Steve Brouwer is the author of Robbing Us Blind: The Return of the Bush Gang (Common Courage Press, 2003); Sharing the Pie: A Citizen’s Guide to Wealth and Power in the United States (Holt Paperbacks, 1998), The Export of the American Gospel: Global Christian Fundamentalism (Routledge, 1996), and Conquest and Capitalism, 1492–1992 (Big Picture Books, 1992). From September 2007 to May 2008 he lived in the mountains of western Venezuela and wrote about the participation of rural Venezuelans in the Bolivarian Revolution. Four of his articles about the students and doctors in Medicina Integral Comunitaria can be found on his blog. His book on Revolutionary Doctors will be published by Monthly Review Press in 2009.

On August 19, 1960, Che Guevara gave a talk to the Cuban Militia “On Revolutionary Medicine”:

A few months ago, here in Havana, it happened that a group of newly graduated doctors did not want to go into the country’s rural areas and demanded remuneration before they would agree to go…

But what would have happened if instead of these boys, whose families generally were able to pay for their years of study, others of less fortunate means had just finished their schooling and were beginning the exercise of their profession? What would have occurred if two or three hundred campesinos had emerged, let us say by magic, from the university halls?

What would have happened, simply, is that the campesinos would have run, immediately and with unreserved enthusiasm, to help their brothers… What would have happened is what will happen in six or seven years, when the new students, children of workers and campesinos, receive professional degrees of all kinds…

If we medical workers—and permit me to use once again a title which I had forgotten some time ago—are successful, if we use this new weapon of solidarity…

Today, the vision of Che, who as a young Argentine medical graduate had ventured to Guatemala because he hoped to contribute to revolutionary change, has finally been realized. Cuba and its doctors have made a tremendous commitment to “solidarity” on the international level, and the “new weapon” is being successfully deployed. In fact, I can testify, from my own experience living in a village in the mountains of Venezuela last year, that Che was not exaggerating the revolutionary outcome: the campesinos are already running, “immediately and with unreserved enthusiasm, to help their brothers.”

In the community I lived in, a settlement of about 125 campesino families where no one spoke English, most residents had never attended high school and almost no one had been near a traditional university. Yet there are eleven young women and men from these families enrolled in a demanding six-year medical program that will graduate them as full-fledged doctors in medicina integral comunitaria (comprehensive community medicine). Some of the students are nineteen and just out of high school, others are closer to thirty and raising young children, but all are very enthusiastic about integrating good health and good medical care into the fabric of their community. Some of them have told me that they dream of a day in the future when they, like Che, can take their revolutionary knowledge and spirit to other countries and serve as internationalist physicians themselves.

Their experience is the newest reflection of how Cuba, in concert with the people of many nations in Africa, Latin America, and the Caribbean, is transforming the training of doctors, nurses, and other health professionals while also delivering medical care to poor populations that in the past seldom received any attention at all. This dynamic notion, planted by Che and others at the beginning of the Revolution, has taken decades finally to develop, and now has come to fruition: thousands of doctors have been created who are capable of practicing and teaching revolutionary medicine, and they are putting this “weapon” to good use.

In 2003, this positive force was deployed on a massive scale in order to aid the Bolivarian Revolution in Venezuela in delivering health care to its long-neglected population. The process began when a strike by the Venezuelan Medical Federation created such a total breakdown in medical service that the mayor of the Libertador section of Caracas, Fredy Bernal, sought to directly hire Venezuelan doctors to form a new community medical network. But only fifty Venezuelans applied for the positions, and just twenty of those doctors were willing to work in Libertador’s impoverished neighborhoods.

The frustrated mayor then asked the Cuban Embassy for help, and Cuba responded by dispatching a small group of highly trained physicians who had extensive experience working with medical brigades in other nations. Within a few months, hundreds more Cuban doctors arrived in Caracas to add their skills to the new network of family care. The experiment was so successful that the Venezuelan government decided the pilot program, called Barrio Adentro (inside the barrio), should be duplicated nationwide. In scarcely more than a year, by mid-2004, there were more than ten thousand Cuban doctors working in Barrio Adentro and meeting the needs of urban and rural residents all over the country. This massive deployment of medical force did not go unnoticed by antirevolutionary forces in the hemisphere.

“We are concerned that Cuba is developing a limited biological weapons effort,” said John Bolton, U.S. undersecretary of state for George W. Bush, on March 30, 2004, repeating an allegation he made in May 2002. It was clear to most observers, even within the Bush administration, that Bolton’s accusations that Cuba was developing “Weapons of Mass Destruction” in the form of deadly biological materials concocted in the laboratory, were unfounded. It was also clear from Bolton’s rhetoric, however, that the U.S. government was escalating its longstanding hostility toward Cuba because its attempts to isolate and impoverish Cuba were failing. So were its efforts to undermine the Bolivarian Revolution.

It was ironic that the most prominent of all the cooperative ventures being pursued by the Cuban and Venezuelan government involved a very different kind of biological warfare, a benign and energetic campaign by medical professionals to defeat germs and disease and bring quality health care to the majority of the Venezuelan people. The United States, the world’s only military superpower and, until very recently, the master of global financial capital, rightly feared that Cuba’s example of international solidarity would be admired by many nations around the world, at a time when the U.S. image was more tarnished than ever before. It could do little to frustrate the capacity of Cuba, a small and poor nation, to deploy its human capital in such a useful and impressive manner.

How Did Cuba Develop This Capacity?

Ever since 1959, Cuba, despite its limited economic resources, has been building a very effective health system that is the envy of all developing countries and many developed nations as well. Its performance, measured by global statistical standards such as infant mortality rates and adult longevity, bears this out, as does an educational system that has been able to produce more physicians per capita than any other nation on earth. In 2007 Cuba had one doctor for every 155 citizens, compared to 1 for every 330 in Western Europe, and one for every 417 in the United States.1

In 1958, before the Cuban Revolution, there was one doctor for every 1,051 people, a ratio that deteriorated when many physicians, about half of the total number, decided that they did not want to practice medicine in revolutionary Cuba and left to seek their fortunes in the United States and other countries. By 1967, there were only about 3,000 physicians practicing, less than one for every 2,000 Cubans, and the process of rebuilding their ranks was by necessity slow. When the University of Havana Medical School had reopened after the triumph of the Revolution in 1959 (the former dictator, Batista, had closed the university in 1956), only 23 of its 161 medical professors had come back to teach.2 By 1975, the country finally regained its prerevolutionary ratio of doctors to citizens, a figure that was not particularly low by third world standards, but far from first world levels. What made the Cuban health delivery system exceptional in those years was its commitment to the egalitarian provision of medical service, the emphasis on various preventive measures in health programs that reached almost all citizens, and the high awareness of health issues among the public because of government education campaigns.

Cuba did not rest on its laurels, however. In 1984–85, the nation decided to keep improving its health system by adopting the program called Medicina General Integral (Comprehensive General Medicine), which created family medicine teams, comprised of one doctor and one nurse, that were designated to serve every neighborhood in the country. By 2004, the teams served more than 99 percent of all Cubans, with each team having a small neighborhood of 120–150 families under its care. The doctor and nurse were able to have regular office or home visits with each family, thus becoming aware of the most pressing medical issues for each individual and the neighborhood as a whole. The practice of gathering vital statistics on everyone and the emphasis on preventive care and health education meant that citizens were more conscious of maintaining good health, thus leading to a marked reduction in hospitalization rates. With time, diagnostic centers or “polyclinics” were constructed and staffed by a variety of medical specialists who had modern laboratories and imaging equipment at their disposal. Each polyclinic was built to serve a sizable cluster of small neighborhoods and usually served a total of 20,000 to 40,000 people.

This emerging program managed to survive despite the harsh experiences of the “Special Period,” the decade of the 1990s, when the Cuban economy sank into a severe depression due to the collapse of its major trading partners in the Soviet Union and Eastern Europe. There was a severe shortage of medicines and medical equipment, exacerbated, of course, by the U.S. economic blockade, that presented real challenges to those trying to offer treatment and led to the overall deterioration of facilities and equipment in consulting offices, polyclinics, and hospitals. During this time of hardship, there were two especially remarkable achievements by the Cuban medical system and Cuban society in general. First, the strict rationing and sharing of very scarce food supplies allowed all Cuban children to maintain a healthy diet even though the average calorie intake for adults was just barely adequate. Second, the education of Cuban doctors was not only continued, but accelerated. Making use of its greatest asset, human capital, the Cuban medical universities managed to graduate 38,000 physicians during the 1990s, four times the number produced during the 1970s.

By the beginning of the twenty-first century, Cuba was gradually rebuilding its economy, but still was considered relatively poor in terms of per capita income. In 2002, the nation decided it should use its modest economic gains to promote a “revolution within the revolution,” a process of restoring socialist values that had been under such duress during the Special Period. The renovation of facilities that served all citizens was given priority, particularly community medical offices, the neglected polyclinics and hospitals, and public schools.

By 2007, Cuba was boasting health statistics, such as an infant mortality rate of 5.3 for every 1,000 live births and an average adult lifespan of 77 years, that placed it in the top ranks in the world alongside rich, industrialized first world nations.3 One of primary reasons that this was possible was that Cuba, by 1998, had 5.8 physicians for every 1,000 citizens, a number unmatched anywhere in the world. Whatever limitations it faced in matching the high-tech medicine practiced by first world countries, including the United States, had been overcome by the degree of community interaction and preventive care provided by the vast army of family medical personnel practicing medicina general integral. This numerical advantage has simply kept growing, so that in 2007 there were 6.5 doctors for every 1,000 citizens, compared to 3.1 per 1,000 in Western Europe, and 2.4 per 1,000 in the United States (OECD figures 2007). This advantage is even greater when it comes to comparing those who can deliver direct general care to families and individuals. In Cuba, family doctors, most of them specialists in comprehensive community care, number about 3 for every 1,000 citizens. In the United States, all those who provide similar care to patients in their offices—family practice doctors, general practitioners, and general internists—amount to just 0.7 doctors per 1,000 citizens.

What to Do with These Riches of Human Capital?

Devote Them to Demonstrating That ‘Another World Is Possible’

The extraordinary number of physicians in this small nation, 72,417 as of 2007, has allowed Cuba to mobilize thousands of medical professionals (including nurses, dentists, and medical technicians) who are willing to go anywhere in the world to provide disaster relief and treat poor populations who do not have access to adequate health care.4 Revolutionary Cuba has always been willing to do this in the spirit of international solidarity, even when they had a shortage of personnel to treat their own citizens. In 1963, the first Cuban doctors traveled to Africa to help deliver health care in the newly independent Algeria, which suffered a dearth of medical professionals when the French colonialists departed. Later, Cuban physicians volunteered to go to sub-Saharan Africa, including those who accompanied Che Guevara on clandestine missions in the Congo in the 1960s. They also accompanied Cuban troops fighting alongside soldiers of the revolutionary Angolan government in its bitter wars against apartheid South Africa and rebel forces backed by the United States.5

These early experiences abroad were followed by larger commitments of Cuban medical aid when the increase in numbers of available personnel made it possible to offer humanitarian service to many countries at once. The Cuban presence abroad accelerated with the beginning of Programa de Salud Integral (Comprehensive Health Program) in 1998. This program originated with the Cuban response to two natural disasters, Hurricane George, which devastated large areas in Haiti, and Hurricane Mitch, which inundated both Honduras and Guatemala. Cuba immediately sent brigades of doctors and other medical professionals to help victims, especially in the most remote areas. In these three countries, their presence became semi-permanent, for the first volunteers were replaced by other Cubans who were able to offer primary health care in areas that had no public health services whatsoever. Consequently, for the past ten years, the Cuban commitment has been so indispensable to these three nations that, even when they were governed by conservative regimes friendly to the United States and hostile to the Castro government, the Cuban doctors were not sent home. There was, however, considerable opposition from right-wing elements.

In Guatemala in 2000, the Secret Anti-Communist Army (ESA) sent letters that threatened the lives of 459 Cuban doctors working in the country. The ESA letters, published in the daily newspaper Siglo XXI, accused the Cubans of being “mercenaries cloaked in the noble medical profession” who were spreading “totalitarian communist ideas.” And they warned: “If they do not immediately abandon the country, the executions will begin.” The Guatemalan government never reacted to the threat, and the Cubans never budged.

In Haiti in 2004, after the Bush administration overthrew the government of democratically elected President Aristide, it looked as if the interim government of Prime Minister Gerard Latortue would cave in to U.S. pressure and ask 525 Cuban health workers to go home. But the Haitian government never did so, because it had no other medical alternative; the ranks of Haitian doctors were mostly huddled around the capital competing for the business of well-off clients. Burnet Cherisol, director of Child Care Haiti and a former priest, said, “In many areas the only care available is from the Cuban doctors, even though the current Haitian government doesn’t support them. Few Haitian physicians are willing to venture out this far, where there’s no electricity, no hotel. For them, the good life stops down the road.”6

In Honduras in 2005, President Maduro, prodded by the U.S. embassy and the Honduran Medical Association, announced that the brigade of Cuban doctors was going to be expelled because their presence was too disruptive. The medical association claimed that the Cubans were putting local doctors out of work (when in reality, as in other countries, few Honduran doctors were interested in caring for poor people in isolated areas of the country). However, there was so much protest in favor of the Cuban presence by labor unions and community organizations throughout Honduras that the president had to rescind the order.7

The medical brigades have stayed in these countries because fresh Cuban volunteers keep replacing those who finish their tours of duty. Furthermore, the political climate has proved more favorable, not just toward the Cubans but also toward the young people from each of these nations who have been educated in Cuba. Ever since 2005, the Escuela Latinamericana de Medicina (Latin American School of Medicine) or ELAM, in Havana has been graduating 1,500 to 1,800 foreign students per year from its six-year program. Medical students come from Guatemala, Haiti, and Honduras, as well as forty other countries in Latin America, the Caribbean, and Africa. In Guatemala, when center-left President Colom took office in January 2008, he immediately dispatched his newly elected vice president, Rafael Espada, on an official trip to Cuba to study the Cuban health system. Espada, an experienced cardiologist who once worked in Houston, visited the nine hundred Guatemalan medical students who are studying at ELAM and praised the quality of their education.8

Currently, medical students are receiving a warmer welcome when they return to their home countries after graduating from ELAM. Some are accompanied by Cuban doctors who guide them through the newest stage of international cooperation. For example, when indigenous ELAM graduates from Honduras return to their native Garifuna region on the Mosquitia Coast, they are slated to get post-graduate residency training from Cuban specialists and a handful of Honduran doctors who have decided to participate with them. This enables the graduates to serve their own people in new hospital facilities like the one in the isolated town of Ciriboya. In 2008 the new buildings there were dedicated by Honduran President José Manuel Zelaya Rosales in a ceremony attended by the Cuban health representatives and engineers who helped design and equip the facility. In a startling change of heart, representatives from the Honduran Medical Association, which three years earlier was trying to chase the Cuban doctors out of the country, joined the celebration.9

Various small countries of the Western Hemisphere, long under the yoke of wealthy conservative minorities or military authoritarians and dependent on capital and political instruction from the North, are no longer willing to listen to the United States when it tells them to shun Cuba. The U.S. State Department, in its desperation to exert some kind of leverage against the growing Cuban influence, has tried to get the Cuban personnel to betray their mission by luring them to the United States. To this end, in August 2006 the Bush administration instituted the Cuban Medical Professional Parole program, which specifically targets only Cuban medical personnel and encourages them to defect when they are working in a country outside of Cuba. New Department of Homeland Security rules declare that doctors, physical therapists, lab technicians, nurses, sports trainers, and others will be afforded special treatment and fast access to entry into the United States.10 Out of almost 40,000 Cuban medical workers abroad, there are a few who have taken the bait; perhaps one or two hundred have actually gone to the United States. The motives of most of those defectors, at least the ones who talked to the press, are only ideological to the extent that they are choosing a more comfortable life in a rich capitalist society.

They were tired of the demanding circumstances in which they had to work and are hoping for more money. The small yield from this defection program does not seem worth it, since the United States risks being perceived as a cash-wielding bully that is willing to sabotage humanitarian efforts that have proved so beneficial in so many different countries. Clearly the United States has run out of options in the ideological battle when it has to stoop so low.

The Battle of Ideas and the Creation of a New Generation of Revolutionary Doctors

The creation of the ELAM medical school in 1999 and the formation of new international medical brigades under Programa de Salud Integral in 1998 were closely tied to other ideological and educational efforts that were emerging at more or less the same time. The direction that the Cuban government wanted to pursue became clear in Fidel Castro’s May Day speech of 2000. Fidel told the Cuban people that the ability of their nation to survive and maintain its revolutionary independence depended on being willing to fight and win “a Battle of Ideas.” He emphasized that “Our consciousness and the ideas sown by the Revolution throughout more than four decades have been our weapons. Revolution means… being treated and treating others like human beings.”

The impetus for the “Battle of Ideas” had been generated in 1999 by the successful efforts to repatriate a little boy held in Miami, Elian Gonzales, with his father in Cuba. Mass demonstrations all over the island on Elian’s behalf had mobilized millions of average Cubans, and constituted an important expression of pride by the whole nation. Cuba had managed to emerge from the desperate economic times of the 1990s with its revolution still intact, though a bit tattered and in need of renovation. The “Battle of Ideas” allowed Cubans to reassert the importance of socialist, humanistic values that had been undermined to some extent by the temporary concessions made to capitalist, unequal economic relations during the “Special Period.” Abel Prieto, Cuban minister of culture, explained in 2004 why this renewal process was so important, not just for Cuba, but for a world that for too long had been hearing from the likes of Ronald Reagan, George H. W. Bush, and Margaret Thatcher that “there was no alternative” to their kind of capitalist development. He insisted there was an alternative: “… in contrast to the stupidity, barbarity and the law of the strongest that today intends to impose itself worldwide, we try to defend the idea that another world is possible.”

“We believe,” said Prieto, “that what should be globalized, are not bombs or hatred but peace, solidarity, health, education for all, culture, etc. That is why, when our physicians go to help in other countries, although their mission is to work for medical attention, they are also bearers of our values and our ideas of solidarity. This is the essence of the Battle of Ideas.”11

In this sense, the brigades of Cuban doctors working abroad represented the front lines in a struggle to assert that alternatives to profit-centered human interactions were viable. The concerted effort just kept growing in the first decade of the twenty-first century, to the extent that the Cuban press could report in November 2008 that there were 38,544 Cuban health professionals serving in seventy-five different countries, 17,697 of them doctors.12 The key battleground was Venezuela, where about half of all Cuban medical personnel were working. They served as the catalyst that allowed Venezuela’s new health delivery system, Barrio Adentro, to grow by leaps and bounds.

In 1999, when President Hugo Chávez assumed power in Venezuela, only 4,000 of the approximately 35,000 doctors in the nation were practicing anything resembling family medicine or general practice. When the first small contingent of Cuban doctors arrived, they were faced with the task of replacing a neglected public health system that had deteriorated for almost three decades and was not serving most of the nation’s twenty-five million people.13 Only about 1,500 Venezuelan doctors, some working only part-time, were providing primary care in a dilapidated network of small ambulatory clinics and consulting offices.

Over the five years between 2003 and 2008, thousands of Cubans arrived for two-year tours of service in Barrio Adentro, and many of them signed up again for additional duty. At its peak in 2006, the Cuban presence numbered about 14,000 physicians plus thousands of other medical personnel. By 2008, the number of Cuban doctors had declined as some moved on to work in Bolivia and other countries or returned home. Still, the primary care system established by Barrio Adentro boasted some impressive statistics: care was delivered by 7,878 family medicine specialists (about 7,000 Cubans and over 800 Venezuelan doctors) assisted by 1,499 post-graduate doctors in the same specialty; there were 10,991 new or refurbished consultorios populares (Barrio Adentro outpatient offices); 3,019 Cuban dentists worked alongside 2,024 Venezuelans in Barrio Adentro dentistry offices. Other Cuban physician specialists, such as ophthalmologists and emergency care doctors, were working in diagnostic centers and hospitals. Previously there had been 1 public primary care doctor per 17,300 inhabitants of the country, now there was 1 per 3,400 inhabitants.

There are other impressive numbers that indicate the rapid development and construction of diagnostic clinics (Barrio Adentro II) and new hospital and medical facilities (Barrio Adentro III); and there are statistical indicators, such as an infant mortality rate that fell from 21.4 per thousand to 13.9, that demonstrate how fast, skillful delivery of primary care can quickly change things for the better. But perhaps the most outstanding changes are in the attitudes of the majority of the citizens. Although long marginalized and largely ignored by the private health care system (which still serves the upper strata of society), 70 percent of Venezuelans now assume that they have the right to free medical care and healthy living conditions. The new sense of dignity that Venezuelans gained in their interactions with Cuban medical practitioners was developed from the very beginning in the neighborhood health committees. Before any patients were seen in 2003 and 2004, and before a single consulting office was opened, neighborhoods had to form health committees that found rooms in local homes for the newly arriving doctors and arranged for the preparation of their meals. They also began, with the new physician’s help, to examine the social and physical environment around them.

In 2004, I first visited one of the newly built consultorios in a poor Caracas barrio. It was one of the little red brick, two-story octagonal structures that is immediately recognizable as a Barrio Adentro building all over the country. Once inside I admired the way the tiny office and examining room were neatly squeezed into the first floor space, but it was a large sheet of paper, taped to the wall behind the reception desk, divided into neat boxes and covered with handwritten notations, that really caught my attention. This was a community data sheet compiled by the neighborhood health committee and the Cuban resident doctors who lived in two tiny rooms upstairs. It was based on a thorough survey of all members of the community and showed some baseline figures concerning the state of neighborhood health: How many kids have asthma? How many elderly people are undernourished and need free meals at the community kitchen? How many people have hypertension? This kind of data, displayed in every Barrio Adentro consulting office in the country, reveals that communities are learning from the start to take charge of their own medical system.

How Is It Possible to Sustain the Medical Revolution in Both Cuba and Venezuela, and Even Start Exporting It to Other Countries? Create More Doctors!

The sudden comprehensive expansion of primary health care in Venezuela required extraordinary contributions from a country that is less than half as big in population. The fact that Venezuela could pay for the Cuban services with its significant oil revenues helped the Cuban economy, but the social fabric of Cuba began feeling the strain. So many doctors were being exported to Venezuela that primary care doctors were not as prevalent as they once were in Cuban neighborhoods. Cuban doctors in Havana tried to point out that there were still far more doctors per capita available than elsewhere in the world (after deducting for those who were working abroad, there are 4.8 physicians per 1,000 residents, or twice the number of practicing physicians as in the United States), but this did not necessarily satisfy some residents, who complained to a Boston Globe reporter in 2005 that it was getting more difficult to see the neighborhood doctor who had once been immediately available.14

Cuba realized that it needed to replenish its pool of doctors if it was going to keep expanding its programs of international solidarity in health care (by December 2007 there were already about 2,200 Cuban health care workers, including 1,553 physicians, stationed in Bolivia to support revolutionary change under President Evo Morales). Venezuela, for its part, did not want to be dependent on Cuban medical personnel forever; it was anxious to replace them with its own family practitioners and wished to send its own volunteers on international aid efforts. The two countries were ready to institute new physician training programs that could not only produce thousands of new doctors, but could also produce people better equipped to deal with the myriad social and scientific challenges of promoting good health for all citizens. In 2004, Cuba began a new kind of medical training, the University Polyclinic Medical Training Program, that differs from the traditional medical school model that has been used in Cuban universities and every other country of the world for centuries. In 2005 Venezuela followed suit with a very similar national training program called Medicina Integral Comunitaria.

Each of the these new university programs dispenses with the traditional university campus and creates a “medical university without walls.” In the new system, there is regular classroom instruction at community polyclinics and diagnostic clinics, and this is supplemented by a great deal of participation and observation with family medicine specialists as they attend to patients in nearby Barrio Adentro offices. The university comes to the students, not vice versa, which allows poor and working-class students in urban barrios and rural towns to live at home and learn the practice of medicine within their own communities. In the various sites in Venezuela that I have visited, a small group of students typically works four hours each morning with an individual Cuban physician/teacher at a Barrio Adentro or diagnostic clinic office, then they converge with other small groups at a classroom building in a central location for afternoon classes.

The highly organized classroom material involves a sophisticated new approach prepared by sixty medical professors in Cuba who are specialists in a broad range of biomedical and sociomedical sciences. They have taken traditional subject matter such as anatomy, physiology, and genetics and combined them into new interdisciplinary courses in morphophysiology. All classroom instruction is delivered in a lively combination of video material and lectures by the various physicians/teachers. Outside of class the students can review a DVD of each lesson at home or with their fellow students during their evening or weekend study times. During their morning work hour at the consulting offices, the students are encouraged to ask as many questions as possible that are pertinent to both the treatment of patients and the course content they are currently studying. The doctors think of their teaching as tutoring and they say their close relationships with the students allow them to notice which students assimilate knowledge in different ways or are lagging in particular areas.

The students dedicate themselves to this rigorous course of study for six days a week for six years. Their courses include all the subject matter and material covered in traditional universities, plus they are exposed to a much deeper experience of the human elements of caring for actual patients and understanding the dynamics and problems of real communities. When I asked one Cuban physician/teacher if she thought the daily work component was too much of a distraction from the business of regular study for her students, she laughed and answered, “On the contrary. Their excitement about their academic learning, combined with their enthusiasm for interacting with and understanding our patients, makes them ask questions all the time, so that they are much more dynamic students than those I’ve known in conventional universities in Cuba and this accelerates the learning process. I think by the time they get into their third year, they are at least a year further advanced than traditional Cuban students. They seem more like trusted medical colleagues than students.”

As for the students, the educational structure allows them to form strong bonds with the doctors, who are, in effect, tutors sharing their knowledge, as well as master craftsmen patiently pointing out details and necessary skills to their apprentices. They also serve as models of revolutionary dedication. The doctor quoted above completed other tours of duty in Yemen, Ethiopia, and Haiti before coming to Venezuela, and her students say that she is inspiring them in the same direction. The Medicina Integral Comunitaria educational program is being replicated at so many locations around Venezuela that it is producing large numbers of new doctors. There are slightly over 20,000 students enrolled in the first three years of Medicina Integral Comunitaria, with another 4–5,000 who will form the fourth year in early 2009 after they successfully complete their six-month premedical course.

In Cuba, the introduction of the similar University Polyclinic Medical Training Program is also producing a great expansion in the number of family medicine students, with over 12,000 Cuban students enrolled. This is in addition to the nearly 17,000 Cubans who are studying at the traditional medical universities. As if that’s not enough, Cuban institutions such as the Latin American Medical School, ELAM, and other university programs are offering free medical education to 24,000 foreign students, including about 100 from the United States. ELAM has also opened a program in Venezuela, so that about 800 foreign students are studying with the MIC students in various communities around the country.

Socialist Medicine versus Capitalist Medicine

Cubans, with the help of Venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the United States, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs. The U.S. students emerge from their four years of study burdened with an average of $140,000 of debt. So it’s not surprising that they have a desire to earn high salaries, either to pay that debt or simply enjoy the upper-middle-class lifestyle to which most first world physicians are accustomed. Consequently, very few U.S. medical school graduates go into residencies in family practice, the lowest paying specialty.

In an era of severe worldwide economic downturn, the U.S. system of training doctors and delivering medical care is more financially and morally bankrupt than ever. In many parts of the world, people realize that following the U.S. model is impossible as well as immoral, and so they are eagerly watching the Cuban and Venezuelan developments in medical care, especially the new kinds of instruction and service in community medicine. If the new twenty-first century socialist model is successful, and if the first students graduating in a few years are as eager to travel as their Cuban mentors, a bigger wave of revolutionary doctors, filled with concern for humanity, will start spilling over the rest of the world. And the spirit of Che will be happy to say once again: “At the risk of seeming ridiculous, let me say that the true revolutionary is guided by feelings of great love.”

Notes