Elsevier

Public Health

Volume 122, Issue 6, June 2008, Pages 552-557
Public Health

Special focus – scaling up training and education
Going where no doctor has gone before: The role of Cuba's Latin American School of Medicine in meeting the needs of some of the world's most vulnerable populations

https://doi.org/10.1016/j.puhe.2008.03.001Get rights and content

Summary

Objectives: To explore the institutional ethics of Cuba's Latin American School of Medicine (ELAM). As a response to the aftermath of Hurricane Mitch in 1998, Cuba recruited over 11,000 students from marginalized communities in 29 countries to study medicine free of charge. ELAM's stated goal is for students to return to their home communities to apply their skills after a 6-year programme. The aim of this research was to determine if ELAM builds capacity for students to serve vulnerable communities in the global South.

Study design: This paper focuses on ELAM's selection process and curriculum in order to build understanding of its institutional ethics. Much has been written about how medical schools, in the North and South alike, do a great deal to build institutional ethics where graduates seek employment in urban and wealthy centres. By exploring ELAM's training programme, this study aimed to determine if the school is capable of forming an alternative ethic where graduates seek service to vulnerable populations.

Methods: First-person interviews with students, instructors, administrators and government officials were undertaken to build a sense of ELAM's institutional ethics. In addition, a literature review of ELAM's curriculum was conducted through documents obtained via Cuba's online web-portal ‘INFOMED’.

Results: Document analysis and first person interviews revealed themes of community oriented primary care (COPC), within ELAM's core curriculum and an institutional ethics of serving vulnerable populations in the global South. Students are taught the importance of practising prevention and health promotion at the community level, and alongside rigorous training in core clinical competency, students are to embrace COPC practices as part of their daily routines.

Conclusions: ELAM is an important human resource for health capacity building projects. While the quantity of ELAM graduates is remarkable, the importance of this project is the development of an institutional ethic that values success as a graduate's ability to serve the indigent. ELAM's ability to recruit students from vulnerable communities is impressive, and the emphasis of prevention and promotion frameworks at the community level is a badly needed pedagogy for the needs of vulnerable populations in the global South.

Introduction

In 1998, Cuba established the Latin American School of Medicine, ‘Escuela Latinoamericana de Medicina’ (ELAM), to offer students from the region affected by Hurricane Mitch, which struck Central America that year, the chance to study medicine free of charge so that they could eventually practice it at home. ELAM quickly expanded its offer to students from 29 different countries, most of who come from rural areas and from modest means. By 2005, ELAM had recruited over 11,000 students and 1610 had graduated.1 It is a medical school exclusively for foreign students, with all services, books, accommodation, food and necessities covered. The students’ only debt upon graduation is a moral commitment to offer their services in their home country, preferably in underserviced communities.

ELAM is unique in the sense that its students receive an education centred entirely towards an ethical commitment to serve the destitute. Using important principles of empowerment theory,a ELAM builds capacity among its students so they may eventually create broader organizational changes to health care in the locales in which they practice. It is hoped that when the graduates return to the field, they will be able to practice in clinics and treat preventable health problems through community-orientated primary care (COPC).b

Increasing public accessibility to health care, especially in marginalized communities of the global South, goes against current neoliberal trends that limit access to human resources for health to those able to pay for their services. The World Health Organization's 2006 report2 and the People's Health Assembly3 called for a reversal to this trend so that human resources for health can be made available to vulnerable communities in the global South regardless of their ability to pay. ELAM is a fitting example of building the appropriate capacity to meet the needs of such communities.

From engaging both students and graduates, it is clear that they are committed to practising medicine as a service and to promoting COPC as a counter-hegemonic action against neoliberal healthcare structures. While ELAM has already done well in receiving thousands of students,c its institutional ethics make for an important contribution to scaling up human resources for health. However, ELAM graduates will face tremendous difficulties in bringing their unique training, ethics and compassion into existing structurally reformed medical systems. Understanding the values loaded into this medical education can build dialogue regarding how to enhance and sustain primary care at the community level throughout the global South.

Section snippets

Methods

This study was based on document analysis from ELAM's course texts, papers prepared for Cuba's Ministry of Health (MINSAP) that suggest curriculum improvements, and first-person interviews with students, graduates, teachers and administrators. Interviews with students and teachers were conducted in Havana and Cienfuegos. Graduates were contacted in various locations in Ecuador. Administrators were consulted during an international research delegation organized by the non-governmental

Results

ELAM's institutional ethics value the success of its graduates through their ability to apply their skills in vulnerable communities and to meet the needs of indigent people. Themes of service, prevention and promotion at community level run through ELAM's programme of study. The combination of training in clinical skills that allow graduates to cope in environments with poor resources and a lack of social support, and the ethical commitment to meet the needs of the vulnerable come together as

Cuban medical internationalism

It is important to understand the events that led up to the creation of this unique medical school. While the school was established in reaction to the aftermath of Hurricane Mitch, which claimed over 30,000 lives in Central America, it is an accumulation of trends in Cuban foreign policy and community-based primary care.

Since 1961, Cuba has sent medical brigades to war-torn regions of Africa and post-natural disaster regions in Latin America, and, recently, brigades have gone to work in

What is ELAM?

As of July 2006, ELAM was comprised of about 9970 students from 28 different countries. That year, the ELAM campus housed 3891 students in pre-med, Year 1 and Year 2. The 5038 ELAM students in Years 3–6 are trained alongside Cuban medical students in 13 separate faculties of medicine across the country in addition to eight teaching facilities in Havana. ELAM students constituted roughly 90% of Cuba's total 13,000 international medical students.

About half of the ELAM student body studied in

The recruitment process

While receiving health professionals from the USA as part of the 2007 MEDICC delegation, ELAM's senior officials stated that the school is able to recruit individuals who want to return to their home communities rather than seek out lucrative gains. The officials commented that the students come with convictions of wanting to serve the poor; they have come from humble means, and when they arrive at the school, ELAM trains them in public health and clinical competency for communities with hollow

The curriculum

The cornerstone for the Cuban curriculum is the two volume set by Alvarez Sintes,12Temas de Medicina General Integral(Themes in General Integrated Medicine). The curriculum's emphasis is on the social and environmental determinants of health, as well as epidemiology. Chapters such as community health, epidemiology in primary care, demographics, communication and research methods have a dedicated focus on how to recognize and measure health determinants at the community level.

The text is

The pedagogy

For ELAM to produce a ‘new kind of doctor’, a new kind of professor is required. ELAM's Vice-Director, Midalys Castilla Martínez, emphasizes that the instructors have a teaching ethic to make students feel that they are involved in the process.17 Participatory teaching practice shows students that they are they are confident to use their acquired skills successfully. It is an important part of the pedagogy, considering that many students have come from harrowing conditions, and are expected to

Conclusion

ELAM is an important contributor in emboldening human resources for health on a global scale. While the volume of graduates it produces is an important contribution, the strength of this project is its development of an institutional ethic that values success as a graduate's ability to serve the indigent. Its ability to recruit students from vulnerable communities is also exceptional, and the emphasis on prevention and promotion frameworks at the community level is a badly needed approach for

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