Cuban medical education: The cat that couldn’t bark?

The award of almost 200 free scholarships to enable students from United States of America to study medicine in Cuba came as quite a surprise at an All Party Parliamentary Group on Global Health meeting on 4 March 2015, chaired by Lord Crisp, titled ‘Potential Lessons for Primary Care Emerging from the Cuban Model of Medical Education’.  Surely the USA’s long-standing embargo of Cuba would not permit this?  Gail Reed’s TED talk ‘Where to train the world’s doctors? Cuba’  described how this scheme was an initiative of the black caucus of the US Senate. Many of these graduates are now US board certified doctors and are practicing successfully in the disadvantaged, formerly under-doctored, communities from which they came.

Cuba’s reputation for producing dedicated health workers who are prepared to work in difficult or remote health contexts is well known and was profiled by Jose Luis de Fabio, Director of the Pan American Health Organisation in Cuba. Since the 1970s Cuba has been a major producer of health workers with a commitment to international solidarity in health and provides doctors to countries facing severe shortages of health workers. The selection process for entry to Cuban medical education focuses on social skills and competencies as much as academic ability which has helped overcome the mal-distribution of health workers, common in most countries, which leave major  gaps in service provision for poor and marginalised populations.

But perhaps the Cuban experience is not all it seems.  Jimmy Volmink, Dean of the Medical School of Stellenbosch University in South Africa laid out the advantages and disadvantages of a long-standing scheme that trains African students in Cuba with the aim of providing doctors for rural areas. Volmink highlighted the culture shock that awaits rural black African students in Cuba, the language problems, the lack of internet to enable easy communication with relatives back home, and problems of re-integration with South African trained students when they return home for ‘top-up’ courses on malaria,   HIV/AIDS, neonatal infections – preventable diseases that are not common in Cuba.  One returning student said: “if you buy a cat, don’t expect it to bark!”  The culture shock and the process of adaptation experienced by these students may be essential components that makes the Cuban approach so powerful.  Incubating Cuban approaches within Africa – a potentially more logical and less disruptive plan – but without the experience in Cuba may not work so well.

These optimistic and pessimistic views of the transferability and utility of Cuban medical education arise because of different contexts and ways of implementing the Cuban approach – which is very flexible and is modifiable depending on the resources available.  All systems of medical education produce ‘pluri-potential’ doctors who may become family doctors, eye surgeons or psychiatrists. So the cat-dog analogy doesn’t work for me.  Neil Squires, Deputy Director, Public Health England, asked whether the global shortage of family doctors and an imperative for universal health care, would leverage medical schools to focus their core curriculum on graduating functional family doctors.  John Ashton, President of the Faculty of Public Health, described such a scheme operating in the rural mid-west states of USA.

Jim Campbell, Director of WHO’s Health Workforce Department, described the WHO Initiative on transforming and scaling up health professionals’ education and training which has compiled regional case studies.  These provide a substantial evidence base from which to work.  WHO’s commitment to universal health coverage and the new sustainability development goals that will do away with targets, replacing them, for example, with zero acceptance of neonatal and maternal deaths and 100% access to primary care provide compelling reasons for solving the primary care workforce crisis.  The massive growth in health care in high income countries is likely to suck markedly large flows of doctors from low income countries.[Crisp & Chen, 2014] Global action to create primary care doctors and community health workers on an industrial scale is needed now to offset workforce crises in primary care, which in turn provide fertile soil for epidemics of preventable communicable and chronic diseases.

Evaluations of the Cuban model have been conducted in the past but questions of selection of students, training of faculty, competences at graduation, impact on distribution and retention of doctors in disadvantaged and rural communities need to be answered to provide better evidence for policy making.  A DfID funded policy programme grant has been awarded to support Cuban, African and UK collaborative research on the Cuban approach.  In the UK, NICE International, Public Health England and LSHTM are involved.  The research aims to answer these questions:

• Does the Cuban system of medical education result in more equitable distributions of doctors? And in stronger retention of doctors in rural and disadvantaged communities?
• Are doctors trained in the Cuban model equipped with an appropriate set of skills and competencies for primary care? Are they better equipped than doctors trained in conventional ways?
• What lessons can we learn for health professional capacity building from a development perspective? And what can we learn for the NHS here in England?

Medical schools should be capable of assimilating and retaining the lessons learned over the last 40 years: redesigning selection processes to improve access for disadvantaged students; early and long-term contact with patients and their families; shifting teaching into primary care; integrated core training of doctors, nurses and other health professionals. [Frenk et al, 2010]  General Medical Councils may make accreditation more difficult for highly innovative education but they are not the barrier.  Deans of medical schools have more room for initiating change as demonstrated by the Training for Health Equity network (THEnet) and other networks, one of them arising in Africa,  the Consortium of New Southern African Medical Schools.  Once again we have to “turn the world upside down”, asking rich countries to learn these lessons from Cuban medical schools which show how doctors with vision, resilience, relevant competencies and the motivation to work with the most disadvantaged people can be created.

Prof Shah Ebrahim, Honorary Professor of Public Health at LSHTM, is collaborating with NICE International, Public Health England, PAHO and the Cuban Ministry of Health on the DfID-supported project on Cuban medical education model for Africa.

References

Nigel Crisp, Lincoln Chen. Global supply of Health Professionals. N Engl J Med 2014;370:950-7

Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58