FIRST U.S. GRADUATE OF ELAM

‘As an African-American, I feel free here’

BY ROSE ANA DUEÑAS—Special for Granma International—
HOW does it feel to be the first person from the United States to get a medical degree in Cuba?
The answer comes easily to Cedric Edwards, a thoughtful 34-year-old African-American from New Orleans, Louisiana, who received his diploma along with 1,600 other graduates of the Latin American School of Medicine (ELAM) in Cuba on August 20.
"It’s a little scary, but I’m very happy. I want to do my best to be a good example."
Like his classmates from Latin America and the Caribbean, Edwards’ studies were completely free; his modest room-and-board, textbooks and tuition were all paid for by Cuba as part of the Revolution’s efforts to bring medical care to those who need it all over the world.
But unlike his classmates, Edwards comes from a country that has unleashed an economic, political and clandestine war against Cuba in its attempts to overthrow the Revolution since its triumph in 1959.
When President George W. Bush’s administration intensified its aggression against Cuba in 2004, it made an exception – under grassroots pressure – to the economic blockade and travel ban so that more than 80 young people from the United States studying medicine at ELAM could continue to do so, as could future students.
It would have been politically costly for them to deny young Black, Latino and other minority youth, from working-class families, the opportunity to become doctors and serve their communities.
It was in 2000 that Cuba opened ELAM’s doors to qualified U.S. students from such backgrounds whom otherwise would not be able to attend medical school because of the high cost. The students, in turn, pledge to work in needy and underserved communities after graduating.
The program is administered by the Interreligious Foundation for Community Organization(IFCO)/Pastors for Peace, led by the Reverend Lucius Walker of New York. The students come from 19 states plus Washington D.C. and Puerto Rico; 85% of them are from minority groups and 73% are women. Fifteen more students arrived in August to begin their studies.
Edwards, who wants to specialize in internal medicine, talks about how getting his degree was no easy task, even for a "hard-core science person," as he describes himself.
"I didn’t speak any Spanish when I first came," he recalls. "I got a lot of help from my classmates and professors. I realized I was fluent when I didn’t have to carry the dictionary around anymore."
To be a doctor has been a dream for years. "In my first year at college, one of my younger brothers, a high school senior, was injured playing football and was left paralyzed from the neck down. I began to do research on spinal-cord injuries, and became interested in neuroscience. I wanted to help."
After graduating as a scholarship student from Middlebury College with a degree in molecular biology and biochemistry, Edwards took out loans to attend medical school. He finished two years, but then "made a rash decision" after becoming frustrated with how his grades were not reflecting his efforts, and decided to go to law school. "I regretted it. By sheer luck, I found out about the ELAM program from a friend of a friend – I knew it was my chance to get a medical degree."
Edwards’ parents – his mother is a high school teacher and his father a telephone repairman – and friends were against him coming to Cuba.
"There’s a lot of propaganda against Cuba. My parents were scared. They thought it was dangerous. I was scared to death, but I wanted to get my medical degree no matter what, and I also thought it would be a good opportunity to learn about another country, since I had never traveled outside of the States."
Cuba turned out not to be so scary. "I was shocked in a good way. Everybody was friendly. You see people hitchhiking, which you never see in the U.S. It’s a different environment.
"As an African-American, I don’t feel the racial tension that I feel in the States. That feeling is completely new to me. I feel like I’m free, like I can do whatever I want without fear. This place is very safe. You have a lot more young African-American men dying violently in the States than other races; also, there is a huge drug problem. Here in Cuba, though, that is not the case. For example, I would feel safer raising a family here."
His parents are "very grateful. Now they’re a lot more interested in getting to know Cuba." Because they are not legally permitted to travel to Cuba, even for their son’s graduation, his parents could not be part of that special moment. But they have plans to celebrate when Edwards returns.
The young doctor says he’s not involved in politics; however, he affirms, "I don’t agree with the blockade. I think it should be dropped."
Together with his degree, he is taking with him a deep appreciation of Cuba’s medical system.
"I love the fact that regardless of a person’s economic situation, he or she can see a doctor and get preventive care, free of charge." This is quite different from the situation of millions of U.S. people who don’t have medical insurance and therefore only see a doctor when the illness has become severe or when it’s too late.
After celebrating and taking a well-deserved break, Edwards plans to study for his U.S. medical licensing exam and apply for a required residency. He’s not picky about where, as long as he is needed. He believes that the ELAM experience – living, studying and working together with students from dozens of countries, many from indigenous and rural communities – has prepared him to deal with people from any background.
Meanwhile, he needs to look for a job, preferably in the medical field, to be able to start paying back the more than $100,000 in loans plus interest used to pay for his initial years of medical school in the United States.
Critics of the ELAM program say that it will be difficult for someone with a Cuban medical degree to practice medicine in the United States, but Edwards is optimistic.
His brother, now an attorney despite his paralysis, "is part of my motivation. I keep things in perspective," he says. "I try to treat my patients as if they were part of my family. I want to use what I’ve learned to help people."

Cuban Medical Diplomacy: When the Left Has Got It Right

As an addendum to Dr. Feinsilver's article on Cuba's Medical Diplomacy, please note that in August the Bush Administration announced its intention to lure to the U.S. some of the 15 to 20 thousand doctors now providing medical aid mainly in Venezuela and Bolivia by making it easier for Cuban doctors participating in the island's medical program abroad to gain refugee status in the U.S. In her report, COHA Senior Research Fellow Julie Feinsilver analyzes the multiple aspects of Cuban medical diplomacy. A version of this article originally appeared in Foreign Affairs en Español Vol. 6 (Octubre-Diciembre 2006), pp. 81-94.
The Cuban Threat: Medical DiplomacyLiving in a hostile neighborhood led Fidel to look for allies elsewhere. Part of this process has included the conduct of medical diplomacy, which is the collaboration between countries to improve relations and simultaneously produce health benefits. Medical diplomacy has been a cornerstone of Cuban foreign policy and its foreign aid strategy since shortly after the triumph of the 1959 revolution. Despite Cuba’s own economic difficulties and the exodus of half of its doctors, Cuba began conducting medical diplomacy in 1960 by sending a medical team to Chile to provide disaster relief aid after an earthquake. Three years later, and with the US embargo in place, Cuba began its first long-term medical diplomacy initiative by sending a group of fifty-six doctors and other health workers to provide aid in Algeria on a fourteen-month assignment. Since then, Cuba has provided medical assistance to scores of developing countries throughout the world both on a long-term basis and for short-term emergencies.
And now, with help from his friend, Hugo Chávez, who is awash in oil wealth, Fidel is threatening to provide massive amounts of medical aid to improve the health of poor Latin Americans. Rather than a fifth column promoting socialist ideology, these doctors provide a serious threat to the status quo by their example of serving the poor in areas in which no local doctor wouldwork, by making house calls a routine part of their medical practice and by being available free of charge 24/7, thus changing the nature of doctor-patient relations. As a result, they have forced the re-examination of societal values and the structure and functioning of the health systems and the medical profession within the countries to which they were sent and where they continue to practice. This is the current Cuban threat.

Over the past forty-five years, Cuba’s conduct of medical diplomacy has improved the health of the less privileged in developing countries while improving relations with their governments. By the close of 2005, Cuban medical personnel were collaborating in 68 countries across the globe. Consequently, Cuban medical aid has affected the lives of millions of people in developing countries each year. And to make this effort more sustainable, over the years, thousands of developing country medical personnel have received free education and training either in Cuba or by Cuban specialists engaged in on-the-job training courses and/or medical schools in their own countries. Today, over 10,000 developing country scholarship students are studying in Cuban medical schools. Furthermore, Cuba has not missed a single opportunity to offer and supply disaster relief assistance irrespective of whether or not Cuba had good relations with that government. This includes an offer to send over 1000 doctors as well as medical supplies to the United States in the immediate aftermath of Hurricane Katrina. Although the Bush administration chose not to accept the offer, the symbolism of this offer of help by a small, developing country that has suffered forty-five years of US hostilities, including an economic embargo, is quite important.
Symbolic Capital and Symbolic Politics: the Context for Medical DiplomacyBecause good health is necessary for personal well-being as well as societal development, the positive impact of Cuba’s medical aid to other countries has greatly improved both its bilateral relations with those countries as well as its standing and support in a number of multilateral forums. Therefore, as a consequence of its medical diplomacy Cuba has accumulated considerable symbolic capital (goodwill, prestige, influence, credit and power). The creation of symbolic capital requires an initial investment of material capital as well as time in a given project, such as the efforts mentioned above. The resulting symbolic capital may be accumulated, invested and spent just like material capital. Eventually, it can be converted into material capital, which in Cuba’s case has meant both bilateral and multilateral aid as well as trade, credit and investment. This is one of the rewards for the conduct of medical diplomacy.

From the outset of the revolution, Fidel has made the health of the individual a metaphor for the health of the body politic. Therefore, he made the achievement of developed country health indicators a national priority. Rather than compare Cuban health indicators with those of other countries at a similar level of development, he began to compare them to those of the United States. This was particularly true for the infant mortality and life expectancy rates. Both are considered to be proxy indicators for socioeconomic development because they include a number of other indicators as inputs. Among the most important are sanitation, nutrition, medical services, education, housing, employment, equitable distribution of resources, and economic growth. It is, therefore, symbolically important for Cuba to compare favorably with the US in an effort to demonstrate what Fidel sees as the moral superiority of Cuba’s social development policies.

This striving for first world health has been so important that in many of his major speeches, Fidel has dedicated considerable time to discussing his island’s health indicators. His annual July 26 speech this year, given right before his own serious illness was made known to the public, was no exception. In it, Fidel cited the latest data: Cuba’s infant mortality rate was 5.6 per 1000 live births, a figure less than that of the United States, which was 7.0 per 1000 live births according to the latest published data (NCHS 2005, data are for 2002). Life expectancy at birth in Cuba today is the same as for US citizens, 77 years. These achievements make Cuba a model and therefore make possible its medical diplomacy.

In the past thirty-five years Cuba has tripled its number of health care workers. Even more striking is the change in the ratio of doctors to population. This went from one doctor for every 1,393 people in 1970 to one doctor for every 159 people in 2005. This was part of Fidel’s 1984 family doctor plan to put a doctor on every block. Having accomplished this in both urban and rural areas, even isolated ones, Cuba is now exporting this model through its medical diplomacy initiatives.

Cuba’s accomplishments in health realms are not just in primary care or in the production of doctors. There was a simultaneous development of high tech medicine and biotechnology as well. Cuba shares its expertise through numerous international medical conferences that it holds every year and through scientific exchanges. Because research is also an important part of the operation of the health system, in the medical and public health field alone, Cuba publishes fifty-four professional journals.
As early as 1982, the US government recognized Cuba’s success in the health sphere in a report that affirmed that the Cuban health system was superior to those of other developing countries and rivaled that of many developed countries. Despite economic hardship during the 1990s after the dissolution of the Soviet Union and the subsequent loss of its preferential economic relations along with the tightening of the then three- decade-old US embargo, Cuba continuously increased its spending on domestic health as a percentage of total government spending in order to shield the most vulnerable population from the worst effects of the crisis. As a result, the initial deterioration in the population’s health status was short-lived and the health indicators quickly improved. Today, even some US analysts who oppose Fidel Castro agree that Cuba’s health system has produced impressive results despite the many material shortages that it always has faced. Some critics also recognize, albeit reluctantly that Cuban medical diplomacy is producing positive effects in the recipient countries.

Selected Examples of Cuban Medical DiplomacyPerhaps as a portent of things to come, even during the 1970s and 1980s Cuba implemented a disproportionately larger civilian aid program (particularly medical diplomacy) than its more developed trade partners: the Soviet Union, the Eastern European countries and China. This quickly generated considerable symbolic capital for Cuba, which translated into political backing in the United Nations as well as material benefits in the case of Angola, Iraq and other countries that could afford to pay fees for professional services rendered, although the charges were considerably below market rates.

Early success with medical diplomacy and the accumulation of symbolic capital as well as the ability to convert it into material capital, led Fidel to announce in 1984 that Cuba would train 10,000 new doctors specifically to increase the volume of international medical aid. No country other than Cuba has developed doctors as an export commodity. This has paid off handsomely both for the government of Cuba and for the individual doctors involved, as they usually earn considerably more money abroad than in Cuba.

The Cuba-Venezuela-Bolivia ConnectionIt is, indeed, ironic that in 1959 Fidel unsuccessfully sought financial support and oil from Venezuelan president Rómulo Betancourt. It would take forty years and many economic difficulties before another Venezuelan president, Hugo Chávez, would provide the preferential trade, credit, aid and investment the Cuban economy desperately needed. This partnership is part of the Bolivarian Alternative [to the US] for the Americas (ALBA) to unite and integrate Latin America in a social justice-oriented trade and aid block under Venezuela’s lead. It also has created an opportunity to expand Cuba’s medical diplomacy reach well beyond anything previously imaginable despite Fidel’s three-decade-long obsession with making Cuba into a world medical power; an obsession which was analyzed and documented in my 1993 book, Healing the Masses: Cuban Health Politics at Home and Abroad.

By far the largest Cuban medical cooperation program ever attempted is the present one with Venezuela under Hugo Chávez. The symbolic and material payoffs for Cuba are clearly demonstrated, for example, by the oil-for-doctors trade agreements between the two countries. The accords allow for preferential pricing for Cuba’s exportation of professional services vis-à-vis a steady supply of Venezuelan oil, joint investments in strategically important sectors for both countries, and the provision of credit. In exchange, Cuba not only provides medical services to unserved and underserved communities within Venezuela (30,000 medical professionals, 600 comprehensive health clinics, 600 rehabilitation and physical therapy centers, 35 high technology diagnostic centers, 100,000 ophthalmologic surgeries, etc.), but also provides similar medical services in Bolivia on a smaller scale at Venezuela’s expense. And to contribute to the sustainability of these health programs, Cuba will train 40,000 doctors and 5,000 healthcare workers in Venezuela and provide full medical scholarships to Cuban medical schools for 10,000 Venezuelan medical and nursing students. An additional recent agreement includes the expansion of the Latin American and Caribbean region-wide ophthalmologic surgery program (Operation Miracle) to perform 600,000 eye operations over ten years.

The main medical aid programs are the provision of comprehensive health services throughout Venezuela through the Barrio Adentro programs (Barrio Adentro I and II). As of March 25, 2006, there were a total of 31,390 medical personnel (mostly doctors) providing services through Barrio Adentro I, the primary health care program. Of that number, 23,382 were Cubans and the 8008 were Venezuelan. These Cuban “medical diplomats” had conducted 171.7 million medical consultations, of which 67.9 million were carried out in the communities (schools, workplaces, and homes). They visited 24.1 million families at home, something previously unheard of on that scale and in those locales. Moreover, these personnel provided 103.1 million health educational activities as well.

During the same period, under Barrio Adentro II, which provides medical diagnostics and physical therapy and rehabilitation, 10,856 histological exams were conducted, 84.4 million clinical laboratory exams were done, 808,153 CAT scans and 47,454 nuclear magnetic resonance exams were performed, among others. The newly established Comprehensive Diagnostic Centers handled 886,609 emergency room visits and performed 7.2 million diagnostic exams; and the Comprehensive Rehabilitation Wards also established under Barrio Adentro II handled 520,401 rehabilitation consultations and applied 1.6 million rehab treatments.

The second largest medical cooperation program is with Bolivia, where in June 2006, 1,100 Cuban doctors were providing free health care, particularly in rural areas, in 188 municipalities, mainly in the departments of La Paz, Santa Cruz, Cochabamba and Chuquisaca. Cuba already has provided the National Ophthalmologic Institute in La Paz with modern equipment and specialized personnel who, along with Bolivian doctors and recent graduates from the Latin American Medical School (ELAM), have treated over 1,500 patients free of charge. New accords stipulate the opening of two additional ophthalmologic centers, one in Cochabamba and another in Santa Cruz. They each will be able to treat 50 patients a day and the La Paz center will allow doctors to attend to 100 patients a day. As a result, Bolivia will have the capacity to perform ophthalmologic operations on a minimum of 50,000 patients annually.

Cuban sources indicate that by the end of July their medical team had attended one million Bolivians free of charge (to the patient) and had performed 23,000 ophthalmologic operations. Additionally, Cuba offered 5,000 more full scholarships to educate doctors and specialists as well as other health personnel at ELAM in Havana. At present, there are some 500 young Bolivians studying at the school and another 2,000 have started the pre-med course there. The six-year medical school program is provided free for low-income students who commit to practice medicine in underserved communities in their home countries upon graduation.

During the ELAM’S first graduation last August, Venezuelan President Hugo Chávez announced that his country will establish a second Latin American Medical School, so that jointly with Cuba, the two countries will be able to provide free medical training to at least 100,000 physicians for developing countries over the next 10 years. The humanitarian benefits are enormous, but so are the symbolic ones. Moreover, the political benefits could be reaped for years to come as students trained by Cuba and Venezuela become health officials and opinion leaders in their own countries. Today, medical students whom Cuba trained as doctors in the 1970s, are now in positions of authority and increasing responsibility.

Other Western Hemisphere ExamplesCuban medical teams had worked in Guyana and Nicaragua in the 1970s, but by 2005 they were implementing their Comprehensive Health Program in Belize, Bolivia, Dominica, Guatemala, Haiti, Honduras, Nicaragua, and Paraguay. Throughout the years, Cuba also has provided free medical care in its hospitals for individuals from all over Latin America and not just for the Latin American left. Please consult the bottom of this report for a list of countries for which Cuba has provided some type of medical assistance as of December 2005.

Under Haitian President Rene Préval, Cuba began its medical cooperation with Haiti in 1998. Currently, there are approximately 400 Cuban medical professionals working in Haiti on two-year assignments in 110 of the 164 comunes across the island. The program costs the Haitian government approximately US$1.8 million annually, which averages out to cost US$375 per month for each medical professional plus room and board, transportation and exemption for airport departure taxes. Because money is fungible, it is not evident which donor is providing the funding. Although very inexpensive by international standards, this program is relatively costly for the cash-strapped Haitian government and could become even more so if it is expanded as has been discussed recently.

Jamaicans, among others, with little means have been going to Cuba for free eye surgery as part of Operation Miracle. A spokesperson for the Jamaican Health Ministry has indicated that they had received positive feedback on the surgeries that had been administered. The number of patients reported with complications amounted to fewer than three per cent of the 1,854 patients who were treated in Cuba as of 2006.
As previously mentioned, Cuba has offered disaster relief over the years to every country that has experienced an emergency. And most often the offer has been accepted. A recent (2005) example is Guyana, where Cuba sent a team of 40 medical doctors and technicians to provide disaster relief after severe flooding had been recorded in the country.
Because Cuba has been successful in developing health programs at home and has provided medical aid abroad, often under difficult circumstances, some donor countries are willing to provide financial support for Cuban medical assistance in third countries in what is called triangular cooperation. Germany has provided funding for Cuba to develop health programs in Niger and Honduras. France provided some funding to execute a health program in Haiti. Japan provided two million doses of vaccines to vaccinate 800,000 children in Haiti and US$57 million to equip a hospital in Honduras where a Cuban medical brigade works.

Multilateral agencies, such as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) also finance medical services provided by Cuba for third countries. Both organizations provided funding for Cuba’s medical education initiatives. Finally, Cuba’s Comprehensive Health Program, which is being exported to various countries that receive Cuban medical assistance, is supported by 85 NGOs and through triangular cooperation with both governments and NGOs, has received US$2.97 million in support. Although some of the amounts are small, it is clear that donors find that support for Cuba’s medical diplomacy makes professional sense.

Medical Diplomacy Outside of the Western HemisphereCuba dispatched very large civilian aid programs in Africa to complement its military support to Angola and the Horn of Africa in the 1970s and early 1980s. With the withdrawal of troops and the later geopolitical and economic changes of the late 1980s and the 1990s, Cuba’s program was scaled back, but remained. Having suffered a post-apartheid brain drain (white flight), South Africa began importing Cuban doctors in 1996. Already in 1998 there were 400 Cuban doctors practicing medicine in townships and rural areas. By 2004, there were about 1200 Cuban doctors working in African countries, including in Angola, Botswana, Cape Verde, Côte d’Ivoire, Equatorial Guinea, Gambia, Ghana, Guinea, Guinea-Bissau, Mozambique, Namibia, Seychelles, Zambia, Zimbabwe, and areas in the Sahara.

On the African continent, South Africa is the financier of some Cuban medical missions in third countries. This South African-Cuban alliance has been much more limited in scope than the Venezuelan-Cuban deal. Discussions on the extension of Cuban medical aid into the rest of the African continent and a trilateral agreement to deploy over 100 Cuban doctors in Mali with US$1 million in South African financing, were concluded in 2004. Rwanda was to be next in a similar agreement. Cuba also had deployed 400 medical doctors to Gambia. As of December 2005, Cuba was implementing its Comprehensive Health Program in Botswana, Burkina Faso, Burundi, Chad, Eritrea, Gabon, Gambia, Ghana, Guinea-Bissau, Guinea-Conkary, Equatorial Guinea, Mali, Namibia, Niger, Rwanda, Sierra Leone, Swaziland, and Zimbabwe.
Cuban medical teams also have worked in East Timor since 2004 to create a sustainable health system. Currently, 182 medical professionals are providing a variety of services in Cuba’s Comprehensive Health Program. At the same time, Cuba offered full medical school scholarships for 800 East Timorese students to begin work on the sustainability of their program.

Recent Cuban disaster relief medical missions are still providing assistance in post-tsunami Indonesia and post-earthquake Pakistan. Shortly after the tsunami, Cuba sent a medical team and equipment to provide disaster relief. At the time, the team was handling over 150 consultations daily in a military field hospital and a polyclinic. They also were providing some preventive as well as curative care on their visits to refugee camps. Less than a week after the devastating October 2005 earthquake in Pakistan, Cuba sent a team of highly experienced disaster relief specialists comprised of 2300 doctors, nurses and medical technicians. Part of the team worked in refugee camps and Pakistani hospitals. The rest worked in 30 field hospitals located across the earthquake-stricken zone. The team brought everything they would need to establish, equip, and run those hospitals. The cost to Cuba was not insignificant. Two of the hospitals alone cost half a million dollars each. Only recently (May 2006), Cuba sent 54 emergency electrical generators as well.

In the past Cuba has also provided aid to Armenia, Iran, Turkey, Russia, as well as to most Latin American countries that have suffered either natural or man-made disasters. This type of medical diplomacy in the affected country’s time of need has garnered considerable bilateral and multilateral symbolic capital for Cuba, particularly when the aid is sent to countries considered more developed.

In Search of Sustainability: Provision of Medical Education and Training in Cuba and AbroadIn an effort to have a more sustainable impact on the health of the aid recipient countries’ populations as well as a multiplier effect on the immediate aid given, medical education always has been an important part of Cuba’s medical diplomacy. Education and training consist of on-the-job training, seminars, courses and full medical education. As early as the 1970s, Cuban medical professors either established medical schools or taught in medical faculties in Angola, Ethiopia, Guinea-Bissau, Nicaragua, and Yemen. This has been a continuing process ever since.

Cuba has long provided total scholarships for students from other developing countries to study anywhere from secondary school (medical technicians) through post-graduate studies. From 1961 to 2001, almost 40,000 foreign scholarship students had graduated in various medical disciplines from Cuban schools. Of those, 16,472 graduated from institutions of higher education. These numbers peaked in the 1980s before the fall of the Soviet Union. Now, with an oil-for-services agreement with Venezuela, Cuba is vastly increasing its scholarship offerings.

The Latin American Medical School (ELAM) was established in 1998 specifically to train students from poor communities in Latin American and African countries. In exchange for full scholarships, these students must be willing to return to their countries and practice medicine in poor communities for at least five years. After meeting with members of the US Congressional Black Caucus a few years ago, Fidel announced a symbolically significant plan for medical diplomacy with the United States: 500 full scholarships to Cuba’s ELAM for US minority students. Half of the scholarships would be for African Americans and the other half divided between Hispanics and American Indians. So far only a few Americans have accepted the offer.

There were a total of 10,661 foreign medical students from 27 countries studying in Cuba at the ELAM during the 2005-2006 academic year. Of this total, 10,084 were enrolled in medicine, 67 in stomatology (dentistry), 134 in nursing, and 376 in health technology. This is triple the number of medical students enrolled in 2002. To train French-speaking Africans and Haitians, the Cuban Government established the Facultad Caribeña de Medicina (Caribbean Medical School) in Santiago de Cuba, where 254 Haitians and 51 Malian students were studying in 2002.

Graduates from these medical schools take the National Final Cuban Examinations (NFCE) at the end of their program and then do an internship in their home countries. After that, they must take their home country’s qualifying exam just as all other medical students must do to be licensed to practice medicine. Reports from Chile, which has one of the most highly developed health systems in Latin America and a rigorous university system and medical licensing requirements, indicate that the first seven Chilean medical students who have graduated from ELAM and returned to Chile have had their degrees validated by the University of Chile as required and have entered successfully into Chile’s public health system. This suggests that the quality of education provided at the ELAM is high. The fact that Cuban doctors who have found work in Chile on an individual basis have had their credentials validated by the University of Chile in what one Chilean official said was a complicated and demanding process, attests to the overall quality of Cuban medical education.

Medical Diplomacy Wins Friends But Also Makes a Few EnemiesMedical diplomacy primarily wins friends among the governments whose people receive the aid and the patients and students who directly and individually benefit from it. But not all are thrilled to have Cuban doctors in town. In particular, local medical associations and individual doctors have harshly criticized the Cuban presence because of their competition for jobs, their different manner of working and treating patients, and because of the perquisites they receive (principally, free room and board). In some cases, such as in Bolivia and Venezuela, these medical associations have gone on strike to protest the Cuban presence. In these and some other cases, such as in South Africa and Haiti, they have taken their complaints to the press. Despite protests (and strikes), numerous press and other reports from different countries extol the benefits to the patients, many of whom had never seen a doctor before, particularly living and working in their own neighborhood.

Not surprisingly, these medical associations sometimes seek to discredit the Cubans and use what appears to be a technical argument, the questioning of certification standards (credentials) and quality of care. Medical licensing is a standard practice in all countries, but it can be and is used by some who feel threatened by the competition of Cuban doctors willing to serve in areas that they themselves would not go, let alone work. On the other hand, standards are important and ideally, there should be a WHO or other supra-national independent accreditation agency that could establish criteria for and validate medical degrees and licenses or establish equivalences so as to eventually allow for global labor mobility. This, however, would be extremely difficult to negotiate and is unlikely to occur in the next few decades. Therefore, Health Ministries, or, in some cases, medical associations become the gatekeepers for entry into the profession. This is tricky when vested interests are in charge of the licensing or accreditation process or are politically strong enough to block it. In 2003, the Venezuela Medical Federation, which is ideologically opposed to the Chávez government and the Barrio Adentro medical program, filed a lawsuit to prohibit Cuban doctors from practicing medicine there. The court held in favor of the Medical Federation, but the Venezuelan government did not back down.
Similarly, in Bolivia, when the Colegio Médico de Bolivia and the association of unemployed doctors went out on strike to protest the presence of the Cuban doctors, President Evo Morales asserted publicly that the Cubans would stay as long as he is in office. He also exhorted the Colegio Médico to change its attitude and to “pay” with their professional services for their free medical education in public universities paid for by Bolivian taxpayers. Like in the case of Venezuela, the benefits to the host society far outweigh the costs to the local medical professions, which in these two cited cases are ideologically opposed to the government.
At the urging of the Haitian medical association, the previous government asked for a revision of the cooperation agreement to include better control by the Ministry of Health over the mix and quality of medical staff sent as well as the nature of their work in the field. However, this revision has yet to take place. Some malpractice accusations have been made against Cuban doctors in Venezuela, South Africa, Zimbabwe, and Haiti. A much-publicized case in Venezuela proved to be the fault of opposition doctors who refused to treat a patient referred to a hospital by a Cuban doctor. On the other hand, it is quite possible and, indeed, probable that there are some genuine cases that need to be addressed. This would be normal among all cohorts of practitioners and should be properly investigated and remedied.
Rewards For Medical DiplomacyAs stated at the outset of this article, Cuba’s rewards are symbolic and material capital. There is enormous prestige and influence in determining the direction of public health systems in the countries in which Cuba practices medical diplomacy. The training of future leaders in the medical field assures Cuba of on-site support in the future. More importantly, Cuba’s medical diplomacy contributes to the positive views held by other governments as translated into voting results at the United Nations on issues of particular importance to Cuba, such as an end to the US embargo of Cuba and the stressing of human rights issues. Importantly, Cuba was elected to the new UN Human Rights Council by direct, secret ballot in which all member states were elected individually and not in blocs.

In a press conference reported in the daily Última Hora, Paraguayan President Nicanor Duarte Frutos explained why his country would abstain rather than vote in favor of the US sponsored anti-Cuba resolution at the UN Human Rights Commission in Geneva, despite President Bush’s personal call in April 2004 asking for his support. The reason: a cooperation agreement with Cuba dating back more than six years, whereby Cuban doctors provide medical assistance in Paraguay and Paraguayan youths from very poor families are studying in Cuba on scholarships. At that time, there were 600 students involved in the program.

With regard to the US embargo of Cuba, the US State Department’s own data show that in the 2005 General Assembly votes, only Israel, the Marshall Islands and Palau supported the US position. This was the fourteenth consecutive time in which the US position was rejected, but to no material benefit to Cuba since the US has been going it alone for a long time now on this issue. Among Cuba’s trade and aid partners, voting coincidence with the US generally ranked only between 6 and 22 percent during 2005. The overall average coincidence for all countries was only 25%. The LAC average was 19.7%. The Asian group average was 18.7%; the African group averaged 13.5%; the Eastern European group averaged 40.4%; and the Western European and Others (Australia, New Zealand) came in at 46.7%. Cuba’s medical diplomacy should be seen as contributing to this pattern. Rather than isolating Cuba, it is the US that is becoming more isolated on this issue.

Far from being marginalized by Washington’s anti-Havana offensive, Cuba has remained an important member of the Non-Aligned Movement and once again has just hosted the summit of heads of state and government in September and has become the leader of the NAM for the next several years. Cuba previously hosted and led the NAM in 1979. Also Fidel attended the July 2006 MERCOSUR summit, which opened with the signing of a trade agreement with Cuba for mutual preferential market access. The agreement consolidates the already existing bilateral agreements on preferential tariffs that Cuba has had with each of the MERCOSUR members. Although the amount of trade between Cuba and MERCOSUR is not great, the agreement is significant for its timing: just before the release of the US-sponsored Commission for a Free Cuba’s tough report on tightening the US embargo and promoting regime change.

More importantly from an immediate standpoint are the export earnings deriving from medical diplomacy. Data on the amount paid for the various activities involved in Cuban medical diplomacy has always been difficult to establish. Rates paid for doctors have ranged from nothing where the country could not afford to pay, to some rate well below market prices. Nonetheless, rough estimates suggest that the amounts are truly significant and have surpassed earnings from tourism. The Economist Intelligence Unit estimates that the increase in non-tourism services exports between 2003 and 2005 was around US$1.2 billion for a total of US$2.4 billion, which puts non-tourism services ahead of gross tourism earnings (of US$2.3 billion) in 2005. Most of this is medical services.

Official data for export earnings from medical products (medicines and equipment) were below US$100 million in 2004, but there have been press reports citing a figure of US$300 million for such products. Cuba exports medical biotechnology products to 40 countries, but sales data were not available. Two important earnings streams not included in the export data come from the licensed manufacture of Cuban medicines in other countries and joint-venture production facilities abroad. Officials in Havana have indicated that these are significant, but no concrete data is available. Cuba has some licensing agreements, including one in the US for anti-cancer drugs, and even joint venture production facilities in China. Also, treatment facilities are being built in other countries, particularly in the field of ophthalmology, under agreement with Venezuela. The oil-for-doctors agreement is very lucrative for Cuba because of preferential pricing for Cuba’s professional services exports and because Venezuela absorbs the loss for any escalation of oil prices, a factor that has occurred to a considerable degree in recent months. Commercial trade between Venezuela and Cuba surpassed US$ 2.4 billion in 2005 and US$1.2 billon in the first trimester of 2006. Also, on the aid side between 2002 and 2006, Cuba has received some US$50 million for a range of physical development programs from the Organization of Petroleum Exporting Countries Fund. These rewards make medical diplomacy well worth the effort, not to also mention the important humanitarian benefits.

The Cuban ChallengeTaking medical diplomacy a degree further, at the recent MERCOSUR summit in Córdoba, Argentina, Fidel called for a social agenda to globalize solidarity in health and education. He offered Cuba’s experience in health and education to support that agenda. In these remarks, he laid down a gauntlet not only for MERCOSUR, but also for his adversary, the US government. It appears, however, that no one will take him up on it.

Post-Fidel Medical DiplomacyFidel transferred power to his slightly younger brother Raúl Castro just days before the Non-Aligned Movement meeting was convened in Havana. Indications are that although Raúl is the heir apparent, something approaching a de facto collective leadership most likely will govern Cuba in the near future. This leadership group probably will include not only Raúl, but also Ricardo Alarcón, who presides over the National Assembly of People’s Power; Carlos Lage, Vice President; and Foreign Minister Felipe Roque Pérez. None of these figures is expected to alter significantly Cuba’s practice of medical diplomacy in the near term. As long as the export of excess Cuban doctors continues to provide both material capital (e.g., oil-for-doctors) and symbolic capital (e.g., support in international forums), it is likely to be maintained. However, the scale of this program depends more on Hugo Chávez’s largesse than on Cuba’s willingness to continue it.

The temporary export of Cuban doctors also provides a safety valve for disgruntled medical professionals who earn much less at home than less skilled workers in the tourism sector. Their earning opportunities abroad are significant both within the confines of medical diplomacy and even more so, beyond it. This has led to a number of defections, allegedly around six hundred, although some say this figure is too high. This figure could grow if Cuban-American activist groups carry out their threats to assist these doctors serving in foreign lands if they defect. Should this number increase dramatically in this period of political change, the Cuban government may decide that the cost is too great to bear. In an effort to break the oil-for-doctors bond that supports the Cuban economy and create a medical brain-drain, the Bush Administration announced (on August 7) a possible change in its Cuba policy to ease immigration for Cuban doctors who participate in Cuba’s medical programs abroad. This is in sharp contrast to its tightening of policy regarding immigration of Cubans who enter the U.S. illegally. The lure of vastly increased earnings, easy access to high technology, and a much better material quality of life may lead doctors born, raised and trained at great expense in revolutionary socialist Cuba to cease helping those in need in developing countries and depart en masse. If they do, this is unlikely to break the ties that currently bind Cuba and Venezuela. But, this will raise questions about the consistency of US immigration policy. The fact that the Bush administration is trying to destroy Cuba’s medical diplomacy program indicates that the program works. Rather than attempt to destroy it, the Bush administration should emulate it.
Countries in which Cuba provides collaboration in Health by region, December 2005

The AmericasAntigua and Barbuda, Argentina, Aruba, Bahamas, Belize, Bolivia, Brazil, Colombia, Costa Rica, Dominica, Ecuador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Venezuela, Dominican Republic, St. Kitts and Nevis, St. Vincent and the Grenadines, St. Lucia, Suriname, Trinidad and Tobago
AfricaSouth Africa, Angola, Botswana, Burkina Faso, Burundi, Cape Verde, Congo, Djibouti, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Equatorial Guinea, Guinea-Bissau, Guinea, Lesotho, Mali, Mozambique, Namibia, Niger, Rwanda, Sao Tome and Principe, Seychelles, Sierra Leone, Swaziland, Chad, Uganda, Zimbabwe, RASD, Algeria
AsiaQatar, Yemen, Laos, Pakistan, East Timor, Indonesia
EuropeItaly, Switzerland, Ukraine

Source: Statistical Registers of the Central Medical Cooperation Units, 2005 Statistical Yearbook of the Cuban Ministry of Public Health
Julie M. Feinsilver is the author of “Healing the Masses: Cuban Health Politics at Home and Abroad” (Berkeley: University of California Press, 1993). Dr. Feinsilver is a Senior Research Fellow at the Council on Hemispheric Affairs in Washington, DC, and an international civil servant. The views expressed herein are solely her own and do not necessarily reflect those of any institution with which she is affiliated.

This analysis was prepared by COHA Senior Research Fellow Julie M. Feinsilver October 30th, 2006 Word Count: 6100

The Council on Hemispheric Affairs, founded in 1975, is an independent, non-profit, non-partisan, tax-exempt research and information organization. It has been described on the Senate floor as being “one of the nation’s most respected bodies of scholars and policy makers.” For more information, please see our web page at www.coha.org; or contact our Washington offices by phone (202) 223-4975, fax (202) 223-4979, or email coha@coha.org.

The school of life

Cedric Edwards’ path to becoming a doctor took a few unexpected turns

By Mike Rosen-Molina

Cedric Edwards with his degree from the Latin American School of Medicine in Havana, Cuba.Photo By Larry Dalton
Cedric Edwards can be contacted at cedricedwards@hotmail.com.

For Cedric Edwards, the best and worst days of his life were only one day apart.
In September, Edwards, 34, became the first U.S. citizen to graduate from the Latin American School of Medicine, or ELAM, in Cuba. But on the Monday after graduation, Hurricane Katrina tore through Edwards’ hometown of Slidell, La., leaving his house under water and his family homeless. Today he’s living out of a suitcase in Sacramento, struggling to get by.
“Graduating medical school was probably the highest point of my life,” he said. “To come from someplace so high and fall so low was just unreal. It was shocking.”
Living through hurricanes in Cuba and then watching Katrina destroy his hometown, Edwards has seen the best and worst of both countries, and it’s taught him to keep an open mind.
Wearing a New Orleans Saints cap, Edwards is a serious young African-American man, with a passion for chess, opera and the violin. Reading untranslated Spanish medical texts for six years has given him a tendency to sometimes lapse into Spanish, but he still speaks with a thick Southern accent and feels a deep connection to his hometown.
“This was my community,” he said. “And I just kept seeing these images on television, images of poor black people on roofs, going days without food or water. It was as if the government had abandoned them. To have people left for days like this was unacceptable.”
When Katrina hit, Edwards was stuck in Havana. He sat glued to reports coming over the television, not knowing whether his own family was alive or dead.
“I was especially worried about my brother,” said Edwards, who was inspired to go into medicine after his brother was paralyzed from the neck down in a high-school football accident. “I felt so helpless thinking he might be in danger. When you see all this suffering, but you can’t do anything, it’s a terrifying, deeply depressing experience.”
A week passed before Edwards finally found out that his family was alive, living in a hotel.
Slidell was a quiet small town, half an hour from New Orleans, specializing in ecotourism and antique shops. He was scared to death as he left for Cuba, his friends and relatives warning him of crime, poverty and violence.
But he said his decision to attend ELAM was a practical one. Growing up in a poor community, Edwards wanted to find a way to give back, and going to ELAM was the only way to achieve his dream without amassing huge educational debts.
His first weeks in Havana were difficult. He didn’t speak any Spanish; the school Internet connection was always down, so he couldn’t talk to his family; and the summer was heavy with mosquitoes. But Cuba seemed a far cry from the desperate slum he’d imagined, and he came to admire the country’s commitment to training doctors and providing universal health care for all citizens.
At ELAM (established in 1999), medical students from all over the world, including Africa, South America and the United States, receive free tuition, free room and board and a monthly stipend, courtesy of the Cuban government, in the hope that they will use their free education to serve poor communities in their home countries.
Cuba is not a wealthy country. Its hospitals and clinics are a far cry from the high-tech wonders of American medical facilities. But ELAM is listed as an accredited school in the International Medical Education Directory, and its students are eligible to take the U.S. medical-board exam and practice in the United States. Eighty U.S. citizens currently are studying at ELAM.
Like almost everything involving this island nation, the school is surrounded by controversy. Some praise it as an example of Cuba’s commitment to international altruism, while others see it as a cynical political move meant to bolster the country’s reputation.
“[Students’] stories about the ideal Cuba they experienced brings sympathizers into Castro’s sphere of influence,” wrote Agustin Blazquez, a Washington-based documentary filmmaker of Cuba: The Pearl of the Antilles, on the Web site NoCastro.com.
But Sacramento resident William Bronston, who has traveled to Cuba and toured ELAM, said the program is more than PR. “Cuba is dedicated to training people to become the finest physicians, because of an explicit and purposeful commitment to serve and elevate the human experience, not as a propaganda tool.”
For his part, Edwards is uninterested in political hand-wringing. “I can’t say that the program isn’t political, because everything’s political,” said Edwards. “But whatever the purpose behind it, the end result is that it does a lot of good for a lot of countries. Regardless of a person’s politics, I think there are certain aspects of the Cuban health-care system which could be adopted here to make things better for everyone.”
Because he couldn’t return to Slidell after graduation, Edwards has been living with a friend in Sacramento with nothing but a single suitcase. He wants to apply for a residency in the coming year, but first he has to pass the licensing exam, a challenge when he doesn’t have money for preparation courses or exam registration.
In the meantime, he’s hoping to find a sponsor and scrambling to make money any way he can, working as a church janitor during the day while cramming at night. He cuts grass, takes out the garbage and sweeps the floors, all the while looking forward to the day that he can put his medical training to use.

La première fournée internationale de médecins

Des étudiants, des professeurs et le recteur de l'Université latino-américaine des Sciences médicales parlent sur ce centre dont les premiers étudiants terminent leurs études l'an prochain. Ils commentent le niveau élevé de la pratique professionnelle qui caractérise ce centre, notamment à partir de la troisième année du cursus.
Ils viennent des communautés oubliées des Amériques qui subsistent difficilement dans les montagnes, dans la jungle, le long des rivières, qui habitent des petits villages isolés. Ils restent liés à leurs familles, à la terre qui produit le maïs dont les leurs se nourrissent. Ils découvrent, en même temps, la distance, la nostalgie et Cuba. Le début de l'année 1999 a vu la mise en œuvre, près de La Havane, d'un nouveau projet. L'ancienne École de la Marine devenait l'École latino-américaine de Médecine (ELAM) pour accueillir 1 993 étudiants de 18 nationalités. Les premiers arrivants venaient de l'Amérique centrale dont plusieurs pays avaient été touchés par des ouragans. Aujourd'hui, l'École latino-américaine de Médecine compte 8 447 étudiants. Ceux qui font la troisième et la cinquième année d'études travaillent dans les 21 facultés cubaines de médecine et les hôpitaux des diverses provinces cubaines où elles sont situées. Plusieurs de ces étudiants ont livré à GI des expériences qui ont marqué leur vie. En août 2005, les membres du premier groupe rentreront dans leurs pays respectifs avec leur diplôme de médecin. Cette première fournée de médecins issus de l'ELAM sera composée de 1 380 jeunes de 19 nationalités, dont un des États-Unis, arrivé en 2001, qui a pu valider plusieurs matières.
École latino-américaine de Médecine (ELAM)

LE MIEUX QUI AIT PU NOUS ARRIVER Ledesma Liset Arita, 18 ans, fait partie des premiers arrivants. Elle vient d'un petit village du département de Santa Barbara, au Honduras, où une montagne marque la source des eaux thermales qui font la fierté des habitants de la région. Cette jeune Hondurienne, qui ne s'était jamais éloignée de ses parents, nous dit pourtant qu'elle n'a pas hésité quand il a été question de venir faire ses études: "Cuba a une excellente réputation en ce qui concerne la qualité de l'enseignement. Je ne pouvais pas me laisser vaincre par la nostalgie." Comme tous ses compatriotes de la cinquième année, elle fait ses études au C.H.U havanais Calixto Garcia. Les futurs médecins honduriens y suivent des conférences, ils accompagnent les médecins pendant les visites quotidiennes et assurent des tours de garde avec le personnel de ce centre hospitalier. "La méthode appliquée pour l'apprentissage est très bonne, elle pousse l'étudiant à parfaire ses connaissances puisqu'ils sont évalués en permanence et il y a constamment des séminaires, des ateliers et des examens. J'ai été aussi impressionnée toutes ces années par l'attention que les professeurs nous accordent, par leur désir de nous transmettre leurs connaissances" , nous dit Ledesma Liset. Elle précise que, en dehors même des études, cette expérience est enrichissante sur le plan personnel dans la mesure où "nous avons appris à vivre avec des gens de cultures différentes, à comprendre ces dernières, à être plus indépendants et plus responsables". Tomas Bardales, un autre étudiant, résume ces cinq années comme "une période merveilleuse. On a contribué à notre formation en tant qu'individus. Nous sommes arrivés ici à un âge où on commence à consolider les idéaux, la personnalité, et je crois que le mieux qui ait pu nous arriver est d'être venus à Cuba, un des pays les plus prestigieux dans le domaine médical en Amérique et dans le monde". Les étudiants du Honduras et du Guatemala étant les plus nombreux, après ceux du Nicaragua, ils ont été envoyés, à partir de leur troisième année d'études, dans les divers CHU de La Havane. Ceux des autres nationalités ont été distribués dans les CHU des autres provinces. Quelque 200 Guatémaltèques font actuellement la cinquième année. L'un d'entre eux, Guillermo Barrios, 24 ans, envisage le retour comme une épreuve: "Les amis que nous avons laissés chez nous auront changé, nous les retrouverons mariés, en train de travailler. Bien sûr, notre séjour ici nous a donné une vision différente de la vie et j'espère qu'elle nous aidera à mieux nous insérer dans nos propres sociétés. Il y a non pas une mais plusieurs familles cubaines qui vont me manquer, les amis cubains, votre société, la manière d'être des Cubains, leur amabilité et leur hospitalité". Guillermo et son compatriote Tomas expriment leur reconnaissance infinie envers Cuba et les Cubains: "Ils nous ont donné ce qu'on ne trouve nulle part ailleurs; ils nous ont logés, nous ont nourris, nous ont donné les livres, les études, tout". C'est également l'avis de la Chilienne Magdalena Brito qui, à Cienfuegos, a fait de nouveaux amis et a acquis l'expérience nécessaire à l'exercice de la médecine en travaillant aux côtés des spécialistes des deux principaux hôpitaux de cette ville, qui se trouve à plus de 200 kilomètres de La Havane. Si son regard s'assombrit quand elle parle du retour, prévu pour l'an prochain, elle sait en revanche que dans son village froid et oublié du sud du Chili, où elle est née, elle sera à même d'aider les habitants de cette région, où les médecins sont rares.

UN INVESTISSEMENT EN CAPITAL HUMAIN

Le Dr Juan Carrizo compte une bonne trentaine d'années de travail dans le monde de la médecine et de l'enseignement de celle-ci, dont cinq consacrées à l'École latino-américaine de Médecine. Il en est le recteur et il assure qu' "il n'y a pas que les étudiants qui y ont appris quelque chose" dans ce centre. Quand il est question des étudiants qui auront leur diplôme l'an prochain, le recteur de l'ELAM affirme: "S'ils ont grandi ici, nous avons grandi avec eux puisque nous avons appris des choses que nous n'aurions jamais imaginées sur le monde dont ils proviennent. Même si on peut lire sur leurs pays, ce n'est pas pareil que d'apprendre à ressentir avec eux leurs angoisses, de connaître leurs expériences et les problèmes existant dans leurs pays d'origine. Leur comportement même correspond, à certains moments, aux carences qui ont marqué leur vie, aux lacunes de leur éducation ou de leur formation". "Nous les avons vus recevoir une formation appropriée, acquérir les valeurs humanistes et éthiques propres à la profession médicale, apprendre la solidarité puisqu'ils se sont formés dans les principes de nos médecins et, quand ils auront terminé leurs études, ils suivront le but de ce projet. Ils ont, pour la plupart, pris un engagement important: celui d'apporter leur aide à leurs communautés, de retourner dans les régions dont ils proviennent" , précise le recteur Carrizo. En ce qui concerne la reconnaissance de leur titre, le recteur signale que des progrès ont été atteints auprès de certaines universités latino-américaines et des accords bilatéraux ou gouvernementaux ont été passés, notamment avec le Venezuela, l'Équateur, la Bolivie, le Guatemala et le Honduras. Cela va même dans le sens des intérêts de leurs gouvernements dans la mesure où il s'agit d'une masse de jeunes ayant une bonne formation, d'une ressource humaine permettant de réaliser les transformations nécessaires dans le domaine de la santé, d'un investissement en capital humain dont leur fait don notre pays."
Recteur Juan Carrizo Estévez

CEUX QUI COMMENCENT

Nelson Aicaire est Uruguayen. Il transporte en permanence son petit thermos de mate, infusion dont il raffole depuis l'âge de douze ans. Aujourd'hui, il en a 23 et il fait sa deuxième année à l'École latino-américaine de Médecine. "Le niveau du cursus est excellent. Si on le compare aux cursus médicaux d'autres pays, celui-ci consacre beaucoup plus de temps à la pratique, l'étudiant est plus proche du patient et l'on accorde beaucoup plus d'importance à l'aspect social du travail médical. En première année nous avons passé cinq semaines à travailler sur la Médecine générale intégrale en allant dans les consultations des médecins de quartier" , nous explique Nelson. Que pense-t-il faire quand il aura son diplôme? "J'ai grandi dans un orphelinat. Je veux travailler avec ces enfants-là car je sais que les soins médicaux ne sont pas les meilleurs dans ce type d'établissement. Ensuite, j'aimerais aider les habitants des quartiers pauvres de Montevideo. Ce sont des gens qui mangent un jour sur deux¼" D'après Nelson, la santé publique y est totalement déficiente. Et pour avoir accès à la médecine privée, il faut y consacrer en moyenne 200 à 300 dollars US par mois, sans compter les prix des médicaments. Sartoma Sefa-Boakye a des ancêtres africains. Ses parents ont quitté le Ghana il y a trente ans pour s'installer aux États-Unis, où elle est née. Elle a commencé ses études de médecine à l'université de Los Angeles, mais les poursuivre était extrêmement difficile. "Pour faire des études de médecine il faut débourser de 25 à 30 mille dollars par an", précise-t-elle. Sartoma est venue à Cuba il y a deux ans. Son père avait lu un reportage sur l'École latino-américaine de Médecine, paru dans le journal Los Angeles Times à l'occasion d'une visite de l'ex-président James Carter, et elle avait contacté le révérend Lucius Walker, leader des Pasteurs pour la Paix, qui dirige un comité chargé de sélectionner les jeunes nord-américains qui aspirent à obtenir une bourse pour l'ELAM. "Les médecins cubains sont particulièrement habiles sur le plan clinique car ils sont capables de faire un diagnostic juste sans équipement et sans instruments. Dans les pays comme les États-Unis, le personnel médical est très dépendant de l'informatique à l'heure de faire un diagnostic" , signale Sartoma. Elle explique par ailleurs que 80% des habitants de son quartier de Los Angeles n'ont pas de sécurité sociale. C'est avec eux que Sartoma entend travailler à son retour. L'ELAM, c'est ainsi que les étudiants eux-mêmes appellent l'École latino-américaine de Médecine, est devenue le centre de leur vie. Joel José Caraballo, qui vient de l'État de Sucre, au Venezuela, avait toujours rêvé de devenir médecin. Sa famille vit dans une commune suburbaine peuplée essentiellement de descendants des populations amérindiennes. Joel explique que les rares médecins de la région pratiquent des prix trop élevés pour leurs services. Il pense que "le projet de l'ELAM est très important en raison de la situation qui subsiste en Amérique latine" car "il représente une solution fondamentale pour le déficit de médecins et les carences sanitaires de la région."
Une attention personnalisée MAYRA Sanchez Martin est professeur à l'École latino-américaine de Médecine depuis sa fondation. "C'est une expérience nouvelle, unique, assure-t-elle. On a parfois des étudiants de 22 pays dans une seule classe." "Ceux qui ont des difficultés, que ce soit des problèmes d'adaptation ou dans l'apprentissage, bénéficient d'une attention personnalisée de la part des psychopédagogues du Département d'orientation et de développement des étudiants" , relève Wally Parraño, méthodologue, professeur titulaire et consultante en Psychologie médicale. Tito Diaz Bravo, docteur en sciences techniques, professeur de biostatistique et d'informatique, déclare qu'il est "particulièrement intéressant de travailler en fonction de la composition sociale, du caractère hétérogène des classes. Certains étudiants ont une formation appropriée; chez d'autres, elle est déficiente; beaucoup ont besoin de soutien sentimental à cause de l'éloignement d'avec leur famille. Mais ces difficultés sont résolues peu à peu. Ce travail nous permet d'avoir la satisfaction de les guider dans l'apprentissage qu'ils doivent suivre nécessairement pendant ces premières années d'adaptation à un nouveau cadre de vie."

La Havane. 28 Mai 2004 PAR MARELYS VALENCIA, de Granma international

FIRST GRADUATION OF THE LATIN AMERICAN SCHOOL OF MEDICINE

Ceremony attended by heads of state and government• 1,610 youth from 21 countries receive their diplomas from the presidents of Cuba, Venezuela and Panama; Central American, South American and Caribbean premiers, foreign and high-ranking ministers
BY MIREYA CASTAÑEDA —Granma International staff writer—PHOTO: ALBERTO BORREGO
IT was a solemn and, without any doubt, unique ceremony. Everyone present at the first graduation from the Latin American School of Medicine (ELAM) was touched by emotion. It was an unrepeatable moment. Knowing that "wings are not necessary to fly."
1,610 young doctors received their diplomas, rings and prizes for six years of energetic effort. They are not just a few more graduates. The fact that it was about the first graduation from ELAM, that work of "infinite love for humanity" was compounded by the students themselves.
The initiators of a program – without the need for "a humiliating receipt of payment" – without which they could never have realized their dreams of studying for that noble career. They came from the poorest sectors, from indigenous communities, from working-class parents.
Dr. Juan Carrizo, the dean of ELAM, noted during the ceremony in Havana’s Karl Marx Theater, that 71.9% are of that extraction. More interesting, they represent 33 ethnicities; for example, Mayans and Mesquitos, Punas.
"CUBA MAKES YOU PUT YOUR HEART INTO EVERYTHING"
Arnolfo Quintero is a robust transport worker from the city of San Cristóbal in Tachira, the Andean region of Venezuela, but when he tried to comment for Granma International what he felt about his new fully-fledged doctor daughter, the lump in his throat and his tear-filled eyes overcame him.
"We are very proud and emotional. We are very grateful for what President Chávez, President Castro and the Cuban people have done."
Daline, who like all the Venezuelans (51) concluded her studies in hospitals in Camagüey province, feels that she is lucky to have been able to begin her studies at ELAM and now complete them. "I put a lot of my heart into it, moreover, here in Cuba makes you put your heart into everything."
Her compatriot Héctor Domínguez is from the city of La Victoria, in Aragua state. "The news of the scholarships got as far as there, and then the selection, in addition to study averages, was directed at those of us who live far from the capital and had the least economic possibilities for studying medicine."
Both young people affirmed that all the members of the Venezuelan group had committed themselves to work in their countries in areas "where no doctor has a presence and especially, within the Barrio Adentro program. We want to take the best of ourselves."
Venezuela is not an exception. Among a sea of white coats, chance led us to sit down by Rubén Rojas, a young man from the Dominican Republic born into a very poor family. "My parents couldn’t come because they didn’t have the resources (some of those who came to Havana for the graduation did so thanks to loans from and collections in their communities). They are anxiously awaiting me."
Rojas and the other 95 Dominicans studied in Pinar del Río province, and have "many expectations, but the basic one is to help the poor, the most needy" and he already knows that his country’s government has a project for them, the first specialists in General Medicine.
128 YOUNG HAITIANS READY TO SAVE LIVES
For the poor masses, for the most needy, precisely the sectors from where they came. Like Compere Pierre, whose humble family lives in the southern region of Haiti. Along with another 128 young Haitians, he studied in the (Francophone) Caribbean School in Santiago de Cuba (it was announced that this program has also been incorporated into the ELAM).
"On returning to Haiti I want to work to improve my country’s health situation, which has many problems. We are ready and waiting, here in Cuba we have felt the enthusiasm and will of the professors to make us excellent professionals in order to save lives."
THE FERTILE SEED
It was a graduation within a Summit of these simple and brilliant young people. For them, the presence of the man who dreamed of and put into practice that inestimable project – the Cuban president, Fidel Castro, and, at his side, many of those who supported the idea, in first place, the Venezuelan president, Hugo Chávez.
Also present was the president of Panama; the prime ministers of Antigua and Barbuda, Dominica, St. Kitts and Nevis, St. Vincent and the Grenadines; the vice president of Ecuador; the deputy prime minister of St. Lucia; the foreign ministers of the Bahamas, Guyana, Barbados, Belize, the Dominican Republic and Grenada; and ministers from Surinam, Trinidad and Tobago and Jamaica; and, in an outstanding way, the Reverend Lucius Walker (the graduates included a young African American).
MY FATHER IS ONE OF THE THOUSANDS OF DISAPPEARED DURING THE DICTATORSHIP
From a solemn and formal event, the Cuban president transformed things into an agreeable encounter when all the dignitaries present handed diplomas to the 16 best students (from Ecuador, El Salvador, Argentina, Haiti, Bolivia, Brazil, Guatemala, Paraguay, Costa Rica, Chile, Honduras and Peru.
The best students included Argentine María Julia Córdova. "My father is one of the thousands of disappeared during the dictatorship." No questions, no answers, her mother and her, holding hands tightly.
The new doctors dedicated their graduation to President Fidel Castro, "who has given thousands of young people the possibility of knowing that a better world is necessarily possible," to the five Cuban heroes kidnapped in U.S. jails, and "to the people who took us in with their integrity, dignity and love for the homeland."
There remained an oath: "We shall sow the fertile seed of solidarity."
Music is a reflection of the soul of the peoples. Every generation has its symbol and ours is that of composer and poet Silvio Rodríguez (the lines in bold are from some of his songs).
Thus we have to accept his simple "formula for salvation:" "The problem is the soul/ the problem continues to be sowing love."

HIV/AIDS Education Across Cuba

By Mike Fuller

Cuba fulfilled the 2005 World AIDS Day’s promise to fight AIDS with a week of educational activities organized by the national team for the management and fight against HIV/AIDS. This multidisciplinary team - GOPELS according to its Spanish acronym - comprises major ministries, media and civil groups.
The main thrust for December 2005 was to “educate, educate and educate,” said Dr. Rosaida Ochoa, Director of Cuba’s National Center for Prevention of STIs and HIV/AIDS. “We are trying to work on the relationship between individuals and their communities,” explained Ochoa, a designer of the prevention strategy contributing to Cuba’s low prevalence rate, which is rising but is still less than 10% of the Caribbean rate of 1.6% as cited by UNAIDS (2005).
Dr. José Juanes, member of GOPELS, explained in an organizational meeting for World AIDS Day, that Cuba has screened for the disease since 1986, testing all blood donors, pregnant women and those requesting anonymous HIV tests. Dr. Juanes also cited the importance of universal free access to antiretroviral therapy here for those needing it. He said that to date in Cuba there have been 6,682 cases of HIV, with 2,784 developing into AIDS and a total of 1,314 deaths. Males are still the predominant carriers of the disease here, at 80.4% percent of cases; of those, 85% are men who have sex with men.
Community Education
Health promoter Zulima Fis
On the eve of World AIDS Day the agenda was packed, with some street work highlighting prevention in downtown Havana carried out by young health promoters, which was boosted to a full-fledged campaign all over the country the next day. Trained youth sat at information tables or stood with boxes of condoms and leaflets, educating passersby about the most effective ways to prevent the disease.
These volunteers had participated in workshops on sensitivity training, group dynamics, face-to-face consulting and telephone techniques for their 24-hour AIDS hotline, in place all over the country. Promoter Zulima Fis, involved with the project for two years said, “all our community prevention tours in the AIDS van have been well received, and I hope people use the condoms.” In Cuba, when they’re not being given out free like today, condoms only cost five cents apiece.
International and Homegrown Initiatives
World AIDS Day has been celebrated in Cuba since 1988 when the World Health Organization first declared it in London, and international cooperation has been decisive at various moments in Cuban AIDS history. Current and past collaborators include UNDP, UNESCO and UNAIDS, as well as NGO’s like Doctors Without Borders, Hivos and Population Services International. Nevertheless, many initiatives are homegrown now, with Cuba producing generic antiretrovirals since 2001, and HIV/AIDS prevention centers and related offices, hotlines, promoters and events all over the country.
A couple of days later, the Hope Awards for prevention, mutual support and solidarity were given at Cuba’s National Theater, with performances by visual artists, musicians, dancers and actors. Lianett Rodríguez and Mardelis Martínez, a duo from the internationally renowned troupe Danza Contemporanea, told MEDICC Review their choreography was designed to help “raise consciousness and support self esteem.” They explained how both are particularly important to people with HIV, who “suffer from rejection by uninformed people,” and that their mission is to “give AIDS a face.”Daniel Vila, Coordinator of the Amigos del Este HIV/AIDS support group, told MEDICC Review that he had unprotected sex with a woman one night eight years ago and contracted the HIV virus. When his test came out positive he said he felt the world was falling apart and was thankful a psychologist was there to help him learn how to cope.“It took me a long time to assimilate,” he said, “and at first I ran around trying to finish as many things as possible.” That is what is called the “elaboration of grief,” he explained, now well-versed in the language of catharsis and an international speaker on the Cuban experience. There are 31 self-help groups in Havana and 79 in Cuba, and he said there is a palpable commitment from the government to actively fight and inform about AIDS.“Without that, words fade off into inaction,” he said, “everyone has a particular situation but at least national policy supports us, and we all have our meds.” As Daniel walked off the risers at Havana’s National Theater, MEDICC Review asked when was his best moment during almost a decade of HIV infection. Without skipping a beat the award winner said: “Today.”
Cuba & Bolivia Sign Cooperation Accords in Health
By Anna Kovac
Bolivian President Evo Morales’ first foreign visit after winning a majority vote in December was to Cuba, where he signed important cooperation accords in health, education and sports. Among these was an agreement between the two countries to establish a non-profit organization to provide poor Bolivians ophthalmological treatment to cure or prevent loss of eyesight.
Cuba has already provided the National Ophthalmological Institute in La Paz with modern equipment and specialized personnel who, along with Bolivian doctors and recent graduates from the Latin American Medical School (ELAM), have treated over 1,500 patients free of cost.
The new accords stipulate for the opening of two additional centers, one in Cochabamba and another in Santa Cruz, which will each treat 50 patients a day; in La Paz, doctors will be able to attend to 100 a day. As a result, Bolivia will have the capacity to operate on a minimum of 50,000 people annually.
Additionally, Cuba offered 5,000 more full scholarships to educate doctors and specialists as well as other health personnel at ELAM. At present, there are some 500 young Bolivians studying at the school and another 2,000 have started the pre-med bridging course. The six-year education is provided free for low-income students committing to practice medicine in underserved communities upon graduation.
During the ELAM’s first graduation last August, Venezuelan President Hugo Chávez announced that his country will establish a second Latin American Medical School, so that jointly with Cuba, the two countries will be able to provide free medical training to at least 100,000 physicians for Third World countries over the next 10 years. See MEDICC Review Vol. VII, No. 8, 2005.
The Cuba-Bolivia Cooperation Accord also offers aid for the new President’s literacy program (slated to start in July), with the aim of teaching all Bolivians to read and write in 30 months. Cuba will provide didactic material and technical means, as well as experience to the program. Venezuela just ended a two-year literacy campaign using the Cuban method known as “Yes, I Can,” during which over 1.4 million people learned to read and write. Presently Cuba is helping Brazil, Mexico and other countries with similar literacy programs. The accords also include sports, cultural and scientific exchanges.
In January, President Morales visited Caracas where Bolivia also signed cooperation accords with Venezuela, which together with the Cuban accords, fit into a bigger regional integration plan called the Bolivarian Alternative for the Americas or ALBA, as it’s known.
Medical Education Cooperation with East Timor Expanded
By Conner Gorry
East Timor pre-med students Aleito Menezes, Délio da Silva & María Geremias en route to Havana.
Known as the ‘first independent state of the millennium,’ the island nation of East Timor will celebrate four years of independence on May 20th. Since 2004 – nearly half the young country’s life - Cuba has had a medical cooperation program with East Timor that was recently expanded to include a greater presence of Cuban doctors in-country and additional medical scholarships for East Timorese students.
Providing education and training for human resources for health is a top priority in a country that was left with only 35 physicians after violent clashes in August 1999 displaced 75% of the population.[1] In response, Cuba offered over 800 full scholarships for young East Timorese to study at Havana’s Latin American Medical School (ELAM). The first phase of the scholarship program is well under way, with 361 students from East Timor already matriculating in the medical school.[2] The balance began arriving this January to begin the pre-med bridging course, the preparatory course to the standard six-year curriculum (see Spotlight, MEDICC Review Vol. VII, No.8, 2005).
“There are so few doctors in my country and I want to help” said arriving student Délio da Silva about why he decided to apply for an ELAM scholarship. Prospective students are chosen from the 13 districts throughout East Timor, to promote more equitable distribution of the future MDs. The hope is that these students will return to their country to help alleviate the human resources for health crisis there, since ELAM students commit to practicing medicine in underserved communities upon graduation.
Creating a sustainable health system where East Timorese provide health services for their own is the long-term strategy, says Dr. Francisco Medina, head of Cuba’s Comprehensive Health Program (CHP) in the small island nation. There are currently 182 Cuban professionals and technicians working in East Timor under the medical cooperation project.
“We’re the first to get rid of the desk separating doctors from their patients, and many times the first to see them not just as cases, but as human beings,” Dr. Medina told MEDICC Review. This humanist approach is the philosophy underscoring medical education in Cuba and is the foundation for East Timor’s future doctors. Notes & References
Source: East Timor Health Sector Situation Report, January-June 2000, World Health Organization, 2000. According to Cuban officials in East Timor, there are currently 45 doctors there, only 26 of whom work in the public sector.
The students are distributed as follows: 27 in 1st year, 15 in 2nd year; and 319 in 3rd year.

All rights reserved © MEDICC - Medical Education Cooperation With Cuba -


2006 - ISSN: 1527-3172

Cuba Trains Physicians for Wealthy United States

Fitzhugh Mullan, M.D

Affirmative Action, Cuban Style, New England Journal of Medicine Volume 351:2680-2682 December 23, 2004 Number 26
What an irony that poor Cuba is training doctors for rich America, engaging in affirmative action on our behalf, and - while blockaded by U.S. ships and sanctions - spending its meager treasure to improve the health of U.S. citizens.

"I feel as if I'm standing on the backs of all my ancestors. This is a huge opportunity for me," Teresa Glover, a 27-year-old medical student, told me during a recent visit to her medical school. "Nobody in my family has ever had the chance to be a doctor." Glover's mother is a teacher, and her father a dispatcher for the New York subway system. Her background is a mix of African American, Barbadian, and Cherokee. She graduated from the State University of New York at Plattsburgh. "I wanted to be a doctor, but I wasn't sure how to get into medicine. I had decent grades, but I didn't have any money, and even applying to medical school cost a lot."
This young woman from the Bronx may be helping to rectify the long-standing problem of insufficient diversity in the medical profession in the United States. Twenty-five percent of the U.S. population is black, Hispanic, or Native American, whereas only 6.1 percent of the nation's physicians come from these backgrounds.
1 Students from these minority groups simply don't get into medical school as often as their majority peers, which results in a scarcity of minority physicians. This inequity translates into suffering and death, as documented by the Institute of Medicine.
2 Poorer health outcomes in minority populations have been linked to lack of access to care, lower rates of therapeutic procedures, and language barriers. Since physicians from minority groups practice disproportionately in minority communities, they are an important part of the solution to the health-disparities quandary.
In her third year, Glover is negotiating the classic passage from the laboratory to the clinic. But her school isn't in the United States. She is enrolled at the Latin American School of Medicine (ELAM, which is its Spanish acronym) in Havana - a school sponsored by the Cuban government and dedicated to training doctors to treat the poor of the Western hemisphere and Africa. Twenty-seven countries and 60 ethnic groups are represented among ELAM's 8000 students.
Glover's mother heard about ELAM from her congressman, Representative José Serrano (D-N.Y.). "Mom calls me. 'I have news. There's a chance for you to go to medical school.' She waits for it to sink in. 'You'd get a full scholarship.' She waits again. 'But it's in Cuba.' That didn't faze me a bit. What an opportunity!"
The genesis of Glover's opportunity dates to June 2000, when a group from the Congressional Black Caucus visited Cuban president Fidel Castro. Representative Bennie Thompson (D-Miss.) described huge areas in his district where there were no doctors, and Castro responded with an offer of full scholarships for U.S. citizens to study at ELAM. Later that year, Castro spoke at the Riverside Church in New York, reiterating the offer and committing 500 slots to U.S. students who would pledge to practice in poor U.S. communities.
That day, 26-year-old Eduardo Medina was at his parents' house in New York, listening to Castro's speech on the radio. "Castro announces that Cuba has started a new medical school and has invited students from all over Latin America to come, train, and return to treat the poor in their countries. Then he starts quoting figures about poor communities in the U.S. 'We'll be more than happy to educate American medical students,' he says, 'if they'll commit to going home to take care of the poor.' The place went nuts. I'm standing in my basement saying, 'Yes! Yes! Yes!'"
Medina was raised in Brooklyn and Queens, the child of a Colombian father and a mother of Puerto Rican, Jewish, and Irish descent - both public-school teachers who pushed their children to work hard in school. "When I was little, they sent me to a summer enrichment program in Manhattan," recalls Medina. "I would travel on the subway every day withthis huge book bag. I was young and it was hot. But I was excited." The work paid off, and Medina won partial scholarships to a boarding school and to Wesleyan University. "There weren't many students of color at either private school, particularly in the sciences," he says. "Culturally, economically, ideologically, it was a real culture clash for me, but the education was good."
Medina was found to have diabetes when he was 12 years old and spent a week in the hospital. "When I saw what the doctors could do for me, I knew I wanted to be a doctor. In college, I spent a year in Ecuador, and I knew I wanted to practice community medicine." But medicine wasn't going to come easily. Medina had a mediocre grade or two in science courses, a middling score on the Medical College Admission Test (MCAT), and $45,000 in student debts. He worked as a research assistant to buy himself time to retake the MCAT and organize his medical-school campaign. After hearing Castro, Medina applied to ELAM and happily grabbed the chance to attend. "I didn't know if I'd get into U.S. schools, and if I did, I had no idea how I was going to pay."
There are 88 U.S. students at ELAM, 85 percent of them members of minority groups and 73 percent of them women. Recruitment and screening are handled by the Interreligous Foundation for Community Organization (IFCO), a New York-based interfaith organization. Applicants are required to have a high-school diploma and at least two years of premedical courses, to be from poor communities, and to make a commitment to return to those communities. Students who don't speak Spanish start early with intensive language instruction. Glover and Medina get home about once a year. They report that living conditions are spare and English textbooks hard to come by, but they are well taken care of and the education is rigorous.
The Bush administration's restrictions on travel to Cuba have been a thorn in the side of the program from the beginning. Since the Cuban government pays the students' room, board, tuition, and a stipend, the ban was not initially applied to them. But the administration's further attempts this summer to curtail Cuban travel threatened the students and sent their families scrambling for political help. Representatives Barbara Lee (D-Calif.) and Charles Rangel (D-N.Y.) led a campaign of protest, and 27 members of Congress signed a letter to Secretary of State Colin Powell asking that the ELAM students be exempted from the ban. In August, the administration relented and granted the students permission to remain in Cuba.
The Cuban health care system in which these students are working is exceptional for a poor country and represents an important political accomplishment of the Castro government. Since 1959, Cuba has invested heavily in health care and now has twice as many physicians per capita as the United States and health indicators on a par with those in the most developed nations - despite the U.S. embargo that severely reduces the availability of medications and medical technology.3,4 This success clearly plays well at home and has enabled Cuba to send physicians abroad to Cold War hot spots such as Nicaragua and Angola. Yet Cuba has also sent thousands of physicians to work in some of the world's poorest countries. Since 1998, 7150 Cuban doctors have worked in 27 countries - on a proportional basis this is the equivalent of the United States sending 175,000 physicians abroad.5 In the same spirit, ELAM trains young people from these countries and sends them home to practice medicine. Although these programs make political points for Cuba, they also represent an extraordinary humanitarian contribution to the world's poor populations.
The U.S. students face a hurdle that their classmates in Cuba do not. To obtain residency positions in the United States and uphold their side of the deal with Castro, U.S. students will have to pass two steps of the United States Medical Licensing Exam (USMLE) and the new Clinical Skills Assessment test. The first large group of ELAM students will take Step 1 later this year, and the results will be critical to the future of the program.
The ELAM invitation is not limited to minority students, although the emphasis on coming from and returning to poor communities has naturally selected students of color. Physicians from minority groups accounted for only 3 percent of U.S. doctors during the middle years of the 20th century. After the civil-rights movement, the number of minority medical students increased steadily, rising to 11.6 percent of medical school graduates in 1998. Schools used scholarship money, academic enrichment programs, and special admissions criteria to increase minority enrollment. In recent years, such initiatives have flagged - victims of court decisions opposing affirmative action, continued escalation of medical-school tuition, and a supply of minority students that, in the judgment of some medical educators, is tapped out. Today, roughly 11 percent of graduating medical students are members of minority groups.
Glover, Medina, and their schoolmates have gotten into and mastered strong academic programs despite their disadvantaged backgrounds. However, half of all applicants to U.S. medical schools are rejected. By the unforgiving standards of the application process, a C in a science class or a so-so MCAT score dooms an applicant. Castro has removed the financial barriers and bet on motivation to overcome any educational liabilities that students bring with them to ELAM.
Which brings us back to Castro's gambit. Why is he reaching out to U.S. students? What an irony that poor Cuba is training doctors for rich America, engaging in affirmative action on our behalf, and - while blockaded by U.S. ships and sanctions - spending its meager treasure to improve the health of U.S. citizens. Whether one considers this a cunning move by one of history's great chess players or an extraordinary gesture of civic generosity - or a bit of both - it should encourage us to reexamine our stalled efforts to achieve greater racial and ethnic parity in American medicine. If Castro can find diamonds in our rough, we can too.