I requested a year off from school to go to Haiti and work with the Cuban doctors after completing my 2nd semester of 3rd year at ELAM (the Latin American School of Medicine). I am one of 120 American citizens studying medicine in Cuba free of charge, with plans to practice medicine upon graduation in underserved communities of the United States and around the world.
When I arrived, I found several international ELAM graduates (http://elamedicosinternacionalistas.wordpress.com), including 7 United States graduates (http://www.michaelmoore.com/words/mike-friends-blog/cuban-trained-us-docs-complete-haiti-mission), and a number of Haitian medical students working alongside the Cuban doctors. We were stationed at a field hospital set up by the Henry Reeve Brigade of Cuban doctors on January 28th in a small central park of Croix des Bouquet, just outside Puerto Prince. Together we served displaced earthquake victims and patients suffering from inadequate health care services.
In the first six months the hospital was established, we addressed the needs of more than 70,312 patients; 53,588 at the hospital and 16,723 in the field. We performed a total of 2,506 operations on-site, with 786 major surgeries; including emergency caesarean sections, ectopic pregnancies, thyroidectomy, hernias, hydroceles, hysterectomies of uterine fibroids, orthopedic surgeries and more. We assisted 116 natural births. We diagnosed 3,533 patients with our on-site laboratory and diagnostics center. We saw 3,192 patients for x-rays and ultrasounds. We treated 8,778 patients with physical therapy, and we hospitalized 2,053 patients on-site (Information provided by the Henry Reeve Brigade of Croix des Bouquet Statistical Report, June 2010).
When you stepped out of the hospitals and into the streets the only question that came to mind had to be, “where is the aid?” It was obvious, even six months after the earthquake that little progress had been made, with little to no evidence of monetary support. Hundreds of thousands of people were still living displaced in make-shift tent cities. The city still resembled a disaster zone with buildings teetering above cracked foundations, while corpses remain beneath the rubble. The doctors seemed to be the only relief effort making a difference.
The Cuban doctors were accomplishing more than what the international community was willing to recognize. Croix des Bouquet was just one of several field hospitals established by the Henry Reeve Brigade to serve communities in and around Puerto Prince free of charge. CNN even had to apologize after interviewing one of the Cuban doctors and crediting him as Spaniard. Fortunately, Cuban doctors aren’t looking for recognition; they are out to save lives and continue to do so all over the world.
The Henry Reeve Brigade has since moved on to other emergencies, like the fires plaguing Russia. Other Cuban doctors have replaced them to continue serving the Haitian community free of charge. Brazil and Cuba have signed a trilateral accord with the Haitian Health Minister to establish three hospitals staffed by Cuban doctors located in communities surrounding Puerto Prince where health services are limited to non-existent. Cuba has been dedicated to sending doctors to Haiti for 11 years. Amidst the unfortunate circumstances of the earthquake, they continue to fulfill their commitment to the Haitian community by sending doctors. With the success of the students working alongside the doctors, they now have plans to send more students in the years to come.
Note: Article written by Joanna Mae Souers. Photograph titled, “Joanna Mae Souers on Wound Care” was taken by Cuban photographer, Juvenal Balán. The other photographs were taken by Joanna Mae Souers.
We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:
Course Invitation 2011
We invite you to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).
For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.
Sincerely,
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115
Joanna Mae Souers, an American studying medicine at the Latin American School of Medicine (ELAM) has written several times on the portal (see here). She asked us to post the following thank you note:
David Lundquist, President and CEO of Kingston Hospital, of upstate New York, made efforts to organize supplies to donate to the students of the Latin American School of Medicine in Havana Cuba. Supplies included masks, gloves, scrubs, and several other useful items that the students can use during their time in Cuba. Because of the U.S. embargo against Cuba, supplies are limited and students are expected to bring their own. It is very helpful when hospitals can help students out by donating supplies to alleviate them from these costs.
Kingston is where I grew up, and it is wonderful to get such positive support from local hospitals. Many health care professionals don’t know about the program to study medicine in Cuba, but when they hear about the opportunity, in spite of political propaganda, they think it’s great and they look forward to anything they can do to support the students. Cuba is well renowned for their public health care and international relief efforts, but what is little known is that there are over 100 U.S. students studying medicine in Cuba for free, with one catch, the promise to return to the U.S. upon graduation and practice in underserved communities. Is that really a catch? This is a gift from the Cuban government to the American people.
I want to thank Kingston Hospital for their generous donation and I want to encourage other hospitals to donate what they can. If you would like to make a donation of medical supplies or books to the students of ELAM, please contact IFCO & Pastors for Peace via their website www.ifconews.org.
Joanne Mae Souers, a New York State resident studying medicine at the Latin American School of Medicine (ELAM) in Havana, sent us this report on her activities:
Dr. Nelson Gonzalez on Rounds
The Hospital is Our Classroom; The Patient is Our Professor
As third year students at the Latin American School of Medicine the hospital is our classroom and the patients are our professors. We spend our days practicing patient histories and physical exams to tune and then retune our clinical skills. Students from the U.S. and several Latin American countries rotate at Hospital Salvador Allende in central Havana. Students from all over the world can be found at teaching hospitals all across Cuba.
Our first semester focuses on clinical medicine, physical exams, and the relationship built between the doctor and the patient. This is where we step out of the classroom and into the “operating” room as they might say; where medicine starts with “hello.” From the minute your patient walks in the door, you are required to take notes on what signs and symptoms they might reveal to help you develop a good differential diagnosis.
Currently, I am at the Antonio Guiteras Unit of Internal Medicine run by Dr. Nelson Gonzales, a Specialist in Internal Medicine. Every day we are tested on our knowledge of the pathological alterations in the physical exam. We see patients, go on rounds and learn first-hand how a patient is received, examined, diagnosed and treated throughout their stay.
I find our exposure to patients and first-hand clinical experience a essential counterpart to our classroom knowledge. We are constantly applying our skills and seeing new clinical cases. Recently we were addressing cases of dengue fever to control and quarantine a small outbreak in Havana and now we are focusing primarily on cases of suspected H1N1 influenza in adults with compromised health status.
If that isn’t enough patient exposure, fear not, we are on a weekly rotation at the hospital’s walk-in clinic where we see “walk-in” cases and learn from doctors making quick, accurate diagnostic calls. Some of these cases are automatically hospitalized if they come in with severe health conditions requiring admission to the intensive care unit or those who present public health risks and need to be quarantined. Examples of cases quarantined are those who present fever from areas endemic to dengue or present symptoms of an upper respiratory infection and pertain to one of the three risk groups of H1N1: pregnant women, children and/or patients with respiratory illnesses.
Medical Student Souers
I look forward to my third year at the Latin American School of Medicine in Havana, Cuba, where we learn to practice medicine on the bases of altruism, honor and sacrifice as a commitment to society. It is the patient that teaches us medicine; it is the hospital that sets the stage. Dr. Nelson Gonzales profoundly states that he is not such an altruistic being just based on character, but because of his formation as a doctor in Cuba.
We have just published a new issue of Social Medicine/Medicina Social, our bilingual, online journal. It is available in both English and Spanish. Our 13th issue touches on several important issues in world health including the current economic crisis and the WHO Commission’s on the Social Determinants of Health. And, of course, the stories of activists like the young US students (shown below) studying medicine at the Latin American Medical School (ELAM) in Havana. They will be traveling in the Southwest US this summer to discuss their experiences with the American Indian community:
The Economic Crisis and Public Health
Barry S Levy, Victor Sidel
The current global economic crisis seriously threatens the health of the public. Challenges include increases in malnutrition; homelessness and inadequate housing; unemployment; substance abuse, depression, and other mental health problems; mortality; child health problems; violence; environmental and occupational health problems; and social injustice and violation of human rights; as well as decreased availability, accessibility, and affordability of quality medical and dental care. Health professionals can respond by promoting surveillance and documentation of human needs, reassessing public health priorities, educating the public and policymakers about health problems worsened by the economic crisis, advocating for sound policies and programs to address these problems, and directly providing necessary programs and services. Full Text: PDF
An Interview with Sir Michael Marmot
The Editors
In August of 2008 the WHO Commission on the Social Determinants of Health concluded its work with the publication of a report entitled: “Closing the gap in a generation: Health equity through action on the social determinants of health.” The Commission’s chair, Sir Michael Marmot, was kind enough to answer our questions about the Commission’s recommendations. This interview was conducted by email in May of this yea
Social Medicine: We congratulate the Com-mission on its excellent work in bringing attention to the social determinants of health and the Commission’s call for health equity. We appreciated the Commission’s recognition that: “Social Justice is a matter of life and death.” We were also happy that the Commission included representatives of civil society in their work. This was an important affirmation of democratic values.
When thinking about health inequalities people often use the analogue of the ladder to show how the gradient of worsening health outcomes affects all people in society except (presumably) those at the very top. Thinking about the ladder leads us to pose the following question: Is making the ladder shorter (i.e. reducing inequalities) the only approach to inequalities or is it possible to imagine making the ladder disappear entirely?
Sir Michael Marmot: All societies have hier-archies. It is not conceivable, therefore, to have a society with no ladder. The conceptual framework of the Commission on Social Determinants of Health leads us to think of at least two (linked) ways to address the relation between position on the ladder and health: act at the societal level to reduce social inequalities, and break the link between position in the social hierarchy and health.
The first argues for reducing the slope of the social gradient. To see this, suppose, just for a moment, that the ladder were defined on the basis of years of education. People who had three years or fewer had life expectancy of 50 years, those who had 13 years or more had life expectancy of 80 and the rest were ranged in between in a graded way: the social gradient in health. Now if we had a societal change so that everyone had at least 10 years of education, and better health followed as a result, the magnitude of health inequity would be reduced. We have reduced inequities by making the ladder shorter. [...]Full Text: PDF
Participation and empowerment in Primary Health Care: from Alma Ata to the era of globalization
Pol De Vos, Geraldine Malaise, Wim De Ceukelaire, Denis Perez, Pierre Lefèvre, Patrick Van der Stuyft
With the 1978 Alma Ata declaration, community participation was brought to the fore as a key component of primary health care. This paper describes how the concepts of people’s participation and empowerment evolved throughout the last three decades and how these evolutions are linked with the global changing socio-economic context.
On the basis of a literature review and building on empirical experience with grass roots health programs, three key issues are identified to revive these concepts: The recognition that power, power relations and conflicts are the cornerstone of the empowerment framework; the need to go beyond the community and factor in the broader context of the society including the role of the State; and, considering that communities and society are not homogeneous entities, the importance of class analysis in any empowerment framework. Full Text: PDF
Latin American Social Medicine and the Report of the WHO Commission on Social Determinants of Health
RAFAEL GONZALEZ GUZMAN
In October 2008 the Latin American Social Medicine Association (ALAMES) organized an international workshop entitled “The Social Determinants of Health.” Representatives of ALAMES’ seven regions participated in discussions of the various consultative papers prepared by the working groups of the WHO Commission on the Social Determinants of Health as well as the Commission’s final report. The workshop considered how ALAMES should respond to the work of the Commission. In this paper we summarize the main points outlined in the position paper prepared by the Organizing Committee1 as well as a synopsis of the main contributions made by each of the workshop’s study sections. Full Text: PDF
Here is the latest update from from Joanna Mae Souers, one of the US students studying medicine on scholarship in Cuba:
June 2009
Today there are 148 American students studying medicine at the Latin American School of Medicine in Havana. They study within Cuba’s world-renowned system of universal health care. Despite Cuba being a “poor” country, the World Health Organization (WHO) ranks the Cuban system among the top 10 in the world. They study thanks to a scholarship provided within the same system of humanitarian medical solidarity that has placed more than 21,000 Cuban doctors in poor third-world countries.
The 148 students originate from some of America’s poorest and most medically under-served communities. After graduating they plan, in line with the encouragement of the Cuban Government and our own Congressional Black Caucus, to serve the very same under-served communities from which they came.
As students attending ELAM we, have been given an opportunity to do something that has never been done before. On July 26, 2009, 12 American students from ELAM will board an RV for a road-trip of the Southwestern United States. Together we will spend two weeks as humble guests visiting Native American reservations, neighboring communities, hospitals and colleges to spread the word about our medical school opportunity and foster an exchange of information between all participating groups.
As we approach the one month mark in our countdown to departure we are motivated, poised, and excited about the road ahead us. We are busy preparing for the exchange; writing up the material we hope to present, learning about the different communities we plan to visit and organizing our curriculum of exchange with guidance from our community liaisons. So far we hope to visit with the following communities and organizations:
As students, we want to thank the following individuals and organizations for all of their support and guidance during the process of organizing this exchange.
We extend a special thank you to all of our donors and supporters for making this exchange possible, and we want to encourage further support. We are just short of meeting our proposed budget and we hope to make that happen to make this tour possible! We need your support, please check out our link (http://www.medicc.org/ns/index.php?s=30&p=4) and donate now!
Research-based health activism describes a growing sector of the medical and public health worlds where the classic skills of clinical research and epidemiology are combined with grass-roots advocacy to influence federal and state health policy, counteracting the influence of private industry and market forces on public and community health. The Residency Program in Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine has a rich tradition of innovations in community oriented primary care and a history of progressive research and practice. Our faculty, together with experts from throughout the New York Metropolitan area, will provide training in this growing field of research-based health activism.
In October 2009, we will offer a one month elective for 4th year medical students interested in research based health activism. The course, now in its 8th year, combines both didactic and project based approaches, culminating with a research proposal that students can complete at their home institutions.
The didactic lectures will introduce three major topic areas: research methods, health policy, and advocacy skills. Individual and small group mentorship will be provided to help students utilize these skills by developing their own independent research proposal. Other sessions will include physician-activist guest lecturers and visits to state or private health organizations that both create and influence health policy.
Finally, students will develop a research proposal for a project reflecting their interests and an advocacy plan to gain the maximum health policy impact with the results. This proposal will be presented on the final day of the course at a luncheon including all students, the course directors, returning session leaders, and Peter Lurie, MD, MPH, from the Public Citizen’s Health Research Group.
FACULTY AND RESIDENTS:
*Aaron Fox, MD, Clinical Instructor of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Course Director, Research-Based Health Activism Course;
*Viraj Patel, MD, Primary Care Resident, Montefiore Medical Center
FOR MORE INFORMATION: Please contact Aaron Fox, MD at this link: Aaron Fox
Past Programming Tracks:
Health Policy and Activism—The history and the present: Bertrand Bell, MD: Making Real World Change As A Physician—Jo Ivey Boufford, MD: Public Policy—Joseph Ross, MD: Health Care Organization—Ernest Drucker, PhD: A Plague of Prisons: The Epidemiology of Mass Incarceration—Oliver Fein, MD: National Health Insurance for the US: Has Its Time Come?—Paul Lipson, Chief of Staff and Siddharta Sanchez, Community Liaison for Immigration & Environmental Affairs for Bronx Congressman José Serrano: Health Topics as they relate to the policies in the Bronx, NY—Ruth Macklin, PhD: Research Ethics: Protecting Human Subjects of International Research—Eva Metalios, MD: Human Rights Clinic—Barbara Seaman: Women’s Health Activism—Peter Selwyn, MD, MPH: Research and Advocacy at the Dawn of AIDS—Peter Sherman, MD: The Affects of Domestic Violence on Children—Victor Sidel, MD: Social Injustice and Public Health, and War, Terrorism, and Public Health—Hal Strelnick, MD: Health Policy at Local, State, and National Levels—Bruce Vladeck, PhD: Medicare and the Role of Physicians in the Future—Sidney Wolfe, MD: Research Topics/Questions
Research Methods—how to produce activist research:
Matthew Anderson, MD, MSc: Planning the write-up process of your project—Chinazo Cunningham, MD: Grant Writing—Robin Flam, MD, DrPH: Uses of Epidemiology—Aaron Fox, MD: Social Epidemiology—Nerina Garcia, PhD and Lucia Ferra: Qualitative data use and analysis—Alison Karasz, PhD and Galit Sacajiu, MD, MPH: The Underline Construct—Paul Meissner, MSPH: Using Secondary Demographic and Clinical Databases—Robert Roose, MD: Quantitative data use and analysis—Galit Sacajiu, MD, MPH: Research Questions—Nancy Sohler, PhD, MPH and Galit Sacajiu, MD, MPH: Study Designs
Advocacy—how to create change:
David Appel, MD: Lobbying—Ramin Asgary, MD, MPH, MSc:Humanitarian Assistance: The Principles—Oni Blackstock, MD: HIV/AIDS in Ghana: Adherence and Stigma—Bob Goodman, MD—Pharmaceutical Industry and Physicians—Kirsten Goodwin of GMHC: Coalition Building—Hillary Kunins, MD, MPH, MS and Carolyn Chu, MD: Case Workshop: Advocating for Choice—Janice Lieberman, NBC Studio: Media Relations in Health Research and Advocacy—David Matthews: Harm Reduction and HIV: a grass root organization—Steve Max of Midwest Academy: Intro to Organizing and Strategy Building—Mini Murthy, MD, MPH, MS: Women’s Health and Human Rights—Zena Nelson: The South Bronx Food Cooperative—Adam Richards, MD, MPH: Public Health and Human Rights Praxis in Burma—Minesh Shah, MD: Public Speaking—Lanny Smith, MD, MPH, DTM&H: Liberation Medicine, Health and Human Rights—Leonora Tiefer, PhD: FSD-A Case of Disease Mongering and Activist Resistance
The following news (brought to my attention by my dear friend Cristina), from today’s Amy Goodman’s Democracy Now radio show, provides a good exercise in critical thinking: finding the flaws in president Obama’s argument (invalid inferences, false assumptions, etc) that ” it is best to build on the health care system we have”, rather than presumably adopt too radical solutions like single payer (I myself could find four flaws in two minutes! For a fuller argument for why it is misguided at best to build on “the health care system we have” read “Not Change We Can Believe In“).
According to the president, “the vast majority” of Americans get coverage from their jobs, and presumably are satisfied with it.
Another interesting accompanying headline is “Health Industry Says Obama Overstated Pledge to Cut Costs” (surprise surprise!). It looks like, after all, companies “never agreed to specific yearly cuts, but only vague voluntary goals”.
At a town hall-style event in Rio Rancho, New Mexico, Thursday, local resident Linda Allison asked President Obama why the White House and the Democratic-led Congress have ruled out single payer.
Linda Allison: “My question is, so many people go bankrupt using their credit cards to pay for healthcare. Why have they taken single payer off the plate? And why is Senator Baucus on the Finance Committee discussing healthcare, when he has received so much money from the pharmaceutical companies? Isn’t it a conflict of interest?”
President Obama: “If I were starting a system from scratch, then I think that the idea of moving towards a single-payer system could very well make sense. That’s the kind of system that you have in most industrialized countries around the world. The only problem is that we’re not starting from scratch. We have historically a tradition of employer-based healthcare. And although there are a lot of people who are not satisfied with their healthcare, the truth is, is that the vast majority of people currently get healthcare from their employers, and you’ve got this system that’s already in place. We don’t want a huge disruption as we go into healthcare reform, where suddenly we’re trying to completely reinvent one-sixth of the economy.”
In case readers missed Dr. Don McCanne’s excellent analysis and commentary on student debt and speciality selection, below it goes, together with links to the original articles Dr. McCanne comments on.
Where Did All the Doctors Go?
The New York Times
May 3, 2009
Letters
To the Editor:
Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :
As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.
The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.
What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.
Georganne Chapin
Tarrytown, N.Y.
The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.
Subject: Graduate Medical Education: Trends in Training and Student Debt
GAO (Government Accountability Office) May 4, 2009
In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data.
Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle – a predictable schedule and fewer on-call hours – and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care.
Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The median amount of educational debt for indebted medical students graduating in 2008 was $155,000 – a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends — on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training.
This statement from a highly respected executive of a not-for-profit managed care organization, and this new GAO report, both further confirm what we already knew. Medical students are graduating with excessive debt, and this is likely contributing to the decline in the numbers choosing the primary care specialties.
Without increasing total health care spending, a few policies could be adopted which would realign incentives to improve our primary care infrastructure, while relieving students of the necessity of accumulating debt. That would be much easier to accomplish through a single payer monopsony than through a dysfunctional, fragmented, multi-payer, health care financing system.
Our thanks to Diane Appelbaum of MEDICC for sharing this link to an interview with former NFL player Pasha Jackson. Pasha is one of approximately 100 US students studying medicine on full scholarship in Cuba at the Latin American Medical School (ELAM).
Here is a link to the program The World According to Gary. The specific interview is entitled: Gary chats with NFL Player Leaving Football to Study Medicine in Cuba.
For other information about ELAM on the Portal, see this link.
The views and opinions expressed on this site do not necessarily reflect the views of Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University or the Social Medicine Publishing Group.
Our thanks to Diane Appelbaum of 
