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Latin American School of Medicine (ELAM) in 2010by Don Fitz
"ELAM is the revolution realized," says Ketia Brown, a 30 year old third year medical student in Havana from California. The Latin American School of Medicine, ELAM (Escuela Latinoamericana de Medicina) is the 11 year old medical school in Santa Fe, Playa, a 90 minute bus ride from Havana, Cuba. [1] With their educational costs covered by the Cuban government, students focus on returning as doctors to underserved communities in their countries.
Cassandra Cusack Curbelo, a second year Cuban-American student, believes that "There is no experience like thousands coming together with the same idea of medicine. It feels like we are not separated into two continents, but we are one people who share a common history of struggle. This is what ELAM opens our eyes to." [2]
International medicine: A revolutionary dream
Che Guevara also had a vision in 1960, the year after the Cuban revolution. After observing that many graduating doctors did not want to serve in rural areas, he imagined training campesinos to themselves become doctors so they could run "immediately and with unreserved enthusiasm to help their brothers." [3] That year, Cuba sent medical teams to Chile to help after a major earthquake. [4] Cuba's first health contract resulted in its sending a medical brigade to Algeria in 1963. [5]
Che Guevara...imagined training campesinos to themselves become doctors.
When Hurricanes Mitch and Georges devastated the Caribbean Islands and Central America in 1998, Cuba sent doctors and paramedics. Fidel Castro then proposed expanding Cuba's new Comprehensive Health Program (Programa Integral de Salud) by creating ELAM, which began in 1999.
Castro's ability to inspire changes should not be underestimated. I met Exa Gonzalez, a sixth year ELAM student, on a plane to Havana in December, 2009. In high school she studied art and film in Baja California, Mexico. As a teenager, she made two trips to Cuba with her parents, members of the Workers Party (Partido de Trabajo, PT). During her second trip, in 2001, Fidel described ELAM to the PT delegation, which inspired Exa to change her studies to medicine. She entered ELAM in 2002, when she was 19 years old, and spent her first year in pre-med, studying biology, chemistry and physics. [6]
Cuba's Programa Integral de Salud expanded dramatically in 2003, when the Venezuelan Medical Federation attempted to obstruct efforts by President Hugo Chavez to provide health care to underserved communities. Collaboration between Cuba and Venezuela resulted in the Barrio Adentro (Inside the Community) program which brought 10,000 Cuban doctors in less than a year. [3]
The high number of primary care doctors in Cuba
makes it possible to move quickly after disasters like Katrina.
When Katrina slammed New Orleans in August 2005, Castro mobilized hundreds of ELAM graduates and Cuban doctors to help. U.S. President George W. Bush refused to even consider the gesture of good will. A friend told me that it must have been a publicity stunt by Castro, since he knew that Bush would not accept. I replied that, given the breadth and depth of Cuban medical aid to countries in Latin America, the Caribbean and Africa, it would have been an insult by Cuba to ignore the plight of a U.S. city near its shores. The high number of primary care doctors in Cuba makes it possible to move quickly after disasters like Katrina.
Ever since Hurricane Georges in 1998, Cuba has assigned hundreds of doctors to its neighbor, Haiti. Cuba has also been training Haitian doctors since the doors of ELAM first opened in 1999. The only requirement is that when they graduate, Haitians agree to return home to take the place of Cuban doctors (rather than defecting to plush jobs in the U.S. or Europe). [7]
Haiti is merely the most recent example of the enormity of Cuba's international medical work. According to ELAM's website, there are 52,000 Cuban medical workers currently offering their services in 92 countries. [5] This means that Cuba has more doctors working overseas than either the World Health Organization or the combined efforts of the G-8 nations. Thus, "by 2008, Cuban medical staff were caring for over 70 million people in the world." Additionally, almost 2 million people outside of Cuba owe their "lives to the availability of Cuban medical services." [4, pp. 3, 169, 112]
BES
A revolution can only be successful when the new generation takes over from the old. When thousands of students come together because of their dedication to helping others at a school that was built to allow them to fulfill their goals, the ground is fertile for students to take over the leadership of the struggle.
After the third class graduation at ELAM, the Student Congress proposed creating the opportunity to work on specific projects during summer vacation months. The faculty approved and students began designing projects designated as Brigadas Estudiantiles por la Salud (BES, Student Health Brigades) that would take them to clinics in New Orleans, California, the U.S. Southwest and impoverished urban and rural communities of South and Central America.
...there are 52,000 Cuban medical workers currently offering their services in 92 countries.
The Yaa Asantewaa Brigade (YAB), whose key organizers include Omavi Bailey and Ketia Brown, is illustrative of how BES projects function. [8] YAB is the group that will carry out the "African Medical Corp - Ghana Project." It was designed by the Organization of African Doctors (OAD), a group of African and African-American medical students. Founded in 2009 on the ELAM campus, OAD adopted the mission of developing "programs, projects and institutions with the objective of producing an organized, politically conscious and socially-responsible medical body able to meet the needs of African people suffering from health related issues throughout the African world. OAD is composed of 160 students, interns, and residents trained in Cuba currently representing over 35 countries." [8, p 2]
Currently, the "brain drain" of African doctors getting jobs in Europe or the U.S. leaves Ghana with just 1 doctor for every 45,000 residents. Similarly, there are more Ethiopian doctors in Chicago than in Ethiopia. [9] OAD aims to confront the problem head on by strengthening the norm at ELAM that African (and all other) medical students return to serve impoverished communities in their homeland.
The 2010 phase of the Ghana Proposal plans to begin with ELAM students traveling to Ghana to meet with Cuban-trained doctors already there. In the communities they visit, ELAM students intend to
1. Perform an access assessment of the sources of health care that residents already have;
2. Set up health groups of medical students who do physical exams and learn of Ghanaian traditional medicine; and
3. Hold community meetings to strengthen ties with Ghana residents by finding out what health care they want.
If successful in 2010, the YAB hopes to create an internship so that sixth year ELAM students can complete their medical training in Ghana.
ELAM students in Ghana will have experiences that differ vastly from those of medical students in the U.S.. Unlike the overdeveloped countries, where the major causes of death are "life-style" diseases such as strokes and heart attacks, "The 10 principle causes of death in Ghana are all due to preventable infectious diseases." [8, p. 6]
Omavi Bailey
...there are more Ethiopian doctors in Chicago than in Ethiopia. OAD aims to confront the problem .
It is no accident that the YAB aims to look at Ghanaian access to services, beliefs about health care, and desires for change rather than jumping in to provide pre-determined services that may or may not fit the life of an African village. Training at ELAM places heavy emphasis on the evolving social context of medicine, a model that applies particularly well to tight-knit communities.
Even though traditional and natural medicine are often ridiculed in the West, they have "remained the primary mode of prevention and treatment for 85% of African people." [8, p. 6] Thus, the Cuban model of Medicinia General Integral (MGI, General Integral Medicine), which "approaches health care holistically, considering its biological, psychological, cultural and spiritual components," [8, p. 7] prepares students to be a doctor-as-listener as much as a doctor-as-teacher.
Growth of ELAM
The ability of Cuban-trained doctors to listen to people and work with them rather than impose a Western model upon them is one factor that increases the eagerness of countries to send students to ELAM. ELAM opened in 1999 with students from 24 countries: 19 Latin American, 4 African and the U.S.. [5] A six-year program, it graduated its first class in 2005. The next year, 2007, ELAM had students from 27 countries. [9] By 2008, the number of countries with students at ELAM had grown to 40. [3]
The ELAM Director of International Relations told me of expansion to campuses throughout Cuba. As of April 2010, the campuses have a total of 21,018 students from 100 countries. Virtually all of Latin America is represented. Even Colombia, with its notorious right-wing government, has 385 students. Campuses have students from 36 African countries, plus many from the Middle East, Asia, Pacific Islands and the Caribbean. [10]
Training at ELAM places heavy emphasis on a model that applies particularly well to tight-knit communities.
When I asked the Secretary General of the ELAM Project if there were students from England and Australia, she explained, "No, developed countries usually provide medical care and ELAM is designed to help poor countries." [12] However, this could be interpreted as meaning that ELAM does not reach out to the overdeveloped countries. If students are truly dedicated to working in underserved communities, they might be admitted if they apply through the Cuban embassy in their country. This is suggested by the 2010 matriculation table which lists students from Germany, Canada, Israel and Korea.
The internationalism of ELAM reflects the internationalism that runs throughout Cuban medicine. ELAM professors tell their students of participating in relief efforts after disasters in Guatemala, Honduras and Haiti. Students hear from other students as well as from instructors of solidarity campaigns in Africa and Venezuela.
When students do rotations at neighborhood consultorios (family care centers) or community polyclinics, they will work with medical staff who have global experience. While visiting Havana's Policlínico Universitario, its Vice Rector Teresa Frías told me that she had worked in Angola, Tanzania, Brazil and Bolivia. As her co-worker, also named Teresa, provided a tour of the polyclinic, she mentioned that she had worked in Ghana, Venezuela and Brazil.
The medical system aims to deal with 80% of health problems in the consultorio.
Any gathering of medical staff in Cuba is likely to include people who have stories from distant parts of the world. Internationalism is not merely a slogan or ideology in Cuban medicine - it is a core component of a medical culture that pervades the teaching and practice of medicine.
Doctors as teachers
Like many ELAM students, going to medical school would have been impossible for Ivan Angulo Torres. The cost would have been prohibitive, and only 100 students per year enter medical school in his home of Lima, Peru. He was studying hotel administration when he first heard of ELAM in 2002. Two years later, he was in Havana. Four of his relatives attended his July 2010 graduation as the first doctor in his family. [12]
The course of study differs a bit for students, depending on whether they have sufficient pre-med background in biology, chemistry and physics; whether they are from Cuba, Latin America or a non-Latin culture; and whether they are fluent in Spanish. Rather than starting his school year in September, Ivan began his studies in March 2004 because he needed a half year of science courses.
The first two years of medical school included basic classroom subjects such as anatomy, physiology, histology, biochemistry, genetics, organ systems, psychology, pathology and the Cuban medical model with its emphasis on public health. He had contact with a neighborhood consultorio his first year and learned how to give physical exams his second year.
During his third year, Ivan began working with hospitalized patients as a practicum 8-10 am. He made rounds with doctors 10 am-1 pm and took courses such as symptomology, internal medicine, X-rays and English in the afternoon.
His fourth and fifth years saw extensive training in the Cuban MGI model of medicine, which emphasizes people as bio-psycho-social beings whose context of life must be understood in order to treat them. The MGI model teaches doctors how to teach patients to care for themselves largely by changing the social context of their lives, including their communities. During those two years, Ivan studied public health and did two month hospital rotations in areas such as MGI, ear/nose/throat, ophthalmology, obstetrics/gynecology, pediatrics, surgery, orthopedics, urology, dermatology, and psychiatry.
During his sixth year as an intern he was responsible for patients in a consultorio every day and for polyclinic patients one day per week. He also completed all his major rotations begun during his third through sixth years.
From the beginning of their training, ELAM students learn that the core to public health is the neighborhood clinic, or consultorio. The medical system aims to deal with 80% of health problems in the consultorio, which serves about 150 families. [13]
The consultorio is often described as a neighborhood doctor's office, with patients seen on the first floor, the doctor living on the second floor, and the nurse living on the third floor. This is the ideal Cuban model, but it does not capture the wide variation or the close connection between medical students and the consultorio.
...students are integrated into neighborhood health care beginning with their first year of medical school.
In December 2009 Dr. Alejandro Fadragas Fernández and nurse Maité Perdomo showed me their consultorio, which serves about 500 families and 1800 patients, making it larger than is typical in Cuba. [14]
On the wall is a poster, Mural Docente, listing the "teaching staff" of 2 doctors, 4 nurses, 2 first year ELAM or Cuban students, 1 fourth year student, 1 fifth year student, and an intern.
The poster tells us many things. First, medical students are integrated into neighborhood health care beginning with their first year of medical school. Second, Cuban residents are accustomed to international students being part of their treatment. Third, since there are multiple doctors and nurses working at a consultorio, they do not all live in the same building. They may live in the neighborhood or close to it, and the degree of integration into the community is complex.
Fourth, medical teaching is not limited to ELAM but is integrated throughout the practice of neighborhood medicine in Cuba - doctors expect to help train medical students as part of their practice. This is so much the case that medical students use the words profesor and médico (doctor) interchangeably.
The meaning of ELAM for ELAM students
Why do students from throughout the world come to ELAM? For Exa Gonzalez of Mexico, a speech by Fidel Castro changed her life. For Ketia Brown, it was ELAM's unique blend of traditional medicine with modern practice that caught her eye. For Cuban-American Cassandra Cusak Curbelo, it was an opportunity to share the dream of helping others by returning to the land where her grandparents had been revolutionaries.
But for many, it is a combination of being able to afford to go to medical school and participate in a vision. Ivan Angulo was not the only student who never could afford a traditional medical school.
Anmnol Colindres of El Paraíso, Honduras had long wanted to be a doctor, but his father, who had been a forestry worker until the coup of June 28, 2009, could not afford to pay his way. [15] Amanda Louis, from the Caribbean island of St. Lucia, feels that she has an opportunity at ELAM that she never would have had from the salaries of her father, a taxi driver, and her mother, who is a street vendor. [16] Dennis Pratt, originally from Sierra Leone before his family moved to Jonesboro, Georgia, did not want to spend years paying medical school loans and immediately applied when he learned of ELAM. [17]
Like other students from the Pacific island nation of Tuvalu, Jonalisa Livi Tapumanaia is excited that ELAM will make it possible for there to be a doctor on each of the 10 major islands of her home, which is already suffering the rising waters of global warming. Her government can only afford to pay for her to fly home once every three years and her parents cannot cover the cost from the income of her father, who runs a gas station, and her mother, who works in an island court. [18]
It is also costly for Lorine Auma to visit her family in Kenya, and she will see them only once during her six years of study. Her father, an accountant, and her mother, an occasional printer, could not afford the expensive Kenyan medical school. [19] Keitumetse Joyce Letsiela reported that there is no medical school in her native Lesotho and her mother, a teacher, did not have funds to send her to an expensive medical school in neighboring South Africa. [20]
...probably a majority of ELAM students could not attend medical school were it not for its free tuition.
Clearly, a huge number, probably a majority, of ELAM students could not attend medical school were it not for its free tuition. One part of their education is learning that the improvement of medical care in Cuba has meant focusing on preventive family care. U.S. medical practice is so over-specialized that only 11% of doctors are family physicians. In contrast, almost two-thirds of Cuban doctors practice family medicine. While the ratio of family physicians per population is about 1:3200 in the U.S. it is about 1:600 in Cuba, which is the highest in the world. [13]
Many ELAM students I spoke with intend to practice family medicine. But several others feel that the need for affordable specialists in their countries compels them to continue their studies after ELAM. Ivan Angulo from Peru plans to specialize in orthopedics. Dennis Pratt hopes to practice pediatrics and internal medicine in Sierra Leone. Ivan Gomez de Assis would like to practice orthopedics in Brazil. [21] Walter Titz, also from Brazil, would like to practice general medicine for a few years and then study psychiatry. [22]
U.S. medical practice is so over-specialized that only 11% of doctors are family physicians.
When Lorine Auma returns to Kenya, she would like to focus on orthopedics or psychiatry. Perhaps most typical of ELAM students is Joyce Letsiela, who is dedicated to helping underserved communities in Lesotho and feels that there is a serious shortage of both general practitioners and specialists.
Challenges
While ELAM has 500 positions slotted for U.S. students, only 117 were filled as of April 2010. The Interreligious Foundation for Community Organization (IFCO), which screens U.S. applicants to ELAM, strongly encourages low income people of color to apply. But the fundamental requirement is that students demonstrate a commitment to working in distressed communities. [23]
Many young people thinking about going to ELAM contact U.S. students already there. An even better route is to contact IFCO and consider visiting the school. While on campus, it is easy to talk to U.S. students already there as well as students from other countries who speak English.
There are several ways to view a medical school:
1. Physical appearance. Compared to the luxury of U.S. medical schools, ELAM has a few things not to be desired, such as running water being available only at certain hours and toilets that have to be flushed with a bucket. Cuba often has to sacrifice superficialities in order to ensure that everyone has necessities.
2. Quality of training. ELAM provides books in Spanish but other books may be difficult to get. U.S. schools provide training geared directly to U.S. medical board exams, but ELAM students get more hands-on experience earlier.
3. Dedication to creating a new medicine. It is in this dimension that ELAM surpasses every other medical school in the world (though Venezuela may soon have comparable schools). This should be the reason that students apply.
The evening before I departed from my most recent trip to Havana, I had an extensive conversation about the ELAM experience with my daughter, Rebecca Fitz, now a third year student, and her partner, Ivan Angulo, who just finished his sixth year. [24] They detailed many things that ELAM provides at no cost:
- Classes and textbooks.
- Dorm room.
- Meals (three per day).
- Medical services, including emergency and elective surgery. Many ELAM students receive corrective procedures such as eye surgery and braces.
- Items such as two student uniforms, stethoscope, blood pressure cuff, mosquito net, shoes, socks, sheets, blanket, winter coat and silverware.
- Rations, including soap, toilet paper (don't go anywhere in Cuba without your own toilet paper!), laundry detergent, toothpaste, deodorant, and school supplies.
- Stipend of 100 pesos per month. (I got an ice cream on campus for 1 peso. A beer costs about 10 pesos; so, students can chill out from studying by having a beer every three days.)
On the other hand, ELAM presents challenges to students accustomed to life in the U.S. The first requirement for being accepted is being able to document a history of commitment to social justice. ELAM does not exist to give people a free ride through medical school. Students are expected to show that they will give as much to their communities as ELAM gives them.
Students are expected to show that they will give as much to their communities as ELAM gives them.
Though ELAM covers basic expenses while attending school, students must be able to obtain transportation to and from Cuba. This is not an issue for most American students, but many students do not have funds to return home during the summer.
U.S. students are encouraged by IFCO to have completed college level courses in biology, chemistry and physics; they can concentrate on Spanish after arriving. Students from most other countries can begin medical school immediately after graduating from high school and can take any needed science courses during an (additional) first year of pre-med.
Students must be able to live in a land without excess luxury. Most do not find this too difficult since they are aware that Cuba maintains a life expectancy equal to the U.S. by devoting its resources to making sure everyone has what is critical. The economic embargo by the U.S. makes sure that there is not a whole lot more. Students should be prepared to bathe from a bucket and live with hurricanes but without air conditioning. Don't expect to use a U.S. credit card in Cuba.
The cafeteria serves institutional food that lacks the variety that many prefer. It is not unusual to discover difficulty in adjusting to the absence of individual comfort needs, such as brownies, hot running water or private personal space.
There is a norm of being political, which is wonderful for many but can be a surprise for some. For example, students are expected (but not required) to participate in activities of the delegation of their country, and class discussions may include the role of their country in imperialism.
ELAM is designed for students leaving their country for the first time, sometimes at the age of 16, to attend medical school. Americans, who tend to be older, may be surprised by requirements such as physical education courses or spending nights on campus Monday through Friday.
Finally, a large majority of students come from countries which are eager to send students to ELAM to become Cuban-trained doctors. Not so Brazil and the U.S.. The Brazilian Colégio Médico (medical association) has policies distinct from the Lula government's and does not recognize degrees from ELAM. U.S. students do not have this problem; but they must take the same exams as does anyone receiving a non-U.S. degree, and they need to study extensively for questions which match a U.S. rather than a Cuban medical model.
Students should be prepared to bathe from a bucket and live with hurricanes but without air conditioning.
U.S. students cannot expect any support from the U.S. Interest Section, a substitute for an embassy which does not exist due to lack of diplomatic relations between the two countries. Though it is legal to travel to Cuba for educational purposes (such as medical school), the U.S. government has more hostile restrictions on travel to Cuba than any other country and does nothing to support students at ELAM.
An affirmation
Perhaps the extreme antagonism by the most violent country on the planet is an affirmation of the power of ELAM. The Cuban public health model seeks to understand health problems by studying the wholeness and completeness of the human context of those problems.
The Cuban health care system proves that "expensive medical technology is not necessary for effective community-based preventive care." It "has eradicated polio, controlled malaria and dengue, and reduced child and maternal mortality rates to equal or lower than those of much richer and more developed countries like the United States." [25]
ELAM is core to Cuba's efforts to integrate its medical system with the needs of underserved people throughout the world. The Cuban model is based on a belief that illnesses of humanity cannot be seriously addressed without addressing the society that creates the basis for those illnesses.
Ketia Brown told me that "We must attempt to have a revolutionary project in a capitalist world." ELAM is such a project. It is a struggle for a new medical consciousness as a part of the struggle to improve people's health.
Don Fitz produces Green Time TV in St. Louis, Missouri and is editor of Synthesis/Regeneration. He can be reached at fitzdon@aol.com.
Notes
The author would like to thank ELAM Rector Juan Carrizo, Director of International Relations Nancy Remon Sanchez, General Secretary of Project ELAM Wuilmaris Pérez Torres, and Assistant Professor of MGI Dr. Raul Jorge Miranda for explanations of the Cuban medical system, ELAM data, and help with contacting students.
1. Interview with Ketia Brown, ELAM, May 31, 2010.
2. Interview with Cassandra Cusack Curbelo, ELAM, January 23, 2010.
3. Brouwer, Steve. (January, 2009). The Cuban revolutionary doctor: The ultimate weapon of solidarity. Monthly Review, 60 (8), 28-42.
4. Kirk, John M. & Erisman, H. Michael. (2009). Cuban medical internationalism: Origins, evolution and goals. New York: Palgrave Macmillan.
5. Escuela Latinoamericana de Medicina (ELAM), Retrieved July 8, 2010 from http://www.elacm.sld.cu/index.html
6. Interview with Exa Gonzales, In flight over the Gulf of Mexico, December 28, 2009.
7. All information on Haiti is from Emily J. Kirk & John M. Kirk. (Fall, 2010). Cuban medical aide to Haiti: One of the world's best kept secrets. Synthesis/Regeneration. No. 53.
8. Information on the YAB was obtained from the interview with Ketia Brown and the document provided by Omavi Bailey: Yaa Asantewaa Brigade. (August 15-September 5, 2010). African Medical Corps - Ghana Proposal. Latin American School of Medicine, Carretera Panamericana 3 « KM, Santa Fe, Playa, La Habana, Cuba CP 19142. For information on the Organization of African Doctors, see www.africanmedicalcorps.com. Though Cuba provides support to the Ghana Project, it needs additional funding. Donations can be made at http://www.birthingprojectusa.org.
9. DuRand, Cliff. (November, 2007). Humanitarianism and solidarity Cuban-style. Z Magazine, 44-47.
10. Interview with Nancy Rem¢n S nchez, ELAM, May 30, 2010.
11. Interview with Wuilmaris Pérez Torres, May 30, 2010.
12. Interview with Ivan Angulo Torres, Havana Cuba, May 31, 2010.
13. An excellent and readable description of the role of the consultorio in the Cuban health system is: Dresang, Lee T., Brebick, Laurie, Murray, Danielle, Shallue, Ann & Sullivan-Vedder, Lisa. (July-August, 2005). Family medicine in Cuba: Community-oriented primary care and complementary and alternative medicine. Journal of the American Board of Family Medicine, 18 (4), 297-303.
14. Interview with Dr. Alejandro Fadragas Fernández and Maité Perdomo, Consultorio No. 5, Havana, Cuba, December 30, 2009.
15. Interview with Anmnol Colindres, ELAM, May 26, 2010.
16. Interview with Amanda Louis, ELAM, May 28, 2010.
17. Interview with Dennis Pratt, ELAM, May 26, 2010.
18. Interview with Jonalisa Livi Tapumanaia, ELAM, May 28, 2010.
19. Interview with Lorine Auma, ELAM, June 2, 2010.
20. Interview with Keitumetse Joyce Letsiela, ELAM, June 2, 2010.
21. Interview with Ivan Gomez de Assis, ELAM, May 27, 2010.
22. Interview with Walter Titz, ELAM, June 2, 2010.
23. For detailed information on ELAM, current curriculum for U.S. students and an application, see http://www.pastorsforpeace.org/
24. Interview with Rebecca Fitz and Ivan Angulo Torres, Havana, Cuba, June 3, 2010.
25. Whiteford, Linda M. & Branch, Laurence G. (2008). Primary health care in Cuba: The other revolution. Lanham: Rowman & Littlefield Publishers, Inc., p. 2.
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