Cuba’s Latin American School of Medicine -- `an example of internationalism and human solidarity’

“We are one people who share a common history of struggle.” — Cassandra Cusack Curbelo, second-year ELAM student

By Don Fitz

May 18, 2011 – Links International Journal of Socialist Renewal, an earlier version of this article first appeared at Monthly Review in March – A revolution can only be successful when the new generation takes over from the old. When thousands of students come together because of their dedication to helping others at a school that was built to allow them to fulfill their goals, the ground is fertile for students to continue the struggle.

Students are assuming defining roles at the Latin American School of Medicine (Escuela Latinoamericana de Medicina or ELAM), the 12-year-old medical school in Santa Fe, Playa, a 90-minute bus ride from Havana, Cuba. With their educational costs covered by the Cuban government, students learn new social relationships in medical practice that they will use in underserved communities in their countries.

International medicine: A revolutionary dream

In his article, “The Cuban Revolutionary Doctor”, Steve Brouwer describes a vision that Che Guevara had in 1960, the year after the Cuban Revolution. After observing that many graduating doctors did not want to serve in rural areas, Che imagined training campesinos to become doctors so they could hurry “immediately and with unreserved enthusiasm to help their brothers”.[1] That year, Cuba sent medical teams to Chile to help after a major earthquake.[2] Cuba’s first health contract resulted in its sending a medical brigade to Algeria in 1963.[3] In 1998, when Hurricanes Mitch and Georges devastated the Caribbean islands and Central America, Cuba sent doctors and paramedics. Fidel Castro then proposed expanding Cuba’s new Comprehensive Health Program (Programa Integral de Salud) by creating ELAM, which began in 1999.

Castro’s ability to inspire changes should not be underestimated. I met Exa Gonzalez, a sixth-year ELAM student, on a plane to Havana in December 2009. She had studied art and film in high school in Baja California, Mexico. As a teenager, she made two trips to Cuba with her parents, members of the Workers Party (Partido de Trabajo, or PT). During her second trip, in 2001, Fidel described ELAM to the PT delegation, and inspired Exa to change her studies to medicine. She entered ELAM in 2002, when she was 19 years old, and spent her first year in pre-med, studying biology, chemistry, and physics.[4]

Cuba’s Programa Integral de Salud expanded dramatically in 2003, when the Venezuelan Medical Federation attempted to obstruct efforts by President Hugo Chávez to provide health care to under-served communities. Collaboration between Cuba and Venezuela resulted in the Inside the Community (Barrio Adentro) program, bringing 10,000 Cuban doctors to the latter country in less than a year.[5]

When Hurricane Katrina slammed New Orleans in August 2005, Castro mobilised hundreds of ELAM graduates and Cuban doctors to help. US President George W. Bush refused even to consider the gesture of goodwill. A friend told me that it must have been a publicity stunt by Castro, since he knew that Bush would not accept. I replied that, given the breadth and depth of Cuban medical aid to countries in Latin America, the Caribbean and Africa, Cuba would have considered it an insult to ignore the plight of a US city near its shores. The high number of primary care doctors in Cuba makes it possible to move quickly after disasters like Katrina.

The US media’s slighting of Cuban medical solidarity continued through the 2009 earthquake in Haiti. As corporate news reports over-emphasised US aid, they seriously underreported Cuba’s efforts, to the point of misidentifying a Cuban doctor as “Spanish”.[6] In fact, ever since Hurricane Georges in 1998, Cuba has assigned hundreds of doctors to neighbouring Haiti. Cuba has also been training Haitian doctors since the doors of ELAM first opened. The only requirement is that, when they graduate, Haitians agree to return home to take the place of Cuban doctors (rather than defecting to plush jobs in the United States or Europe).

Cuba has already trained 550 Haitian doctors, and there are 567 Haitian students in ELAM. As a result of Cuban efforts, Haiti saw a greater than 50 per cent decrease in infant mortality, maternal mortality and child mortality, and between 1999 and 2007, an increase in life expectancy from 54 to 61 years of age. As Haitian President René Préval said, “You did not have to wait for an earthquake to help us.”[7]

During the first three days after the earthquake, Cuban doctors provided more medical care than any other country. In addition to ELAM graduates already in Haiti, 184 Haitian students from ELAM (along with US ELAM graduates) came to help. “Cuba was soon responsible for over 1,500 medical personnel in Haiti.”[8] This compared to 550 medical personnel from the United States at the same time. And, while the United States had treated 871 patients, Cuban-trained staff had treated 227,143. Of course, Haiti was out of the headlines after a few weeks, and most non-military Americans departed. But, just as they were present before the disaster, Cubans stayed afterwards, not just to treat patients but also to continue to build a new health-care system.

Haiti is merely the most recent example of the enormity of Cuba’s international medical work. According to ELAM’s web site, there are 52,000 Cuban medical workers currently offering their services in 92 countries.[9] This means that Cuba has more doctors working overseas than either the World Health Organization or the combined efforts of the G8 nations. Thus, “by 2008, Cuban medical staff were caring for over 70 million people in the world”. Additionally, almost 2 million people outside of Cuba owe their “lives to the availability of Cuban medical services”.[10] The spirit of international solidarity is the core to the teaching curriculum at ELAM. As its web site announces: “The work that ELAM graduates carry out today in all countries of the world constitutes an example of internationalism and human solidarity. It is a symbol of love for life and social justice that is without precedence in history.”[11]

Student health brigades

After the third class graduation at ELAM, the Student Congress proposed creating the opportunity to work on specific projects during summer vacation months. The faculty approved, and students began designing projects designated as Student Health Brigades (Brigadas Estudiantiles por la Salud or BES) that would take them to clinics in impoverished urban and rural communities of South and Central America, as well as throughout the rest of the world, including the United States.

The Yaa Asantewaa Brigade (YAB), whose key organisers include Omavi Bailey and Ketia Brown, is illustrative of how Brigadas Estudiantiles por la Salud projects function.[12] YAB is the group that 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, OAD adopted the mission of developing “programs, projects and institutions with the objective of producing an organised, politically conscious and socially responsible medical body able to meet the needs of African people suffering from health related issues throughout the African world. OAD is composed of 160 students, interns, and residents trained in Cuba currently representing over thirty-five countries.”[13]

Currently, the “brain drain” of African doctors getting jobs in Europe or the United States leaves Ghana with just one doctor for every 45,000 residents. Similarly, there are more Ethiopian doctors in Chicago than in Ethiopia.[14] OAD aims to confront this problem head on by strengthening the directive at ELAM that African (and all other) medical students return to serve impoverished communities in their homelands.

The 2010 phase of the Ghana Project began 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. set up health groups of medical students who do physical exams and learn Ghanaian traditional medicine; and

3. hold community meetings to strengthen ties with Ghana residents by finding out what health care they want.

Depending on the results, YAB hopes to create an internship so that sixth-year ELAM students can complete their medical training in Ghana. ELAM students in Ghana will have experiences that differ vastly from those of medical students in the United States. Unlike the over-developed countries, where the major causes of death are “lifestyle” diseases such as stroke and heart attack, “The 10 principal causes of death in Ghana are all due to preventable infectious diseases.”[15] It is no accident that YAB aims to look at Ghanaian access to services, beliefs about health care and desires for change, rather than jumping in to provide predetermined 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.

Even though traditional and natural medicine are often ridiculed in the West, they have “remained the primary mode of prevention and treatment for 85% of African people”.[16] Thus, the Cuban model of general integral medicine (Medicina General Integral or MGI), which “approaches health care holistically, considering its biological, psychological, cultural and spiritual components”, prepares students to be doctors-as-listeners as much as a doctors-as-teachers.[17]

Growth of ELAM

The ability of Cuban-trained doctors to listen to people and work with them, rather than impose on them a Western model, is one factor that increases the eagerness of countries to send students to ELAM. Progressive Americans who yearn for health-care systems like those in Canada and Western Europe seem unaware of the tremendous prestige that Cuban-style medicine holds for impoverished countries. The Cuban health-care system proves that “expensive medical technology is not necessary for effective community-based preventive care”. It “has eradicated polio, controlled malaria and dengue, and reduced child and maternal mortality rates to equal or lower than those of much richer and more developed countries like the United States”.[18]

ELAM offers the hope that other countries can accomplish similar goals. It opened in 1999 with students from 24  countries: 19 Latin American, four African and the United States.[19] A six-year program, it graduated its first class in 2005. By 2007 ELAM had students from 27 countries.[20] By 2008 the number of countries with students at ELAM had grown to 40.[21]

The ELAM director of international relations told me of expansion to campuses throughout Cuba. As of April 2010, the campuses totalled 21,018 students, from 100 countries. Virtually all of Latin America is represented. Even Colombia, with its notorious right-wing government, has 385 students. Students come from 36 African countries, plus many from the Middle East, Asian, Pacific islands and the Caribbean.[22]

When I asked the secretary general of the ELAM Project if there were students from England and Australia, she said, “No, developed countries usually provide medical care and ELAM is designed to help poor countries.”[23] However, this could be interpreted as meaning that ELAM does not reach out to the over-developed countries. If students are truly dedicated to working in underserved communities, they might be admitted if they apply through the Cuban embassy in their country. This is suggested by the 2010 matriculation table, which lists students from Germany, Canada, Israel and Korea.

The internationalism of ELAM reflects the internationalism that runs throughout Cuban medicine. ELAM professors tell their students of participating in relief efforts after disasters in Guatemala, Honduras and Haiti. Students also hear from other students of solidarity work in various African countries, Haiti and Venezuela.

When students do rotations at neighbourhood consultorios (family care centres) or community polyclinics, they work with medical staff who have global experience. While visiting Havana’s Policlínico Universitario, its vice-rector Teresa Frías told me that she had worked in Angola, Tanzania, Brazil and Bolivia. As her co-worker, also named Teresa, provided a tour of the polyclinic, she mentioned that she had worked in Ghana, Venezuela and Brazil.

Any gathering of medical staff in Cuba is likely to include people who offer stories from distant parts of the world. Internationalism is not merely a slogan or ideology in Cuban medicine—it is a core component of a medical culture that pervades the teaching and practice of medicine.

Doctors as teachers

Like many ELAM students, going to medical school would have been impossible for Ivan Angulo Torres of Lima, Peru. The cost would have been prohibitive and only 100 students per year enter medical school in Lima. When he first heard of ELAM in 2002, Ivan was studying hotel administration. Two years later, he was in Havana. Four of his relatives attended his July 2010 graduation as the first doctor in his family.[24]

The course of study differs a bit, depending on whether students have sufficient pre-med background in biology, chemistry and physics; whether they are from Cuba, Latin America or a non-Latin culture; and whether they are fluent in Spanish. Rather than starting his school year in September, Ivan began his studies in March 2004 because he needed a half-year of science courses.

The first two years of medical school included basic classroom subjects such as anatomy, physiology, histology, biochemistry, genetics, organ systems, psychology, pathology and the Cuban medical model, with its emphasis on public health. Ivan had contact with a neighbourhood consultorio his first year and learned how to give physical exams his second year. During his third year, he began working with hospitalised patients as a practicum from 8 to 10 in the morning. He made rounds with doctors from 10 am to 1 pm, and took courses such as symptomology, internal medicine, X-rays and English in the afternoon.

His fourth and fifth years saw extensive training in the Cuban MGI model of medicine, which emphasises people as bio-psycho-social beings, whose context of life must be understood in order to treat them. The MGI model teaches doctors how to teach patients to care for themselves, largely by changing the social context of their lives, including their communities. During those two years, Ivan studied public health and did two-month hospital rotations in areas such as MGI, ear/nose/throat, ophthalmology, obstetrics/gynecology, pediatrics, surgery, orthopedics, urology, dermatology and psychiatry. During his sixth year as an intern, he was responsible for patients in a consultorio every day and for polyclinic patients one day per week. He also completed all his major rotations begun during his third through sixth years.

From the beginning of their training, ELAM students learn that the essence of public health is the neighbourhood clinic, or consultorio. The medical system aims to deal with 80 per cent of health problems in the consultorio, each of which serves about 150 families.[25] The consultorio is often described as a neighbourhood doctor’s office, with patients seen on the first floor, the doctor living on the second floor and the nurse living on the third floor. This is the ideal Cuban model, but it does not capture the wide variation or the close connection between medical students and the consultorio.

In December 2009, doctor Alejandro Fadragas Fernández and nurse Maité Perdomo showed me their consultorio, which serves about 500 families and 1800 patients, making it larger than is typical in Cuba.[26] On the wall is a poster, Mural Docente, listing the “teaching staff” of two doctors, four nurses, two first-year ELAM or Cuban students, one fourth-year student, one fifth-year student and an intern.

The poster tells us many things. First, medical students are integrated into neighbourhood health care, beginning with their first year of medical school. Second, Cuban residents are accustomed to international students being part of their treatment. Third, since there may be multiple doctors and nurses working at a consultorio, they do not all live in the same building. They live in the neighbourhood or close to it, and the degree of integration into the community is complex. Fourth, medical teaching is not limited to ELAM but is integrated throughout the practice of neighbourhood medicine in Cuba—doctors expect to help train medical students as part of their practice. This is so much the case that medical students often use the words profesor and médico (doctor) interchangeably.

The meaning of ELAM for ELAM students

Why do students from across the world come to ELAM? For Exa Gonzalez of Mexico, a speech by Fidel Castro changed her life. For Ketia Brown from California, ELAM’s unique blend of traditional medicine with modern practice caught her eye.[27] For Cuban-American Cassandra Cusack Curbelo, a second-year student, it was an opportunity to share the dream of helping others by returning to the land where her grandparents had been revolutionaries.[28] But for many, it is a combination of being able to afford to go to medical school and participate in a vision. Ivan Angulo was not the only student who could never have afforded a traditional medical school.

Anmnol Colindres of El Paraíso, Honduras, had long wanted to be a doctor, but his father, who had been a forestry worker until the coup of June 28, 2009, could not afford to pay his way.[29] Amanda Louis, from the Caribbean island of St. Lucia, feels that she has an opportunity at ELAM that she never would have had, based on the salaries of her father, a taxi driver, and her mother, a street vendor.[30] Dennis Pratt, originally from Sierra Leone before his family moved to Jonesboro, Georgia [United States], did not want to spend years paying medical school loans and immediately applied when he learned of ELAM.[31]

Like other students from the Pacific island nation of Tuvalu, Jonalisa Livi Tapumanaia is excited that ELAM will make it possible for there to be a doctor on each of the 10 major islands of her home, which is already suffering the rising waters of global warming. Her government can only afford to pay for her to fly home once every three years—her father, who runs a petrol station, and her mother, who works in an island court, cannot cover the cost.[32]

It is also costly for Lorine Auma to visit her family in Kenya. She will see them only once during her six years of study. Her father, an accountant, and her mother, an occasional printer, could not afford the expensive Kenyan medical school.[33] Keitumetse Joyce Letsiela reported that there is no medical school in her native Lesotho, and her mother, a teacher, did not have funds to send her to an expensive medical school in neighbouring South Africa.[34]

Clearly, a huge number, probably a majority of ELAM students, could not attend medical school were it not for its free tuition. One part of their education is learning that the improvement of medical care in Cuba has meant focusing on preventive family care. US medical practice is so over-specialised that only 11 per cent of doctors are family physicians. In contrast, almost two-thirds of Cuban doctors practice family medicine. While the ratio of family physicians per population is about 1:3200 in the United States, it is about 1:600 in Cuba, the highest such ratio in the world.[35]

Many ELAM students I spoke with intend to practice family medicine. But several others feel that the need for affordable specialists in their countries compels them to continue their studies after ELAM. Ivan Angulo from Peru plans to specialise in orthopedics. Dennis Pratt hopes to practice pediatrics and internal medicine in Sierra Leone. Ivan Gomez de Assis would like to practice orthopedics in Brazil.[36] Walter Titz, also from Brazil, would like to practice general medicine for a few years and then study psychiatry.[37]

Amanda Louis reports that her Caribbean home of St. Lucia has only has one oncologist and one ear, nose and throat doctor, but feels there are enough general practitioners and ob/gyn doctors. She would like to specialise in nephrology (kidney) disorders. Yell Eric thinks that there are many general practitioners in his African island country of Sao Tomo Principe, and is not sure if he wants to specialise or not.[38] When Lorine Auma returns to Kenya, she would like to focus on orthopedics or psychiatry. Perhaps most typical of ELAM students is Joyce Letsiela, who is devoted to helping underserved communities in Lesotho and feels that there is a serious shortage of both general practitioners and specialists.

Challenges

While ELAM has 500 positions slotted for US students, only 117 were filled as of April 2010. The Interreligious Foundation for Community Organization (IFCO), which screens US applicants to ELAM, strongly encourages low-income people of colour to apply. But the fundamental requirement is that students demonstrate a commitment to working in distressed communities.[39]

Many young people from the United States who think about going to ELAM find ways to contact US students already there. An even better route is to contact IFCO and consider visiting the school. While on campus, it is easy to talk to US students already there, as well as students from other countries who speak English.

There are several ways to view a medical school.

1. Physical appearance. Compared to the luxury of US medical schools, ELAM has a few things to be desired. Its running water is available only at certain hours, and toilets have to be flushed with a bucket. Cuba often has to sacrifice superficialities in order to ensure that everyone has necessities.

2. Quality of training. Although ELAM provides books in Spanish, other books may be difficult to get. US schools provide training geared directly to US medical board exams, but ELAM students get more hands-on experience earlier.

3. Dedication to creating a new medicine. It is in this dimension that ELAM surpasses every other medical school in the world (though Venezuela may soon have comparable schools). This should be the reason that students apply.

The evening before I departed from my latest trip to Havana, I had an extensive conversation about the ELAM experience with my daughter, Rebecca Fitz, now a third-year student, and her partner, Ivan Angulo, who just finished his sixth year.[40] They detailed many things that ELAM provides at no cost: (1) classes and textbooks; (2) dorm room; (3) meals (three per day); (4) medical services, including emergency and elective surgery (many ELAM students receive corrective procedures such as eye surgery and braces); (5) items such as two student uniforms, stethoscope, blood pressure cuff, mosquito net, shoes, socks, sheets, blanket, winter coat and silverware; (6) rations, including soap, toilet paper (do not go anywhere in Cuba without your own toilet paper!), laundry detergent, toothpaste, deodorant and school supplies; and (7) stipend of 100 pesos per month (I got an ice-cream on campus for 1 peso. A beer costs about 10 pesos; so students can chill out from studying by having a beer every three days.).

Conversely, ELAM presents challenges to students accustomed to life in the United States. The first requirement for acceptance is being able to document a history of commitment to social justice. ELAM does not exist to give people a free ride through medical school. Students are expected to show that they will give as much to their communities as ELAM gives them.

Though ELAM covers basic expenses while attending school, students must be able to obtain transportation to and from Cuba. This is not an issue for most US students; but many students do not have funds to return home during the summer. IFCO encourages US students to complete college-level courses in biology, chemistry and physics prior to attending ELAM, advising that they can concentrate on Spanish after arriving. Students from most other countries can begin medical school immediately after graduating high school, and can take any needed science courses during an additional first year of pre-med.

Students must be able to live in a land without excess luxury. Most do not find this too difficult, since they are aware that Cuba maintains a life expectancy equal to the United States by devoting its resources to making sure everyone has what is critical. The US economic embargo makes sure that there is not a whole lot more. Students should be prepared to bathe from a bucket and live with hurricanes but without air conditioning. Do not expect to use a US credit card in Cuba.

The cafeteria serves institutional food that lacks the variety that many prefer. It is not unusual to experience difficulty in adjusting to the absence of individual comfort needs, such as brownies, hot running water, or private personal space. There is a norm of being political, which is wonderful for many, but can be a surprise for some. For example, students are expected (but not required) to participate in activities of the delegation of their country, and class discussions may include the role of their country in imperialism.

ELAM is designed for students who leave their country for the first time, sometimes at the age of 16, to attend medical school. Americans, who tend to be older, may be surprised by requirements such as taking physical education courses or spending nights on campus Monday through Friday.

Finally, a large majority of students come from countries that are eager to send students to ELAM to become Cuban-trained doctors. This is not the case with Brazil and the United States. The Brazilian medical association, Colégio Médico, has policies distinct from the Workers Party government and does not recognise degrees from ELAM. US students do not have this problem, but they must take the same exams as does anyone receiving a non-US degree, and they need to study extensively for questions based on a US rather than a Cuban medical model.

US students cannot expect any support from the US Interests Section, the substitute for an embassy (a US embassy does not exist, due to lack of diplomatic relations between the two countries). Though it is legal to travel to Cuba for educational purposes (such as medical school), the US government employs more hostile restrictions on travel to Cuba than on any other country, and does nothing to support students at ELAM.

An affirmation

Perhaps the extreme antagonism by the most violent country on the planet is an affirmation of the power of ELAM. The Cuban public health model seeks to understand medical problems by studying the wholeness and completeness of the human context of those problems. ELAM is central to Cuba’s efforts to integrate its medical system with the needs of underserved people throughout the world. The Cuban model is based on a belief that illnesses of humanity cannot be seriously addressed without addressing the society that creates the basis for those illnesses.

This model has attracted well over 20,000 international students. Cassandra Cusack Curbelo believes that “there is no experience like thousands coming together with the same idea of medicine. It feels like we are not separated into two continents, but we are one people who share a common history of struggle. This is what ELAM opens our eyes to”.

According to Ketia Brown, a third-year medical student, “ELAM is the revolution realised. We must attempt to have a revolutionary project in a capitalist world.” ELAM is such a project. It is a struggle for a new medical consciousness as a part of the struggle to improve global health.

[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 KDHX-TV.]

Acknowledgments

The author would like to thank ELAM Rector Juan Carrizo, director of international relations, Nancy Remón Sánchez, general secretary of Project ELAM, Wuilmaris Pérez Torres, and assistant professor of MGI, Dr Raul Jorge Miranda, for their information and assistance on this article.

Notes

1. Steve Brouwer, “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity”, Monthly Review, vol. 60, no. 8 (January 2009): 28-42.

2. John M. Kirk and Michael H. Erisman, Cuban Medical Internationalism: Origins, Evolution and Goals (New York: Palgrave Macmillan, 2009).

3. Escuela Latinoamericana de Medicina (ELAM), http://elacm.sld.cu/index (retrieved July 8, 2010 – now at http://www.sld.cu/sitios/elam/).

4. Interview with Exa Gonzales, in flight over the Gulf of Mexico, December 28, 2009.

5. Brouwer, “The Cuban Revolutionary Doctor”, 28-42.

6. All information on Haiti is from Emily J. Kirk and John M. Kirk, “Cuban Medical Aid to Haiti: One of the World’s Best Kept Secrets”, Synthesis/Regeneration: A Magazine of Green Social Thought, no. 53 (Fall 2010).

7. Ibid.

8. Ibid.

9. Escuela Latinoamericana de Medicina (ELAM), http://elacm.sld.cu/index.html (now at http://www.sld.cu/sitios/elam/).

10. Kirk and Erisman, Cuban Medical Internationalism, 3, 169, 112.

11. Ana Fernández Assán, Escuela Latinoamericana de Medicina (ELAM), http://elacm.sld.cu/index.html (retrieved July 8, 2010 – now at http://www.sld.cu/sitios/elam/).

12. Information on YAB was obtained from the interview with Ketia Brown and the document provided by Omavi Bailey: Yaa Asantewaa Brigade, August 15-September 5, 2010. African Medical Corps—Ghana Proposal. Latin American School of Medicine, Carretera Panamericana 3 ½ KM, Santa Fe, Playa, La Habana, Cuba CP 19142. For information on the Organization of African Doctors, see http://africanmedicalcorps.com. Though Cuba provides support to the Ghana Project, it needs additional funding. Donations can be made at http://birthingprojectusa.org.

13. Ibid., 2.

14. Cliff DuRand, “Humanitarianism and Solidarity Cuban-Style”, Z Magazine, November 2007, 44-47.

15. Interview with Ketia Brown and the document provided by Omavi Bailey: Yaa Asantewaa Brigade, 6.

16. Ibid.

17. Ibid., 7.

18. Linda M. Whiteford and Laurence G. Branch, Primary Health Care in Cuba: The Other Revolution (Lanham: Rowman & Littlefield Publishers, Inc., 2008), 2.

19. Escuela Latinoamericana de Medicina (ELAM), http://www.sld.cu/sitios/elam/.

20. Emily J. Kirk and John M. Kirk, “Cuban Medical Aid to Haiti”.

21. Brouwer, “The Cuban Revolutionary Doctor”.

22. Interview with Nancy Remón Sánchez, ELAM, May 30, 2010.

23. Interview with Wuilmaris Pérez Torres, May 30, 2010.

24. Interview with Ivan Angulo Torres, Havana, Cuba, May 31, 2010.

25. On the role of the consultorio in the Cuban health system, see Lee T. Dresang, Laurie Brebick, Danielle Murray, Ann Shallue and Lisa Sullivan-Vedder, “Family medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine”, Journal of the American Board of Family Medicine, vol. 18, no. 4 (July-August, 2005): 297-303.

26. Interview with Dr. Alejandro Fadragas Fernández and Maité Perdomo, Consultorio No. 5, Havana, Cuba, December 30, 2009.

27. Interview with Ketia Brown, ELAM, May 31, 2010.

28. Interview with Cassandra Cusack Curbelo, ELAM, January 23, 2010.

29. Interview with Anmnol Colindres, ELAM, May 26, 2010.

30. Interview with Amanda Louis, ELAM, May 28, 2010.

31. Interview with Dennis Pratt, ELAM, May 26, 2010.

32. Interview with Jonalisa Livi Tapumanaia, ELAM, May 28, 2010.

33. Interview with Lorine Auma, ELAM, June 2, 2010.

34. Interview with Keitumetse Joyce Letsiela, ELAM, June 2, 2010.

35. Lee T. Dresang et al., “Family Medicine in Cuba”.

36. Interview with Ivan Gomez de Assis, ELAM, May 27, 2010.

37. Interview with Walter Titz, ELAM, June 2, 2010.

38. Interview with Yell Eric, ELAM, June 2, 2010.

39. For detailed information on ELAM, current curriculum for US students, and an application, see http://pastorsforpeace.org.

40. Interview with Rebecca Fitz and Ivan Angulo Torres, Havana, Cuba, June 3, 2010.