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Cuba: Reversing the medical `brain drain’ – the many faces of ELAM

ELAM students.

By Don Fitz, Havana

November 7, 2010 – Links International Journal of Socialist Renewal -- Cuba is doing more than any other country in the world to reverse the “brain drain” of doctors abandoning impoverished areas. A physician who leaves Sierra Leone for South Africa can earn 20 times as much. Higher pay in English-speaking countries lures medical graduates from India (10.6% of doctors), Pakistan (11.7%), Sri Lanka (27.5%), and Jamaica (41.7%). Only 50 of 600 doctors trained in Zambia remained there after independence. There are more Ethiopian doctors in Chicago than in Ethiopia.[1]

The Cuban alternative is the 11year old Escuela Latinoamericana de Medicina (ELAM, Latin American School of Medicine). With their educational costs covered by the Cuban government, students focus on returning as doctors to under-served communities in their countries.

The more than 20,000 medical students in Cuba receive much, much more than a free education — they are participating in a project to build a new model of medicine for the world’s poor. Students are well aware that they represent 1 of 100 countries, each of which has a unique relationship to the yoke of imperialism.

ELAM students learn the Cuban model of medicina general integral (MGI). A literal translation is “general integral medicine”, but a conceptual translation is “public health and primary care”.  MGI emphasises the wholeness of biology, sociology, economics and politics in establishing the context of health and disease. In Cuba, it is impossible to separate efforts to create a new medical awareness from the struggle to improve health care. This article describes how ELAM affects the medical consciousness of 13 of its students.

Exa Gonzalez

Of all the ELAM students I spoke with, Exa (25 years old) is the only one I met in the air over the Gulf of Mexico. Exa was sitting next to me on the plane as I told her of my hassles getting to Cuba to visit my daughter at ELAM. She let me know, “I’m a sixth-year students there.”

Exa is from the town of La Paz in Baja California, Mexico. Though her mother speaks Spanish and English, Exa speaks Spanish and French, as does her father, who teaches social sciences. Both of her parents have been active in the Mexican Partido de Trabajo, (PT, Workers Party). In 2001, her father took Exa and her mother on two trips to Cuba with the group Amistad Entre Cuba y México (Friendship between Cuba and Mexico).

In high school, Exa was interested in art and took courses in film. But she had been interested in helping people since she was a child. She also knew that Cuba had sent doctors to Central America to aid in hurricane relief.

On her second trip to Cuba, Fidel Castro spoke to her delegation and described ELAM. That changed her life. She decided that the best way to fulfill her childhood goal would be to become a doctor. When she entered ELAM at 19, she had to spend several months studying biology and chemistry in pre-med.

Like most students from Latin America and Africa, Exa began medical school right after high school. She described her first year at ELAM as her “sad year”, when she found herself in a culture very different from Mexico and felt so alone that she wanted to leave. But her mother continuously encouraged her and she decided to stay. When we spoke, Exa was completing her final year at ELAM.

Anmnol Colindres

Anmnol (22) was waiting outside the Consultorio Médico No. 17-2 in Havana with ELAM students from the US, Chile, Brazil and Venezuela, when he told me of life in Honduras. His entire family was affected by the June 28, 2009, coup against President Zelaya, which destroyed jobs throughout the country.

Anmnol’s father had been a forestry worker. But with the economic devastation following the coup, the market for lumber crashed and he lost his position. He is working for lower pay as an agricultural director at a farm.

Anmnol’s 20-year-old sister was one semester from completing school but had to drop out when grants disappeared after the coup. She hopes to be able to re-enter school if the economy stabilises. Anmnol’s 17-year-old brother planned to study engineering in Venezuela; but, those hopes were dashed as the new Honduran regime showed its hostility to the government of Hugo Chavez.

Anmnol had long wanted to be a doctor, but the expense was out of the question for his family. After studying for a year and a half to be a teacher, he heard of ELAM. According to Anmnol, Honduran students are selected for ELAM by a mixed system of exam scores, lottery selection and recommendations. The socialist and revolutionary parties are so small that they only recommend a handful of students.

His high exam scores gained Anmnol approval to attend ELAM in 2006. But he did not have the money to fly to Cuba; so, he had to work for a year in a company making small boxes.

Under Zelaya, Cuban-trained doctors could work in Honduras. Graduates from ELAM had begun a clinic to offer free medical care, but they were shut down after the coup and thugs attacked the medical students and doctors.

Honduran doctors tend not to want to work in areas that have the greatest need, leading to a bad distribution of medical care. The Honduran doctors’ peak body Colegio Médico (analogous to the American Medical Association) would like to privatise government-based medical care and supports the coup. There is a real danger that it will not recognise doctors trained at ELAM. It may be necessary for students graduating from ELAM to form their own medical association when they return to Honduras.

One of the largest shortcomings of medical practice in Honduras is too few specialists. After graduating from ELAM Anmnol would like to get a grant to study cardiology in Spain before returning to poor areas of Honduras.

Ivan Angulo Torres

In 2002, Ivan (28) was studying technical administration of hotels in Lima, Peru. He says that it would have been impossible—a crazy idea—for him to even think of studying medicine. Only 100 students per year are admitted to medical school in Peru and even with his father being director of a secondary school, his family could not have afforded it.

But his father is also a member of the Partido Socialista Revolucionario (PSR, Socialist Revolutionary Party), one of the left parties that can nominate young people to attend ELAM. Ivan became the first PSR-recommended student at ELAM.

When he arrived in Havana, Ivan began to meet students from all over Peru, each with different backgrounds and experiences. But adjusting to ELAM was a challenge. He found Cuban Spanish different to Peruvian Spanish and it was six months before Ivan felt he could understand Havana speakers.

Ivan just completed ELAM’s six-year program. New doctors in Peru must work for a year in rural areas where there is a shortage of all services, including medical care. There is also a shortage of medical specialists in Peru and Ivan would like to study orthopedics. He hopes to practice in either in Peru’s jungles or in the province where his family lives. He does not see Peru’s government as having particularly good or bad relations with Cuba and expects his degree to be treated as if it were from any other country.

Ivan Gomes de Assis

Ivan Gomes (23) is a second-year student at ELAM from Salvador City, in the state of Bahía, Brazil. After finishing his studies, he taught mathematics and statistics in high school, largely because he felt that maths could show people how to understand the corruption that is rife in the government.

His father is a lawyer and Ivan’s family participated in progressive activities such as assisting people in receiving medical care despite their inability to pay. When he was 20, he learned of ELAM through the internet and was impressed that the school did not focus on teaching students to become wealthy doctors. He decided that practicing medicine would be the best way to work with Brazil’s poor.

Brazilians are typically admitted to ELAM through left parties and Ivan had no history with the left. But he was interviewed with Cuban embassy staff, who endorsed his admission. When he finishes medical school, he would like to study orthopedics and practice in rural areas of Brazil where there are few specialists.

Ivan finds school at ELAM difficult, partly because the US blockade makes it hard to access the internet. He feels ELAM is a great school, but prefers to study independently and does not like making a lower grade if he skips classes. He also is not used to working in groups, as much as ELAM requires.

Ivan is concerned about the way doctors fit into Brazil’s corruption and gross inequality. The Brazilian Colegio Médico (Medical Association) is independent of the Brazil’s Workers Party (PT) government and does not want doctors trained in Cuba to receive certification or practice medicine in Brazil. Ivan expects a continuing political struggle over the role of Cuban training but is confident that he will find a way to practice medicine with the poor.

Walter Titz

Walter (23) is a second-year student from São Paulo, Brazil. He dreams of creating Cuban-type community medicine in Brazil. Ever since he was in high school, Walter thought that a career in medicine would be important. He went to the Catholic University of Santos and studied journalism for two years.

ELAM was still in the back of his mind and he realised that his activism with the Brazilian Communist Party could be important in admission, since progressive parties in Brazil recommend students. Walter was also active in student groups working in solidarity with the Movimento dos Trabalhadores Rurais Sem Terra (MST, Landless Workers’ Movement).

Walter’s father is a newspaper editor who had been active in the Workers Party; but, due to disappointment with the Lula government, is moving closer to the Brazilian Communist Party. His mother, who works in the legal system, was not happy with Walter leaving Brazil for school. Yet she was always very supportive of his work and is now glad for him to be at ELAM.

Upon arriving at ELAM, Walter found the school system to be very different from Brazil’s. There is also an enormous difference between political environments at ELAM and Brazil. At ELAM, he works with students who envision how they would like to change their own countries. They see how Cubans can survive with very little by having the necessities of life.

Walter reports that Latinos at ELAM come from realities that differ strikingly from both Cuba and the US. Many arrive thinking that there is no suffering in the US. But they learn otherwise when they talk with US students and are inspired to learn of their opposition to US government policy.

When he gets his degree, Walter would like return to his community to practice general medicine for a few years and then study psychiatry. But he says that the Brazilian Colegio Médico is rich, very elitist, and does not recognise degrees from Cuba. For Walter, building a new medical system in Brazil is a necessity for practicing public health medicine.

Amanda Louis

Amanda (26) explains that, “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 first year student from St. Lucia, a Caribbean island with 165,000 inhabitants.

She graduated from high school in 2000, went to Sir Arthur Louis Community College and then taught integrated sciences and chemistry. When Amanda learned that the maximum age for admission to ELAM was 25, she applied right away. But she was not accepted the first time and had to apply again.

Though she was a youth organiser in St. Lucia, political and social work did not count toward admission. Her school grades were the most important factor. She is in the first class from St. Lucia to go to ELAM in Havana — previous classes have gone to other cities in Cuba.

After receiving her medical degree, Amanda would like to focus on kidney disorders. She reported that there are enough general practitioners in St. Lucia, but only one oncologist and only one ear, nose and throat doctor.

Students from St. Lucia will have no trouble with their medical degree being recognised. Amanda will have to work for the government for five years to pay for her transport and incidental costs.

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 [neighbourhood medical offices] and polyclinics”, she explains. Amanda feels that after being at ELAM students will return to St. Lucia with a different way of looking at people. “Cuba shows how people can have simple things and be happy.”

Cassandra Cusack Curbelo

Cassandra (31) is the only student from the United States at ELAM who applied directly to the Cuban Interests Section in Washington DC rather than the Interreligious Foundation for Community Organisation (IFCO), which typically screens US applicants. She is one of the few Cuban Americans at ELAM.

Cassandra is from Hialeah, near Miami, Florida. Her mother was born in Cuba and came to the US with Cassandra’s grandparents shortly after the 1959 revolution due to misinformation being spread by the US. Her grandparents soon felt that they had been tricked. They are still strong supporters of the revolution.

Cassandra’s grandmother only had third-grade schooling in Cuba and her mother had to struggle hard to get her education. They would both like to visit Cuba, which puts them in conflict with most Cuban Americans. Cassandra feels that the dictatorship which existed before the Cuban revolution now exists in Miami. People could lose their jobs in Miami if they speak in favour of the revolution. She finds that young people are far less hostile towards the Cuban government, despite the flood of horror stories they hear.

Cassandra decided to go to medical school some time between her trips to Cuba in 1996 and 2006. In school she studied film and then social work. Before coming to school in Cuba, she was actively involved in anti-war coalitions, immigrant rights, animal rights and anti-World Trade Organization efforts.

She applied for admission to ELAM when she approached the age limit of 30 for US students. Cassandra is finishing her first year. Though she had the option of going directly into medical school, she decided to take a year of pre-med, since the last time she had taken science courses was 1994–97.

Cassandra’s work with ELAM’s student government helped add a course on popular education, with topics such as Chinese medicine, as an elective for the second year. The student government sponsors many activities, such as supporting the Brazil’s Landless Workers’ Movement.

Cassandra feels a strong obligation to return to the US to practice a Cuban model of medicine which emphasises family medicine and gynecology. She finds it inspiring to meet people with the same idea of health care and wants to see more using the model.

When she first came to Cuba after high school, she saw how people do not need a lot of material possessions, but need a sense of belonging and safety, which they can find on the island. Living with thousands of people from the Americas has been the most tremendous experience of her life. “It doesn’t feel like we are from two continents but more like we are one people who share a common history and a common struggle. ELAM opens our eyes to the struggles we share.”

Ketia Brown

When I met Ketia (30) she was pouring energy into the Ghana Project. The medical brain drain is so bad in Ghana that the country is left with just one doctor for every 45,000 residents. The Ghana Project is one of the many efforts designated as Brigadas Estudiantiles por la Salud (BES, Student Health Brigades) that ELAM students design and carry out themselves during summer vacation. It builds on the emphasis on traditional forms of medicine taught at ELAM and widely practiced in Africa.

The 2010 phase of the Ghana Project plans to begin with ELAM students travelling 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 the sources of health care that residents already have;

2. create health groups, who do physical exams and learn of Ghanaian traditional medicine; and,

3. hold community meetings to strengthen ties with Ghana residents by finding out their desires for health care.

If successful in 2010, the Ghana Project hopes to create an internship so that sixth-year ELAM students can complete their medical training in Ghana.

A student from California, Ketia first heard of ELAM in 2003. She wanted to go to medical school, but not in the US because her first interest was in public health. ELAM was a perfect match.

She had been teaching in high school. Her mother was also a teacher and her father coordinated the work of school janitors in his district. After getting her medical degree, Ketia would like to continue to work with high school students and practice natural and spiritual medicine. She would love to open a wellness clinic emphasising the changes people need to make in their lives.

“ELAM is the revolution realised”, 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.” She sees ELAM as such a project.

Dennis Pratt

Dennis (26) 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 the rural areas, his family made its way to neighbouring 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. Dennis is currently 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 under-served in Sierra Leone, which has a national health care system that controls the hospitals even though there is simultaneous private practice.

Sierra Leone has a good relationship with Cuba and Dennis feels he will have no trouble practicing medicine there. He would like to do a combination of public health education, pediatrics and internal medicine.

Lorine Auma

Lorine (18) is a pre-med student from Kisumu in western Kenya. Her family has to pay for her transport and she can only visit them once during her six years of study. Before graduating, she may get to spend a summer in Ghana with the Organisation of African Doctors.

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. After reading an advertisement about ELAM scholarships, she applied to the Kenyan Education Ministry. Kenyan students are selected for study in ELAM by the government without involvement of political parties. Lorine received an interview and was accepted.

Her father, an accountant, and her mother, an occasional printer, were very happy that she would be going to Cuba. The Kenyan government gives students loans for medical school, which are paid back by deductions from their pay 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 they rarely have multimedia 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.

When she graduates, Lorine would like to specialise in orthopedics and psychiatry. She likes to talk with people about their problems and feels that a high number of Kenyans suffer accidents and need orthopedic treatment.

Lorine likes the medical education at ELAM but finds it different from what she expected. She is impressed with studying the history and sociology of medicine and the variety of educational opportunities, such as the possibility of going to Ghana. She sees living in Cuba as difficult and thinks ELAM teaches students about life.

Yell Eric

Yell (18) is from Trinidade, a city in the African island country of São Tome Principe. He speaks Portuguese and is learning Spanish during his pre-med year at ELAM. Yell finished high school when he was 17 years old but did not immediately receive a grant to continue his education and so began working at an information technology store.

When he was 18, the government told him that, based on his grades and exam scores, he was accepted for medical school, but they could not tell him where. Shortly before leaving home he learned that he would be going to Cuba.

At ELAM, he finds it a struggle to master the pre-med science courses. Since there are plenty of general practitioners in São Tome Principe, he plans to study a medical specialty; but he is not sure what it will be.

Yell reports that he will be required to work for three years in a government job to pay back the cost of his transport to and from Cuba. Though both state and private medical jobs are available in São Tome Principe, Yell feels he could provide the most help in a government facility.

Keitumetse Joyce Letsiela

Joyce (18) is a first-year student from rural Lesotho in southern Africa. After talking with a doctor she knew and seeing an advertisement for ELAM, she realised it might be possible to go to medical school and completed an application during her last year of high school. She was accepted due to her good academic performance.

Her mother, a teacher, was both happy and scared she would be studying so far away. The Lesotho government loans her money for transport, 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 had to learn Spanish. She misses home and is becoming used to Cuba after getting to know Lesotho students and making other friends.

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. Since there is no medical school in Lesotho, the main option is studying in South Africa. But very few go because of the cost.

Joyce says that there are only two doctors in the public hospital near her home. She would like to help people who are now without medical care. Working with people is more important to her than making a lot of money. She would like to choose a specialty but has not made a decision yet on what it will be.

Jonalisa Livi Tapumanaia

Jonalisa (22) may be among the first students to see her homeland Tuvalu go under water due to global warming. Students from her delegation are thrilled that ELAM will make it possible for each of the 10 major islands that make up her Pacific nation to have its own doctor. Now, the very few doctors in Tuvalu are at the hospital on the major island. Patients’ conditions worsen or they die as a result of having to travel by ferry for treatment.

Jonalisa graduated with a degree in marine science from the University of the South Pacific in Fiji. Since she has had plenty of biology, chemistry and physics courses, her only concern in pre-med is mastering Spanish.

Jonalisa heard about ELAM from the Tuvalu Ministry of Health. The Tuvalu government recognises medical degrees from Cuba and pays for her transport; but, it will only cover one trip home during her six years of study. Her father, who runs a petrol station and food shop, and her mother, a magistrate in the island court, do not make enough for additional plane fares. Jonalisa will spend most of her summers in Cuba.

She is still adjusting because Cuba is hotter and life is so different. She had to get used to people kissing her on the cheek instead of shaking hands. Tuvaluan women do not expose themselves as much by wearing sleeveless shirts or miniskirts. Jonalisa is used to living in a thatched roof home, going to school barefoot, and having parents make decisions (or trying to) concerning marriage.

Like most others in Tuvalu, Jonalisa is a Methodist in the Ekalesia Kelisiano Tuvalu church. She’s heard that the old people used to worship the trees, the moon and the stars, but that is not a part of her life.

Western culture has profoundly changed life in her island nation. This includes three Cuban-trained doctors. But the largest change is the rising sea level from global warming. In 2008 a big wave hit one island and most people’s belongings were swept away. The storms are getting worse. The tide is higher than it used to be. Much of the land is being eroded and one of the smaller islands no longer exists. Rising sea levels have made an air strip almost unusable. People who are the most worried about climate change are already talking about migrating to other places like Fiji or New Zealand.

The ELAM experience

Several themes run through these 13 stories. The one they all have in common is a desire to provide medical care to people who might not otherwise receive it except for Cuban-trained doctors. Absent is any discussion of becoming wealthy by practicing medicine, a highly unlikely outcome for an ELAM graduate.

Many students had decided early in their lives that they wanted to be doctors and then discovered that ELAM matched their needs. Others did not even consider the possibility of becoming a doctor until they heard of ELAM.

The youngest students I spoke with were 18 years old and the oldest was 31. The African students were the youngest and the Americans the oldest. This is consistent with an expectation in the US that students complete undergraduate school before going to medical school, while students from Latin America and Africa often go directly from high school to medical school.

All countries where students came from have under-served communities, very often in rural areas. Cuba responds to this by requiring medical school graduates to work for a year in one of the provinces. ELAM students anticipate practicing medicine in areas of their countries with the greatest need.

Methods which countries use to select students for ELAM vary enormously. In some countries political affiliations and recommendations are critical. In others, it is purely a basis of grades.

While most countries are eager to have Cuban graduates, some are hostile. The medical association in Brazil will not recognise a degree from ELAM. While the US does not hinder ELAM students, it does nothing to help them and makes travel difficult. Honduran students trained in Cuba have been attacked.

One of the most interesting questions is whether students plan to specialise. The Cuban medical model of Medicina General Integral emphasises family practice as the basis for a holistic medicine. The excellent level of care which Cubans receive is attributed to the high number of family doctors in neighbourhood consultorios.

Yet, a majority of students had either picked out or thought about a specialty. This may appear to be a contradiction between the Cuban school preaching general medicine and its students practicing specialties. In fact, it is not. In many of the countries students come from there insufficient specialists or too few specialists and general practitioners.

Most students would be unable to attend medical school without ELAM. This indicates that the shortage of doctors in impoverished areas has nothing to do with a shortage of young people willing and capable of going to medical school in order to serve those communities. The shortage is due to the unwillingness of governments, especially in the rich countries, to provide adequate medical training.

My discussions were designed to capture a wide range of experiences and were not structured to be representative of students at ELAM. However, the breakdown of seven discussions with women and six with men is close to the gender breakdown of ELAM students in Havana, which includes 4807 women and 4868 men.

There are 3406 pre-med, first-year and second-year students living at the main ELAM campus near Havana, 6169 third- through sixth-year students in the Havana area, for a total of 9675 non-Cuban students at ELAM. Cuban and non-Cuban students at campuses in other provinces number 11,343, for total of 21,018 medical students enrolled in Cuba in April 2010.

The table below shows the number of Havana-area students from each of 100 countries, grouped by geographic area. Though Africa has the highest number of countries (36) represented at ELAM, the 7777 Latin American students from 15 countries comprise more than 80% of students. Africa is next with 9.1% of students, followed by the Caribbean with 7.3%. A much smaller portion of the student body is made up of those from Asia (0.7%), Europe (0.1%), the Middle East (0.5%), Canada/US (1.2%) and the Pacific Islands (0.7%).

Enrollment at ELAM in April 2010 by geographical area

(Number of students in parentheses. Total = 9675)

Latin America (7777):

 

Africa (877):

 

North America (118):

1. Argentina (385)

 

1. Angola (139)

 

1. Canada (1)

2. Belice (95)

 

2. Benin (13)

 

2. United States (117)

3. Bolivia (524)

 

3. Burkina Faso (1)

 

 

4. Brazil (511)

 

4. Cameroon (1)

 

Asia (72):

5. Chile (338)

 

5. Cape Verde (3)

 

1. Buthan (5)

6. Columbia (385)

 

6. Chad (1)

 

2. Cambodia (3)

7. Costa Rica (208)

 

7. Congo (7)

 

3. East Timor (26)

8. Dominican Republic (297)

 

8. Djibouti (42)

 

4. India (5)

9. Ecuador (497)

 

9. Equatorial Guinea (2)

 

5. Korea (1)

10. El Salvador (416)

 

10. Ethiopia (8)

 

6. Laos (1)

11. Guatemala (371)

 

11. Gabon (6)

 

7. Malasia (21)

12. Guyana (163)

 

12. Ghana (23)

 

8. Mongolia (1)

13. Honduras (395)

 

13. Guinea Republic (38)

 

9. Viet Nam (9)

14. Mexico (547)

 

14. Guinea-Bissau (4)

 

 

15. Nicaragua (415)

 

15. Kenya (13)

 

Pacific Islands (64):

16. Panama (461)

 

16. Lesotho (11)

 

1. Kiribati (12)

17. Paraguay (507)

 

17. Madagascar (3)

 

2. Nauru (8)

18. Peru (411)

 

18. Malawi (7)

 

3. Solomon Islands (24)

19. Puerto Rico (3)

 

19. Mali (7)

 

4. Tonga (2)

20. Surinam (12)

 

20. Mauritania (2)

 

5. Tuvalu (10)

21. Uruguay (327)

 

21. Mozambique (8)

 

6. Vanuatu (8)

22. Venezuela (509)

 

22. Namibia (17)

 

 

 

 

23. Niger (5)

 

Middle East (50):

Caribbean (709):

 

24. Nigeria (6)

 

1. Israel (1)

1. Antigua and Barbuda (35)

 

25. São Tome Principe (13)

 

2. Jordan (3)

2. Bahamas (17)

 

26. SADR (109)

 

3. Lebanon (7)

3. Barbados (13)

 

27. Seychelles (1)

 

4. Oman (1)

4. Bermuda (1)

 

28. Sierra Leone (5)

 

5. Palestine (25)

5. Dominica (16)

 

29. South Africa (346)

 

6. Syria (1)

6. Grenada (11)

 

30. Swaziland (1)

 

7. Yemen (12)

7. Haiti (448)

 

31. Tanzania (21)

 

 

8. Jamaica (122)

 

32. Togo (1)

 

Europe (7):

9. Saint Kitts and Nevis (7)

 

33. Tunisia (1)

 

1. Bulgaria (1)

10. Saint Lucia (24)

 

34. Uganda (3)

 

2. Cyprus (1)

11. San Vicente (12)

 

35. Zambia (3)

 

3. Germany (1)

12. Trinidad and Tobago (3)

 

36. Zimbabwe (6)

 

4. Moldova (3)

 

 

 

 

5. Portugal (1)

Other (1):

 

SADR = Sarhawi Arab

 

 

1. San Cristobal (1)

 

       Democratic Republic

 

 

 

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