CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE

Experience of Cuban Faculty
in Establishing a Medical School
in the Republic of The Gambia

Arturo Menéndez Cabezas, MD, PhD

Introduction

Cuban academic collaboration with Third World countries has a decades-long tradition, as a contribution to the training of qualified human resources to improve health in those nations. This took on a new dimension with the Comprehensive Health Program (PIS, according to its Spanish acronym), that since 1998 has been extended throughout Central and South America, the Caribbean, Africa and Asia. One example is a medical school established in the Republic of The Gambia.

Background

Cuban medical collaboration with the Republic of The Gambia began in May 1996 with the arrival of a medical team composed of 22 specialists including three dentists, 12 nurses and two technicians, who were assigned to various hospitals and health centers by the Gambian government’s Department of State for Health and Social Welfare.[1]These professionals laid the groundwork for long-term, expanded cooperation based on humanistic and internationalist principles, and offered further training to general practitioners and nurses from The Gambia and other countries working in the public sector. Scholarships for young Gambians to study in Cuba were also included in the bilateral agreements at this stage.

In April 1999, the President of the Republic of The Gambia visited Cuba.[2] As a result of top-level conversations, this small sub-Saharan West African country joined the Comprehensive Health Program, including assistance in organizing and setting up an in-country medical school there.

In May 1999, a Cuban delegation led by the Director of the Collaboration Division of the Ministry of Public Health, made a working trip to The Gambia to prepare for the June arrival of the rest of the Cuban medical team, which included a number of medical school professors.

At that time, the country still had no university, although the goal had existed for many years prior. A government-designated commission of experts had even drawn up a voluminous report of recommendations for establishing a national university, and the legislature had agreed to establish such an institution the previous March.[3] During the previous few years, collaboration with a private Canadian university permitted training professionals in a few fields, excluding medicine, and at a high cost to the country.

However, there did exist a broad, well organized and fruitful experience in training of general and obstetric nurses, as well as environmental and public health officers - all at the technical level - at the Schools of Nursing and Public Health, which together with the Schools of Education and Agriculture constituted Gambia College. Although not at the university level, the country had two more prestigious institutions under the Department of Education for technical-level training in administration, finance and trade.

The main points agreed upon concerning opening the medical school included:

• Begin medical training by Cuban faculty in October 1999;
• The Gambians would set up a preparatory course for young people wishing to pursue a career in medicine, from which a maximum of 25 students would be selected;
• The recently renovated Gambia College School of Nursing would temporarily lend a number of its classrooms to the medical school;
• The Gambian authorities would look for ways to acquire necessary books and laboratory equipment;
• The Cuban curriculum would serve as a provisional program that could be revised once the university was constituted.
• Questions concerning accreditation and degree granting were left for later analysis.

Prior to the arrival of the new Cuban medical contingent in June, the Gambian Secretary of State for Education named the Chairman and other members of the “University Council,” (the governing body of the university in the British tradition), comprised of notable figures in the fields of science, culture, government and the private sector.

Organizational Phase

On June 16, 1999, the Cuban professors arrived in The Gambia as part of a new group of 156 health professionals and technicians, to organize and begin university-level medical training in the country. The faculty included nine teachers from medical sciences institutes and schools from several Cuban provinces. Table 1 summarizes the group’s composition.

As is evident, most of the faculty had a good deal of teaching experience, as well as having held various positions of responsibility in medical schools or in public health. Three had some international collaboration experience and two had been active participants in establishing new medical schools in Cuba.

In addition to this team, two specialists in Family Medicine and other Cuban specialists from the contingent collaborated at various stages of the school’s development.

Activities conducted in this phase were:

• Curriculum revision, including formulation of course content for each of the first year, first semester subjects;
• Updating resources needed to begin teaching;
• Coordinating sessions with the University Council and officials from the Health and Education ministries;
• Identification of areas, labs and other facilities in schools, research and health centers that could provide support or help in teaching activities;
• At the request of the University Council, presentation of a detailed report on Cuban postgraduate education, with an emphasis on development of specialists, to assist in the process of making categories or academic ranks comparable;
• Convening an advanced English course for those Cuban faculty with English-language difficulties, to be taught by a teacher from Gambia College.

In September 1999, leaders from the West African Health Organization (WAHO) visited the school, and together with the World Health Organization (WHO) representative, convened the main stakeholders involved in the opening of the school to analyze the proposed curriculum. The group included the Departments of Health and Education, the University Council, the local WHO office, representatives of other government agencies, and the Coordinator of the Cuban faculty. The group became an ad-hoc working commission for establishing the medical school.

Table 1: Characteristics of the first Cuban faculty offering university-level medical training in The Gambia, 1999

During the meeting, several regional principles and policies were discussed regarding the training of human resources for health, including community orientation and the need for general practitioners with skills in the basic medical specialties, who were capable of working in difficult situations, as well as being prepared in disaster management. Concrete suggestions for taking steps towards beginning the teaching of medicine in the country were also made. Internships were not to be included in the curriculum. After discussion of all these aspects, a consensus was reached on changes to be incorporated into the curriculum, and the Cuban faculty was charged with formulating the revisions, which contemplated incorporating a year of pre-medical studies, among other things.

Based on the WAHO report and other documents and materials from the region and its universities facilitated by the organization and WHO, as well as on a preliminary definition from the Department of Health concerning the competencies required of the school’s graduates, the Cuban faculty formulated the mission and philosophy of the new curriculum; outlined the characteristics of the school; and offered a proposal on the organization of the pre-medical course. The aforementioned working commission discussed and provisionally approved the proposal until such a time as the new university had sufficient maturity and conditions to revisit this aspect.WHO announced it would provide some material resources and a consultant, beginning important assistance from this international organization.

The two-semester introductory or pre-medical course was designed as a group of introductory subjects to reinforce and update knowledge in basic sciences - Biology, Chemistry and Physics - as well as English and the social sciences. The student selection process began at the same time. The admissions committee included two representatives from the University Council, one from the university administration, one each from the Departments of Health and Education, and three Cuban faculty members. They interviewed 68 applicants and reviewed their records, including high school academic performance, scores on the regional ordinary and advanced exams - with special emphasis on biology, chemistry and English - as well as their marks on the preparatory course organized by the Department of Education. They examined their level of motivation, vocational aptitude, previous health-related work experience and oral communication skills. They also took into account their general health and age, without imposing rigid limits. At the end of three days they reached a consensus on 25 students: 22 males and 3 females between the ages of 19 and 25, and one 34-year-old.

On October 1, 1999, the first introductory or pre-med course was inaugurated. The 25 students and the Cuban professors were joined by the Chairman of the University Council, representatives from the Departments of Education and Health, and representatives from WHO, UNESCO and other institutions throughout the country.[4] The coordinator for the Cuban professors presented the components of the introductory course as well as the medical program curriculum. Classes began the following day.

The WHO Director for Africa visited the school in March 2000, resulting in the donation of a photocopier and computer for use at the Nursing School’s library, important for reproducing teaching materials. That same month, a Memorandum of Understanding regarding the medical school was signed between the University of The Gambia and the Cuban Ministry of Public Health.

In November 2000, as part of the preparatory work for the University of The Gambia, the Faculty of Medicine and Allied Health Sciences held its First Methodological Workshop. In addition to the medical school curriculum, the workshop analyzed proposals for university-level programs in Nursing and Public Health, which, at the request of the university authorities and the Department of Health, were scheduled to begin at the end of 2000 or beginning of 2001.[5] Thus, the Cuban faculty also contributed to the first steps in curriculum formulation for these professions.

Features Of The Medical School’s Curriculum

The medical school curriculum includes the following features:

• It is a 6-year program that includes one year of pre-medical or introductory courses offered by the Schools of Science and Humanities, followed by five years of medical studies;
• Community orientation: Community Medicine and Primary Health Care (CM and PHC) is taught throughout all years of the curriculum, and includes several subjects plus community work. It also includes disaster preparedness training. Students are required to present and defend a community health project in their final year;
• The first three semesters of the medical sciences curriculum cover basic biomedical sciences, with an inter-disciplinary approach. Human Anatomy, considered an integrated discipline, includes the origin and development of tissues, organs and other parts of the human organism (Embryology); characteristics of cells and tissues (Histology); and the structures of the various systems, parts and organs (Gross Anatomy), with the particularity that the themes are structured according to regions of the body. Physiology themes are distributed during the semesters, taking into account the morphological and Biochemistry themes that have come before, and in many cases there is a horizontal relationship between Physiology and Biochemistry;
• Clinical disciplines emphasizing practical training are offered as rotations. Rotations in Internal Medicine include the “minor” clinical specialties, and those in Surgery include the various surgical specialties;
• Electives are offered in the final years;
• There is no internship year. Instead, following graduation, there is a year or more of practice at an institution accredited by the Medical and Dental Council;
• Professional competency exams are administered in blocks with the participation of outside (external) examiners. The first block is given at the end of the first three semesters of the basic or pre-clinical courses; the second follows what are known as the para-clinical subjects (Pathology, Pharmacology, Microbiology, Hematology); and the third block is given at the end of the fourth year following clinical rotations in almost all specialties. The final competency test is given in the final year after completing consolidating rotations in the four basic clinical disciplines (Internal Medicine, Surgery, Pediatrics and OB/GYN), as well as all subject matter and practical work in Community Medicine and Primary Health Care, including a successful defense of a student’s community health project.

Table 2 shows the subjects by semester and year of study.

Table 2: Medical Curriculum: Faculty of Medicine and Allied Health Sciences, University of The Gambia

Medical Teaching Phase

In December 2000 the first year of the medical program began and the Coordinator of the Cuban professors was officially named Dean, the first official appointment at the new Gambian university.

There were still no laboratories. Construction, funded by WHO, was being completed on the anatomy laboratory adjacent to the Pathology Department at the Royal Victoria Hospital in Banjul. Some textbooks had been received from WHO and other donors, and the Cuban faculty had prepared various study materials for the first semester classes. On this basis, the University administration approved initiation of classes even though most practical activities had to be postponed. A good part of the laboratory work in Histology and Embryology was possible, thanks to microscopes lent by Gambia College. Physiology and Biochemistry coordinated with the Hospital for some practical activities. At the end of December, the anatomy laboratory was completed and arrangements were being made to obtain cadavers and formaldehyde to preserve them - a difficult task given the traditions and predominant beliefs in the country, as well as the absence of any legislation on the subject. In February 2001, hands-on training in Anatomy began with the dissection of the first cadaver.

At the same time, the selection process for the second group of medical students and the first nursing and public health students took place, enrolling 29 new students in medicine. Not without overcoming numerous difficulties, the first year of the medical program concluded satisfactorily in September 2001. The medical school had become an indisputable fact. Cuban faculty alongside other mainly African professionals, also joined the teaching staff for the Nursing and Public Health programs. During the 2001-2002 academic year, the first professional exams were given and it is significant that external examiners recognized the quality of student preparation. During the 2002-2003 academic year, the first clinical rotations began.

At present, the school is in a consolidation phase with Cuban, Gambian and other African teaching staff. Recently the University named a Gambian professional as Dean, with a Cuban specialist serving as his Advisor. New Cuban faculty have joined the staff, and efforts are being made to add Gambians and other professionals from the region. The Gambian Medical and Dental Council has completed two inspections at the Royal Victoria (Teaching) Hospital and has authorized continuation of studies, as well as having made a series of recommendations that would permit total accreditation of the medical program. The West Africa Health Organization, which coordinates and promotes health policies in the region, has recognized the school, maintaining close collaboration and exchange with it.

Final Considerations

The experience of Cuban medical collaboration in The Gambia through the Comprehensive Health Program, and particularly the project to establish a medical school there, has become part of the history of Cuban cooperation in health, and offers a concrete response to the goals outlined in the World Declaration on Higher Education in the 21st Century.[6] Overcoming serious obstacles in a severely resource-scarce environment, Cuban faculty and Gambian professionals, students and authorities were able to accomplish the daunting task of establishing a medical school with a curriculum that integrates regional and Cuban experiences, and is based on internationally recognized principles of medical education.

REFERENCES

1. Alfonso P. Personal communication from the Head of the Cuban Medical Team in The Gambia from 1996-1999.
2. Granma . Havana, April 12, 1999.
3. University of The Gambia. Historical Background. In: Special Convocation. Programme Brochure. pp.19. February, 2001.
4. Daily Observer , Banjul, Gambia. October 1, 1999, pp 1.
5. I Workshop on Teaching Methodology. Sponsored by WHO and The University of The Gambia. Faculty of Medicine and Allied Health Sciences. Brochure. November, 2000.
6. UNESCO. World Declaration on Higher Education in the 21st Century: Vision and Action. World Conference on Higher Education. Paris, October 5-9, 1999. Rev. Cubana Educ. Med. Sup. 2000. 14(3)253-69.

The Author

Arturo Menéndez Cabezas, MD, PhD, Specialist in Clinical Biochemistry and Public Health Administration, Professor, Higher Institute of Medical Sciences, Camagüey, Advisor to the Dean, School of Medicine and Allied Health Sciences, University of The Gambia. E-mail: dean.fmas@qanet.gm, artemen.cab@gmail.com