by Don Fitz
The best evidence for the Cuban revolution’s strides in dismantling institutional racism is found in medical data, which show both Black and white Cubans living as long and at least as healthily as the average American. Cuba’s health care system recognizes that social inequities lead to bad health outcomes. “Since poverty creates bad health, the Cuban health system is intertwined with reducing differences in housing, income and education.”
Cuba’s Fight Against Racism in Health Care
by Don Fitz
“Economic indicators suggest that Cuba is a developing country; but, by health care standards, it is a developed country.”
Cuba began revolutionizing health care in 1959 and continues through today. Early efforts to include all Cubans in the medical system were quickly followed by sending Cuban doctors to Africa, Latin America and the Caribbean. Cuba is now expanding its training of doctors who will be able to transform medical systems throughout the world.
At the time of the 1959 revolution, Afro-Cubans comprised about 40% of the population and received vastly inferior health care. Medical services were concentrated in the cities, whose residents had more money and were lighter-skinned.
Though the government quickly outlawed overt racial discrimination, unequal access to services is more subtle. The revolutionary goal of full medical care for all benefited millions of Cubans, but especially those in the countryside. The number of rural hospitals went from 1 in 1958 to 54 in 1984. Unlike the US, today there are virtually no differences in access to medical care by income, ethnicity or rural/urban living.
Cuba has eliminated polio, brought malaria and dengue under control, and lowered child and maternal mortality to the same levels as rich countries. The island nation currently has an HIV prevalence which is one tenth of the US and a life expectancy of 78.0 years, exactly equal to the US.
“Though the government quickly outlawed overt racial discrimination, unequal access to services is more subtle.”
These amazing accomplishments have occurred despite continual efforts by the US to isolate and destroy Cuba economically. Cuba’s economy is a tiny fraction of those in the West. Economic indicators suggest that Cuba is a developing country; but, by health care standards, it is a developed country.
The building block of Cuban medical care is the neighborhood consultorio, which provides basic care to about 150 families. Its primary health care model focuses on at-risk sectors of the population, such as the very young, the very old and those with common medical problems. It heads off medical crises before they occur.
Sanitation, potable water and immunization are essential components of Cuban health care. Since poverty creates bad health, the Cuban health system is intertwined with reducing differences in housing, income and education.
Cuba proves that expensive technology is not necessary for good medical care. Its preventive and primary care system focuses on keeping people well. The more costly fee-for-service system of the US focuses on sickness. This makes Cuban medicine an attractive model for poor countries of Africa and Latin America.
At the same time that Cuba was developing its own medical system it jumped into helping other countries. Cuba’s first health contract involved its sending a medical brigade to Algeria in 1963. Its international health care solidarity is perhaps best known for the doctors and paramedics it sent to the Caribbean Islands and Central America during Hurricanes Mitch and Georges in 1998, as well as the Barrio Adentro (Inside the Community) program which brought 10,000 Cuban doctors to Venezuelan in 2003–04.
Less well known is the medical aid that has gone to Africa. When its soldiers went to Angola in 1975 to support the newly independent government against the CIA-backed forces of UNITA, 700–800 Cuban health professionals went also. Another African initiative included hundreds of doctors sent to Ethiopia about the same time. Medical aid to Mozambique followed in the 1980s. In 1978, 13% of Cuba’s 12,000 doctors were working overseas. The major area to receive aid was sub-Saharan Africa.
Cuba’s medical assistance program was expanding so much that Fidel Castro proposed creating a medical school to bring students from around the world to Havana for their education. In 1999, the Latin American School of Medicine, ELAM (Escuela Latinoamericana de Medicina) opened its doors near Havana. With their educational costs covered by Cuba, students focus on learning how to practice medicine in underserved communities.
“At the time that the US had 550 medical personnel in Haiti, there were 1500 from Cuba.”
Neighboring Haiti has been one of the largest recipients of Cuba medical aid. There are 567 Haitian students in ELAM, which has graduated 550 Haitian doctors. Cuban efforts in Haiti have meant a greater than 50% decrease in infant mortality, maternal mortality and child mortality and an increase in life expectancy from 54 to 61 years of age between 1999 and 2007. Haitian President René Préval said, “You did not have to wait for an earthquake to help us.”
Cuban doctors provided more medical care than any other country during the first three days after the 2010 earthquake. In addition to ELAM graduates already in Haiti, 184 Haitian students from ELAM (along with US ELAM graduates) came to help. At the time that the US had 550 medical personnel in Haiti, there were 1500 from Cuba. They had treated 227,143 patients when the US had treated 871. Within a few weeks, most non-military Americans departed and Haiti was out of the headlines. Just as they were present before the disaster, Cubans stayed afterwards —not only to treat patients but to help build a new health care system.
A New Generation Prepares to Take Over
The thousands of international students who have graduated from ELAM return home with a concept of preventive and community health. Though a large majority of ELAM students are from Latin America, the largest number of countries represented are African. ELAM students come from Angola, Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Congo, Djibouti, Equatorial Guinea, Ethiopia, Gabon, Ghana, Guinea Republic, Guinea-Bissau, Kenya, Lesotho, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Sao Tome Principe, Sarhawi Arab Democratic Republic, Seychelles, Sierra Leone, South Africa, Swaziland, Tanzania, Togo, Tunisia, Uganda, Zambia and Zimbabwe.
During three trips to Havana in 2009 and 2010, I spoke with administrators, professors and students at ELAM. Below is what a few students told me of their experiences.
Amanda Louis explained “Cuba gives people like me an opportunity to study medicine that we would never have anywhere else.” Her father is a taxi driver and her mother is a food vendor, but health problems prevent her from working very much. Amanda is a 26 year old first year student from St. Lucia, a Caribbean island.
After receiving her medical degree, Amanda would like to focus on kidney disorders. She reported that St. Lucia has only 1 oncologist and only 1 ear, nose and throat doctor. Amanda will have to work for the government for five years or else reimburse it for money it fronted for her transportation and incidental funds.
Though St. Lucia physicians think that a degree from Cuba is not as good as other schools, Amanda thinks it is better. “Here, they give us more hands on work with patients at the consultorios and polyclinics.”
Amanda feels that ELAM students will return to St. Lucia with a different perspective. “Cuba shows how people can have simple things and be happy.” She expects that ELAM students will practice a more humble form of medicine than is typical for St. Lucia.
Lorine is an 18 year old premed student from Kisumu in western Kenya. Her family has to pay for her transportation and she can only visit them once during her six years of study. Before graduating, she may get to spend a summer in Ghana.
Lorine speaks Swahili, English and Spanish and has long wanted to be a doctor. In high school everyone took the same subjects; so, she was not able to take more science courses.
Her father, an accountant, and her mother, an occasional printer, were very happy that she would be coming to Cuba. The Kenyan government gives students loans for medical school, which are paid back by deductions from paychecks when they become doctors.
Lorine thinks that ELAM gives a better medical education than she would have gotten in Kenya, where the state university has small classrooms. Professors often cannot see all the students and rarely have multi-media presentations. At ELAM, she can hear what professors are saying, she can ask them questions, and they often call on students in class. The private university in Kenya is good but it is far too expensive for her.
Yell is from Trinidade, a city in the African island country of Sao Tome Principe. He speaks Portuguese and is learning Spanish during his first year at ELAM studying premed. When he was 18, the government told him that, based on his grades and exam scores, he was accepted to medical school. But they could not tell him which school he would be attending and he learned that he would be coming to Cuba shortly before he left home.
At ELAM, he finds it a struggle to master the science courses he is taking during his year of premed. He plans to study a medical specialty, but he is not sure what it will be.
Yell will be required to work for three years in a government job to pay back the cost of his transportation to and from Cuba. Though both state and private medical jobs are available in Sao Tome Principe, Yell feels he could be most useful in a government facility.
Keitumetse Joyce Letsiela
Joyce is an 18 year old first year student from rural Lesotho. After talking with a doctor she knew and seeing an advertisement for ELAM, she realized it might be possible to go to medical school and completed an application during her last year of high school.
Her mother, a teacher, was both happy and scared she would be studying so far away. The Lesotho government loans her money for transportation which Joyce must pay back after graduating. She will go home this year but the government will not cover the expense.
Joyce speaks Sesotho and English but found ELAM hard at the beginning because she is having to learn Spanish. She misses home but is becoming used to Cuba. What she likes best about ELAM is meeting people from all over the world. She sees ELAM students as independent and serious. Cuba was Joyce’s first choice for medical school.
Joyce gives the highest priority to helping people who are now without medical care. Since there is no medical school in Lesotho, the main option is studying in South Africa. But very few go because of the cost.
Dennis lived the first 13 years of his life in Bo, Sierra Leone where he spoke the regional Mende language as well as Krio. When civil war ripped the country apart and his cousins were killed along with people throughout rural areas, his family made its way to neighboring Guinea in 1997. In 2001 they moved to Jonesboro, Georgia where his brother had been living.
Medicine had been in the back of Dennis’ mind for years, but he couldn’t bear the thought of graduating with a huge debt to pay back. In 2006, he heard of ELAM and looked it up on the web. He liked what he read, applied in 2007 and began his studies at ELAM in 2008, when he needed to take Spanish during his first year. At 26 years of age, Dennis is finishing his second year at ELAM.
He would like to take board exams in the US after graduating, but spend most of his time in Sierra Leone. Most communities are underserved in Sierra Leone, which has a national health care system that controls the hospitals even though there is simultaneous private practice.
After ELAM’s third class graduation, students began designing Brigadas Estudiantiles por la Salud (BES, Student Health Brigades). A good example of BES projects is the Yaa Asantewaa Brigade (YAB), whose key organizers include Omavi Bailey and Ketia Brown. YAB will carry out the “African Medical Corp — Ghana Project.” It was designed by the Organization of African Doctors (OAD), a group of African and African-American medical students founded in 2009 on the ELAM campus.
Currently, the “brain drain” of African doctors getting jobs in Europe or the US leaves Ghana with just 1 doctor for every 45,000 residents. OAD aims to strengthen the expectation that African (and all other) medical students from ELAM return home to serve impoverished communities.
The 2010 phase of the Ghana Proposal plans to begin with ELAM students traveling to Ghana to meet with Cuban-trained doctors already there. In the communities they visit, ELAM students intend to …
1. Perform an access assessment of available sources of health care;
2. Perform physical exams and learn Ghanaian traditional medicine; and,
3. Hold community meetings to discover what type of health care Ghana residents would like to receive.
If successful in 2010, the YAB hopes to create an internship so that sixth year ELAM students can complete their medical training in Ghana. It is no accident that the YAB aims to look at Ghanaian access to services, beliefs about health care, and desires for change rather than jumping in to provide pre-determined services that may or may not fit the life of an African village. Training at ELAM places heavy emphasis on the evolving social context of medicine, a model that applies particularly well to tight-knit communities.
“Training at ELAM places heavy emphasis on the evolving social context of medicine.”
Even though natural medicine is often ridiculed in the West, it is the major type of prevention and treatment for African people. Using ELAM’s methods of community health care, YAB will build on African traditions.
Ketia Brown sees her experiences at ELAM and in Ghana as critical for her medical education. After getting her degree, she would like to continue her work with high school students and practice natural and spiritual medicine. She would like to open a wellness clinic emphasizing the changes people need to make in their lives.
“ELAM is the revolution realized,” Ketia told me. “It is a reflection of what can be done with medicine.” She strongly believes that “We must attempt to have a revolutionary project in a capitalist world.” For her, ELAM is such a project. Its new medical consciousness is a part of the struggle to redesign global health.
Don Fitz produces Green Time TV in St. Louis, Missouri and is editor of Synthesis/Regeneration: A Magazine of Green Social Thought. He can be reached at [email protected]