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When it comes to preventative care, the shortcomings in American medical education mirror the failings in our health-care system as a whole. "There's nothing the Cubans are doing that people couldn't think of here — it's just they are looking upstream" at prevention, explained Dr. Lynn Berry, chronic disease program manager at Oakland's Highland Hospital, who has conducted research in Cuba.
Berry pointed out that Alameda County has "pretty strong" community health care. "We have La Clínica de La Raza, the Ethnic Health Institute, Native American Health Services," which emphasize prevention and education to avoid the costs, medical and financial, of end-stage care. But "ours is a market system," Berry said, a system "organized around insurance and payer source, not necessarily the long-term health of the patient."
Cuba redesigned its medical system out of financial necessity following the collapse of the Soviet Union. Faced with a supply crisis brought on by the lack of Soviet funding, Cuba revamped its medical education system towards primary care. By the mid-Nineties, they had established a comprehensive neighborhood-based family medicine standard: a consultario (neighborhood clinic) in every locale, and a revised medical school curriculum to embed family care into the model.
The island's health care starts with a top-down mandate for a "bottom-up" approach to health care. Too poor to rely on high-tech equipment or expensive, invasive procedures, the Cuban model stresses prevention and spreads health-care responsibility beyond doctors — into schools, work sites, and neighborhoods. A national network of polyclinics ensures the mandate. People in all walks of life are expected to cooperate in health publicity campaigns and other measures to prevent disease.
The United States' fifty-year-old embargo on goods to the island also has played a role in shaping Cuba's medical care system. The embargo prohibits or restricts the sale of some medical equipment and punishes other countries that deliver essential cargo. Drugs and medical supplies are sporadic, especially in Cuba's rural areas, where clinics work with outdated X-ray machines. And because US pharmaceutical companies develop most major new drugs, Cuban physicians don't have access to many new medicines on the world market. Countries like Spain and Venezuela donate, but routine medical supplies remain scarce or absent from some Cuban clinics.
Still, Dr. Davida Flattery, an internist at Highland Hospital, was struck by Cuba's "bottom-up" approach when she observed their health system last year. "What really impressed me about Cuba was their focus on the non-medical determinants of health," she said. It's standard in Cuba, she added, to engage the psycho-social factors of a patient — level of sanitation, presence of abuse or addiction, and food habits. Doctors and nurses, in fact, make home visits to evaluate these things personally.
Americans trained in Cuba see firsthand the glaring differences between the two medical education systems. Melissa Rose Mitchell learned, for example, that Cuba highlights rural medicine. "In lots of situations the professor will ask, 'What's the best test?' We'll say 'CT scan, ultrasound.' They'll say 'Well you don't have ultrasound, you're in the middle of nowhere, in the mountains, you have no electricity or phone. ... What are you going to do?'"
Many past and current students of the Latin American School of Medicine in Havana, where Mitchell attended, had lived or worked in poor and underserved neighborhoods in the United States, and were chosen to study in Cuba so they could take what they learned back home. And their Cuban education equipped them to deal with health problems of the poorest communities in the United States far better than if they had gone to Harvard.
Havana medical students, for example, are trained to stabilize people in places with no electricity or potable water. One might think those skills irrelevant in the wealthy United States, but a number of poor American communities have come to resemble sections of Third World countries — especially after a disaster (see Hurricane Katrina).
The lack of doctors in America's neediest communities is exactly what the Interreligious Foundation for Community Organization wanted to remedy as they began recruiting for the Cuban scholarships. The resulting program also is quite diverse — far more diverse group than any US med school. The majority of students in Latin American School of Medicine in Havana are African Americans from New York or California, 85 percent are minorities, and 73 percent are women.
And most of the students are trained as "médicos de la familia," or family practitioners. But, as the students saw, medical supply shortages plague the system, and despite diabetes intervention and screening programs in schools and workplaces across the country, the Cuban national diet remains high in fat and sugar. Like the US poor, Cubans don't have easy access to fresh fruits and vegetables — or the habit of eating them — and this hinders their health. Cuba's food distribution system from the countryside to the cities is substandard. The nation imports more than 50 percent of its food.
Mitchell said the training and experience suited her. "They train us just like they train Cubans," she said. "Every Cuban, regardless of specialty, has to do two years of family medicine. Until you can deal with basic, vital situations, you are not allowed to mess with other parts of the body."
After graduating last summer, Mitchell settled in Oakland to work and prepare for the boards, but she says her calling is rural medicine. She used her summer breaks from medical school, in fact, to work in a mobile health-care clinic serving rural populations outside of Birmingham, Alabama, a conservative city with stark wealth disparities. "Every two weeks or once a month, this clinic on wheels visited parts of the state where some of the houses did not have electricity or indoor plumbing. Not because it couldn't be gotten, but because people didn't have the money to invest in it." When asked if the poverty compared to that of rural Cuba, she responded: "The poverty was more intense" in some areas of rural Alabama than in rural Cuba, she said, "because there were no social services."