| Affirmative Action, Cuban Style, New England
Journal of Medicine Volume 351:2680-2682 December 23, 2004 Number 26
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.
"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.
1 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.
2 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
JosÚ Serrano (D-N.Y.). "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
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-Miss.) 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!
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
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.3,4 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.5 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
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.