by on January 16, 2018 in CubaTrade – Featured Story, Healthcare
American citizen Steve Singh Gill, a full-time student at Cuba’s Latin American Medical School outside Havana, sits up tall in his lab coat talking with the assurance of the doctor he will become in a few more years.
“There’s a famous phrase that the doctor who only knows of medicine knows nothing of medicine, meaning that we have to be integrated doctors, that we need to know about medicine, but we [also] need to know about our community. We need to know that the source of illnesses really lies in community factors, community conditions, social conditions, economic conditions, and environmental conditions,” Singh Gill told Cuba Trade.
Singh Gill is one of five U.S. students enrolled in the now 19-year-old school, which goes by the acronym ELAM (short for Escuela Latinoamericana de Medicina). It has now has graduated over 28,000 foreign-born doctors, including 170 Americans. The program recruits heavily from poor countries or low-income communities in more prosperous ones. Students receive six full years of free room, board, and medical training – seven if they need to learn Spanish – on the agreement they return to their places of origin and make serving the underserved populations a lifelong endeavor.
Singh Gill says that mission was always central to his career plans, which is why he chose to attend the ELAM. After graduating, he hopes to return to his native Los Angeles to serve as a primary care doctor the old-fashioned way: living and practicing medicine in the same house, or at least in the same neighborhood. Lowering overhead costs and living close to patients, he makes it easier for certain sectors of the population to access affordable healthcare, he explains.
“It really opened my eyes to what the profession could do,” Singh Gill said, noting that his state has a high concentration of immigrants and minorities who often lack the time and resources to see a doctor, much less one who looks and talks like them.
“Latinos are the largest ethnic group in California but less than 2 percent of the physicians in California are Latino,” said Singh Gill, who is of Nicaraguan and Indian descent.
How U.S. Students Enroll in the ELAM
About 90 percent of the U.S. doctors trained at the school continue working in needy communities well after their residencies are over, notes the New York-based humanitarian nonprofit IFCO/Pastors for Peace. The organization, one of the nation’s oldest anti-embargo groups, serves as the main U.S. recruiter for the ELAM, working to identify and prepare worthy candidates. As stipulated by ELAM, they generally recruit college graduates aged 25 or under, and the vast majority of them are Americans who come from areas where access to affordable medical care is low.
On the back end, the California-based organization MEDICC (Medical Education Cooperation with Cuba) which offers scholarships to help ELAM graduates defray the cost of their U.S. medical board exams.
MEDICC founder and Cuba representative Gail Reed says altruism and social conviction aren’t the only good thing the U.S. can reap from Cuba’s free program. She says Cuba’s advances in science and health policy have led to high life expectancy, low infant mortality, and innovative pharmaceuticals to treat cancer and diabetes. Cuba’s healthcare system has also had excellent results in curbing infectious diseases, from HIV/AIDs to malaria and Zika, all of which plague communities with limited access to healthcare but also transcend social and class boundaries.
“Uneven access to medical care is bad for everyone’s health, so it’s important that best practices are applied across the board,” she said. “What the ELAM grads bring home is a dedication to making everyone’s health better by applying their scientific knowledge.”
A lot of what Cuba does best, she says, comes down to community-based prevention campaigns that start with ensuring patients get regular check-ups. “For example, they start a hypertension prescription with exercise and diet rather than a pill, and the doctors can help them stick with it because they’re right there in the community,” she said.
What U.S. Graduates Bring Home
Tampa Bay doctor-in-residence Graham Sowa graduated from ELAM last year. He says he saves patients and clinics time and money in lab work by operating as he did in Cuba – spending a few extra minutes talking to the patient to really understand the problem.
“I think I have a higher threshold for tolerance before ordering tests,” he told Cuba Trade, after noticing that his U.S.-trained colleagues often run more lab tests and spend more time analyzing them via computer in order to come to the same prognosis. He also said that improved communication helps manage patient expectations about pain, which can then cut down on prescribed painkillers. That, he says, can help curb the nation’s skyrocketing rate of opioid addition.
For him, this efficiency can result in shorter hospital stays. On the flip side, Dr. Marco Perez, a 2010 ELAM graduate, says the medical program gave him the skills to ensure patients stay in the hospital until they feel they’re truly on the mend. “When I was a medical student there I wasn’t pressured at all about moving patients and getting them out of the hospital,” said Perez.
La’Shelle Anita Manning is excited that her ELAM degree will set her up for jobs working as a physician in the minority communities she grew up in around the U.S. Mid-Atlantic, but she wants her knowledge to influence public health policy the world over. Having obtained an undergraduate degree in biochemistry at Ohio’s Oberlin College, and a master’s in public health from Drexel University in Philadelphia that included fieldwork in Gambia, she was already on that path when she arrived at ELAM. But she wanted a medical school program that would bring her path full circle.
“I didn’t like the idea of medical school in the States because it would just be all science and medicine. I wanted a program that had a very social mission,” she said.
Back in the Washington, D.C., area, she’ll have plenty of opportunities to fulfill that long-term goal as it is home to the U.S. Congress, the National Institute of Health, the United Nations’ Pan-American Health Organization, and dozens of think tanks and social and economic development groups.
ELAM Rector Antonio López Gutiérrez says faculty and staff share her vision. The school was founded in 1999, a year after Cuba sent medical brigades into the Caribbean and Central America to care for victims of the devastating Hurricanes George and Mitch.
“The commander in chief,” as he refers to the late Fidel Castro, “said that the most important thing wasn’t sending doctors to resolve the health crises that followed but to train doctors who could continue developing their own health systems,” said López Gutiérrez, who has been at the helm of ELAM for two years. Prior to that, he spent ten years working as the rector of the University of Medical Sciences in Santiago de Cuba, where he helped to train about 1,000 Haitian doctors.
“There’s power in being able to show that our country has a lot of economic necessities, as many countries do, and yet we are able to offer them something they can develop throughout the rest of the world,” he said. “When I was in Mexico, I saw that their hospitals had a lot of technology but it didn’t reach everyone, and in our country, in spite of our economic scarcity, we have high-quality hospitals where everyone can go.”
Gutiérrez noted that the current ministers of health in Bolivia and Costa Rica are both ELAM graduates, and that this year ELAM accepted about 1,000 medical students from Colombia – part of Cuba’s efforts to support the peace accords between the Colombian government and the FARC guerrilla movement.
Asked about his own inspiration for teaching medicine, his eyes grew watery. He said one of the most impactful moments of his career was serving for two years and two months as a doctor and professor of medicine in Angola, where in 1975 the Cuban military assisted in a guerrilla war to overthrow Portuguese colonial rule, contributing to a civil struggle that would last until 2002.
He said Portuguese medical professors were more likely to withhold important medical information over fears that up and coming Angolan doctors would start competing with their private clinics. On the other hand, Cuban doctors accustomed to capped Communist salaries had nothing to lose by imparting all the medical skills they knew.
“I’ll never forget the desire that the Angolan students had for learning, they were so eager to learn because they saw how different we were,” Gutiérrez reflected.
The Cultural Connection
Aside from conducting fieldwork, the students generally stick around the facility because it’s a 45-minute drive from Havana. At night, they educate and entertain each other with “cultural galas,” in which groups from around the world showcase their native foods, dances, dress patterns, and other customs.
“The best part about it to me is being in a community with people from all over the world that are really in disadvantaged positions and were given this opportunity. You learn a lot from those people,” said Perez, who now serves New Mexico’s Navajo community at Lovelace Westside Hospital in Albuquerque.
During his time at the ELAM, Perez says he was humbled to meet the best and brightest minds from around the world and discover that many of them – especially ones coming from isolated or marginalized communities in places like the Amazon – first had to play catch up by learning to use a computer. The Americans could help them with that skill, and in exchange, those students taught folks like Perez the importance of being respectful of other ways of life and keeping an open mind.
This happens a lot with his Navajo patients, who may ask to bring a tribal healer to the medical consultation.
“I tell them, ‘I’m a doctor, I know medicine and what I can give you is my advice. But you’re free to have your spiritual leader come and give you advice as well,’” he said, noting that while this slows the appointments, it can make for a speedier recovery back home because the community joins in the recovery efforts. “They listen to what you’re saying even more because they can see that someone’s not judging them for what they believe,” Perez said.
The Luxury of Learning
The U.S. ELAM students know they’ll eventually head back to a capitalist system, but they won’t be under as much pressure as peers who rack up tens of thousands of dollars in medical school debt. U.S. student loans is what prompts many doctors to specialize in more lucrative medical fields that don’t necessary translate to public health solutions.
A 2016 study by the Association of American Medical Colleges projected a shortage of as many as 35,600 primary care physicians by 2025. It also noted that if more people in low-income areas could afford to get to the doctor, that shortage could crest 96,000 doctors.
During her six years of higher studies in the United States, Manning worked two jobs and still took out loans, which she stacked with loans from her bachelor’s in biochemistry at Oberlin College. Medical school tuition in the U.S. would have been crippling, but as long as she’s studying in Cuba, her expenses are covered and her U.S. debt is on a long-term deferment plan.
“Here I can focus on studying medicine. I don’t have to worry every semester about where I am going to get the money from,” she said. “It’s refreshing. It’s a break – all that stuff is on pause.”
Privileges, Limitations, and Lessons Learned
ELAM says its foreign students have everything they need during medical school. In fact, it might be more comfortable than what they had back home. The large facility comes with a spectacular oceanside view, sports fields, dormitories, cafeterias, a barber and beauty salons, a computer lab with internet access, and cable television with up to ten stations.
But over the years, those very luxuries have raised some concerns among Cubans, especially ones studying in the other state-run schools, notes Dr. Romy Aranguiz, a Cuban doctor who works in Fort Meyers, Fla. She began her medical studies in Cuba and finished them with a specialization in rheumatology in the United States. The ELAM program started in 1999, while she was studying at the University of Medical Sciences of Havana. Her professors asked students like her to mentor ELAM’s incoming class, and that stirred up some mixed emotions. Cuba was barely on the road to recovery after the collapse of the Soviet Union sent it into an economic crisis.
“We liked the concept that they would go back and help in poor communities, but we were a little upset because things were already hard for us,” she said, noting that while ELAM students had all their expenses covered, their Cuban counterparts had practically no access to the latest books or transportation to get to class. “I think it was a normal reaction, but it was also nice because up until then, we didn’t have access to people from elsewhere. To meet people from other countries was a great experience,” she said.
She agrees with ELAM faculty and students that Cuba has one of the best preventative healthcare systems in the world, one that can stretch limited resources to meet a wide array of needs. Still, she says her own specialization doesn’t exist in Cuba, which isn’t focused on the medicines and procedures needed for treating debilitating muscle and joint problems.
“The population is aging really fast, the middle-aged population is dying at high rates, there’s not enough young people to take the jobs – how are you going to keep working with arthritis? It’s a problem,” she said.
Plus, she added, many ailments can be quickly diagnosed with just one CT scan or MRI, technology which is hard to come by in most Cuban hospitals. “You cannot do empirical medicine without resources,” she said. López Gutiérrez agrees the lack of resources can create obstacles. For example, even if the U.S. embargo allows for the sale of most medicine and medical supplies to Cuba, medical books and some medical equipment are not.
“It would be so much more cost-effective if we could purchase these things from Florida,” he said, although he added that Cuba has defended itself by creating its own medical books, and coordinating carefully so that schools know exactly what items they need before going on a supplies mission to Asia.
In addition to campaigning for widespread health education and preventative medicine, Aranguiz says ELAM graduates could have a powerful voice for ending the U.S. embargo. “These students can be advocates for a better future in Cuba,” she said, noting how the embargo stifles its ability to stay technologically relevant.
Back in Albuquerque, Perez is off to a good start. As the U.S. healthcare debate rages on, he says he has plenty to discuss. “When people say that providing healthcare for everyone is very expensive and not very feasible, I can say I have first-hand experience working in a country where healthcare is for everyone,” he said. “The numbers are great, their health indicators are very good – in some cases better than ours here – and they also spend a lot less because they have great patient education where the community knows what to do, when to go to the hospital and when not to, what to do in certain cases, and how to prevent and manage chronic diseases.”