|
||||||||||||||||||||||||||||
INTERNATIONAL COOPERATION REPORT Joining Forces to Develop The entire country of Niger, population 11.5 million, has only 386 doctors; Tanzania has just 216 dentists for 36 million; and in Zimbabwe, a country of almost 13 million, there are only 12 pharmacists.[1] Such dire statistics, and many more like them, have led a mosaic of public health stakeholders to sound the alarm on the human resource crisis already threatening the world’s health outcomes.
Efforts are collaborative, from both the public and private sector: WHO is dedicating its 2006 World Health Report, provisionally entitled “Working for Health,” to the emergency and in July, Baylor College of Medicine and Bristol-Meyers Squibb announced a joint initiative dubbed the “AIDS Peace Corps.” This five-year treatment project in Africa is distinguished by a program design that trains local doctors and provides technical support so African health authorities are able to treat their populations once the project ends. Its reference point is the seminal report (Healers Abroad) by the Institutes of Medicine released earlier this year, advocating the U.S. government take just such an initiative. Enabling the local health workforce to care for its own population is critical to providing a sustainable solution to a problem that is hard to quantify. Still, in its comprehensive Human Resources for Health, the Joint Learning Initiative “estimate[s] the global shortage at more than 4 million (healthcare) workers; sub-Saharan Africa countries must nearly triple their current number of workers by urgently adding at least 1 million workers.”[2] For almost three decades, Cuba has collaborated with health authorities around the globe to develop medical education programs to train such urgently-needed professionals (see Table 1) with curricula formulated to meet international standards and local health needs. In this way, the Cubans have established medical schools and provided badly needed faculty reinforcements.
In South Africa, the Gambia and Venezuela, Cuban professors have adapted various problem-based learning curriculum designs, adding their own strong community-based education experience that speaks to primary healthcare needs in these countries (Community Health Diagnosis as a Curriculum Component: Experience of the Faculty of Health Sciences, Walter Sisulu University, Eastern Cape, South Africa). Often, they’ve had to wean themselves from more traditional teaching methods to capture the best of this combined approach. Dr. Julio Aguirre, of the Health Sciences Faculty and coordinator of the Cuban professors at Walter Sisulu University (UNITRA) since 1996 says, “problem-based learning is a process where students…develop the capacity to think and put things together and integrate knowledge” through clinical health scenarios provided by actual cases. Dr Aguirre’s colleague Dr. Mayra Garí, another veteran professor from the Cuba-UNITRA collaboration elaborated: “problem-based learning puts emphasis on the diseases that are important for that particular country and community…the students learn based on real cases [and] in that way are learning to apply knowledge in a medical context…then, when they go to the community or the hospital, they know what to do; they become a lot more effective.” Professor E.L. Mazwai, Dean of UNITRA’s Health Sciences Faculty credits the Cuban’s implementation of the program for sensitizing students to the health needs of the community and increasing their commitment to serve. The Gambia’s First Medical School Tiny Gambia fits squarely into the sub-Saharan profile of a country under siege from the combined pressure of poverty and disease. In 2002, Gambians had a life expectancy of 54 and 62% of adults were illiterate; more than 82% of the population was living on less than US$2 a day and the country counted only four physicians per 100,000 population.[3] Given this backdrop, The Gambia’s President, Dr. Alh. Yahya A.J.J. Jammeh prioritized health and education, and made the progress of young women a political commitment in this Muslim nation. Primary school became free for girls; dozens of health centers were built; a new hospital in Farafenni town went up; and perhaps most important of all, the School of Medicine became the lead faculty in establishing the first university in Gambian history.
As a result, in September 1999, the first Cuban professors arrived in The Gambia, led by Dr. Arturo Menéndez ( Experience of Cuban Faculty in Establishing a Medical School in the Republic of The Gambia). The curriculum slowly began to take shape, with further assistance from Cuba and the World Health Organization. In 2006, The Gambia will graduate the first 15 physicians from the school, which has incorporated the Royal Victoria Teaching Hospital for the clinical years. This 540-bed hospital has undergone major changes to merit accreditation as a teaching facility, including complete remodelling of the accident and emergency services, blood bank, and ICU; plus a new pediatric wing, dental clinic, pharmacy, administration buildings, library and teaching labs and classrooms. In 2004-2005, the School had an enrollment of 109 students including the pre-med or bridging course - a good number of them women. The School also trains nurses and offers a public health degree. A total of 12 Cuban professors staff the school - eight in Basic Sciences and four in Clinical Sciences. Professors from Nigeria, Sierra Leone and The Gambia complete the teaching staff of 21. The Student Perspective Ousman Sanyang and Abba Hydara expect to be among the school’s first graduates. Their stories are not unique, and they help to illustrate the hopes, frustrations, and commitment of their classmates. Ousman, who comes from the urban area of Serrekunda adjacent to the capital, had the opportunity to study in another West African country and even in the USA, but when he heard about The Gambia’s own school, he opted to enroll at home. “The most important thing for the school at the beginning was that we had the will of government, of the students and of the lecturers. The facilities came later,” he told MEDICC Review. “The Cuban professors sometimes brought their own books, or would photocopy materials. We didn’t have Internet or even textbooks at first. We were sometimes frustrated. But our Cuban professors - who should have been put off by the lack of facilities - just said ‘this is how we started in Cuba, too.’ And so we got going.” “What I’ve found is that practicing in a developing country is not easy. It has its limitations. The facilities for sophisticated diagnostic equipment often don’t exist, for example. But if we can make a diagnosis based on a detailed clinical history and a thorough physical examination - which is true for 85% of cases - then we even have an edge over students trained in Western Europe or the States. And that’s what our training concentrates on.” Dr. Nestor Shivute, World Health Organization representative in The Gambia, notes that “we did not have medical doctors trained here before. They were trained in Western countries. And they tended to stay there, and only come home to visit….Yet, the most important resources are human resources. They are the key.” One issue faced by the Gambian government - as in virtually all developing countries - is that government salaries are not on par with private sector earnings, and additional benefits have yet to be put in place. Special allowances for physicians posted in rural areas, plus additional benefits in the public sector, are among the incentives the ministry is reviewing in order to have a better chance to keep the doctors The Gambia is now training. Abba Hydara’s father is an accountant, his mother a rice farmer. He grew up in his grandfather’s compound of some 50 relatives in Brikama, near Banjul. Earlier he received training as a physician’s assistant and was certified to operate on cataracts. He said it was the presence of Cuban professors at The Gambia’s medical school that convinced him that “finally something was going to happen. I saw all these professors from Cuba looking serious, and the Cubans are no jokers! So it seemed the school was finally going to be set up.” He gave up a more comfortable position with the health ministry to go to school, and dug in with the Cuban professors in pre-medical and basic sciences. “The team of teachers was under pressure, especially because of language,” he noted. “But in the end, only one had problems, and the other eight stayed with us. They taught us never to take anything for granted; to study and be disciplined; and their system was very good for us since it includes almost weekly evaluations. That kept us on our toes.” “But above all,” he said, “they brought their spirit. From the start it was clear that they were teaching to prepare us, to make sure we understood we had a responsibility to our people, to help them come out of the cycle of disease and poverty and ignorance. They never minced words about that. And so, from the beginning, we visited communities and families to get a sense of their problems, and to lay the foundation for ourselves.” The students make a commitment to serve in the public health system (a practice known as “bonding”) for the same period of their studies - six years. While tuition is US$600 annually, all students until now have received scholarships either from the World Health Organization or The Gambian government. Venezuela – Defying The Paradigm From cataract operations to trade agreements, literacy campaigns and sporting events, Cuban-Venezuelan cooperation has been flying along at Mach speeds recently. With education and health care among the highest priorities for Hugo Chávez’ government, it should come as no surprise that Cuba – internationally recognized in both fields – should be called upon to help. Venezuela’s health workforce goals are Homeric, with the first phase aiming to graduate 60,000 physicians by 2015. To make this a reality, the country has embarked on a multi-faceted medical education strategy that includes availing itself of scholarships offered in Cuba, like those at the Latin American Medical School ( Top Story: Where There Were No Doctors), and the creation of the Comprehensive Community Physician Training Program (CCPTP; Programa de Formación de Medicina Integral Comunitaria) in Venezuela itself. Part of the government’s universal primary care system in poor neighborhoods known as “Barrio Adentro,” the Program is a partnership between Venezuelan and Cuban health authorities, physician mentors, and medical educators, to train 40,000 of these new doctors in Venezuela. Months of intense planning, coordinating, program design and staff training preceded a nationwide call for applicants that netted more than 20,000 students who are expected to begin medical school on October 3. These are not run-of-the-mill medical school classes however, as the program introduces several pedagogical and methodological innovations. To learn the details, MEDICC Review conducted exclusive interviews in Caracas this August with the health professionals responsible for the new curriculum design. The fundamental innovation is re-focusing the learning environment to emphasize community settings. No longer will students spend the first two years of their medical education solely in the classroom. Instead, the curriculum is split between the classroom and clinic, whereby the students work as “assistant interns” in a local Barrio Adentro clinic under the mentorship of qualified Cuban physician-instructors. How it Works There are 7,898 local clinics across Venezuela in the Barrio Adentro project; most of them staffed by a Cuban doctor-Venezuelan nurse team in a setup similar to the family doctor-nurse team in Cuba. According to the new curriculum, each Cuban doctor has two Venezuelan students assisting half-days in their clinic, attending classes the rest of the time in multipurpose classrooms with some 35 other students. The Venezuelan program is six years, with five years spent in the clinic-classroom module and the sixth year as interns.
Dr. Luis Armando Wong, of the Cuban faculty coordinating team in Venezuela, explained, “this education system defies the paradigm because even from the basic sciences stage, students aren’t only learning in the classroom; they’re learning in the clinic, with real patients. So they read about heart disease in class and then see it at the clinic in a living person, not a cadaver.” Although classes don’t start until October, many students have already been working in the clinics in a “familiarization” program coupled with bridging coursework in Biology, Chemistry and Spanish to bring students to the same starting point. Dr. Neisy Torres, attending physician at the Bloque 26 clinic that serves over 2,000 people in the 23 de Enero neighborhood of Caracas, has already begun working with her two Venezuelan students. “The familiarization stage is complicated,” she told MEDICC Review, “but after a time, the students begin to feel like health professionals.” Another innovative aspect of the Venezuelan program is how the coursework is taught. In a new step for Cuban teaching staff, the problem-based component calls for related basic sciences subjects to be combined into one module called Human Morphophysiology, allowing for a more holistic, integrated understanding of the human body and the pathologies affecting it. Using a methodology that treats anatomy, physiology, histology, immunology, embryology and other subjects together rather than separately, teachers present scientific content in a way that more closely resembles how students will see it expressed in everyday clinical practice. Despite new methodologies, certain fundamentals of the Cuban public health philosophy have been translated to the Venezuelan program – above all, the emphasis on primary care and prevention. In a visit to the Cardiovascular Center, Director Dr. Luis Manuel Reyes explained that most of the patients he sees already suffer from heart disease or hypertension, and are surprised when “we focus on prevention and health promotion, dedicating 10 to 15 minutes of each patient visit discussing prevention.” Other hallmarks of Cuban public health are also found here, as Cuban doctors practice what their own professors preached back home: “treat the patient, not the disease.”
Challenges & Horizons Coordinating thousands of students, some from isolated, jungle communities who might travel to their clinic or classroom by canoe, (the program is designed to prevent brain drain to the cities by allowing people from rural areas to study close to home), matching them with clinics and professors, plus designing the curriculum, has demanded a monumental effort. Drawing up autochthonous educational materials that speak to the Venezuelan health picture and learning environment was among the initial challenges, along with training Cuban faculty in the innovative pedagogical model. According to its designers, Cuban physicians serving as mentors have been required to take post-graduate courses in three areas, the pillars of the teaching methodology for the Venezuelan program: • Seminars to update knowledge in basic sciences and their integration; • Pedagogical preparation in medical education for lecturers; • Methodological preparation specific to the Comprehensive Community Physician Training Program curriculum. Ongoing evaluation of the program, the professors and the students - another aspect of the integrated Cuban philosophy of health that has been transported to Venezuela - is vital to the success of this “university without walls…the University of Barrio Adentro” as Dr. Wong called it. Professors, like students, partake in weekly evaluations to measure their progress, prepare for upcoming course units, share and debate ideas. To facilitate learning, interactive CDs and other audio-visual materials detail which subjects need to be mastered by when; and the clinical-classroom model, in which students are working alongside their tutors, encourages dialogue between teacher and pupil to further enhance learning. Venezuelan-Cuban cooperation in medical education also includes a post-graduate component in family medicine. Equivalent to a residency in Cuba, it lasts 30 months and has been adapted for the Venezuelan system, thus far enrolling 1,050 general practitioners. Ten Master’s degree options in medicine and two in dentistry are also available, and - addressing another piece in the health workforce puzzle - medical technicians will begin their training in Venezuela in October. At the historic first commencement of the Latin American Medical School in Havana on August 20th, President Hugo Chávez took human resource goals from the Homeric to the Herculean, announcing that a second Latin American Medical School would be founded in his country. References
|
||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||
Former health minister Dr. Yankuba Kassama recalls that President Jammeh made his first visit to Cuba in the late 1990’s, where he discussed his proposal. The Gambia needed a medical school to train doctors with a commitment to serve. Says Dr. Kassama: “We needed to sensitize people that nation-building is about sacrifice sometimes. If (professionals) don’t stay, who will build this country?”
