Monday, April 18, 2016

Can Cuban Medicine Help Solve American Inequality?
Nearly a hundred Americans are studying medicine at Cuba’s Latin American School of Medicine (ELAM), where they are taught preventive medicine to treat the underserved.

Samantha Marie Moore, a sixth-year ELAM student from Detroit, Michigan, examines Estrella Gomez Mesa, 76, during morning rounds at the Salvador Allende Hospital in Havana, Cuba, October 6, 2015. Behind is patient Ofelia Favier, 85. All U.S. students at ELAM continue years three to six of their medical training at Salvador Allende Hospital. Photos by Allison Shelley.

The Salvador Allende hospital is an oasis of green in Cerro, a run-down neighborhood of Havana, far from the oceanfront hotels and tourist restaurants of Cuba’s capital. Originally built in 1899 to provide care to Spanish colonists, the hospital campus is smattered with colonnaded buildings set amidst well-tended parks. That it resembles a small liberal arts college is appropriate: Salvador Allende is now a teaching hospital, with 532 beds and more than 5,000 medical students, most from sub-Saharan Africa and Latin America. There are even some students from the United States.

Samantha Moore, a sixth-year student from Detroit, is working in the gerontology ward, where she is learning to care for the elderly. In an airy building filled with colorful tiles and natural light, geriatric patients sat chatting on the veranda one recent morning. Moore leaned over her patient Ofelia Favier, who has lost a leg to diabetes and was admitted for dehydration. She moved her hands around her patient’s delicate frame, gently pushing and prodding. “Good morning, Mami,” she said in Spanish.

“How are you feeling? How was your night? Does anything hurt?”

Favier, who is 85 years old, was not in a good mood. “It never hurts, I’m fine, I don’t have any more fever. I am hungry. I wish the cafeteria would hurry up.” Moore let out a hearty laugh and went to check on breakfast, which consisted of rice, beans, and eggs.

“I love patient care,” said Moore. In Cuba, she added, students learn about the importance of environmental design factors — like how the ward’s natural light, free-flowing air, and soothing pastel colors help with patient recovery. “It’s an amazing education; you’d never learn this in the States.”

(Free-flowing air has been shown to be more effective than the air conditioning or recirculating air you often see in American hospitals, which are a significant factor in hospital infection rates.)

Moore is one of 93 American students studying at The Latin American School of Medicine, known by the Spanish acronym ELAM. In a sense, it is Cuba’s answer to places like Harvard’s Kennedy School of Government, training professionals from all over the globe. But unlike the Kennedy school, which is more geared to the Davos set, ELAM’s students are specifically training to work in low-income communities. Almost all students at ELAM attend for free, either through grants from the Cuban government or else paid by their home governments.

In return, they are expected to go back to their home countries and work with medically underserved communities using the low-resource, prevention-focused medicine commonly practiced in Cuba.

In the U.S., only a small number of medical school graduates specialize in primary care, and the number who choose family practice has dropped by 50% between 1997 and 2005, according to The New England Journal of Medicine. Less than ten percent of medical school graduates in 2013–14 went into a family medicine residency according to a report by The American Academy of Family Physicians. The report noted “the failure of [American medical] schools to deliver on a key measure of social responsibility.”

Moore, 35, said that she had always wanted to go to medical school but never had the money to do it. Instead, she earned a Masters in computer science.

She encountered ELAM through Pastors for Peace, a New York-based organization that works with the school to select U.S. students. Moore said she was inspired by a sermon from the organization’s founding director, the late Rev. Lucius Walker, who described ELAM as a place where one could train as a doctor to work with the underprivileged and medically underserved.

Moore, who is now studying for her board exams, is looking to do a residency in internal medicine back in Detroit. She even wants to incorporate house calls into her work, a common practice in Cuba.

“I don’t see why people who don’t have the ability to get to a clinic shouldn’t have access to a doctor,” she said.

Dr. Carlos Campos examines patient Ariel David Torres, 28, as third-year ELAM students watch at the Salvador Allende Hospital in Havana, Cuba, October 6, 2015. All U.S. students at ELAM continue years three to six of their medical training at Salvador Allende Hospital.

Globally, the need for doctors is urgent. There is currently a deficit of seven million doctors, nurses, and other health care workers in developing countries — and that number is expected to nearly double in the next 20 years. The WHO warns that the United Nation’s Sustainable Development Goals, like reducing maternal and infant mortality, will not happen without more health care workers.

Even with all of the new funding for global health these days, professional training remains one of the most critically underserved needs. Passing out emergency supplies is one thing; the multi-year intensive schooling needed to train physicians requires a whole different level of commitment.

Foreign aid is notoriously faddish: a few years ago the “teach a man to fish” parable was omnipresent. But as often happens, the rhetoric did not equal reality. Most foreign aid today is aimed at achieving a particular outcome, such as fighting a disease, providing emergency food, or alleviating the effects of a natural disaster or crisis.

The Cuban model takes a fundamentally different approach: it teaches people essential skills, so that they can be responsible for their own outcomes.

Third-year ELAM students prepare for a class at the Salvador Allende Hospital in Havana, Cuba, October 6, 2015. All U.S. students at ELAM continue years three to six of their medical training at Salvador Allende Hospital.

ELAM opened in 1999 in the wake of Hurricane Mitch, which devastated the Caribbean and Central America. The idea was to help replace doctors that had been lost among Cuba’s neighbors. Since then, the school has trained more than 26,000 doctors from 124 countries around the world.

In one small lab class, two dozen students were drawn from Chad, Sierra Leone, Angola, South Africa, Congo, Belize, and New Jersey. “Whenever we learn about epidemics, we hear about it from colleagues who experienced them first hand,” said Agyeiwa Weathers, who comes from Newark. For instance, Saada Ly, a student from Conakry, Guinea, recalled the impact of his country’s lack of health care workers during the 2015 Ebola outbreak. “All the world saw that my country’s health system was deficient,” he said.

The school provides six years of medical education, as compared to four in U.S. medical schools. The extra years are spent learning about public health, tropical medicine, and Cuba’s unique focus on prevention. Doctors learn to make diagnoses by knowing about their patients’ working and living conditions, and by interacting, touching, and listening.

Students from the United States started attending ELAM in 2001, after members of the Congressional Black Caucus met with Fidel Castro and heard about the training program. Representative Bennie Thompson told the Cuban leader that his constituents did not have access to decent medical care. Castro immediately offered 500 spots to American students. (To date, 134 U.S. students have graduated, and more than 50 are now in residency programs.)

There are no laptops in an ELAM lecture hall. Unlike U.S. medical schools, where most training takes place in the classroom, Cuban medical students spend a lot of time treating patients and performing procedures like inserting a catheter, setting broken bones, or delivering a baby.

That hands-on training is helpful when they come back to the U.S., said Dr. Susan Grossman, who runs the program for medical residents at Woodhull Medical Center in Brooklyn, which has three ELAM graduates. By the time doctors start their residencies, said Grossman, they have a lot more clinical experience than the typical American medical school graduate.

Woodhull, a public hospital, specializes in patient-centered community care, making the ELAM graduates a natural fit. “All three of these residents are very patient-focused and have excellent communication skills,” said Grossman. “I don’t know if that’s because of their training or their personalities. They have excellent clinical training.”

A student works on his computer in a study room at the library of the Escuela Latinoamericana de Medicina (ELAM), the Latin American School of Medicine, on the outskirts of Havana, Cuba, October 1, 2015. Like the rest of Cuba, internet access is patchy, slow and limited on the campus. Teaching at ELAM is focused less on technology and more on hands-on, interactive learning.

In Cuba, doctors learn to make diagnoses based largely on their in-person examinations, and may spend an hour with patients if the situation requires it. They use blood and radiological tests to confirm their diagnoses. Many U.S.-trained doctors, by contrast, rely on tests to guide their diagnoses.

“In some countries, technology has become a substitute for medical thinking,” said Dr. Enrique Beldarraín, an epidemiologist and public health historian at Cuba’s National Center for Medical Sciences.

The formality of the U.S. medical system was odd at first, said Dr. Joaquin Morante, a graduate of ELAM who is now a third-year resident at Woodhull. Morante, who grew up in The Bronx and attended undergrad at Cornell, recalls being reprimanded by an attending physician when he greeted a patient with, “Hey buddy, how’s it going?” He defended his approach: “I speak to them as a [fellow] New Yorker,” he said.

Morante acknowledged there are some medical issues that Cuba did not prepare him for. One is the widespread antibiotic resistance that occurs in U.S. hospitals. And unlike the U.S., gunshots wounds are extremely rare in Cuba.

Another American alumna, Dr. Keresse Gayle, recently completed her residency at Newark Beth Israel. From a medical perspective, she said the biggest transition from Cuba to the U.S. “was from not having enough options to having way too many.”

ELAM students are far from pampered, she recalled. Gayle shared a room with 9 other women, stored her things in a footlocker, and had to share one bathroom between 50 people. Students get a small allowance and have basics provided, such as deodorant, maxi pads, and toothpaste. “We’re used to a certain level of comfort in the U.S.,” she said. “You don’t have running water 24 hours a day. There are blackouts sometimes. It’s a challenging place.”

Dr. Vallentina Cuello Vargas, center, uses a cadaver to explain the vascular system to a first year anatomy class at Escuela Latinoamericana de Medicina (ELAM), the Latin American School of Medicine, on the outskirts of Havana, Cuba, October 1, 2015.

One warm Wednesday afternoon at ELAM, an impromptu teaching session was taking place.

Cassandra Cusack Curbelo, a sixth-year student who grew up in Miami, stopped to talk with three third-year students from South Africa, who are taking refuge from the heat on a shady bench. The South Africans, Noluvuyo Dingele, Diago Jalkie, and Felicity Bulo, were excited to talk to the more experienced student.

“How do you feel now?” asked Jalkie.

“Tired,” said Curbelo.

“No, I mean as a doctor,” Jalkie said, referring to the fact that from their third year on, ELAM students spend much of their time directly treating patients. “How do you feel?”

“Tired,” said Curbelo, smiling. She had come to ELAM with a mix of idealism and adventure. She and her friends referred to it as “revolutionary disco summer camp.” But fairly quickly she was confronted with the responsibilities of being a physician, with ELAM’s focus on hands on training, plus the realities of living in Cuba, which is a far cry from the well-appointed medical schools of the U.S.

She told the eager students about one of her experiences when she was herself a third-year and first starting to see patients. She was working the night shift, and a man had come in pouring sweat, blood pressure dropping, and began going into convulsions. He was going to into shock. Curbelo was hurriedly trying to get an IV into him when the lights went. Fortunately, she said, she had a penlight, which she held between her teeth as she inserted the IV and stabilized the patient. “It was my first experience with guerilla-style Cuban medicine,” she said.

The South Africans listened to the story wide-eyed, imagining themselves in such a situation. “I am investing in a penlight,” said Bulo with conviction.

Yanelis Tefeda Martinez, 16, left, and Katia Lara Najaru, 21, wait out the final days of their pregnancy in a special medical unit for high risk pregnancies at the San Blas Polyclinic, a regional clinic near Cienfuegos, Cuba, October 4, 2015. Both women are married. Martinez, who is 32 weeks pregnant with her first child, has been at the clinic for 25 days. Najaru, who is 36 pregnant with her second child, came to the clinic ten days ago because she was considered underweight. Cuba’s heavy emphasis on prevention — one of the fundamental things taught at ELAM — is epitomized in the country’s approach to prenatal care.

Life for Cuban doctors is said to be hard, with a common joke being that they earn the same as hospital janitors (apparently they make more, with a recent government pay hike putting them around $60 a month). But living in similar circumstances as patients has its benefits. Doctors get to know many of the personal issues, social pressures, and environmental factors that could be affecting a patient’s health.

It becomes a critical part of their preventive approach: identifying risks and paying attention to patients.

A common practice in Cuba is for doctors to make house calls, a practice many in the U.S. only know from television. “I feel like medicine is an art, but in the States it’s just a business,” said Katherine Leger, a fifth-year student who grew up in the Dominican Republic and attended Ithaca College. She believes medicine in the U.S. is too impersonal, hurried, and money-driven. “If you don’t make a patient comfortable, how are you going to find out what they really have?”

From the beginning of their education, students at ELAM start working in neighborhood clinics, or consultorios. Each is staffed by a doctor and a nurse, who are responsible at most for 200 families.

The doctor sees patients regularly to identify risk factors like smoking, alcoholism, and high blood pressure. They then take steps to help alleviate those issues, like getting patients into support groups and showing them how to make lifestyle changes.

“If we had that in the U.S. the health disparities would be gone,” said second-year student Nikolai Cassanova, a 27-year-old Jamaica-born student who grew up in Brooklyn, New York. He was particularly impressed that the doctor in his consultorio knew the names of all of the patients.

“I would love to see how many doctors in the U.S. know their patients by name.”

The emphasis on preventive care appears to have paid off. Researchers found that the 40-year period during which Cuba emphasized primary care coincided with a 40 percent decline in infant mortality (even as GNP had not substantially changed), as well as evidence of a substantial decrease in hospitalizations for cardiovascular disease.

One area of special focus in Cuba is prenatal care — a pregnant woman in Cuba will see a doctor at least ten times. In the U.S., by comparison, more than a fifth of Latino and African American women have had trouble getting prenatal care, according to the US Department of Health and Human Services.

Before the Cuban Revolution, even the act of giving birth was extremely dangerous, remembers 81-year-old Isolina Martínez Bacallao. The patronage system in the pre-revolutionary days meant that it was up to the local mayor to decide who got to go to the hospital and who did not, she said. Women often died in childbirth because they could not see a doctor. “Now the change is like night and day,” said Martinez. “The doctors run after the pregnant women in order to take care of them.”

The focus on Cuba’s primary care today stems from the belief that it is better to prevent than to cure, said Dr. Angeline Cedré Cabrera, a professor at ELAM who specializes in maternal and infant health.

In addition to the normal biomedical training they receive as doctors, students are taught values of humanitarianism, solidarity, and ethics. “Here, students learn to be both a doctor of science and a doctor of conscience,” she said.

Students move between classes on the campus of the Escuela Latinoamericana de Medicina (ELAM), the Latin American School of Medicine, on the outskirts of Havana, Cuba, October 2, 2015. The campus, a former naval academy, includes housing, exercise facilities and a clinic in addition to classrooms. There are 2880 students from 80 countries studying in their introductory, first and second years of medical school on site.

How the Cuban approach to medicine will translate around the world remains to be seen. Thousands of South Africans have come to ELAM in recent years to help fill the country’s large shortage of physicians. The Cuban focus on prevention is a big change from South Africa, said Jalkie, the third-year student. In South Africa, he said, “it’s like we wait for people to get sick and then we try to help them.”

To be sure, the Cuban training has serious limitations. Those who experience the receiving end of Cuban medical care abroad sometimes complain that the doctors lack the technique to treat really sick patients, and are not always up on the latest technology and medications.

And the politics of health in Cuba are, of course, highly sensitive. The Cuban government remains an authoritarian regime; public officials’ offices are adorned with photos of the Fidel and Raul, and sometimes Hugo Chavez, and their aphorisms are prominently displayed on public buildings. And despite Cuba’s much touted medical system, the Ministry of Public Health makes access for reporters and academic researchers difficult.

But the Cuban system has shown the world how a population can be healthier on a dime budget, even though they may not have the resources to deal with advanced or dramatic diseases, said Dr. Daniel Palazuelos, an instructor at Harvard Medical School, who has worked with Cuban doctors in Haiti and Mexico. “They are like really good U.S. family doctors — they will answer perfectly well 95% of the questions facing the majority of the population,” he said.

Students walk through the campus of the Escuela Latinoamericana de Medicina (ELAM), the Latin American School of Medicine, on the outskirts of Havana, Cuba, October 2, 2015. The campus, a former naval academy, includes housing, exercise facilities and a clinic in addition to classrooms.
At the Salvador Allende hospital, in the remarkably non-depressing gerontology ward, Ofelia Favier’s son Julián sits by the door to her room. He has been there for 24 hours, alternating with his daughter and his brother. As is standard practice for all patients, a family member or other caregiver is always there.

“I am here to help her if she wants to get out of bed, go the bathroom, to take some steps,” Julián said. “She is my root, so I take care of her.”

Samantha Moore says she is looking forward to applying the lessons and experiences she’s had in Cuba back in Detroit. “It’s a great feeling to walk down the street and have somebody say, ‘Hey, Doctora, how are you?’”

Sam Loewenberg and Allison Shelley reported from Cuba on a fellowship from the International Reporting Project (IRP). Allison Shelley is a documentary photographer focused on women’s health and justice, and displacement issues. Her website is www.allisonshelley.com.

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