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How Cuba mobilises to defeat public health emergencies

Medical students in Cuba.

[Read more about Cuba's health-care system HERE.]

By Don Fitz

February 8, 2012 -- Submitted to Links International Journal of Socialist Renewal by the author, having first appeared at BlackAgendaReport.com -- “I’m on pesquizaje”, my daughter Rebecca told me. “All of the third, fourth and fifth year medical students at Allende have our classes suspended. We are going door-to-door looking for symptoms of dengue fever and checking for standing water.”[1]

As a fourth year medical student at Cuba’s ELAM (Escuela Latinoamericana de Medicina, Latin American School of Medicine in Havana), she is assigned to Salvadore Allende Hospital in Havana. It handles most of the city’s dengue cases. Although she has done health canvassing before, this is the first time she has had classes cancelled to do it. It is very unusual for an outbreak of dengue fever, a mosquito-borne illness, to occur this late in the season. She remembers most outbreaks happening in autumn, being over before December, and certainly not going into January–February.

Groups of medical students are assigned to a block with about 135 homes, most having two to seven residents. They try to check on every home daily, but don’t see many working families until the weekend. The first sign of dengue they look for is fever. The medical students also check for joint pain, muscle pain, abdominal pain, headache behind the eye sockets, purple splotches and bleeding from the gums.

What is unique about Cuban medical school is the way ELAM students are trained to make in-home evaluations that include potentially damaging lifestyles — such as having uncovered standing water where mosquitoes can breed.

Dengue is more common in Cuba’s cities of Havana, Santiago and Guantánamo than in rural areas. Irregular supply of water to the cities means that residents store it in cisterns. Cisterns with broken or absent lids and puddles from leaky ones are prime breeding sites for the Aedes aegypti mosquito, the primary vector (carrier) of dengue.[2]

DF and DHF

There is a significant difference between dengue fever (DF) and dengue hemorrhagic fever (DHF). DF is a virus which usually lasts a week or more and is uncomfortable but not deadly.[3] DF has four varieties (serotypes). If someone who has had one type of dengue contracts a different serotype of the disease, the person is at risk for DHF. Early DHF symptoms are similar to DF but the person can become irritable, restless and sweaty, and go into a shock-like state and die.[4]

DF can be so mild that many people never know that they had it and that they are at risk for the far more serious DHF. This is why the Cuban public health model of reaching out to people is important in preventing a deadly epidemic. There are no known vaccines or cures for DF or DHF — the only treatment is treating the symptoms. With DHF, this includes dealing with dehydration and often blood transfusions in intensive care.[3, 4]

Each year, there are more than 100 million cases of DF, largely in sub-Saharan Africa, the Caribbean, Latin America, south-west Asia and parts of Indonesia and Australia.[4] Between 250,000 and 500,000 cases of DHF occur annually and 24,000 result in death.[5]

Dengue was not identified in Cuba until 1943. Epidemics hit the island in 1977-1978 (553,132 cases), 1981 (334,203 cases of DF with 10,312 cases of DHF), 1997 (17,114 DF cases with 205 DHF cases) and 2001–2002 in Havana (almost 12,000 DF cases).[2]

Climate, mosquitoes and health

Climate change could make conditions more comfortable for mosquitoes that are vectors for dengue. During the last half a century, Cuban health officials have calculated a 30-fold increase of Aedes aegypti mosquito.[5] Since the 1950s, the average temperature in Cuba has increased between 0.4 and 0.6°C. Health officials are well aware that “…increasing variability may have a greater impact on health than gradual changes in mean temperature...”[2]

The 1990s were a very hard time for Cuba. Known as the “special period”, this was when collapse of the Soviet Union caused oil to dry up, the country’s production (including food) to plummet and illnesses to increase.[6] It was also a time when there was a climb “in extreme weather events, such as droughts, and … stronger hurricane seasons.”[2] Increases in climate variability meant winters have become warmer and rainier.

Conner Gorry, senior editor of MEDICC Review in Havana, reports that “My friends and neighbours tell me they can't remember ever having to fumigate or think about dengue in the winter.”[1] Another consequence of a more ups and downs in the climate is “… insults to the upper respiratory tract, increasing viral transmission, particularly among infants and children.” [2]

Mobilisation

Medical students in Havana come from 100 countries about the globe.[7] No matter what accent they have when speaking Spanish, they don’t have trouble getting into homes. In Havana, there is nothing unusual about a foreigner in a bata (white medical jacket) walking through homes, poking into yards and peering on roofs to see if there is standing water.

Always in need of extra cash, an enormous number of Cubans have some sort of less than totally legal activity going on in their homes (such as a nail parlor in the living room). But it does not occur to either the resident or the medical student that the inspection would be for anything other than public health reasons.

Cuba has experienced more than half a century of mobilisation campaigns like current efforts to control dengue. Soon after the 1959 revolution Cuba mobilised the literacy campaign which sent teachers and students to every corner of the island to teach citizens to read and write. Every hurricane season, the neighbourhood Committees for Defence of the Revolution (CDRs) are prepared to move the elderly, sick and mentally ill to higher ground if an evacuation is necessary. Campaigns against diseases like polio and dengue have made Cubans used to the government bringing public health efforts into their homes.[6]

Beginning in the 1960s, the CDRs worked with thousands of trainers, who, in turn trained 50,000 more Cubans to teach the importance of polio vaccinations. As a result, Cuba has not had a polio death since 1974. CDRs actively encourage pregnant women to regularly visit their neighbourhood doctor’s office and patrol the community to enforce the ban on growing succulents that attract mosquitoes.[6]

Cuba investigates

Cuba places a very high value on researching preventive medicine. MEDICC Review (Medical Education Cooperation with Cuba) is a peer-reviewed open access journal which works to enhance cooperation among “global health communities aimed at better health outcomes”.[8]

Cuban researchers have played a key role in developing the widely accepted model that DHF is determined by “the interaction between the host, the virus and the vector in an epidemiological and ecosystem setting”.[9] In Cuba, this translates to (a) the most important risk factor for getting DHF is having a second infection of DF which is a different strain; (b) being infected a second time in a specific order of DF strains places children at a higher risk for DHF than adults; (c) white Cubans are at a higher risk for DHF than Afro-Cubans; but, (d) those who already have sickl- cell anemia, bronchial asthma or diabetes are at higher risk.

Cuban researchers openly discuss weaknesses in their health-care system. One study indicated that there could be a “marked under-counting” of dengue due to missing a large number of cases. This finding occurred even though the study examined data during a time of “maximum alert”, suggesting that undercounting could be very widespread. [10]

A typical finding is that the community must feel that the dengue control program belongs to them if it is to be successful and sustainable.[11] Some of the best work I’ve seen on the role of public health takes an honest look at effects of “the absence of active involvement of the community” in dengue control. The authors felt that Cuba’s outdoor spraying of adult mosquitoes “is of questionable efficacy”. Instead, they focused on “the bad conditions or absence of covers on water storage containers” in the city of Guantánamo.[5]

The study had a control group of 16 neighbourhoods that carried out the usual practices of home inspections, measuring the degree of mosquito infestation and larviciding (applying chemicals to kill mosquitoes during the larval stage of growth). In contrast, their intervention group did everything that the control group did, but added intense involvement by local activists. “Formal and informal leaders” of the community worked with health professionals “to mobilize the population and change behavior”, such as covering water containers correctly, repairing broken water pipelines and not removing larvicide.

Measuring the number of mosquitoes in the two groups revealed dramatic results. The authors concluded that “community-based environmental management integrated in a routine dengue prevention and control program can reduce level of Aedes infestation by 50–75%”.[5]

Rebecca told me that when medical students inspect the homes of Havana residents, they find that the overwhelming majority comply with public health policy. But some do not. A few cannot afford the proper lid for cisterns. Some have mental problems that limit their ability to cooperate. And a very few just don’t give a damn, even if they could be raising mosquitoes that infect their neighbours. Cuban-style public health research is critical in identifying barriers that communities need to overcome if they are to protect themselves from disease.

Imagine

Do you remember Hurricane Katrina and the number of New Orleans residents who languished while the state and national governments did nothing meaningful? Do you remember the photos of the 1000 Cuban doctors in batas ready and waiting to come to New Orleans, just like they went to Nicaragua, Honduras, Haiti, Venezuela, Sri Lanka, Pakistan and dozens of other countries hit by disasters? Do you remember the US government, that would increase the suffering of its own people rather than accept help from Cuba?

It may be difficult, but imagine that, at the height of the Katrina disaster, the US closed medical schools in Gulf coast states and coordinated the work of attending to medical and public health needs of the poorest in New Orleans. It may contradict your life-time of experiences, but imagine that medical schools across the US sent their students to survey living conditions of poor black, brown, red, yellow and white Americans to determine what causes elevated mortality rates and then announced that no one would return to medical school until they were part of a national plan to resolve health-care needs.

It may bend your mind to the border of hallucination, but imagine that health-care professionals throughout the world demanded that people of the global South be spared the mosquito infestations, rising waters, droughts, floods, species extinctions and all other manifestations of climate change brought on by the gluttonous overproduction of the 1% in the global North. Imagine new medical care based on help going to those who need help the most, rather than obscene wealth going to those who invest in the sickness industry.

Imagine citizens welcoming health professionals to walk through their homes because they do not fear being reported to the police and because they have seen mobilisation after mobilisation improve their lives rather than ensnare them in empty promises. Imagine a new society.

[Don Fitz (fitzdon@aol.com) is editor of Synthesis/Regeneration: A Magazine of Green Social Thought. He is co-coordinator of the Green Party of St. Louis and produces Green Time in conjunction with KNLC-TV.]

Notes

1. My Spanish-English dictionary does not include “pesquizaje” but Conner Gorry, senior editor of MEDICC Review, says that Cuban health professionals use “pesquizaje activa” to mean “active screening” when they go door-to-door. Email message from Conner Gorry January 24, 2012.

2. Lázaro, P., Pérez, Antonio, Rivero, A., León, N., Díaz, M. & Pérez, Alina (Spring, 2008). “Assessment of human health vulnerability to climate variability and change in Cuba”, MEDICC Review, 10 (2), 1–9.

3. Dengue fever, A.D.A.M. Medical Encyclopedia. PubMed Health. Retrieved on February 6, 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002350/.

4. Dengue hemorrhagic fever, A.D.A.M. Medical Encyclopedia. PubMed Health. Retrieved on February 6, 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002349/.

5. Vanlerberghe, V., Toledo, M.E., Rodriguez, M., Gómez, D., Baly, A., Benitez, J.R., & Van der Stuyft, P. (Winter 2010). “Community involvement in dengue vector control: Cluster randomized trial”, MEDICC Review, 12 (1), 41–47.

6. Whiteford, L.M., & Branch, L.G. (2008). Primary Health Care in Cuba: The Other Revolution. Lanham: Rowman & Littlefield Publishers, Inc.

7. Fitz, D. (March 2011). “The Latin American School of Medicine today: ELAM”, Monthly Review, 62 (10) 50–62. Also see http://links.org.au/node/2325.

8. Medical Education Cooperation with Cuba. Retrieved February 6, 2012 from http://www.medicc.org/ns/index.php?s=3&p=3.

9. Guzmán, M.G. & Kouri, G. (2008). “Dengue haemorrhagic fever integral hypothesis: Confirming observations, 1987–2007”, Transactions of the Royal Society of Tropical Medicine and Hygiene. 102, 522–523.

10. Peláez, O., Sánchez, L, Más, P., Pérez, S., Kouri, G. & Guzmán, M. (April 2011). “Prevalence of febrile syndromes in dengue surveillance, Havana City, 2007”, MEDICC Review, 13 (2),47–51.

11. Díaz, C., Torres, Y., de la Cruz, A., Álvarez, A., Piquero, M., Valero, A. & Fuentes, O. (2009). “Estrategía intersectoral y participativa con enfoque de ecosalud para la prevención de la transmisión de dengue en el nivel local”, Cadernos Saúde Pública, 25 (Supl. 1), S59­S70. http://dx.doi.org/10.1590/S0102-311x2009001300006.

Comments

Cuba-trained doctors making difference around the world

By Catherine Porter

June 2, 2012

The Star (Canada) http://www.thestar.com/News/World/article/1203466

SANTA CLARA, CUBA—Every morning, on the edge of town, you can witness a spectacular migration. Hundreds of students in white lab coats pour from a squat university building on to the street, around the line of horse-drawn wagons, and into nearby hospitals.

You can play a game, watching from your perch beneath a flowering flamboyant tree: where do you think the guy with dreadlocks is from? What about the girl with a hijab? Some have telltale signs — an Argentinean or Angolan flag stitched over their medical uniforms.

They are international students at the world’s largest medical school, the Escuela Latinoamericana de Medicina — ELAM.

To put the school’s size in perspective: the University of Toronto has 850 medical students and Harvard University has 735. ELAM has twelve times more students than those two schools combined: 19,550. And, despite being a poor country, every single one of those students is on full scholarship.

Nabeel Yar Khan rushes among them, his stomach growling from missing a miserable mess-hall breakfast, glasses gleaming, short hair gelled to a peak like an angry bird from the popular video game. Most locals guess from his brown skin that he is one of the 906 Pakistani students granted scholarships since the deadly 2005 earthquake. But, peer closely at the back of the grey knapsack strapped over his shoulders and you see a small red maple leaf pin.

Yar Khan is from Scarborough — Malvern, to be precise.

He is rushing toward the low-slung, pink pediatric hospital — a place where the third and first worlds collide. Here, he can learn how to transplant a kidney, but patients bring their own buckets and kettles to heat water for baths.

For the past week, Yar Khan, 25, has been caring for 8-year-old Paulina, a girl with long curly hair tied loosely into a ponytail and a half-naked Cabbage Patch doll beside her in bed.

She is here for a urinary tract infection, her eighth this year. She smiles warmly as he checks her abdomen. The hospital’s head of nephrology, Dr. Maria Del Carmin Saura, joins him and class begins.

“When is a urinary tract infection considered chronic?” she asks Khan in Spanish.

“When there are more than three in a year,” he replies.

“What are the causes?” she asks. “What is the treatment?”

Satisfied with his answers, she steps back and Yar Khan continues his examination.

“He is a very good student,” Del Carmin confides before blowing a kiss to Paulina and leaving the room. “He’s really curious and part of a group of students that help one another a lot, which is important. . . . Canada will have a good doctor.”

Yar Khan is the first Canadian student at ELAM. Chances are, he will be the last.

Like most things in today’s Cuba, Fidel Castrol gets credit for starting ELAM.

In October 1998, he dispatched a team of doctors to the Central American countries that were being pounded by Hurricane Mitch. In a matter of days, more than 11,000 people died in the resulting floods and mudslides. Upon arriving in the mostly rural areas, the Cuban doctors discovered that many people suffered chronic, long-term illnesses. Instead of broken bones, they were treating river blindness and stunted growth. In places like the Mosquito Coast of Honduras, the Cubans were the first doctors the patients had ever seen.

Castro came up with a variation on the “teach-a-man-to-fish” theory: instead of leaving Cuban doctors in disaster areas indefinitely, he would teach locals to become their own doctors.

A naval academy on the outskirts of Havana was reclaimed and, at a speed perhaps only achievable under communism, the last naval students were shipped out by January. The next month, the first busloads of Nicaraguan students pulled up.

Half a year after the hurricane, ELAM’s initial 1,932 medical students began their classes in a six-year program. Raul Castro, Fidel’s younger brother who replaced him as president in 2008, opened the school.

“He said that this was a school to graduate the doctors for all the world,” says Eladio Valcarcel Garcia, one of the school’s founders, who had helped run the naval academy. The memory makes him weep. “He told me I’d no longer be preparing children for war, but to heal the world.”

The school quickly expanded to include students from more than 110 countries, from Mozambique and Yemen to Cambodia and East Timor. According to the school, more than two-thirds come from poor, rural families. Many represent first nations — the Kiche of Guatemala or Igbo of Nigeria.

Most could never afford medical school — or even access one.

Here, they study for free. They are given a bed in a dorm room, three basic meals a day, textbooks and a monthly stipend of 100 pesos — enough for a bottle of shampoo and one beer. (That’s about $3.90, or four days’ pay for a Cuban doctor.)

The only anomaly on the list of recipient countries, until recently, was the United States — Cuba’s bitter enemy. Sixty-seven Americans have already graduated from the school, and another 116 are currently enrolled — all from poor communities that rarely produce doctors, Garcia says.

“It is not a political idea,” he says, adding in the next breath: “They blockade us from medicine that could save children’s lives.” (After our interview, ELAM announced the school would not accept any more American students because of the American embargo.)

The school was supposed to close after 10 years, when enough new doctors would have graduated to replace the Cubans in the students’ home villages. But, as ELAM’s reach expanded to include the entire developing world, the end date has been pushed back indefinitely.

“We created this school to provide health for all,” Garcia says. “It’s 2012 and we still don’t have health care for everyone. So we have to continue working on this.”

Given ELAM’s mandate, you might presume Yar Khan comes from the troubled Kashechewan reserve in Northern Ontario or a rundown apartment at Jane and Finch.

But his family lives in a neat, four-bedroom home on a leafy suburban street in Scarborough.

His parents are immigrants of Indian descent. His father works for the Workplace Safety and Insurance Board. His mom answers the phone at a food distribution company.

Yar Khan worked throughout high school and his two years at York University, but he didn’t have to. His parents paid his tuition and living costs.

They aren’t wealthy by Canadian standards. But compared with most students at ELAM, Yar Khan is well-off. His closest friend, Carlos Roberto Perez, hasn’t flown home to El Salvador for two years because of the cost — not even when his mother died.

How Yar Khan became the school’s first Canadian student is a story of a little chance and a lot of perseverance.

During his second year at York, Yar Khan wandered through a campus international development fair and learned about Canada World Youth, a non-profit organization that sends young Canadians abroad on exchanges. He applied and was sent to rural Cuba.

He describes a party at his Cuban friend Eykel’s one-room concrete house to describe how the experience changed him. After dinner, Eykel turned on the stereo and the entire family — mother, father, grandmother — danced together.

“It made me look at life differently,” says Yar Khan. “You can have little but still be happy. Money can’t buy happiness. Even though I wasn’t with my family, I still felt love and affection here.”

While in Cuba, Yar Khan phoned the Cuban Embassy in Ottawa to ask about ELAM. Their response: the school wasn’t open to Canadians. Upon his return to Toronto, he launched a letter and telephone campaign, which also proved fruitless.

After Christmas 2007, he flew back to Cuba and camped out in the Foreign Affairs Ministry building — to no avail.

Two days later, the phone rang back in Scarborough. It was the Cuban Embassy in Ottawa. He had been accepted.

“I was jumping around, banging on the walls, I was so excited,” he recalls.

Less than a month later, he started classes in Cuba.

Along with sugar, cigars, 1950s cars and Fidel Castro, Cuba’s health-care system is the country’s pride and defining characteristic.

Dr. Margaret Chan, director general of the World Health Organization, recently praised the Cuban medical system as a model for the world. “People in this country are very fortunate,” she said.

Cubans have more doctors per person than anyone else on the planet. Most residential blocks still have a local medical consultorio — a doctor’s office with the doctor living upstairs on call. (This has been changing, as many doctors have been sent on missions to Venezuela over the past decade.)

Medical treatment is more hands-on and less technology-driven, mostly because MRIs and lab tests are expensive. They call it preventive — meaning people see their doctor regularly, before there is a crisis. The results are stellar: Cuba was the first country in the world to eliminate polio and measles. According to a 2006 journal of epidemiology, it has the lowest rate of AIDS in the Americas. Cuba has a lower infant mortality rate than Canada and the United States. The average lifespan, at 78, is just three years lower than Canada’s.

None of this is an accident. From the beginning, Fidel Castro set out to make Cuba an international medical superpower, according to Julie Feinsilver, author of Healing the Masses: Cuban Health Politics at Home and Abroad.

When a 9.5-Richter earthquake struck Chile just a year after the Cuban revolution in 1959, Castro sent a medical team even though half of Cuba’s 6,000 doctors had fled the country. Three years later, when Algeria’s independence led to a similar brain drain, Cuba provided 56 doctors for 14 months.

“They believed Cuba owed a debt to humanity for assistance the nation received during the revolution,” says Feinsilver.

Cuban doctors have also been sent on development missions around Latin America and Africa: starting vaccination campaigns in Angola and Ethiopia, working in rural South Africa and starting and staffing medical schools in a half-dozen countries like Yemen and Ghana where doctors are scarce. (In Ghana, local newspapers report that citizens are more likely to see a Cuban doctor than a local one.)

Since 2006, Cuban doctors have restored vision to 2.2 million Latin Americans through simple eye surgeries.

Today, the tiny country of Cuba, population 10 million, sends more doctors to assist in developing countries than the entire G8 combined, according to Robert Huish, an international development professor at Dalhousie University who has studied ELAM for eight years .

There are 68,600 Cuban doctors now and more than 20 per cent of them — or 15,407 — are on missions in 66 countries.

They have saved 4 million lives over the past five decades, they say.

“We are the army of doctors in the world,” says Dr. Jorge Juan Delgado Bustillo, the country’s deputy director of medical co-operation, standing in front of a giant map on which almost every country in Africa and Latin America sports a little Cuban flag. “We don’t fight with guns. We fight with our knowledge and hands to assist people.”

Most Cubans I spoke to call these medical missions a gesture of solidarity. More than once, I heard the same phrase: “We don’t have much. But what little we have, we share.”

But there is a business model here, too. More than two-thirds of the medical internationalistas are in Venezuela, which repays the Cuban government with cheap oil.

Cuban medical teams are in other rich countries, like Qatar, where they are paid $1,000 a month — more than 30 times their regular salary of $35. About 40 per cent of the Qatari wage goes to the Cuban government, Delgado says. “Every student studies medicine here free. It’s their responsibility to their society.”

Critics of the system call this modern slavery. Dr. Julio Cesar Alfonso runs Solidaridad Sin Fronteras (Solidarity without Borders), a Miami-based charity that assists Cuban doctors get their American accreditation. Since the George W. Bush administration created a special visa program for Cuban medical internationalistas in 2006, about 800 Cuban doctors have defected from international missions, he says.

“They work long hours and receive tiny salaries while the Cuban government makes good money,” says Alfonso. “Doctors in Cuba won’t tell you the truth. They are scared to speak openly about this.”

Statistics are hard to get in Cuba. But author Feinsilver estimates Cuban medical exports surpassed the $2.3-billion tourism industry earnings of the early 2000s.

If the money is big, the political returns are even bigger. Cuban doctors have earned their country many international allies, essential in Cuba’s long, cold fight with the United States. In April, most Latin American and Caribbean countries at the Summit of the Americas rejected the American demand that Cuba not attend the next forum.

Experts call this “medical diplomacy.” ELAM fits neatly into it. Most countries that receive Cuban doctors send students to the school. In 2004, Paraguayan President Nicanor Duarte Frutos said he would not support another American anti-Cuba resolution because of Cuban doctors in his country and the 600 Paraguayan students at ELAM.

“Dimi Chocolito,” Yar Khan says to a passing South African.

Que tal mi hermano?” he asks an East Timorese.

Next is a guy from Paraguay before he finally settles into conversation beside the line of coches — horse-drawn carriages that are Santa Clara’s version of buses — with a student from Guinea Bisau.

“I’ve learned so much about the world here,” Yar Khan says, as we clip-clop toward the city centre. “Did you know Nicaragua is the only country in the world that has sharks in lakes?”

Back in Scarborough, Yar Khan’s parents thought of him as their reserved, driven, middle child. He has always worked hard, signing himself up for Kumon classes in Grade 7 because he thought he needed help with math. He volunteered a lot, running a kids’ soccer team and helping at the local hospital. But he wasn’t super social. He kept to his close friends from grade school.

Four years in Cuba have transformed him.

The Cuban Yar Khan is short and funny — “I’m 5-foot-4, hopefully,” he says — and outgoing. He kisses his teachers on the cheek goodbye and strokes the arms of patients while talking to them. He talks to strangers on the street in an easy Spanish, which he taught himself.

“At the beginning of the year, he told me he wanted to be paired with a Spanish-speaking student,” recalls Gloria (Prof Katty) Catalina Bacallao Martinez, who taught Khan semiology (the science of symptoms) last year. Yar Khan missed the intensive Spanish classes most foreign students receive during their first six months at ELAM. He was admitted too late, thrown directly into pre-med sciences. He wanted the Spanish-speaking partner to do the bedside talking.

“I told him ‘No. You must acquire the ability to speak good Spanish for your patients,’” Bacallao continues. “When he finished, he spoke more fluently than the Spanish students.”

Yar Khan lives at the top of a mottled, four-storey building, in a room with six other men. They each have a mattress on a bunk bed, a wooden locker and a miniature desk. Amazingly, another six men were billeted here, but they sleep at their girlfriends’ places. The room is so small, it’s hard to imagine how they would fit. As it is, Yar Khan has to move desks to make enough room to unfurl his prayer rug.

There are no bedside lamps. The last one to bed turns out the fluorescent lights. There was no electricity at all between 8 a.m. and 4 p.m. during Yar Khan’s first two years here.

The men share one toilet and one shower, when it works. Most of the time they bathe from a bucket of water.

The food served in the gloomy canteen below is predictably terrible — mostly rice and black beans.

Yar Khan’s father sends him $150 every month to buy essentials, when he can find them. Santa Clara has been out of toilet paper for about a week — rumour has it the factory shut down.

“There were two hurricanes during my first year here,” he says. “You couldn’t find fruit or vegetables in town for four weeks. Or eggs.”

Last year, after Yar Khan’s Canadian bank changed its credit cards, he went four months without being able to access money. His friends paid for his beer and the odd dinner out with what little they had. When he was recovering in hospital from an appendectomy, Perez — his poor Salvadoran friend — brought him green mangoes and tamarind fruit that he had picked.

Yar Khan has learned first-hand that Cuban motto: “We don’t have much, but what little we have, we share.”

“This program has changed me into a better person,” he says.

ELAM students don’t sign formal contracts promising to use their free degrees in poor, rural communities. The hope is that the school experience will inspire them to do that. According to ELAM’s administration and international scholars, about 80 per cent follow through.

“Many have made efforts toward humanitarian outreach rather than hightail it into radiology or some specialization that sees the top pay scale,” says Dalhousie’s Huish.

He is talking particularly about the American graduates who would have incurred huge debts had they studied medicine at home.

“Many of them are in self-organized health brigades. Some went to New Orleans to do community-based care with other physicians. Others have gone to work in Oakland, the Bronx, and one grad set up an NGO to promote safe maternity in Ghana.”

At ELAM’s main campus near Havana, Eladio Valcarcel Garcia, the teary administrator who helped found the school, says the 2010 Haitian earthquake, which killed up to 300,000, was a perfect test case. The Cuban government tapped ELAM to gather 356 graduates to join the large contingent of Cuban emergency doctors heading to help. “We had to stop calling. All of them said yes. They came from Guatemala and Mali and Nigeria, Morocco. We still have 102 graduates there.”

Yar Khan has two more years of medical school and likely a residency program in Canada before he decides where he will practice. He is certain he wants to be a pediatrician. From there, he is wavering between working in a developing country with Doctors Without Borders or heading to Canada’s north, where doctors are rare.

“This is survival of the fittest. I’ve gone through so many obstacles to get here,” Yar Khan says with a smile. “I can survive with minimum essentials anywhere.”

It is unlikely another Canadian will ever follow him to ELAM. The Cuban government has made no moves to open the door to others.

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