The Social Medicine Portal

Studying Medicine in Cuba: The Experience of two US Students

In a posting dated March 23, 2008, we wrote about the Cuban government’s offer of medical scholarships to US students: How US students can get a free medical education in Cuba. We have just published an article by two American students studying in Cuba: Razel Remen and Lillian Holloway. They discuss their experiences at the Latin American Medical School (known as ELAM for its Spanish initials). The article is found in the July, 2008 edition of Social Medicine. It begins:

“Introduction

The health of the world’s population is divided into two groups, those who have access to health care services and those who do not. The effects of this divide can be seen on the international level where life expectancy in Switzerland averages 80 years as opposed to 38 years in Zambia. Infant mortality rates are often used as a general indicator of health and socioeconomic conditions since rates are affected by factors such as access to perinatal health care. A direct relationship has been shown between higher income and education level and lower rates of infant mortality. This may explain in part an infant mortality rate of 4.5 per 1,000 live births in Connecticut in comparison with 12.2 in the Washington, DC area.

A major influence in access to services is the availability of trained health care workers. The World Health Organization estimates that the world will need at least 4,250,000 additional health workers to address these health disparities. In the face of this work force crisis we are left wondering how to fill in the gaps left by the mass exodus of health workers from developing nations to industrialized ones.

Cuba has tried to address these problems by sending thousands of healthcare professionals to work in some of the most impoverished and medically underserved regions in the world. Over the years, their attempts have evolved to include training professionals from underserved areas to provide enduring sources of health care for their populations. Perhaps the most valiant of efforts was the creation of the Latin American School of Medicine in Cuba (called ELAM, Escuela Latinoamericana de Medicina), which currently is training over 10,000 students from at least 27 countries, including the United States. Despite ELAM’s impressive numbers, its founders recognized that solutions to what has become a global health care crisis depend not only on the number of physicians produced but also on how they are trained as providers of care. To that end training is oriented toward primary care, public health and hands-on clinical experience. Perhaps no one can speak better about the training at ELAM than the actual students sitting in its classrooms. The following is a student perspective on ELAM and its educational program highlights, as viewed by two of its North American students.”

To read the rest of the article, please click here.

-posted by Matt Anderson

Social Medicine Vol 3 No 2: Progressive Health Reforms in Latin America

We have just published Volume 3, Number 2 of Social Medicine. The full table of contents in available on line. Here is some information about the articles:

Earlier this year we invited Asa Cristina Laurell, a prominent Mexican public health activist to prepare a special issue on progressive health reforms in Latin America. Dr. Laurell was the head of the Mexico City Health Department from 2000-2006 and - had the Mexican elections not been stolen by the right - she would currently be Mexico’s Minister of Health. She contributed a paper describing the Health Department’s experience with providing free medicines and medical care to people who did not qualify for coverage under Mexico’s employment-based Social Security System. Other papers examine Brazil’s Unified Health System, the SUS, which is one of the world’s largest public health systems; the Venezuelan attempts to provide free health to the all citizens with assistance from the Cubans; Uruguay’s moves to a public-private system that will guarantee the right to health; and finally Bogota’s experience with providing poor communities with access to health care through the Health at Home program.

American readers may be particularly interested in the article by Razel Remen and Lillian Holloway, two US students studying medicine at the ELAM school in Havana Cuba.

We publish two articles of original research. A Hong Kong team reports on public attitudes during the SARS epidemic in 2003, while Dr. Paula Acevedo presents data on reproductive patterns among Latin American immigrants in Spain.

Sadly, we publish the last article written by Edmundo Granda, one of the founders of ALAMES, the Latin American Social Medicine Association. He passed away in April of this year. He approved the final galleys of the Spanish version of his paper via blackberry from the hospital on the week he died. His paper considers the historical trajectory of ALAMES and where Latin American Social Medicine may be heading.

Finally, Dr. Lanny Smith interviews Chilean activist Victor Toro, a political refugee from Pinochet’s Chile, who is now facing deportation from the US, his home of nearly 2 decades. Ironically, he has been a immigrant rights activist (and patient of Dr. Smith) in the Bronx, New York, for most of these years. His account of becoming ill in an ICE detention facility mirrors the concerns discussed in our July 10^th posting about Dr. Homer Venters.

Posted by Matt Anderson

Robert Greifinger (Social Pediatrics 1976): Public Health Behind Bars

What does a social medicine doctor do?

Robert Greifinger, an RPSM graduate in Social Pediatrics in 1976, has been extensively involved in examining the prison system from a public health point of view. Last year, he published Public Health Behind Bars: From Prisons to Communities, the title of which suggests his social conception of the problem of prisons and health. He is currently an adjunct Professor at the John Jay College of Criminal Justice. Previously, he was the Chief Medical Officer for the New York State of Correctional Services, which was responsible for the health care of 68,000 inmates.

Public Health Behind Bars: From Prisons to Communities was favorably reviewed in the New England Journal of Medicine in May and in the Journal of Urban Health in April.  It will be reviewed in the July issue of the Journal of Correctional Health Care [14(1) July 2008 pp. 232-235].

The health of prisoners and the impact of mass incarceration on the communities we serve is an area of very interest in the DFSM.

Here is the description of the book from the publisher’s website:

• Prisoner reentry is a topic of current interest in correctional and public health
• Coverage includes both health care and topics in law and public policy
• Contributors are experts from such fields as public health and correctional health

Projecting correctional facility-based health care into the community arena, Public Health Behind Bars: From Prisons to Communities examines the burden of illness in the growing prison population, and analyzes the considerable impact on public health as prisoners are released. More than forty practitioners, researchers, and scholars in correctional health, mental health, law, and public policy make a timely case for correctional health care that is humane for those incarcerated and beneficial to the communities they reenter. These authors offer affirmative recommendations toward that evolutionary step.

Chapter authors identify the most compelling health problems behind bars (including communicable disease, mental illness, addiction, and suicide), pinpoint systemic barriers to care, and explain how correctional medicine can shift from emergency or crisis care to primary care and prevention. In addition, strategies are outlined that link community health resources to correctional facilities so that prisoners can transition to the community without unnecessarily taxing public resources or falling through the cracks. Between the authors’ research findings and practical suggestions, readers will find realistic answers to these and similar questions:

• Can transmission of HIV, tuberculosis, and other communicable diseases be reduced and prevented among prisoners?
• How can correctional facilities treat addiction more effectively?
• What can be done to improve diagnosis and treatment of psychiatric disorders?
• Can correctional care benefit from quality management and performance measurement?
• How can care be coordinated between correctional and community health care providers?
• What are the health risks to communities if action is not taken?

Public Health Behind Bars: From Prisons to Communities is a challenge of immediate interest to readers in correctional health and medicine, public and community health, health care administration and policy, and civil rights.

posted by:Matt Anderson

Yeshiva University’s Institute for Public Health Sciences

Last Tuesday (7/8/2008) brought Dr. Jonathan Tobin from Yeshiva University’s Institute for Public Health Sciences to Social Medicine Rounds. He came to lead a showing and discussion of the PBS documentary Unnatural Causes: Is Inequality Making Us Sick? Dr. Tobin is well-known in the public health community for his work as head of the Clinical Directors Network, Inc (CDN). CDN is a “not-for-profit network that supports community-based health centers, including their patients, practitioners and organizations.” The CDN website is full of clinical resources relevant to the work of Community Health Centers in the US.

Dr. Tobin’s visit was an opportunity for us to learn something about Yeshiva’s Institute for Public Health Sciences. The Institute is currently awaiting certification from New York State to offer a Master’s level degree in Public Health as well as a Certification of Public Health training. At the present time they are sponsoring educational activities, which have included a public health grand rounds series and a 14-session course on public health approaches to obesity. In September of 2007, they hosted a two day conference on Diversity & Disparity in Health and they are interested in forming academic think-tanks to look at particular health problems in a multi-disciplinary way. These activities are all posted on their website.

Homer Venters (RPSM IM 2007) on Immigration Detainee Health Care

What do Social Medicine doctors do?

Dr. Homer Venters, a 2007 RSPM Internal Medicine Graduate, is currently working as an Attending Physician at the Bellevue/NYU Program for Survivors of Torture and is a Public Health Fellow, New York University. During his residency at Montefiore, Dr. Venters worked with Bronx Defenders, a legal aid organization in the Bronx, helping to get people involved in the criminal justice system into primary care. This work resulted in the publication of an article about the tragic case of Scott Ortiz in the Harm Reduction Journal. His work as a resident was awarded the Dan Leight Social Medicine Award.

On June 4 2008, Dr. Venters testified in front of the House Judiciary Committee’s Subcommittee on Immigration, Citizenship, Refugees, Border Security, and International Law. He discussed problems with the medical care provided to Immigration and Customs Enforcement (ICE) detainees. It is clear to people working in the field that ICE detainees are not accorded the same medical care provided to other US prisoners. Dr. Venters outlined some of the reasons why. Specifically he pointed out that the ICE medical system is designed to care for acute problems; it is not set up for persons with chronic medical issues. To quote from his testimony:

“This institutional aversion to caring for detainees with chronic disease is evidenced in recent detainee deaths. One year ago, a 23 year old transgender woman, Victoria Arellano was detained by ICE. Ms. Arellano had AIDS and was taking a life saving medicine to prevent opportunistic infections that could quickly cause pneumonia and death were she to stop. These medicines are essential for people with AIDS and even a brief interruption risks sickness and death for a patient. Despite reporting her medical history and her medication when detained (and throughout her detention), Ms. Arellano was refused her medicine. Over the following weeks, Ms. Arellano developed a cough and fever, which should have prompted hospitalization and evaluation. Instead, Ms. Arellano was given an inappropriate antibiotic by the detention center medical staff, was still refused her needed medication, and returned to her cell. By the time Ms. Arellano’s cellmates staged a protest to draw attention to her deteriorating condition, she had become very ill and died soon thereafter, comatose and shackled to her bed. Faced with a common chronic disease, ICE medical staff withheld the correct medicines, gave inappropriate medicines and failed to seek more competent care for Ms. Arellano. The care that Ms. Arellano required would be routine in almost any medical clinic or hospital in the United States.”

The full testimony is available at the following link: http://judiciary.house.gov/media/pdfs/Venters080604.pdf

Posted by Matt Anderson

Fifty-nine percent of US physicians support National Health Insurance

One of the advantages of belonging to Physicians for a National Health Program is their excellent newsletter. It offers reprints of articles related to the advocacy of a single payer plan in the US.

Perhaps the most interesting reprint in the last PNHP report was the letter published April 1, 2008 (not a joke we hope) in the Annals of Internal Medicine by Aaron E. Carroll and Ronald T. Ackerman. The text of this letter can be downloaded from the PNHP website. In 2007 Carroll and Ackerman surveyed 5000 randomly selected members of the AMA, 51% of whom replied. They asked only two questions:

1) In principle do you support or oppose government legislation to establish a national health insurance?

The answer to this question was: Strongly support - 28%; Generally support -31%; Neutral - 9%; Generally opposed - 15%; Strongly opposed - 17%. In short 59% of US physicians support a government sponsored national health insurance.

2) Do you support achieving universal coverage through more incremental reform?

The answer to this question was: Strongly support - 14%; Generally support-41%; Neutral -21%; Generally opposed - 10%; Strongly opposed - 14%.

The authors compared these numbers to a similar study they had done in 2002 when 49% of physicians supported a national health insurance. Support had increased in every specialty of medicine except pediatric subspecialists (who had high levels of support in both surveys).

The Carroll and Ackerman study has been criticized for failing to demonstrate that their sample accurately reflected the views of US physicians. It’s hard to know how biased the sample was. What does seem to be clear is that in 5 years, using the same methodology, Carroll and Ackerman found that support for a National Health Insurance had increased from 49% to 59%. This change is probably spurred by the growing difficulties physicians are having with getting reimbursed by the insurance companies.

The fact that the American College of Physicians, the 124,000 member association for internists came out in December 2007 in favor of a univeral health insurance is also strong evidence of physician support for a national solution. The ACP position paper is entitled “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries” and covers many of the key issues in this debate.

It would be nice if some pharmaceutical company, or perhaps a large HMO, would do a big-scale survey of physicians asking if they supported a National Health Program. But since single-payer has been declared out of the question by the political class, we aren’t holding our breath for such a survey.

Of course, a government-sponsored National Health Insurance has many advantages other than physician reimbursement. To quote from PNHP: “The U.S. spends twice as much as other industrialized nations on health care, $7,129 per capita. Yet our system performs poorly in comparison and still leaves 47 million without health coverage and millions more inadequately covered.”

The PNHP is urging physicians to sign a letter to the Presidential Candidates urging them to consider a single payer plan. The link is at www.pnhp.org/letter. Their website is very well set up to put you in touch with your representatives in government.

Posted by Matt Anderson

Health Cooperatives

A cooperative is an autonomous association of persons united voluntarily to meet their common economic, social, and cultural needs and aspirations through a jointly-owned and democratically-controlled enterprise. Cooperatives are based on the values of self-help, self-responsibility, democracy, equality, equity, and solidarity. In the tradition of their founders, cooperative members believe in the ethical values of honesty, openness, social responsibility, and caring for others. The cooperative principles are guidelines by which cooperatives put their values into practice: 1. Voluntary and Open Membership; 2. Democratic Member Control (one member, one vote); 3. Member Economic Participation; 4. Autonomy and Independence; 5. Education, Training and Information; 6. Co-operation Among Cooperatives; and 7. Concern for Community.

Based on coop principles and values, people create different forms/models of health care cooperatives. One of the most known model is the user/client-owned model. User or client-owned health cooperatives are set up by individuals in the same community to help them meet their own health care needs. Members of the coop determine goals and practices, thereby enabling ordinary citizens to empower themselves with respect to health care. Members-owners each contribute shares of capital and subsequently contribute to operating costs, usually by prepaid premiums and appoint managers to negotiate contracts with health insurance and health care providers. Often these cooperatives purchase and operate hospitals and other facilities, and hire professional and other staff. Services range from simple preventive care and basic insurance to advanced curative and rehabilitative interventions. There are also cooperatives owned by health professionals and pharmacy coops. In fact, cooperatives are being used as the model in the social economy and the delivery of a wide range of social services around the world.

Community Health Centres that follow the cooperative model are non-profit organisations, owned and operated by the members who use their services. Members elect a board of directors who govern the centre. Each member has one vote, regardless of the number of shares held by the member. Members and users are involved in defining the centre’s mission, mandates, goals, and the types of services offered. With the cooperative model, community participation can be facilitated through Board representation, committees of the Board, development of needs assessment, satisfaction surveys, fundraising, volunteer involvement etc. Community Health Centres that are not cooperatives provide similar programs and services as a cooperative, but the level of community membership and control is not as extensive.

For more on Health care cooperatives visit:

• International Health Co-operative Organization
• BC Institute for Co-operative Studies (Health Coops)
• International Co-operative Alliance, ICA
• Health care coops links, University of Wisconsin Center for Coopratives
• United Nations, Coop Enterprise in Health and Social Care Sectors, A Global Review, 1997

— Prepared by Franklin Assoumou Ndong, B.A., M.Sc., Sherbrooke (Québec), Canada, September 2004.

Class and Health

Social Medicine had its birth during the Industrial Revolution in Europe as health statistics (a relatively new tool) made clear that disease and death were linked to poverty and exploitation.

One of the first empiric studies examining this question was done in the 1820’s by the French physician Louis Rene Villerme. Villerme looked at mortality statistics in Paris and noted marked differences in death rates between one section of the city and another. After considering several possible explanations, he concluded that poverty was the main determinant of differentials in death rates. We are fortunate that his original publication from 1830 is available online at the French National Library. We have discussed Villerme’s paper in greater detail in an article entitled “Social Medicine 101.”

Twenty years later Friederich Engel’s impassioned The Condition of the Working Class in England, described in detail the devastating health impact of the Industrial Revolution on workers and their families.

Two centuries later these problems are very much with us. As Vicente Navarro pointed out in a 2004 Monthly Review article entitled “Inequality is Unhealthy“, a member of the corporate class in Europe lives some 7 years longer than an unskilled worker who is chronically unemployed; in the US, the gap is 14 years.

The debate over health inequalities in the English-speaking world was revitalized by Sir Douglas Black’s 1980 report on inequalities and health (most of which is available on the website of the Socialist Health Association). The Black Report is a very rich document born out of the flowering of Social Medicine in England after World War II. Later Allison Quick and Richard Wilkinson introduced the idea that mortality depends upon the degree of inequality in a society, irrespective of the absolute wealth of the country.

In the United States we are told there is no social class and the Federal government does not routinely collect statistics on class and health. Class issues are often discussed in racial terms or in terms of “inequality”. Inequality.org provides an introduction from a US perspective. The New York City-based Russell Sage Foundation has published a number of interesting social critiques, which are available on their website. There are several papers on the topic of inequality and health. See The Social Dimensions of Inequality, a literature review of the Foundation.

Matt Anderson

Struggle for Health: Short Course for Health Activists: Brazil, September 2008

Our friends at the People’s Health Movement have just announced the next short course for health activists, being offered in Porto Alegre, Brazil, September 7-20, 2008.  This course will be offered in Portuguese, Spanish and English.

The curriculum is an interesting one, and can be viewed at the International People’s Health University (IPHU) website. Of particular interest is the Resource Library at the IPHU website which includes a very rich selection of readings, Powerpoints and other materials (including videos) on the course content.

The curriculum includes:

• the struggle for health: achievements, strategies and new directions
• working with communities and with grass roots health organizations
• comprehensive primary health care: achievements, lessons and new
  directions
• the political economy of health: globalization, the WTO, the IMF and
  the WB; local issues and global pressures
• the right to health: principles, achievements and new directions
• people’s health and the environmental struggle
• research: part of the problem and part of the solution
• social determinants of health (poverty, oppression and hierarchy)
• alienation and exclusion
• racism and sexism

The 11 day course is presented by the International People’s Health University (IPHU) and the People’s Health Movement (PHM) in association with the School of Public Health of Rio Grande do Sul. The teaching faculty is drawn from Latin America and beyond. Priority is given to students from the Southern Cone. For more information about IPHU and the Porto Alegre Short Course go to www.phmovement.org/iphu. Further inquiries should be directed to the Course Coordinators (porto@phmovement.org).

The short course is offered periodically in various venues and languages. It was, for instance, offered at the US Social Forum in June of 2007.

Matt Anderson

[This entry was updated on 7/13/2008]

Opportunity to do Community Health Research in Cuba: December 2008

Earlier this week we received the following announcement from MEDICC which we are reproducing with their permission. Opportunities to visit Cuba and do research are very limited:

MEDICC is contacting community health professionals to announce an exciting opportunity for research on Cuba’s primary care health system, December 7 - 14, 2008.

MEDICC (Medical Education Cooperation with Cuba) supports US health professionals undertaking field research in Cuba by providing background materials, guidance on research objectives, and opportunities for publication of research findings. Please see our on-line publications athttp://www.medicc.org.

Over the past several decades, community clinics in the US have mobilized to confront issues of growing disparity and lack of access to health care - all in the face of enormous challenges.

Cuba’s health outcomes often resonate with those in the United States working to find innovative approaches to health problems in medically underserved communities. Despite high levels of poverty, health indicators in Cuba are on par with industrialized countries, including the U.S. Particularly noteworthy are Cuba’s emphasis on community-oriented primary care, the integration of clinical medicine and public health, preventive medicine and effective use of limited resources (see attached article).

The research program in Cuba will be tailored to participants’ interests, and will include meeting with Cuban colleagues and community health leaders, as well as field research on Cuba’s functioning models of primary care, including:

• Polyclinics (the centerpiece of the community-based system)
• Family doctor-nurse offices (or consultorios)
• Community mental health clinics
• Maternity Homes (for high risk pregnancies)
• Community organizations such as the sanitary brigades and the Federation of Cuban Women
• Health programs for the elderly (circulo de abuelos)

Full time health professionals conducting research in Cuba are allowed to do so under the US Treasury’s general license for professional research (see attached). Marazul Charters, an agency licensed to provide travel arrangements to Cuba, organizes the program and books travel. Costs usually range from $2600-$2800 for a week, including airfare from Miami or Cancun. MEDICC serves as an academic consultant for the actual research program and in some cases may be able to provide partial fellowships.

If you are interested in participating in this December 7 - 14 opportunity or would like further information, please let us know by July 2 by writing to admin1@mediccatlatna.org. We will then contact you to discuss your research interests. You can also contact Marazul Charters directly at 1-800 223-5334 ext. 16 for further information on traveling to Cuba on the US Treasury’s general license for professional research. Also, please let us know of any colleagues affiliated with community clinics whom you think might be interested in this opportunity and we will contact them. We look forward to hearing from you.

posted by: Matt Anderson