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Learning Medicine the Cuban Way

The Bay Area is a hub for new doctors who want to practice family medicine and help the poor, yet had to leave the country to learn how to do it.



Melissa Rose Mitchell was discouraged. After taking the Medical College Admission Test, she was uneasy about applying to medical schools. In prep courses for the exams, she had glimpsed her future as a doctor, and she didn't like the environment she saw. "People were like, 'What kind of doctor do you want to be?' and it was all based on how much money you make," the Oakland resident recalled. "It was a really scary moment, because this thing that all my life I had wanted to do without question, all of a sudden I'm thinking, 'I don't know if I want to do this.'"

Mitchell had scraped together the money to prepare for and take the med-school admissions test, but even as she studied, she had begun to waver. "It had taken me over a year to save the $1,400 for the test and prep course and they said, 'We recommend that you apply to no less than twenty schools,' at about $200 each." And there were still the costs of plane tickets and a proper suit to interview at schools. She did well on the exams, but Mitchell was spending a lot of money to fulfill her goal of serving the poor.

But then her boyfriend saw a blurb in a church newsletter that appeared to assuage her growing worries. It was a unique offer to study in Cuba, the impoverished nation 90 miles from Florida that is internationally known for its training and use of doctors. She applied through the Interreligious Foundation for Community Organization in New York, a group whose mission is to "increase minority participation in medicine" and therefore increase the doctor-patient ratio for underserved areas.

Cuba began educating American medical students after members of the Congressional Black Caucus met with Fidel Castro in 2000. Congressman Bennie Thompson of Mississippi told Castro about areas in his district that suffer from extreme doctor shortages. The Cuban president responded by promising scholarships for 500 Americans to attend medical school in Cuba, under the umbrella of the Latin America School of Medicine. To qualify, the students would have to show aptitude and a commitment to work in underserved communities in the United States. Since then, 34 have graduated, and more than 160 are currently enrolled.

The Bay Area, it turns out, is something of a hub for the Cuba school of thought, where Cuba-trained students, unencumbered by the massive debt that plagues grads from US medical schools, have the luxury to do the kind of medicine that Cuba instructs — family medicine. The island's medical schools focus on nutrition and other preventative approaches. Cuba also is well known for its focus on the "social determinants of health."

The Cuban experience also may provide important lessons for our current health-care crisis. With a fifth of our per capita GDP, Cuba has health statistics comparable to those of industrialized nations. In the shabby, eroding, and commodity-deprived neighborhoods of Old Havana, Cubans also enjoy a better doctor-patient ratio than Americans: 59 doctors per 10,000 people compared to 26 for us.

Cuban life expectancy also matches that of the United States, its infant mortality rate is lower, and the island's HIV/AIDS transmission is among the lowest worldwide. Cuba's aggressive health-care delivery system also costs much less — around $200 per capita annually, compared to our $7,000. And it provides timely and primary care for every citizen — near universal accessibility. To the Cuban government, health care is a right.

This fact highlights a gap in the health-care reform initiative proposed by Congress and President Obama. Those currently without insurance, who will receive coverage with the bill, will feel the lack of family practitioners as basic care continues to be undervalued in favor of more profitable types of medicine.

At a White House forum early last year, the president spelled out the problem bluntly: "We're not producing enough primary-care physicians," he said, pointing to a daunting chain of obstacles. "The costs of medical education are so high that people feel that they've got to specialize."

According to the Association of American Medical Colleges, the average debt for a US medical school graduate in 2008 was $154,607. American doctors, as a result, feel forced to take up specialized practice, because ultimately the higher pay will ease their enormous student debt. Yet without enough primary care doctors, experts say, health-care costs grow exorbitant, end-stage care increases, and thousands of family practice residence positions go unfilled every year.

Doctors graduating in Cuba have no such excuse to specialize, and the island does not graduate members of an elite profession. Instead, it's a veritable doctor-producing machine with more than 70,000 physicians for a population of just 11 million.

And after medical school in Havana, Mitchell would return to the United States debt free.

Many students enter American medical schools wanting to do family care but get discouraged, said Dr. Richard Quint, retired faculty at UC San Francisco and a medical consultant to the Oakland nonprofit group Medical Education Cooperation with Cuba. American medical schools deem primary care as having secondary import, he contends. "The overall structure of our 'non-health system' is fragmented and skewed toward specialty practices," he said. "Faculty in medical schools make comments suggesting you shouldn't go into primary care because it's not stimulating or high-achieving enough." It also no secret that physicians are reimbursed highly for procedures and surgeries rather than for preventive medicine and diagnoses. And the need for primary care in underserved areas often doesn't make it into the textbooks or the classroom.

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