specialty, but has not yet decided what it will be.
Jonalisa Livi Tapumanaia
Jonalisa (22) may be among the first students to see her homeland go under water due to global warming. ELAM will make it possible for each of the ten major islands that make up her Pacific nation of Tuvalu to have its own doctor. The few doctors in Tuvalu are at the hospital on the major island. Jonalisa graduated with a degree in marine science from the University of the South Pacific in Fiji. Jonalisa heard about ELAM from the Ministry of Health. The government recognizes medical degrees from Cuba and pays for her transportation, but it will only cover one trip home during her six years of study. Cuba is hotter and life is very different than in Tuvalu. She had to get used to people kissing her on the cheek instead of shaking hands. Tuvaluan women do not expose themselves as much by wearing sleeveless shirts or miniskirts. Jonalisa is used to living in a thatched roof home, going to school barefoot, and having parents make decisions (or trying to) concerning marriage. Like most others in Tuvalu, Jonalisa is a Methodist in the Ekalesia Kelisiano Tuvalu church.
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The ELAM experiences reflect conversations that ELAM students have had with each other on a daily basis. Students observe the MGI model of medicine that has brought the Cuban life expectancy up to the level of the U.S., despite a very low Gross Domestic Product and a vicious U.S. embargo. Rather than being isolated as a progressive minority, they are surrounded by thousands of like-minded students from countries that suffer oppression in a myriad of ways. This is the social context for spending six years studying the Cuban approach to health care. Students are anything but passive participants. They become enmeshed in creating a new global medical culture.
Don Fitz produces "Green Time TV" in St. Louis, Missouri and is editor of Synthesis/Regeneration: A Magazine of Green Social Thought which is sent to members of the Greens/Green Party USA. All discussions were with students in ELAM or Havana between May 26 and June 2, 2010, except with Exa Gonzales, which was in the air over the Gulf of Mexico on December 28, 2009, and the January 23, 2010 discussion with Cassandra Cusack Curbelo, the only one by phone.