New England Journal of Medicine
Volume 351:2680-2682 December 23, 2004 Number 26
Affirmative Action, Cuban Style
by Fitzhugh Mullan, M.D.
"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
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
Josť 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 opportunity!"
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! Yes! 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 pay."
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 poor populations.
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
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.
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