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.

“Un dolor caliente y penetrante atravesó mis huesos. No podía estirar mis piernas y los deseos de vomitar eran constantes. Me tomé los analgésicos y usé la medicina tradicional como las compresas de hojas sobre mis piernas. Hasta que ellos no hicieron el estudio no supe que tenía mis riñones dañados”. Manuel Antonio Portillo, 46 años de edad, Las Brisas, Departamento de San Miguel.

“Ellos me hicieron un chequeo completo en el hospital [como parte del estudio] y mis resultados estaban todos bien, excepto los relacionados con mis riñones; tenía una enfermedad crónica renal, en fase 3. Para mí no es fácil seguir las recomendaciones de mi doctor aquí en el campo porque nuestro trabajo es muy duro y la jornada laboral muy larga”. Roberto Reyes, 43 años de edad, Nueva Esperanza, región del Bajo Lempa.

The US National Institutes of Health predict climate change will cause an additional 250,000 deaths between 2030 and 2050, with damages to health costing US$2–$4 billion by 2030. Although much debate still surrounds climate change, island ecosystems—such as Cuba’s—in the developing world are arguably among the most vulnerable contexts in which to confront climate variability. Beginning in the 1990s, Cuba launched research to develop the evidence base, set policy priorities, and design mitigation and adaptation actions specifically to address climate change and its effects on health.

Two researchers at the forefront of this interdisciplinary, intersectoral effort are epidemiologist Dr Guillermo Mesa, who directed design and implementation of the nationwide strategy for disaster risk reduction in the Cuban public health system as founding director of the Latin American Center for Disaster Medicine (CLAMED) and now heads the Disasters and Health department at the National School of Public Health; and Dr Paulo Ortiz, a biostatistician and economist at the Cuban Meteorology Institute’s Climate Center (CENCLIM), who leads the research on Cuba’s Climate and Health project and is advisor on climate change and health for the UN Economic Commission for Latin America and the Caribbean (ECLAC).

Neonatologist Dr Fernando Domínguez served two years in a remote municipality of Cuba’s Guantánamo Province upon graduation from medical school in 1973. Continuing his commitment to vulnerable populations, he joined the Cuban team in the Democratic Republic of the Congo, serving as a family doctor attending neonates and children. After returning to Cuba, he completed his pediatric residency and later became head of the neurodevelopment department at Havana’s Ramón González Coro University Maternity Hospital, where he has worked for over three decades.

Dr Domínguez holds a doctorate in medical sciences, and since 1995 has served on the board of the Cuban Society of Pediatrics, where he was President from 2005-2011. He is also a member of the Ministry of Public Health’s National Bioethics Commission; President of the Scientific Council of the Manuel Fajardo Medical School; on the Executive Board of the Latin American Association of Pediatrics; and a member of the Permanent Commission of the International Pediatric Association (IPA). Since 2010, he has served on IPA’s Commission for Child Environmental Health and is the Editor-in-Chief of the pediatric section of Infomed, Cuba’s national health portal.

David, Daniel y Diego, los tres ¨Ds¨, nacieron a las 32 semanas por cesárea en la provincia oriental de Granma en Cuba. Ellos pesaron entre 1 520 y 1 780 gramos cada uno. Su madre, Dayanis Díaz, no producía leche suficiente para sus trillizos y tan solo 24 horas después de su nacimiento, estaban siendo alimentados con leche pasteurizada del banco de leche humana del hospital. Durante un mes, los tres Ds fueron alimentados con esta leche donada hasta que Dayanis comenzó a producir leche suficiente, momento en el cual su leche suplementaba la del banco de leche. Poco después, los trillizos fueron dados de alta, con un peso de 2 500 gramos. “Todos los días doy gracias por la paciencia, la comprensión y el apoyo del equipo del banco de leche”, dice Dayanis.

En Santiago de Cuba, Jorge Rodríguez nació prematuramente, con bajo peso, y estuvo en estado crítico durante los primeros días. Trágicamente, su madre murió al dar a luz y el equipo de neonatología comenzó a alimentarlo con leche del banco local. Después de tres meses, estaba suficientemente sano como para irse a casa “gracias al banco de leche humana y el espíritu voluntario de las donantes. Estamos muy agradecidos”, dice el padre de Jorge.

A hot, piercing pain ran through my bones. I couldn’t stretch my legs and got nauseated a lot. I took painkillers and used traditional medicine like leaf compresses on my legs. It wasn’t until they did the study that I found out I had renal damage.” Manuel Antonio Portillo, 46 years old, Las Brisas, San Miguel Department.

“They did a full check up in the hospital [as part of the study] and my results were all fine—except they discovered I have chronic kidney disease, stage 3. It’s not easy following all my doctor’s recommendations out here in the fields: our work is hard and our days long.” Roberto Reyes, 43 years old, Nueva Esperanza, Bajo Lempa region.

Concebir, desarrollar, mantener y perfeccionar un sistema de salud universal es una tarea extraordinariamente compleja. Para su implementación efectiva se necesita tanto de voluntad política, aplicada de forma consistente y estratégica, como de datos y análisis epidemiológicos precisos, además de una educación médica de calidad y de la participación activa de la población. Sin embargo, también hacen falta recursos —financieros, tecnológicos, farmacéuticos y profesionales— un reto continuo para una pequeña nación insular sometida a restricciones económicas, como es el caso de Cuba. De hecho, incluso algunos países altamente desarrollados, como los Estados Unidos, no han alcanzado aún una cobertura universal de salud.

David, Daniel, and Diego were born at 32 weeks via caesarean section in Cuba’s eastern province of Granma—they weighed between 1520 and 1780 grams each. Their mother, Dayanis Díaz, wasn’t producing enough milk for her triplets and just 24 hours after birth, they were being fed with pasteurized milk from the hospital’s breast milk bank. For a month, the three Ds were nourished with this donated milk until Dayanis started lactating sufficiently, at which point her own milk supplemented that from the milk bank. Shortly thereafter, the triplets were discharged, weighing in at 2500 grams. “Every day I give thanks for the patience, understanding and support of the milk bank team,” says Dayanis.

Las estadísticas tienen la capacidad de asombrarnos: en Cuba, el suicidio es una de las diez primeras causas de muerte y el 25% de las personas que acuden a las instalaciones de salud han sido diagnosticadas con depresión. Casi el 25% de todos los cubanos adultos fuman y, a pesar de que actualmente disminuye el hábito de fumar, se ha alcanzado un pico de fumadores del 31% en hombres y en la población negra. A su vez, el 25% de los ingresos en las salas de emergencia en Cuba resultan positivos para el alcohol, y hay una lenta tendencia al aumento del consumo de alcohol entre las cubanas de 15 a 24 años de edad.[1-3]

La Conferencia Internacional de Alma-Atá sobre la Atención Primaria de Salud marcó un punto decisivo en la salud mundial: un consenso que fue difícil de ganar estableció el servicio de salud como un derecho humano y la atención primaria accesible como fundamental para alcanzar la meta de ‘salud para todos’, y especialmente, para ir cerrando la brecha entre países ricos y pobres. En ese momento, Cuba ya había transformado su propio enfoque de salud, con la adopción de un sistema de salud pública único y universal, mediante el diseño de una atención primaria basada en servicios de salud en la comunidad. Pero justo después de la reunión de Alma-Atá fue que Cuba lanzó su más audaz reforma en la atención primaria de salud: el Programa del Médico y la Enfermera de la Familia. Introducido en 1984, el programa se expandió rápidamente, ubicando médicos y enfermeras en los barrios y en las zonas rurales por toda Cuba. Los equipos eran responsables de la salud de una población definida geográficamente y reportaban a un policlínico local. Su tarea era implementar una estrategia de servicios integrados, orientados a la comunidad, con énfasis en la prevención, la promoción de salud, la participación pública y la responsabilidad del paciente.

A stranger proffers a smile. A friend tells a joke, eliciting a hearty laugh. Without realizing it, you’re singing along to a song on the radio. Who hasn’t felt the pick-me-up of a smile, song, or laugh? In 1971, Dr Hunter “Patch” Adams, (with tongue firmly in cheek), founded the Gesundheit Institute to promote laugh therapy as an important component of comprehensive clinical practice. Once considered an unconventional—and in some circles, unconvincing—approach, today, this method is taught and employed in countries as diverse as Russia, the United States, Afghanistan and Cuba.

Erratum:

The following erratum has been corrected in all versions of this article:

Page 15, photograph: caption should read “Reyna (AKA Mantequilla), a professional actor and clown, in the Therapeutic Clowns International workshop at the William Soler Pediatric University Hospital.”

Statistics have the capacity to startle: in Cuba, suicide is one of the top ten causes of death and 25% of people presenting in health facilities have been diagnosed with depression. Almost 25% of all Cuban adults smoke, and while smoking overall is on the decline, the figure spikes at 31% for both men and black Cubans. Meanwhile, 25% of those admitted to Cuban emergency rooms test positive for alcohol use and there’s a slow upward alcohol consumption trend among Cuban women aged 15–24 years. [1–3]

In April 2013, a consortium of regional health ministries, nongovernmental organizations, aid agencies, clinical specialists and researchers from diverse sectors convened in San Salvador to discuss the epidemic of chronic kidney disease of unknown or non-traditional causes (CKDu) plaguing agricultural communities in Central America and beyond. The three-day meeting, where presentation of research on the clinical and epidemiological characteristics of CKDu roused significant debate, led the Pan American Health Organization to declare CKDu “a pressing and serious health problem [which] represents a burden for families, communities, health systems and society as a whole.”[1]

This High-level Meeting on Chronic Kidney Disease of Non-Traditional Causes in Central America (24–26 April) followed several international meetings at which Dr María Isabel Rodríguez, El Salvador’s Minister of Health, presented studies on the disease burden in her country, where end-stage renal disease is the leading cause of hospital deaths. She outlined results of original scientific research by Dr Carlos Orantes (first published in MEDICC Review), that described an “elevated prevalence of chronic kidney disease, chronic renal failure and risk factors” among the patients studied, noting that “the most common [form] was chronic kidney disease of unknown cause, associated with neither diabetes nor hypertension.”[2]

In this interview with MEDICC Review, Dr Rodríguez discussed the gravity of the problem in Salvadoran agricultural communities; the importance of CKDu research in other countries; and the urgent need for intersectoral action and active community participation to confront and control the epidemic.

The Alma-Ata International Conference on Primary Health Care was a watershed in global health: the hard-won consensus established health care as a human right and accessible primary care as fundamental to ‘health for all,’ and especially to closing the gap between rich and poor countries. At the time, Cuba had already transformed its own health approach by adopting a single, universal public health system, and by devising primary care based on health facilities in the community. But it was on the heels of the Alma-Ata meeting that Cuba launched its most daring reform in primary health care: the Family Doctor-and-Nurse Program. Introduced in 1984, the program expanded rapidly, posting doctors and nurses in neighborhoods and rural areas across Cuba. The teams were responsible for the health of a geographically defined population and reported to a local polyclinic. Their task was to implement a strategy of integrated, community-oriented care emphasizing prevention, health promotion, public participation and patient responsibility.

Conceiving, building, maintaining and refining a universal health system is an inordinately complex undertaking. Its effective implementation requires everything from political will consistently and strategically applied, to accurate epidemiological data and analysis, plus quality medical education and active citizen participation. It also takes resources—financial, technological, pharmaceutical and professional—a perennial challenge for a small, economically-constrained island nation like Cuba. Indeed, even some highly developed nations like the United States have yet to achieve universal health coverage.

The following erratum has been corrected in all versions of this article.

Sánchez A, Gorry C. Immunodiagnostics: The Convergence of Biotech and Public Health. MEDICC Rev. 2013;15(1):7–10.

Page 7, Table 1, Cuban Immunoassay Technology in the National Public Health System, in row heading “Ectopic pregnancy and trophoblastic disease (human chronic gonadotropin),”  “chronic” should be “chorionic.”

After graduating more than 12,000 doctors since its founding in 1999, Cuba’s Latin American Medical School (ELAM, the Spanish acronym) is tackling one of its greatest challenges to date: how to track graduates from over 65 countries and measure their impact on health outcomes and policy in their local contexts?