Medical education in Cuba

At one medical school you can study for free_even if you are an American citizen, report Danni Kirwan and Dave Baguley

Americans graduating from the Latin American School of Medicine

The first eight American citizens to complete the entire six year Latin American School of Medicine degree in Havana graduated this summer. It specialises in training doctors to work abroad in impoverished communities, and most of its students come from Latin America, the Caribbean, or Africa. The students pay no tuition fees.

It seems bizarre that Cuba should select its long time adversary the United States as one of its beneficiaries and train its doctors for free. The US is more than three hundred times richer than Cuba. The US has regarded Cuba as a political enemy since the Cuban revolution of 1959, and, more recently, President George Bush named it as one of the countries in the "axis of evil." Is this recent chapter in Cuban history an act of unparalled altruism or a clever exercise in propoganda?

The eight graduating American students all come from ethnic minority backgrounds and need merely to take their American board exams, in the same way that British doctors do to gain licences to work in hospitals in the US. In the US only 6% of physicians come from under-represented ethnic minorities, and massive inequalities exist in the health care received by US citizens of different ethnic groups.

The eight US graduates have promised to work in deprived areas of the US, in keeping with the humanitarian ethos of the school. Furthermore, the graduates have vociferously praised the school's values, with one of the graduates quoted in a recent Guardian newspaper article: "Health care is not seen as a business in Cuba. When you are sick they are not going to try to charge you or turn you away if you don't have insurance. We have studied medicine with a humanitarian approach" (www.guardian.co.uk, 26 Jul 2007, "Eight Americans graduate in boost for Cuban health care").

This is not the first time Cuba has offered medical aid to the US: Fidel Castro offered to send 1500 doctors to help the victims of Hurricane Katrina. Although the previous high profile offer of aid was rejected by the US government, the US State Department has now classified training at the Latin American School of Medicine as a "cultural exchange" programme to get around the embargo that bans most Americans from travelling to Cuba.

The US embargo against Cuba is an economic, commercial, and financial impediment, originally imposed in 1962 to try to weaken President Castro's regime. It is the most enduring trade embargo in modern history and it has had a persistent detrimental effect on Cuba's economy. Between 1989 and 1993, gross domestic product decreased by 35% and exports by 75%. In the 1990s the Cuban government introduced a series of adjustments to try to halt the crisis and revive the economy; almost all sectors, including health care, had to cope with a decrease of 50% or more of investment budgets.

The US's economic blockade is one of the world's few sanctions that explicitly includes food and medical supplies. The United Nations has called the embargo illegal and a violation of human rights and has repeatedly called for it to be lifted. The embargo has caused an increase in the prices of drugs and medical supplies, leading to longstanding shortages. Necessity, therefore, has become a driving force behind the Cuban drug industry, which is capable of producing 80% of the 1000 medicines used.

Cuba's health system, its public health model in particular, has won international praise. One of the few communist developing countries, it has struggled largely unsupported in the task of providing health care to its population of 11 million. Choosing not to be a member of the World Bank or the International Monetary Fund has meant no financial support from these institutions. Yet in 2001 the World Bank's president, James Wolfensohn, congratulated Cuba for "the great job" it has done in health and education. Cuba is ranked 51 in the UN Development Programme's human development index, fifth in its region.

Health care has always been a priority under the Castro administration. Cuba boasts one doctor for every 170 of its people, compared with a ratio of one to 188 in the US and one to 250 in the United Kingdom (www.who.int). In 2003 both under 5 year old (8 per 1000) and infant mortality rates (6 per 1000) were by far the lowest in Latin America and the Caribbean, where regional averages of 32 per 1000 and 27 per 1000 exist. Additionally, life expectancy is 77 years, seven years higher than the regional average. Before Castro's government infant mortality was 60 per 1000 live births and life expectancy was 55 years.

These health indictors may be surprising given that Cuba remains a poor country with gross national income per capita estimated at $1170 (£575; €825) in 2003; this compares poorly with an average for Latin America and the Caribbean of $3311 (www.unicef.org). The high levels of poverty have many causes, but a large contributing factor is the US imposed trade restrictions.

In addition to providing for the health needs of its own people Cuba has been able to train doctors in excess of its requirements, allowing it to export doctors. This element of internationalism has long been an important component of the Cuban health system; since the first medical mission to Algeria in 1963, tens of thousands of Cuban medics and paramedics have worked abroad. By 1991 Cuba had more fully qualified doctors working abroad than did the World Health Organization, which bestowed its Health for All award on Castro in 1988. Currently 32,000 Cuban doctors work in 72 developing countries.

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

       

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