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.