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Medical Education & Health Equity: An Opportunity For The New Administration



December 12th, 2008
by Fitzhugh Mullan

I visited Cuba last week for an international conference entitled “Medical Education for the 21st Century: Teaching Health for Equity.” Havana is beautiful, dilapidated, and lively. Rickety, vintage Buicks and three-wheeled “coco taxis” ply the streets. Spectacular and decrepit 19th century buildings are being lovingly refurbished by workmen using block and tackle to haul concrete mixed with sewer water to the upper floors. Everyone smokes and pharmaceuticals are in short supply, but infant mortality and longevity rates are among the best in the world. Whatever Cubans think about their government, they extol the country’s medical care system.

Seven hundred people (including 180 Americans) showed up for the conference sponsored the Cuban Ministry of Health and the Pan American Health Organization. Some surely came in the spirit of getting to Cuba before change came (Cuba in the late Castro and early Obama years), but most were there for the topic — health equity in medical education, the social accountability and social mission of medical schools. Medical education in many parts of the world is available only to the children of political, social, and financial elites. Health systems often reflect this disparity with little medical care available outside of the wealthier sector of society. It was concern about these ubiquitous and hard-wired inequities that that drew most of the conferees.

The range of medical schools reporting on strategies to redress these inequities was impressive. The University of the Philippines Medical School at Leyte has pioneered the use of “ladderized” education that trains young men and women as community health workers and progressively offers the most gifted students nursing and medical eduation and degrees. The Walter Sisulu University School of Medicine in Umtata, South Africa, trains rural physicians in the most remote parts of that country, and the new University of Northern Ontario educates physicians to staff the vast northern and aboriginal areas of Canada. Venezuela’s “Barrio Adentro” program keeps medical students in their own communities using a combination of distance learning and dedicated medical tutors to train thousands of physicians for practices in those same poor and rural areas.

The stars of the conference were the Cubans who have made what they call “international cooperation in health” central to their national health policy and a keystone of their foreign policy. Dr. Yiliam Jiménez, Vice Minister of Foreign Relations, presented the current Cuban strategy for medical education for global health. In 1998, after decades of training small numbers of foreign medical students, the Latin American School of Medicine was opened to educate non-Cubans in large numbers. Student recruitment focused on people from poor and rural areas and of aboriginal or minority ancestry for whom medical education is beyond reach.

Today the school has 5,000 graduates and 8,000 students enrolled from 24 countries mostly in Latin American and Africa. (120 students from the U.S. are enrolled as well.) Since 2005, Cuba has increased the intake of non-Cuban students from these same countries in its 26 other medical schools, with a target of graduating 100,000 doctors for the world by 2015. The Cuban commitment to health equity through medical education also entails sending faculty abroad to staff or start medical schools. Cubans have opened schools in Gambia, Burkina Faso, Tanzania, Eritrea, and Equatorial Guinea.

The government policy that underlies these enormous contributions to global health is surely strategic as well as humanitarian. Cuba has always used its doctors as an instrument of foreign policy, sending them to conflict zones in Angola, Ethiopia, and Nicaragua in the past and to Venezuela in large numbers today. Most Cuban physicians, however, serve in countries with little geopolitical clout and scant natural resources. They traffic in good will, a valuable commodity for Cuba. Some dismiss Cuba’s traveling doctors as a cynical or opportunistic move on Cuba’s part. Yet it is hard to see how engendering support with healers is anything but a good idea. Alternative strategies are in play as we speak, in countries that use weapons or scarce commodities to build allegiances. If global powers decided to compete for influence using medical care rather than munitions, would this not be a better world?

A Recommendation To President-Elect Obama:
A U.S. Global Health Service
  

Which raises the question of the role of the United States — undoubtedly the world’s medical education superpower. Not only do we have a large and growing physician workforce, but we are the preferred residency training destination for physicians from all corners of the world. Global health is hugely popular with medical students and residents, many of whom are ready to consider extended work abroad. What might we do to put this powerful medical education engine to work in the developing world? To be sure, there are numbers of nongovernmental organizations that do send U.S. physicians abroad, and many medical schools have partnership programs with schools abroad. But where is our government in putting its shoulder to the global workforce crisis? Why don’t we have a medical teacher corps? Why aren’t we working to build new medical schools in countries that desperately need them? Why don’t we use loan repayment to mobilize hundreds of young physicians to work on the front lines of global health?

We will soon have a new administration concerned with reframing the role of the U.S. in the world. A U.S. Global Health Service that addresses educational scale-up around the world, built on the principle of equity in medical education, would do a lot for world health and for the U.S. presence in the world.

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1 Trackback for “Medical Education & Health Equity: An Opportunity For The New Administration”

  1. Health Affairs Blog
    December 12th, 2008 at 12:55 pm

7 Responses to “Medical Education & Health Equity: An Opportunity For The New Administration”

  1. Gail Reed Says:

    Fitz’s comments hit the mark. My organization–MEDICC–endorsed the event in Cuba (as a US-based organization we could not do more, given the US travel restrictions and embargo), and I followed the conference organization up to opening day. Nevertheless, I was surprised at the level of participation from all continents, and the depth of discussion spurred on by some of the world’s most innovative medical schools. It is worth noting that without exception, these schools have been established in response to the urgent need for medical care in the communities where their graduates are expected to practice–and often where the graduates come from themselves.

    On the question of the US service corps abroad: in a better world, wouldn’t it be impressive to see US and Cuban docs team up to serve in shortage areas around the globe, and to train more doctors and other health professionals where they are so sorely needed? We have a ways to go…

  2. James McGee Says:

    Where is our government in putting its shoulder to the global workforce crisis?
    Fair question!
    A US Global Health Service might be a good idea.
    But I would put a US Domestic Health Service ahead of that.
    US Medical schools do not graduate enough students to fill all of the internships and residencies. It would make sense that we attract physicians from “all corners of the world” – most of whom are educated at their own countries expense. I doubt if that brain drain enhances our image.
    But when US medical students finish their medical training with an unconscionable debt burden, is it a surprise that our doctors would be unwilling to unable to put their creditors on hold in order to enhance the image of the US in the world.
    I would suggest that “equity in medical education” include substantial federal support for the education of doctors in this country.
    When they graduate, the debt they owe should be to their country, not to their bank.
    Maybe then we can focus on the very noble and worthwhile goals you outline.

  3. David Redford Says:

    Cuba’s “medical image” is not really something they can be proud of. That’s why education is the way to go.

  4. ttakaro Says:

    I also recently returned from Havana where I was embarking upon collaborations regarding Cuba’s disaster response capacity and climate change. Cuba has set an example in the Caribbean for storm disaster preparedness. This past hurricane season was once again a devastating one for the region with three category 3-4 storms lashing the islands. It is the first season in several years that there was loss of life from hurricanes in Cuba with 4 deaths from Hurricane Ike. The toll on the nearby island of Hispaniola is in the hundreds lost since the 2000 season. Ike claimed more than 30 lives in the US. Gulf Coast. Cuba’s disaster preparedness is responsible in large part for this successful protection of human life (see G Mesa . The Cuban health sector & disaster mitigation. MEDICC Review 10: 5-8. 2008). As the frequency and intensity of storms increase as predicted under most future climate models, Cuba’s organization and planning will be looked to by other vulnerable populations.

  5. David Keller MD Says:

    While I agree that public health measures are important, the provision of primary care and preventive services send an important message of concern and sustainability to people living in often dire circumstances. My colleagues and contacts in the field in Latin America tell me that Cuban physicians are valued by the people in many Latin American countries, and those Cuban physicians that I have met have seemed to be disciplined clinicians who are focused on the well-being of the community that they serve (I would contrast them to many of the physicians that I met who trained in the old Soviet system, who seem to be less well informed about the current state of Western medicine). I lack enough experience to generalize; I wonder if Dr. Burney has data on the quality of Cuban Medical Training? In quantity, they put us to shame.

    By the way, Fitz, it was a great conference.

  6. MDMcDonald Says:

    Fitzhugh,

    Great contribution. I spent a week in Cuba on a WHO Health Information Infrastructure panel evaluating the Cuba health information system. Infomed, the Cuban National Health Information System is clearly one of the best in Latin America and the Caribbean, even with the very significant constraints on infrastructure support from within the country. The Cuban community health approaches appear to be outstanding, which is likely to do more for the overall health status of Cubans than the Cuban medical system’s ability to do world class secondary and tertiary medical care. That said, if I needed brain surgery, I would prefer to enter the health system in Boston than in Havana.

    On the issue of a U.S.-based Global Health Corps, clearly its time has come. This is a critically important capability that we are building into the U.S. Resilience System, under the National Sustainable Security Infrastructure Initiative. There is strong reason to believe that American health professionals committing themselves to addressing health needs of the world’s most vulnerable billion people in the years ahead will play a critical role in our country’s efforts to regain a positive image around the world. That said, those populations would be far better served by the kind of population-based health services delivered in Cuba than the kind of medical care that is being taught and practiced in the United States today.

    Michael D. McDonald

  7. RobertBurney Says:

    In contrast to US physicians, Cuban doctors are regarded as poorly trained and borderline competent. Cuba is not a place you want to go for healthcare if you have a choice. To their credit, Cuba has established schools and permanent facilities in other countries, in contrast to the American tradition of sailing in to “do good work” and then sailing home.
    The greatest gains in World Health will probably come more from clean air, clean water, and immunizations–all things the U.S. could do well at less cost than providing direct healthcare.

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