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 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-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 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 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. |