How Cuba mobilises to defeat public health emergencies

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.