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SPOTLIGHT Doctors for the (Developing) World Cuba’s contribution to the world’s health workforce has been essentially a practical one, focusing on health care delivery and medical education writ large: today, 24,950 Cuban health professionals serve in 68 countries[1]; and in an unprecedented effort, 12,000 international students are enrolled on full scholarship in Cuban medical education institutions. Medical students alone account for more than 11,000 of them - a figure expected to reach over 25,000 in 2005-06.
Source: Viceministry for Medical Education, Ministry of Public Health, Havana. July, 2005. A Bit of History 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 ( International Cooperation Report: Joining Forces to Develop Human Resources for Health). Moreover, Cuban professors would provide the backbone for struggling medical schools in other countries of the Global South - including Angola and South Africa ( Community Health Diagnosis as a Curriculum Component: Experience of the Faculty of Health Sciences, Walter Sisulu University, Eastern Cape, South Africa). The Latin American Medical School Program
Discovery of the underlying disaster of entire populations without health care led the Cuban government to two decisions: 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. 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 27 countries, and in the case of the United States, attracted students even in the absence of a bilateral accord. Approximately 1,000 students from other nations - primarily African - are studying medicine in Cuba under other programs. In all cases, the basic curriculum consists of a 6-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. LATIN AMERICAN MEDICAL SCHOOL:
Source: Latin American Medical School, August 2005 Differences in 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 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 from 27 countries - 51% of them women. Graduates’ commitment: Students know when they enroll that they are expected to make a commitment to serve in undeserved 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 the students themselves, 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 ( MR Feature: Profiles in Commitment: Conversations with ELAM Students ). 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. 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 ( Top Story: Where There Were No Doctors). 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. The scope of the Cuban programs continues to grow: at the Latin American Medical School’s first graduation on August 20, President Fidel Castro announced the country will join with Venezuela to train 100,000 physicians for developing countries - including 60,000 new scholarships for Venezuela and 30,000 for the rest of Latin America and the Caribbean. This means a total of 100,000 new physicians - from low-income families themselves - for these countries over the next ten years. Will 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? Cuban medical educators predict the majority will - but even if only some do, then Cuba will have made a substantial contribution.
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By 2004, Cuba had over 68,000 doctors (1 X 165 inhabitants), and a total of over 380,000 health workers. 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 ( 
By far the most ambitious program for international medical training is the Latin American Medical School. When the fury of Hurricanes Georges and Mitch struck Central America and the Caribbean in 1998, 1,000 Cuban doctors were sent as volunteers to the disaster zones. 