July 21, 2015: graduation day in Havana. / E. Añé
Call them intrepid trailblazers or just plain stubborn: over 200 US students, mainly from under-represented minorities and low-income families, decided they would become the doctors needed by their communities, and that Cuba’s Latin American Medical School (ELAM) would prepare them for the job.
In doing so, they accepted a host of challenges, not the least of which was studying in a country lauded for its population health indicators, but vilified for decades by their home government. Under President George W. Bush, even their enrollment required intercession from then Secretary of State Colin Powell and the Congressional Black Caucus, whose members represent districts with some of the poorest health indicators in the United States. Once they were accepted by ELAM, with its own hefty academic requirements, it was unclear if they could cope with living in Cuba, a poor country with limited resources. And then came the challenge of passing the US Medical Licensing Examination (USMLE), required of all US medical students to secure residency placements.
Added to these hurdles was another big question: would they actually serve in remote, inner-city and poor communities or just take the free medical education and abandon the social objectives cultivated by their alma mater?
ELAM’s concept is a simple but bold one: that providing free medical education to bright students driven to become doctors, but without the financial means to do so, will motivate them to return to serve in communities like their own. They spend six years learning basic sciences, clinical medicine and public health. Since the first graduation in 2005, ELAM has trained nearly 25,000 doctors—most women and many of them indigenous—from 84 countries, including the USA.
A decade after the first US graduate received his diploma from ELAM, 113 have followed. While most (especially recent) grads are still finishing their USMLE exams, 40% of the total are already in residencies or have completed them: of these, 90% have chosen to practice in three main primary care specialties—family medicine (61%), internal medicine (23%) and pediatrics (6%). Of US graduates already practicing, 65% work in Health Professional Shortage Areas (HPSAs) and/or Medically Underserved Areas (MUAs). The success of these doctors also helps destigmatize the Cuban program; US foreign medical graduates are often viewed as substandard, the assumption being that they studied abroad because they couldn’t get accepted anywhere else. But often, as in the case of ELAM-trained doctors, US medical education poses a financial, not intellectual, barrier to their training.
The Medical University of Havana is one of 14 medical schools in Cuba. At its July graduation ceremonies, diplomas were handed to over 1200 doctors from Cuba, Central and South America, the Caribbean, Africa, and Asia—including ELAM graduates, among them 21 from the United States.
MEDICC Review interviewed several US ELAM graduates as they readied to leave for home—Wyoming, Louisiana, Pennsylvania, Texas, Florida and elsewhere. They talked candidly about the advantages and challenges of studying medicine in Cuba, the licensing process for practice in the United States, and their plans for the future.
MEDICC Review: Did you always dream of becoming a doctor?
Tia Naquel Tucker: I always wanted to be a clinician, but didn’t have a positive experience in pre-med as an undergraduate—I was disillusioned with our medical education and health system in general. While I was in the Peace Corps in Morocco, we were doing a lot of health outreach and promotion and I realized what we need in the United States, especially in Louisiana where I come from, are public health programs.
Top, center. Dr Tia Naquel Tucker, MPH Tulane University, MD Latin American Medical School. / E. Añé
Jessica Lucey: My grandfather was the only doctor in a small Ohio town. He was my inspiration. But I didn’t see how I could be a doctor and help in the bigger picture. I discovered it was possible after reading Tracy Kidder’s book about Dr Paul Farmer Mountains Beyond Mountains. It sounds like such a cliché! How many doctors has Farmer motivated to pursue careers in public health? Yet his example showed me that I could be a doctor and help in the bigger, global health picture. To do that, I started looking at medical schools with a social justice approach—in Canada and France for example.
Nate Kratz: I didn’t always dream of being a doctor. Before coming to Cuba, I was agitating for social change, protesting and traveling. Medicine interested me—there’s always a need, all over the world—but I didn’t see how it fit with my social values.
MEDICC Review: What finally brought you here to Cuba, to ELAM, to study medicine?
Veronica Flake: When I learned about Cuba’s universal health system and the Latin American Medical School—they’re integrative, have a public and global health focus, and they’re free—I knew this is where I wanted to study. Back in Philadelphia, where I’m from, my friends and family were disconcerted at first. “Cuba?! Why Cuba?,” they asked me. But after I explained the public health approach here and finished my first year, they were completely on board.
Nate Kratz: I was living in the squatter’s community at the Autonomous University of Mexico [established in the 1960s by a group of students who occupied the Philosophy Department; today an alternative community and center for social justice—Eds.] where they invite speakers to talk about different issues and someone told me about ELAM. It struck me: a medical school where people from all over the world are working for real, tangible change is in line with my social values.
A few years later, I was deep in the Peruvian Amazon in a settlement of about ten houses—this was really remote jungle, anacondas in the trees and all—and a friend got sick. We went to the tiny health clinic and the doctor was wearing a lab coat with the ELAM insignia—a recent graduate. It was too serendipitous to ignore.
Jessica Lucey: I was looking for a medical school with a social justice approach, as I mentioned…I was pretty reckless actually: I withdrew my other applications and put all my eggs in the ELAM basket. Luckily I was accepted and came running to Cuba. That was six years ago and despite all the hard work and difficulties, I don’t regret it for a second: I love the ELAM program.
Tia Naquel Tucker: I was just as reckless! I was working at an HIV non-profit and one of my epidemiology professors told me about Cuba’s approach to HIV. At that time in the United States, the dialogue around HIV was focused on Ryan White and here were the Cubans, actually doing something to contain and control the virus. I was blown away. When I heard about ELAM —a school with students from around the world and professors who consider health a human right—I knew it was what I was looking for. I didn’t apply anywhere else; I said, “if I don’t get into the Cuba program, I’m not going to medical school.”
MEDICC Review: What’s it like to live and study in Cuba? The culture shock can be intense, I’m sure.
Jessica Lucey: At the beginning, you can’t even think about it being six years long. It’s too overwhelming—the day-to-day here can be frustrating. But you develop tools to survive. My survival strategy was to go to the library and take out every book written by doctors—I’ve read everything by Atul Gawande for example. This helped me stay focused on why I wanted to do this in the first place and reminded me of the magic of medicine.
Veronica Flake: Over the past six years, I’ve often thought: “will this ever end?!” You have days where it’s blazingly hot, you’re working long hours, missing family, and doubts creep in. Cuba definitely isn’t for the faint of heart. But everything started to click for me in fourth or fifth year—I realized I had solid clinical skills, I was performing physical exams and I thought: “I CAN do this, I AM capable.” Honestly, though, I’m ready for it to be over. I aced the practical and written exams [ELAM students take the Cuban licensing exams, as well as the USMLE—Eds.]. It’s surreal to wake up in the morning and not have to go to the hospital; it hasn’t sunk in that I’m actually done!
Nate Kratz: I’m one of two US graduates this year who entered ELAM without a university degree. I graduated high school and did several semesters at US universities before coming, but the learning curve was steep. At ELAM I had to learn how to study, take exams, use a scientific calculator—I’m not sure I ever successfully learned how to use it! But we had study groups and I consulted my professors when I had doubts. By year two, my grades qualified me to be a teacher’s assistant, where I gave night classes to first-year students.
For me, Cuba wasn’t a hard adjustment: I spoke good Spanish and I was coming from really tough living conditions, so I was prepared to live without water or electricity occasionally, broken toilets, and few comforts. And the ELAM atmosphere is intoxicating—it’s international, everyone is speaking Spanish and other languages, including indigenous, there’s so much enthusiasm; it aligned well with my ideals. Staying in one place for six years was new to me, but I loved it.
l. to r. Dr Nate Kratz, MD Latin American Medical School; Dr Veronica Flake, BA University of Pittsburgh, MD Latin American Medical School. / C. Gorry
MEDICC Review: Are there advantages to studying medicine in Cuba? Disadvantages?
Jessica Lucey: The brilliance of the Cuban health system is its structure. There’s a chronic shortage of resources, of course, but the community-based model—where there’s no separation between doctors and patients—is well designed and adaptable to the US context. Not everything we learned is applicable, but inserting primary care services in communities is. I should also mention the bio-psychosocial approach. This is how medicine is taught and practiced here; this is also applicable in the US context. And it’s not new: This was my grandfather’s experience as a small town family doctor.
I did an internship at a family clinic last summer in Magnolia, Mississippi, population 3000. And the difference between those trained in the USA and me was notable. The US-trained doctors were very knowledgeable about pharmacology and sophisticated diagnostic imaging—something I knew little about. On the other hand, I was light years ahead in hands-on clinical experience and how to interact and communicate with patients.
Tia Naquel Tucker: One advantage is learning and serving in a community-focused model. I love family medicine. I’m a family physician and think like one. As soon as a patient comes in to see me, I’m thinking about their social determinants, risk factors and everything else that might affect their health.
Nate Kratz: Cubans are very relaxed and friendly, which creates a positive learning atmosphere. They’re also extraordinarily medically literate—there’s a strong culture of health and medicine here. They’re willing to be examined by students doing clinical rotations, which is another advantage. Having a trainee doctor examine you can be uncomfortable, but Cubans—they want to help you learn.
Dr Jessica Lucey, BS University of St Andrew (Scotland), MD Latin American Medical School. / E. Añé
I remember the first patient I ever examined. I was in third year and there was a dengue epidemic. I’d learned the theory about how to treat dengue in class, but this was the first time I was examining a patient. She was in a lot of pain and was so kind as I examined her with my inexperienced hands. She showed so much grace and generosity. I was very grateful to her; it’s a moment I’ll never forget.
That same medical literacy Cubans have is one of the disadvantages: Everyone knows everything about medicine! They all know a doctor or are related to one, so they’ll disagree with your diagnosis or treatment. Patients here know how to advocate for themselves—sometimes it goes beyond advocacy. Some Cuban patients can be very demanding and you have to work with that.
Veronica Flake: During my first rotations, I did meet some patient resistance because I’m not Cuban. I was pretty self-conscious about it. But after a couple of years in rotations, I was more confident, I had more skills. I think my personality helped too: I would tell pushy patients kindly, but firmly: “You have to wait your turn in line” or “please knock, rather than barge in, I will attend to you as soon as I can.” And Cubans responded to my professionalism.
By fifth year, patients were asking specifically for me and by sixth year, during my OB/GYN rotation, I heard things like, “An American doctor was in the delivery room when my daughter gave birth!”
MEDICC Review: Would you recommend ELAM to other US students? What advice would you give them?
Veronica Flake: First, prepare for a very long journey. Being resilient and steadfast and having longterm vision are important to success at ELAM. Being ready and willing for a fair amount of personal growth are other qualities that serve well here. Cuba forces you to live outside your comfort zone so you need to be okay with that. In the USA, people tend to be very independent, but here, you need to depend on others—colleagues, professors, neighbors. Asking for help is a skill you’ll use all the time. And don’t shelter yourself: make Cuban friends, learn the bus routes, become a part of the community.
It’s also important to realize that Cuba will change you. You won’t change Cuba.
Nate Kratz: Absolutely. Studying at ELAM is an amazing, transformative experience. Over six years, I’ve watched my classmates—from different places and with different challenges—grow and learn. But not everyone can adapt to Cuba; I think we need a socially accountable medical school like ELAM in the USA. My hometown in Wyoming borders a Native American reservation and many of my childhood friends were from there. They have 70% unemployment, 40% of the population struggles with addiction—it’s a complex picture and an underserved area, with health professional needs. For traditional cultural reasons, young people from the reservation are unlikely to come to Cuba to study, but they might consider a similar school closer to home.
My best advice is rid yourself of expectations and preconceptions about what Cuba should be. Keep an open mind and open heart. Prepare for adventure!
Jessica Lucey: The conditions here are not for everyone and some students drop out because they find day-to-day living too hard. But other people thrive in Cuba—those who do Peace Corps, for example, have no trouble adapting to conditions here [Several US ELAM students and graduates are former Peace Corps volunteers—Eds.]. For those who stick it out, there are amazing advantages, like the clinical experience you get. I’d advise someone wanting to study here to soak up as much patient experience as possible. The practical, hands-on experience we get here is amazing.
Like Veronica, I’d advise future ELAM students to lean on your local support system. Once, a professor invited me to Christmas breakfast, which sounds weird (I’m not sure that would ever happen in the United States…), but he knew I was alone on this important family holiday and reached out. Learning here transcends the classroom, it transcends the clinical setting.
MEDICC Review: You’re graduating right now. What are your plans?
Nate Kratz: I’ve passed the first two steps of the USMLE and I’m headed to New York City to practice with a supervising doctor under the limited-license possibilities there. This is like a physician’s assistant and there are conditions and restrictions to this kind of license, but it will give me more clinical experience and provide me the chance to treat patients in English. Being bilingual also allows me to reach more patients. Then, afterwards, I want to enter a residency and specialize in internal medicine, then work internationally—there are underserved areas everywhere.
Tia Naquel Tucker: I’m committed to doing a family medicine residency in Louisiana. We have very poor primary care in my home state and family medicine tends to carry a stigma in the United States, so I know this is where I’m needed.
I have two dreams beyond residency: one is to open a health and wellness clinic in Louisiana that incorporates the comprehensive, bio-psychosocial approach we learned in Cuba. My vision is to provide primary health care services, of course, but also an exercise center, stress reduction and management programs, a kitchen to provide nutrition education—whatever the community defines as its needs. It will also be designed with sustainability at its core—something the Cubans are working to improve in their own health system.
Secondly, a group of US ELAM graduates wants to support our Latin American colleagues in their own efforts to establish family doctor clinics and we’ve talked about doing two-week rotations during our vacations in Peru and Honduras. Cuba estimates it costs about $US20,000 annually to run a family clinic in Latin America, and by providing the human resources on a volunteer basis, we would be helping our colleagues get started treating vulnerable communities.
Veronica Flake: I want to be a family doctor with a focus on global health and maternal/child health. As a family doctor, you get to see all sorts of patients, with all sorts of health problems. I think family medicine is amazing in its breadth. I imagine myself working with immigrant communities—maybe on the US–Mexican border or in South America. I’m not sure yet, but I definitely want to provide no- or low-cost health services to communities in need.
Jessica Lucey: I always wanted to be an OB/GYN, but my plans changed because I realized that if I became an OB/GYN, I wouldn’t be treating half the people I might. After studying here, I became fascinated with family medicine. Now I’m interested in doing family medicine with a focus on women’s health in inner-city Los Angeles (LA). There are many underserved areas there, with an immigrant population of between 60% and 80%.
So with Evelyn Gandara, another ELAM grad from LA, I dream of opening a family clinic there, with the community-based approach used in Cuba, sliding-scale prices, abortion services and the like. We have the cultural sensitivity, we speak Spanish and although there are many bilingual nurses, there are very few bilingual doctors. I feel we owe it to our community to provide accessible, sliding-scale health services.
To do this right, to make it effective for the community and sustainable, my colleague is pursuing a degree in business administration and I’m going for a degree in medical records and billing. We need this because a Cuban medical education prepares you for everything except how to run a business and how to treat gunshot wounds. Both of which we’ll need in Los Angeles!
Courtesy ELAM
