Background

By 2005, Cuba had 70,594 doctors (1 X 159 inhabitants), and a total of over 447,000 health workers (4).  But this was not always the case:  right after the 1959 revolution, nearly half the country's 6,000 physicians emigrated.  Yet, imbued with the spirit of the times, as independent Caribbean and African countries emerged from colonialism, Cuba began almost at once to train students from developing countries alongside their own.  "The idea of international assistance in health was part of our activity, part of our principles from the beginning," asserts Dr. Francisco Durán, Director of Higher Medical Education in Cuba's Ministry of Public Health. From 1966 through 2004, nearly 4,000 international students graduated from Cuban medical schools - some found today among the developing world's health ministers and secretaries of health.

In 1976, a medical school in Yemen was founded by Cuban professors - and under bilateral agreements in later years, Cuban faculty would go on to found another eight schools of medicine in Africa, Latin America and the Caribbean, and the "university without walls" in Venezuela. Later still, Cuban professors would provide the backbone for struggling medical schools in other countries of the Global South - including Angola and South Africa. 

The Latin American Medical School Program

The most ambitious program for international medical training is the Latin American Medical School (ELAM in Spanish).  When the fury of Hurricanes Georges and Mitch struck Central America and the Caribbean in 1998, 1,000 Cuban doctors volunteered their services in the disaster zones.

The underlying disaster of marginalized populations without health care prompted two decisions by the Cuban government:  offer Cuban medical teams for longer-term assistance to bolster local health systems, and open a medical school in Cuba with 10,000 scholarships for students from those countries.  This became the Comprehensive Health Program (CHP), aimed to build in sustainability to Cuba's international health cooperation for the first time, since the long-term goal was for these graduates to replace the Cuban doctors on the ground in their countries, swelling the ranks of health professionals in underserved areas.

By 2004, enrollment in the program topped 9,000, and by 2005, it hit the 10,000 mark.  Government-to-government agreements have expanded the program to 29 countries, and in the case of the United States, attracted students even in the absence of a bilateral accord. (5) In all cases, the basic curriculum consists of a three-month to one-year pre-medical bridging course, which includes Spanish language for those who need it; two years of basic science at either the Havana or Santiago campuses; followed by four years of clinical rotations, when students are dispersed to Cuban medical schools in all 14 provinces and train alongside Cuba's future physicians.

The Cuban Approach to International Medical Education

Even a cursory look at the brain drain leads to the conclusion that training more professionals is only part of the solution to a complex problem:  national health systems must be able to retain health professionals (primarily in the public sector) and also to distribute them where they are most needed (often the most remote and difficult places). While Cuban health authorities are not in a position to address these issues directly, their philosophy of medical education and the process of student recruitment itself merit continued appraisal, since they represent a significant departure from most medical training around the world.

Student recruitment:  The majority of these international scholarship students are recruited from underserved communities - from poor, remote, marginalized and indigenous populations.  This has resulted in a Latin American Medical School student body made up of 101 ethnic groups. Additionally, 51% of the students are women. (3)

Graduates' commitment:  Students know when they enroll that they are expected to make a commitment to serve in underserved communities - their own or another - upon graduation.  This is reinforced throughout their studies, says Dr. Durán, "not by any course on ‘humanitarianism,' but by the examples they have at hand.  Cuban doctors who have been abroad in very difficult situations are all around these students. And they see people, their Cuban patients, who have a right to health care."

The commitment is also reinforced by a summer program devised by students from some countries, in which they spend part of their vacations serving in their home communities under the supervision of Cuban professors.  This can sometimes provide dramatic assistance to local health systems, as in the case of the dengue epidemic in Tegucigalpa, Honduras, where over 400 Honduran students went to work on health brigades to control the outbreak and carry out vital community education.

The curriculum:  The study plan embodies the Cuban philosophy that also inspires the organization of the island's health system, combining population-based public health principles and prevention with clinical medicine.  In concrete terms, this means that students are exposed to working with Cuban communities even in their basic science years and that public health is an important subject in their clinical training.  The focus is bio-psycho-social; individual, family and community.  For developing countries, where health professionals must be especially conscious of the economic, social, cultural and environmental determinants of health in order to be effective, this approach to training gives them essential tools.

The scenarios:  In addition to Cuban communities, the program includes two important elements that tailor studies to the students' home situation.  The first is enhanced emphasis on tropical and infectious diseases, a curriculum component designed by Cuba's Pedro Kourí Institute of Tropical Medicine.  And second, a pilot experience in early 2005 offered sixth-year students the opportunity to return to their home countries for the last six months of their internship, mentored by Cuban professors serving there.  Interns from Haiti, Venezuela, Honduras and Guatemala were among the first to participate.  The success of the pilot has led to expansion to other countries as of 2007.  

The "calling":  It is difficult in today's material world to suggest a paradigm shift in what it means to be a doctor.  But that is precisely what the Cuban approach to medical training is proposing: to reverse the trend that has patients becoming clients and customers, and healers becoming income-driven service providers. The Cuban premise is that medicine as merchandise has not - and will not - guarantee health for the world's poor majorities; health as a human right must be guaranteed by health professionals who believe the same, and who are willing to make sacrifices to make it possible.

Scaling up:  Cuban authorities have concluded that to graduate the minimum 128,000 additional physicians and nurses needed in the Americas (5), massive training programs are required. And the scope of Cuban programs continues to grow:  at the Latin American Medical School's first graduation on August 20, 2005, President Fidel Castro announced the country would join with Venezuela to train 100,000 physicians for developing countries over the next decade - including 60,000 new scholarships for Venezuela and 30,000 for the rest of Latin America and the Caribbean. 

This scaling up began in earnest in Cuba during the 2006-2007 academic year: 12,000 students from other nations - primarily African and Latin American - began medical studies in Cuba under a new program that replicates the "university without walls" model first piloted with Cuban medical students, then carried to Venezuela.  (Some 13,000 Venezuelan students are enrolled in the program there, sponsored by the Cubans and six Venezuelan universities.)  According to this model, students are based at campuses in the Cuban countryside for their class work, and professors mentor them in clinical studies involving local clinics and hospitals. 

Results & Prognosis

Will the majority of these graduates be the harbingers of a fundamental shift in the profession of medicine for the Third World, in desperate need of their services and commitment?  Will they live up to their communities' expectations?  Find jobs and make a difference? Or will they simply add to the internal and external migration of the developing world's professionals?

The answers - and the onus - lie more with the forces and structures outside Cuba. Some of the region's public health systems are providing for the insertion of the new graduates, offering them posts in poor and especially indigenous, communities.  But in others, the IMF legacy freezing public health jobs makes it tougher for them to practice, and in still others, local medical societies simply fear this new breed of public health doctor. 

Yet, one thing is absolutely clear:  the need for these new physicians could not be greater, as indicated by the sobering statistics from the first graduating class of 2005.  Factoring in both the Latin American Medical School and other foreign graduates in Cuba that year, the number of new doctors for the 47 countries of the developing world plus the USA totaled 1,800.  Those 47 - many in Africa - have an average physician-population ratio of 9.8 physicians per 10,000 inhabitants, compared to Europe and the USA which average 30, and Cuba at nearly 60. (6) 

Latin American Medical School Curriculum

Source: Vice Ministry for Medical Education and Research, Ministry of Public Health

1. Forensic Medicine and Medical Ethics
2. Complementary/ Alternative Medicine, called "Traditional and Natural Medicine" in Cuba

References

1. "Mirando al futuro desde la Cooperación Internacional", Power Point presentation by Dr. Yiliam Jiménez, 26 June 2006, Havana. 
2. "Datos Históricos de la Cooperación Médica", Unidad de Colaboración Médica, Ministry of Public Health, Havana, June, 2003. 
3. Countries are:  Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cape Verde, Djibouti, Dominican Republic, Ecuador, El Salvador, Guatemala, Guinea Bissau, Guinea-Conakry, Equatorial Guinea, Haiti, Honduras, Jamaica, Mali, Mexico, Nicaragua, Nigeria, Panama, Paraguay, Peru, United States, Uruguay, and Venezuela.  Source: Dr. Midalys Castilla, Vice Rector for Academic Affairs, Latin American Medical School, Havana, communication to the author, 27 December, 2006.
4. Statistical Yearbook, 2005.  Ministry of Public Health, Havana.
5. Health Human Resources Trends in the Americas: Evidence in Action, Pan American Health Organization, September 2006, p. vii.
6. Data from World Health Organization and Pan American Health Organization, annual reports and The Joint Learning Initiative