This article originally
appeared in the New
England Journal of Medicine, and was republished in Portside.
"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.
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. 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
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-NY). "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-MS) 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
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
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 pay."
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 Cuba.
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. 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. 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 program.
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.
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.