[Marxism] Affirmative Action, Cuban Style - New Eng. Journ. of Med. December 23, 2004

Ralph Johansen michele at maui.net
Fri Dec 24 14:53:03 MST 2004

New England Journal of Medicine  
Volume 351:2680-2682  December 23, 2004  Number 26 

sent by David McReynolds

What an irony that poor Cuba is training doctors for rich America,
engaging in affirmative action on our behalf, and - while blockaded 
by U.S. ships and sanctions - spending its meager treasure to improve 
the health of U.S. citizens.

Affirmative Action, Cuban Style

by Fitzhugh Mullan, M.D. 
"I feel as if I'm standing on the backs of all my ancestors. This is a
huge opportunity for me," Teresa Glover, a 27-year-old medical student,
told me during a recent visit to her medical school. "Nobody in my family
has ever had the chance to be a doctor." Glover's mother is a teacher, and
her father a dispatcher for the New York subway system. Her background is a
mix of African American, Barbadian, and Cherokee. She graduated from the
State University of New York at Plattsburgh. "I wanted to be a doctor, but
I wasn't sure how to get into medicine. I had decent grades, but I didn't
have any money, and even applying to medical school cost a lot." 

This young woman from the Bronx may be helping to rectify the
long-standing problem of insufficient diversity in the medical profession
in the United States. Twenty-five percent of the U.S. population is black,
Hispanic, or Native American, whereas only 6.1 percent of the nation's
physicians come from these backgrounds.1 Students from these minority
groups simply don't get into medical school as often as their majority
peers, which results in a scarcity of minority physicians. This inequity
translates into suffering and death, as documented by the Institute of
Medicine.2 Poorer health outcomes in minority populations have been linked
to lack of access to care, lower rates of therapeutic procedures, and
language barriers. Since physicians from minority groups practice
disproportionately in minority communities, they are an important part of
the solution to the health-disparities quandary. 

In her third year, Glover is negotiating the classic passage from the
laboratory to the clinic. But her school isn't in the United States. She is
enrolled at the Latin American School of Medicine (ELAM, which is its
Spanish acronym) in Havana - a school sponsored by the Cuban government and
dedicated to training doctors to treat the poor of the Western hemisphere
and Africa. Twenty-seven countries and 60 ethnic groups are represented
among ELAM's 8000 students. 

Glover's mother heard about ELAM from her congressman, Representative
José Serrano (D-N.Y.). "Mom calls me. 'I have news. There's a chance for
you to go to medical school.' She waits for it to sink in. 'You'd get a
full scholarship.' She waits again. 'But it's in Cuba.' That didn't faze me
a bit. What an opportunity!" 

The genesis of Glover's opportunity dates to June 2000, when a group from
the Congressional Black Caucus visited Cuban president Fidel Castro.
Representative Bennie Thompson (D-Miss.) described huge areas in his
district where there were no doctors, and Castro responded with an offer of
full scholarships for U.S. citizens to study at ELAM. Later that year,
Castro spoke at the Riverside Church in New York, reiterating the offer and
committing 500 slots to U.S. students who would pledge to practice in poor
U.S. communities. 

That day, 26-year-old Eduardo Medina was at his parents' house in New
York, listening to Castro's speech on the radio. "Castro announces that
Cuba has started a new medical school and has invited students from all
over Latin America to come, train, and return to treat the poor in their
countries. Then he starts quoting figures about poor communities in the
U.S. 'We'll be more than happy to educate American medical students,' he
says, 'if they'll commit to going home to take care of the poor.' The place
went nuts. I'm standing in my basement saying, 'Yes! Yes! Yes!'" 

Medina was raised in Brooklyn and Queens, the child of a Colombian father
and a mother of Puerto Rican, Jewish, and Irish descent - both
public-school teachers who pushed their children to work hard in school.
"When I was little, they sent me to a summer enrichment program in
Manhattan," recalls Medina. "I would travel on the subway every day with
this huge book bag. I was young and it was hot. But I was excited." The
work paid off, and Medina won partial scholarships to a boarding school and
to Wesleyan University. "There weren't many students of color at either
private school, particularly in the sciences," he says. "Culturally,
economically, ideologically, it was a real culture clash for me, but the
education was good." 

Medina was found to have diabetes when he was 12 years old and spent a
week in the hospital. "When I saw what the doctors could do for me, I knew
I wanted to be a doctor. In college, I spent a year in Ecuador, and I knew
I wanted to practice community medicine." But medicine wasn't going to come
easily. Medina had a mediocre grade or two in science courses, a middling
score on the Medical College Admission Test (MCAT), and $45,000 in student
debts. He worked as a research assistant to buy himself time to retake the
MCAT and organize his medical-school campaign. After hearing Castro, Medina
applied to ELAM and happily grabbed the chance to attend. "I didn't know if
I'd get into U.S. schools, and if I did, I had no idea how I was going to

There are 88 U.S. students at ELAM, 85 percent of them members of
minority groups and 73 percent of them women. Recruitment and screening are
handled by the Interreligous Foundation for Community Organization (IFCO),
a New York-based interfaith organization. Applicants are required to have a
high-school diploma and at least two years of premedical courses, to be
from poor communities, and to make a commitment to return to those
communities. Students who don't speak Spanish start early with intensive
language instruction. Glover and Medina get home about once a year. They
report that living conditions are spare and English textbooks hard to come
by, but they are well taken care of and the education is rigorous. 

The Bush administration's restrictions on travel to Cuba have been a
thorn in the side of the program from the beginning. Since the Cuban
government pays the students' room, board, tuition, and a stipend, the ban
was not initially applied to them. But the administration's further
attempts this summer to curtail Cuban travel threatened the students and
sent their families scrambling for political help. Representatives Barbara
Lee (D-Calif.) and Charles Rangel (D-N.Y.) led a campaign of protest, and
27 members of Congress signed a letter to Secretary of State Colin Powell
asking that the ELAM students be exempted from the ban. In August, the
administration relented and granted the students permission to remain in

The Cuban health care system in which these students are working is
exceptional for a poor country and represents an important political
accomplishment of the Castro government. Since 1959, Cuba has invested
heavily in health care and now has twice as many physicians per capita as
the United States and health indicators on a par with those in the most
developed nations - despite the U.S. embargo that severely reduces the
availability of medications and medical technology.3,4 This success clearly
plays well at home and has enabled Cuba to send physicians abroad to Cold
War hot spots such as Nicaragua and Angola. Yet Cuba has also sent
thousands of physicians to work in some of the world's poorest countries.
Since 1998, 7150 Cuban doctors have worked in 27 countries - on a
proportional basis this is the equivalent of the United States sending
175,000 physicians abroad.5 In the same spirit, ELAM trains young people
from these countries and sends them home to practice medicine. Although
these programs make political points for Cuba, they also represent an
extraordinary humanitarian contribution to the world's poor populations. 

The U.S. students face a hurdle that their classmates in Cuba do not. To
obtain residency positions in the United States and uphold their side of
the deal with Castro, U.S. students will have to pass two steps of the
United States Medical Licensing Exam (USMLE) and the new Clinical Skills
Assessment test. The first large group of ELAM students will take Step 1
later this year, and the results will be critical to the future of the

The ELAM invitation is not limited to minority students, although the
emphasis on coming from and returning to poor communities has naturally
selected students of color. Physicians from minority groups accounted for
only 3 percent of U.S. doctors during the middle years of the 20th century.
After the civil-rights movement, the number of minority medical students
increased steadily, rising to 11.6 percent of medical school graduates in
1998. Schools used scholarship money, academic enrichment programs, and
special admissions criteria to increase minority enrollment. In recent
years, such initiatives have flagged - victims of court decisions opposing
affirmative action, continued escalation of medical-school tuition, and a
supply of minority students that, in the judgment of some medical
educators, is tapped out. Today, roughly 11 percent of graduating medical
students are members of minority groups.1 

Glover, Medina, and their schoolmates have gotten into and mastered
strong academic programs despite their disadvantaged backgrounds. However,
half of all applicants to U.S. medical schools are rejected. By the
unforgiving standards of the application process, a C in a science class or
a so-so MCAT score dooms an applicant. Castro has removed the financial
barriers and bet on motivation to overcome any educational liabilities that
students bring with them to ELAM. 

Which brings us back to Castro's gambit. Why is he reaching out to U.S.
students? What an irony that poor Cuba is training doctors for rich
America, engaging in affirmative action on our behalf, and - while
blockaded by U.S. ships and sanctions - spending its meager treasure to
improve the health of U.S. citizens. Whether one considers this a cunning
move by one of history's great chess players or an extraordinary gesture of
civic generosity - or a bit of both - it should encourage us to reexamine
our stalled efforts to achieve greater racial and ethnic parity in American
medicine. If Castro can find diamonds in our rough, we can too. 

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