Friday, November 14, 2008

Fidel´s WMDs versus Bush´s WMDs - World Medical Doctors are more powerful than Weapons of Mass Destruction

(originally written in June of 2007)
This is a confrontation that has been brewing for 45 years: the United States versus
Cuba. George W. Bush and Dick Cheney have been acting more and more belligerent, as if they believed that their WMDs, the most deadly collection of "weapons of mass destruction" in the world, are superior to Cuba's own brand of WMDs.

What the North Americans ignore, at their peril, is that Cuba's WMDs are "World Medical Doctors," an incomparable force for peaceful cooperation that is winning the admiration of people the world over (except in the United States, where almost everyone, including the media, is unaware of their existence.) How can the U.S. assortment of nuclear and biological warheads compete with tens of thousands of highly trained, humanitarian physicians?

One example of a superior weapon
One of the Cuban WMDs is a young ophthamologist working at a Barrio Adentro 2 diagnostic clinic in the town of Sanare in the mountains of Venezuela. Dr. Eulogio (his first name – all the patients seem to call the Cuban doctors by their first names) is one of over 30,000 medical professionals who are currently serving people outside of Cuba, and 20,000 of them in Venezuela alone. In January of 2007, he and his older colleague, Dr. Frank, spent about six hours talking about medical care and medical education.

The Cuban doctors are treating thousands of people each month at the various Barrio Adentro sites around Sanare. There are several small neighborhood medical offices that treat outpatients, and one new diagnostic clinic that has an intensive care unit and medical specialists, plus MRI and X-ray equipment.

But they also have another job – training the doctors who will one day replace them. At present 42 local residents of the municipality are going to medical school through an intensive training program known as “integral community medicine.”

Dr. Frank has four second-year students who follow him around on his medical rounds and appointments during the week, observing diagnosis and care while discussing physiology and pathology that are pertinent to their current studies. Their afternoons are spent in intensive classes which include CDs designed by the best professors at medical schools in Cuba. The CDs are available for the students to watch as many times as they like, allowing them to review the information and concepts in the lectures with local instructors such as Dr. Frank.

In January of 2007, Dr. Frank spent hours talking to three students from the Dickinson College in Pennsylvania about the concepts and practice of medical care and education in Cuba and Venezuela.

After studying six days a week for six years, these students will become family physicians who will treat everyone in this agricultural area. If, at some point, they want to become specialists, they would have to do another three years of study and residency.

Some of the local students recently completed high school and others, like Juan, are more than twice their age. A forty-seven year-old man in his second year of training, Juan says that he dreamed of going to medical school over twenty years ago but that was financially impossible for him and his family, so he worked for years as a nursing assistant in a local physician’s office. While he gets a small scholarship while completing his studies, Jose says he is only able to pursue his medical career because of strong financial and moral support from his wife and their extended families.

This physicians’ training program is being implemented nationwide on a huge scale, so that by 2012 there will be 23,000 new doctors in Venezuela, all educated to provide medical care in their home towns and barrios. Some of these physicians will undoubtedly become WMDs, or World Medical Doctors, and will be available to join their Cuban counterparts in deployment to Latin America and other parts of the globe.

Dr. Frank and Dr. Eulogio say that the Venezuelan students are the beneficiaries of a “revolution within the revolution” in Cuba, where the system of education is being radically changed. In Cuba, too, doctors are now being trained differently, and are starting go on rounds to see patients in their first year like in Venezuela, rather than in the fourth year as in the past. Other kinds of educational progress are also evident; for instance, increasing quality of primary and secondary schools, where class sizes are being reduced to 15-20 students per teacher.

The doctors think the scholastic achievements of their Venezuelan students are impressive, but they emphasized something else: “What is even more satisfying for us to see is the creation of moral and ethical values that allow them to really influence their own communities.”

I told the two doctors that I had talked to several people in the waiting room downstairs who were very happy with their care at Barrio Adentro II. They felt comfortable because the Cubans treated them as equals and enjoyed answering questions and chatting with them. During the lengthy time I spent talking with Dr. Frank and Dr. Eulogio, many people banged on the door and stuck their heads in just to say “Hi!”

“I think we and our students are creating a new model of what a medical professional is supposed to be,” explained Dr. Eulogio. “The old Venezuelan stereotype of a doctor, at least in the cities, was somebody driving around in a fancy car with black windows and air-conditioning. So nobody knows who they are -- people only get to see them in their offices if they can pay.”

One of the people responsible for this extraordinary investment in human capital is Dester Rodriguez, a military general and a director of PDVSA, the Venezuelan national oil company. He is responsible for overseeing the billions of dollars of oil profits that are channeled directly from PDVSA into the “misiones,” the social missions that are designed to lift the majority of Venezuelans out of poverty. He likes the idea that he is financing ultra-sophisticated human weaponry, but he doesn't refer to them as WMDs. He puts them in a category "more powerful than atomic weapons" and calls them "missiles of love." [see article on “Sowing the Oil”]

Fighting capital with human capital – the battle of WMDs is a “Battle of Ideas”

After the Soviet Union collapsed in 1989, the United States and George Bush the Elder announced that there was a “New World Order.” They expected to impose a global capitalist regime that would allow no room for any small, revolutionary nations like Cuba. The U.S. economic blockade had damaged Cuba in previous decades, but in the 1990s it became much more devastating because the Cubans no longer engaged in significant trade with the Eastern Europe and Russia. The Cuban economy sank into a true depression and the production of goods and services fell by at least 30%. The nation struggled to feed its people, and only by imposing strict food rationing did it prevent the health of its children from deteriorating. The capitalist world waited for Cuba to collapse.

When Cuba invigorated its tourist industry in a effort to attract dollars and euros into their economy, it did not allow capitalist values to overwhelm revolutionary values. But it wasn’t easy, particularly since some people working in the tourist industry were earning a lot more than professionals in various kinds of public and social service jobs.

Cubans decided to emphasize the kinds of social solidarity and humanistic concern for other people that distinguishes their society, and to contrast them with the materialistic and self-centered behavior that characterize advanced capitalist societies. When Fidel Castro addressed the nation on May Day in 2000, he told the Cuban people that Cuba would survive by engaging in a Battle of Ideas: "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 ….it is challenging powerful dominant forces from within and without the social and national milieu …. it is a profound conviction that there is no power in the world that can crush the power of truth and ideas.¨

Interviewed four years later, Abel Prieto, the Cuban Minister of Culture, expanded on this theme and explained why the Battle of Ideas was connected to Cuba’s programs of international medical assistance. “… 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. Against the neo-liberal model, this fierce version of capitalism that reserves for a small minority the luxury of consumerism and excludes ¾ of the population of the world, we propose the defense of the values of social justice and authentic democracy. We believe 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.”

As the United States has kept expending its energy and hundreds of billions of dollars on neo-colonial wars, it did little to engage the Cubans on the philosophical battlefield. Some State Department figures weakly declared in 2005 that the U.S. wanted to engage in its own “battle of ideas,” without pointing out that the Cubans had defined the terrain of the battlefield five years earlier.

There were some efforts at genuine humanitarian assistance by the U.S., such as military helicopters delivering medical aid to Pakistan in the wake of a terrible earthquake in late 2005. In 2007 the State Department played up the visit of a U.S. hospital ship to Panama where it dispensed free medical care. But these efforts paled beside he much more extensive aid that Cuba dispensed to Pakistan (1,500 doctors and nurses living in wintry conditions they had never experienced before) and to Latin America and the rest of the world.

Cuba has more than 45,000 students studying medicine, almost 20,000 of them coming from poor parts of Latin America and Africa (as well as a handful of students who come from poverty-stricken areas of the United States.) The U.S.A., almost thirty times bigger in population than Cuba, and hundreds of times greater in material wealth, has roughly 64,000 students in medical school.

For a refreshing look at the practice of Cuban medicine and medical education as they affect many parts of the world, see the feature-length film, Salud, directed by Connie Field. She is a veteran documentary film-maker who was previously nominated for an Academy Award for Rosie the Riveter, the story of working women in the U.S. during World War II.

Thursday, November 13, 2008

WMDs -- World Medical Doctors – now being produced in Venezuela (WMDs Part 2)

(originally written in October of 2007)

Jonas, left, with his brother and his father
Jonas lives on a tiny dairy farm on the hill above Monte Carmelo. His father is intensely proud that his son is studying to be a medical doctor. “He’s only in his second year,” he said, “and already he sees patients.”

“Remember, Papá,” cautioned Jonas, “we do see the patients and talk to them, but we don’t treat them yet. We’re just there to observe and assist our teachers and ask questions.”

“I know that,” his father responded. “What I mean is that it’s important that all of you are learning to talk to the patients, treating them like friends and fellow human beings.”

Jonas is not the first person in his extended family to attend medical school, according to his father. He tells the story of his niece, who many years ago dreamed of being a doctor. Her mother, who was very poor, worked constantly to save every penny and told her daughter to study hard. The extended family pitched in to help the mother.

“She really did go to medical school,” explained Jonas’ father, “at one of the big city universities. Then she her got her training in a specialty, and now sees lives and sees her patients in a rich neighborhood of Caracas. Of course, now, as far as she’s concerned, I don’t exist. In fact, my niece doesn’t want to associate with anyone in the family and doesn’t talk to any of us.”

This is why the government has introduced a totally new system of teaching doctors. The old system, centered around elite universities where only a tiny minority of poor and working class students are enrolled, has continued to turn out professionals who want to work in the urban centers and enjoy a fairly rich, upper-middle class lifestyle. These kinds of universities, home to many of the students who are currently protesting against the constitutional reforms, are not unique to Venezuela, for their counterparts exist all over the world.

The Venezuelan government has avoided the temptation to abruptly seize control of these older universities and force them to operate in a manner that serves the poor majority. Instead, it has simply bypassed them and constructed a new kind of university.

Where is this university? All over Venezuela, because it exists in the realm of ideas, not in a particular set of buildings. The Mission Sucre school of Integral Community Medicine trains students where they live, utilizing the local medical facilities and doctors in their towns and neighborhoods as the campus and professors. The students enter with the expectation that they are choosing a vocation that involves serving the people and their home communities after they finish their training.

This unique form of education could not exist without Cuban doctors. They arrived by the thousands to staff the Barrio Adentro neighborhood medical offices that sprouted up all over the country in 2003 and 2004 and brought free health care to poor barrios and rural areas that had neglected for many decades. The Cubans are helped by a four or five thousand Venezuelan doctors who were trained in the old system, but for reasons of social commitment and political conviction have chosen to work with the poor.

Party time for medical studentsAfter dancing, Doctor Barbara, takes a break at the feet of her students, Magale, Antonio, and Luisa.About a month ago Jonas invited me to walk up the mountain to his house where I joined him and his fellow students for a little rest and relaxation. It was Sunday, time for a little music and dancing, plus sitting and chatting and enjoying the view over the valley below. Barbara, the dynamic Cuban physician who holds the students to a rigorous schedule the other six days of the week, took charge of the family kitchen and prepared a big pot of tasty stew.

All of the students are residents of some part of the municipality surrounding Sanare (comparable to a county in the U.S.) and are enrolled in the second or third year of the Mission Sucre medical program (also see earlier article, Fidel’s WMDs) Their Cuban and Venezuelan teachers work in local “ambulatorios” (free public walk-in facilities in various neighborhoods and villages) or in the Barrio Adentro 2 Diagnostic Clinic in the middle of Sanare.

The medical career is demanding. After completing six months of classroom preparation to make sure everyone is starting out on an equal footing, the students commit themselves to a six-year program. Beginning in the very first year, the students are spending part of each day with patients in medical settings. They spend their mornings accompanying doctors as they see patients and offer treatments, looking after medical records and medications, weighing and measuring babies and children while the doctors attend to the rest of the family. Their afternoons are spent in the classrooms. Nights are for study, reviewing CDs that cover the material of each class lecture, and some sleep.

The first year serves to sort out the serious students, the ones who truly have a vocation for medicine, and the less committed drop out. Jonas thinks that the students who come from the rural villages and farms are most likely to stick with the program, perhaps because they are used to hard work. His fellow student Luisa comes from La Bucarita, an isolated coffee-growing village more than two hours out of Sanare by Jeep. She’s living with an elderly relative in Sanare and really misses the company of her large family, but she’s determined to get her medical degree.

Jonas had been out of high school for a number of years before the new integral community medical program began. During the early years of the Bolivarian Revolution, he and other recent high-school graduates were teaching as temporary rural “maestros,” even though they didn’t have college degrees. They served as literacy volunteers who went to the more isolated areas of the county to work for Mission Robinson, the basic education program that taught illiterate adults to read and now helps them and others to complete their elementary schooling. At the same time, he also continued helping his father with farm work and building a new house for the family.

Doctora Edita is a Venezuelan physician who was serving the poor before the Cubans arrived.

Some Venezuelans, like Doctor Edita Goyo, who trained as a pediatrician in the big city of Barquisimeto, were committed to providing health care to everyone before the Chavez government came to power. The Barrio Adentro program was the answer to Edita’s dreams. It has allowed her to practice medicine for the last three years with dedicated Cuban professionals in the walk-in medical office in Palo Verde, a village just outside of Sanare. Currently she’s works in the same room with the Doctor Barbara, who arrived five months ago and replaced the previous Cuban doctor. (The Cubans generally sign up for a two-year tour of duty, and many re-enlist for another round of service.) They and their six medical students make a formidable team.

Antonio and Luisa bring records and medications as Dr. Barbara consults with a family.Dr. Barbara served in four other countries, including Angola, before coming to Venezuela.Each doctor has a desk, one on each side of the room, where they receive a steady stream of patients while the students perform various tasks. One mother arrived with four little children, two on her knee and two standing and clinging to her. The medical students moved in and entertained the children one by one, then managed to measure them and examine their eyes, ears, and throats. Meanwhile Doctor Barbara took extensive notes on the medical history of the woman, for she was the one who was ill.

The files on individuals and families are extensive and allow the doctors and students to review the various trends within the community. They use this information to create wall charts describing the predominant health care problems in Palo Verde. This provides them with a comprehensive view of the most pressing local needs that “integral community medicine” must address. One important component of the medical team’s work is educating the public about preventative measures. Many of the common maladies enumerated on the wall charts – such as diabetes, asthma, and hypertension – are combated by introducing exercise programs and changing diets.

I saw the wall charts below three years ago in a Barrio Adentro office in Caracas. Volunteers from the local Health Committee had helped the Cuban doctors gather information on every family in the neighborhood. The charts showed exactly how many local residents (and the numbers were high) suffered from preventable afflictions such as malnutrition, hypertension, and asthma. The medical students were having good luck entertaining most of the kids, but this baby simply did not want to get weighed by Jonas. Fellow student Vanesa is amused by the proceedings.

Wednesday, November 12, 2008

The World Medical Doctors down the street (WMDs part three)

(originally written in January of 2008)

An innocent, beautiful little village nestled into the mountains at the northern end of the Andes. Hardly the place anyone would look for one of the greatest concentrations of WMDs in the world. Should we leave town before Bush tries to retaliate?

The new generation of WMDs in Venezuela (for those of you who have not encountered them in two previous posts on Venezuela Notes) are World Medical Doctors in training, and they’re living on all sides of us. Monte Carmelo, a village of about 700 people, has 8 residents who are studying Medicina Integral Comunitaria, or Integral Community Medicine, in the Mission Sucre program of higher education that serves this municipality. A ninth resident is studying medicine in Cuba.

On the left, Mariela, Arelys, and Milena live in Monte Carmelo. Next, Inez is from the nearby village of Bojó, and Karen comes from Peru.

    Milena and Mariela began studying three and a half years ago as part of the first class that now includes twenty-eight students. They responded to public announcements inviting interested people to take an exam that would qualify them to enter the medical training program. Mariela, who had just finished liceo (or high school), had always dreamed of being a doctor but doubted that she would have the opportunity to study at one of the big city universities. “So, when I heard that we could take the test to enter the program in Medicina Integral Comunitaria, I raced down into Sanare to sign up.”

Milena on the other hand, was already out of school, married and the mother of a two year-old daughter when she took the exam. When she and Mariela passed and were accepted into the medical program, they faced a rigorous 6 month preparatory course that was designed to get all students, those fresh from high school and those who had not attended classes for a long time, performing at more or less the same level.

Then they were ready for the course of study itself, a serious commitment that involves completing six years of work, the same amount required by medical schools at many other universities in Europe and around the world.

Their school, however, is unique in two ways. For one, the university training comes to them in their hometowns and prepares them for spending their careers serving the areas they live in or other parts of the country (or world) that have a shortage of doctors and good health care.

Secondly, they begin spending time with patients in their very first year, working three or four hours in the morning, Mondays through Fridays, in the ambulatorios (walk-in offices) and the larger diagnostic clinic created by the Barrio Adentro program. Besides taking note of various kinds of treatment, the students begin developing their communication skills and abilities to interact sensitively and humanely with patients.

In the afternoons, all the students working in various locations converge on a building in Sanare, the large town in the area, for their formal classes. These consist of watching DVDs of lectures from Cuban medical schools, discussing the material and things they have observed with the Cuban doctors who are their local instructors, reviewing other medical information on computers, and also taking weekly exams.

When Mariela and Milena completed their second year, they and all the other students entering the third year were rewarded with gifts: their own computers to use at home. This allows them to take DVD copies of the Cuban lectures and various readings and films with them for night-time review. They were delighted, of course, because few people in Monte Carmelo are lucky enough to have their personal computer and because they feel the complexity and intensity of their work has increased this year. The two of them mentioned their current physiology course in particular since it demands a lot of rapid memorization -- all those bones, organs, muscles, tendons, ligaments and their various functions.

Every fifteen days, two of the third year students have to be on call all night at the Yacambu Diagnostic Center. From 8 pm to 8 am, they help admit emergency patients and assist the lone Cuban doctor who is on call. Sundays, though they are supposed to be a days of rest, are sometimes devoted to a quick medical tour to one of many isolated villages and hamlets in the area. Students will hop into a jeep with a doctor and plow through the muddy mountain lanes to reach people who seldom ever get to Sanare, let alone to a doctor’s office.

All in all, this is a grueling regimen, so I asked how many had dropped out. “Four of five out of the 39 of us,” the students said, “are no longer with us. There was only one who thought it was too simply much work. Another having a baby. The others felt the financial or family pressures were too great. And then, of course, there are six of our original group who aren’t with us here, but are still studying. They’re at the Latin American University of Medicine in Cuba.”

There are other health care students in Monte Carmelo, such as Elsy Perez, a middle-aged nursing student who helps out at the ambulatorio. She was an original member of the village health committee that worked with the first Cuban doctor who arrived in 2003. Now she and 52 other students from the Sanare area, four of them from Monte Carmelo, are enrolled in the Mission Sucre nursing program. Elsy Perez said that previously only one Monte Carmelo resident had completed her nursing degree by commuting an hour and half to the big city of Barquisimeto.

Elsy also works three days, in 7am to 7 pm shifts, at the small municipal hospital in Sanare that is staffed by two Venezuelan doctors. She says that they, possibly because they were trained years ago in the established medical schools in the big cities, are often unsympathetic and harsh with their patients. The nurses notice that some patients are treated much better than others, and this seems to be due to class prejudices held by the doctors, who sometimes will hardly speak to the poorest campesinos. This is in stark contrast to the Cuban doctors Elsy has worked with who give everyone equal attention and treatment, and often put people at ease with their friendly style.

“This is what we want to do, too,” added Arelys, another mother who is now in her first year of study to become a doctor. “We are thinking of medicine as a vocation, our calling in life, our way of serving the people and building socialist values. We don’t want a profession in the old sense, like some of the older Venezuelan doctors, who are motivated by a desire for money and prestige, and want to feel that they are superior to the patients, the nurses, and everyone else.”

This year, a new development in WMDs

Just arrived in Monte Carmelo last week: Karen from Peru and Georgo from Surinam

This week another 335 World Medical Doctors-in-training were thrown into the potent Venezuelan mix of WMD production. If you will recall from the previous posts on this site, about 23,000 Venezuelans are now studying Integral Community Medicine at home and another 4,000 are in medical school in Cuba as part of the 20,000 foreign students training to be physicians under the auspices of Raul and Fidel.

Nine months ago the foreign students started arriving in Venezuela as well, so they could be prepared to study within the Integral Community Medicine program. Now that they have finished the pre-medical course, they are being dispersed around the country. Seven of them have just arrived in Sanare, including Karen and Georgo, pictured above. The two of them were at work in Monte Carmelo on Thursday when I visited the ambulatorio.

No wonder Bush and Cheney are quivering in their cowboy boots. They thought they had knocked off Doctor “Che” Guevara 40 years ago, and now he’s back, multiplied a thousand-fold. As you may recall, after the young Ernesto Guevara finished his motorcycle journey around South America, he quickly completed his medical school exams, and took off again. This time he was determined to put his training as a doctor to work in the service of humanity, so he headed to the one place in Latin America that was having a peaceful social revolution. Guatemala.

Soon after his arrival in 1954, U.S. intervention put an end to Guatemala’s successful experiments with land and labor reform and unleashed a half century of pro-capitalist brutality in Central America. Ernesto had to flee the country to Mexico where he met a new group of friends who were amused by his Argentine habit of saying “che” all the time. Thus, “El Che” was born, the internationalist physician who picked up a gun, joined the Cuban guerrilla fighters, and became a leading “comandante” in their Revolution. He would later die fighting with a small band of revolutionaries in Bolivia.

So it is interesting that, out of the 335 students who left Caracas this week to begin their six years of training in various parts of Venezuela, about half are Bolivians. Perhaps the CIA, which had a direct role in murdering Che after he was captured by the Bolivian Army in 1967, is alarmed by this new threat. Last week, in an intelligence report to the U.S. Senate, the CIA claimed that Cuba and Venezuela were having a negative effect on the governments of Bolivia, Ecuador, and Nicaragua. The chancellor of Bolivia quickly responded, “I don’t know where they are coming from and where they get their information. The people of Bolivia know what relations are like with Cuba and Venezuela.”

Joining the Bolivians who are studying medicine in Venezuela are students from many Latin American countries, including some who are not native Spanish speakers: a large contingent from Brazil, eight from Surinam, and even some Guaraní speakers from Paraguay. They were enrolled in intensive Spanish courses while completing their six-month preliminary training in Caracas.

Georgo, from Surinam, is now speaking pretty good Spanish after completing his intensive course, and he identified me right away. “I think I detect Spanish with an American accent,” he said in very good English, also with an American accent. He explained that in Surinam, once a Dutch colony, English has become the main educational language.

Georgo heard about the medical training in Venezuela and went directly to the Venezuela Embassy to apply for admission to the program. Karen said that she and most of the other forty Peruvians who arrived with her had applied through various revolutionary youth groups to which they belonged. Many of them had previously applied for admission to the Latin American School of Medicine in Havana, but were put on waiting lists because their was such a backlog of interested and qualified young people. Karen herself had been waiting for two years, so was happy to land a spot in the group that came to Venezuela instead.

The enthusiasm for this revolutionary vocation is clearly contagious and spreading rapidly through all the Americas, not to mention Africa, which is home to many other students studying in Cuba and the site of other medical schools that are staffed by Cuban physicians. A number of U.S. students are now attending medical school in Cuba, and one of them finished his studies and passed his state medical board exam to practice medicine last year.

According to Karen and Georgo, another contingent of 650 foreign students will be enrolling in the Integral Community Medicine program in the next two months. And who knows, perhaps there will be some U.S. students joining the others in Venezuela within the next year. If so, we can expect to hear from Washington that Hugo Chavez and Fidel are promoting one more “negative influence,” this one aimed at young U.S. citizens.

Still it’s doubtful that the U.S. health care system will be inundated with socialist doctors anytime soon. But here in Venezuela, it is a different story. Our little village of Monte Carmelo could be the WMD champion of the world, with one out of a hundred people becoming a World Medical Doctor.

(don´t forget to look for the great film on Cuban health projects around the world, Salud.)

Tuesday, November 11, 2008

World Medical Doctors go to class (WMDs, part 4)

(originally written in February of 2008)

After spending the morning helping Dr. Tomasa attend to families at the walk-in office in Monte Carmelo, Jonas will jump on his motorcycle and head for Sanare for afternoon medical school classes.

Last Tuesday afternoon I joined the first-year medical students for classes. There are thirteen students from the Sanare area and seven new foreign arrivals from ELAM, La Escuela Latina America de Medicina (“the School of Latin American Medicine”) which has been training 20,000 foreign students in Cuba and now has opened up an associate branch in Venezuela this year. The idea is to give these new ELAM students the same training that Venezuelans are receiving in Integral Community Medicine.

Doctora Alina, the short, spunky Cuban who was teaching the class, looked a little grumpy when Doctor Umberto, the Cuban director of the local program, told her that I was going to sit in on her class. Perhaps she was wondering if her thirteen Sanare students would perform well on a short quiz on molecular genetics, the previous week’s focus of study; or perhaps she was skeptical about letting a curious, and possibly untrustworthy gringo observe the group. The seven new students – three from Surinam, two from Colombia, one from Brazil, and one from Peru – waited patiently outside while the others took the test because they had not been present for all of the classes during the previous two weeks.

After the quiz, Doctor Alina asked the students to orally explain concepts related to the quiz. Arelys, one of the students from Monte Carmelo, seemed to have no problem explaining the interactions among XX and XY and XYY chromosomes. Then the doctor turned to one of the foreign students, who have been catching up on the readings, and told him to set up a six-part chart related to “operadores, promotores, regulatores, y cistrones.” Frankly, I was a bit lost and so was this particular student, who had a large and sheepish grin on his face as he struggled to write things on the board. The grin didn’t appear to make the doctor happy, and while she refrained from scolding him personally she did suggest to the whole group that a serious commitment to study was necessary. One of the students from Surinam was asked to answer the same question and had no difficulty charting a diagram and explaining the required processes in detail.

Now it was time to change rooms. Up until this point we had all been squeezed into a crowded reception room which had a street entry door on one side, and in the opposite corner, a desk and a computer for Dr. Umberto, the director. He and Dr. Frank, the intensive-care doctor from Sanare’s Diagnostic Clinic were having a discussion about cardiac and arterial blockages. They were searching the internet for discussions of new procedures and then jotting down extensive notes related to the problem they had to solve.

The Sanare area had no intensive care doctor until Doctor Frank arrived from Cuba a few years ago. Now he works in the new Diagnostic Clinic that is equipped with sophisticated imaging equipment and other resources that previously could be found only in the big cities. He dropped by the offices of the Integral Community Medicine program to discuss new emergency treatments with the director.  (Very observant readers will note that he is not the only Dr. Frank working in Sanare. The other, an ophthalmologist, appears in the first blog article about Cuban World MDs.)

When the third-year students came out of an adjoining classroom, our group of first-year students moved in there. This room was larger, quieter, and equipped with old-fashioned school desks and a computer and projector that was set up to show a DVD film to the students. Doctor Alina and the film split the lecture time -- about 65% for the Doctor and 35% for the film -- over the next two hours. The film was well-made, a succinct and informative discussion by a female narrator accompanying charts, drawings, and cartoons. This was different than what I had expected. I had developed the impression, in discussions with other Cuban doctors a year ago, that the new films used in classes were going to be videos of live lectures that had been presented by professors in Cuban universities.

This was not the case. The Cuban medical universities have prepared a whole set of video films designed specifically for the six-year program in Integral Community Medicine in Venezuela. We were watching “Morfofisilogia Humana (human morphophysiology): 1st trimester, 1st year.” Previously the Cubans have gained international recognition for the advances they have made in audiovisual education, especially with their new concepts of how to teach language and reading. While I am
ill-equipped to tell you whether this sophisticated or unsophisticated treatment of human morphology, I can say that I was captivated by the class.

Clearly the film was designed to be an interactive tool, and Doctor Alina made frequent use of the TV remote control to stop and start the action whenever she felt like it. She was very sharp and animated as she added detail, emphasized related material, or repeated the information in a fresh way to make sure the students were comprehending things. They felt free to ask questions at any time.

The general theme, which followed naturally on the previous week’s material, was human reproduction: how the cells of a baby are formed, and how a normal pregnancy is achieved. The “sumario” of the film announced associated themes: “Gametogenesis, Fecundacion, Desarollo de Cigoto, Alteraciones, Contracepcion.” After the film presented the different patterns of chromosomal joining and the exceptional cases, Doctora Alina pointed out some of the abnormal processes which were most likely to lead to birth defects. Later, when the film discussed the way in which the fertilized egg is implanted on the wall of the womb, she spent considerable time answering questions from students about unsuccessful pregnancies and the kinds of incorrect implantation that lead to spontaneous abortions, ectopic pregnancies, etc. “This is the kind of material you need to master,” she said, “because some day you’re going to have to explain these processes to some of your patients.”

After the doctor delved into “blastocistos, zona pelucida, trofoblasto” and other exotic (for me, at least) definitions, there was considerable discussion of the “feminine sexual cycle” and various ways to help women understand their individual variations from the average length of the period and the time of ovulation, including the use of a rectal thermometer. As it turned out, this discussion was related to the homework assignments. After Doctora Alina gave them the straightforward assignment of describing in detail the processes of “ovogenesis” and “spermatogenesis,” she went into different territory.

She gave them the hypothetical case of a long distance truck driver who is on the road most of the month and is married to a woman who travels throughout the country regularly to promote one of the new social missions in Venezuela. They’ve been married for three years and she can’t get pregnant. “What would you, as their doctor,” she asked, “advise them to discuss? And what measures could they take to better their chances of having a child?”

One of the students anxiously waved his hand and said, “I think I read an article about long-distance truckers and the possibility that because of all the time they spend sitting immobile in the cab this is cutting down on their sperm production.”
The doctor rolled her eyes toward the ceiling, and then shook her head emphatically, “No, no, no, that’s a bit of hypothetical speculation and it’s not the avenue of inquiry you should be pursuing, since there is a more straightforward approach that should probably solve this couple’s problem.”

Her last homework question was also intended to make them, as young medical people, practice sharing their knowledge and developing sympathy for the people they will treat: “You are in the walk-in clinic in some little village or in a Barrio Adentro office in a poor barrio, and a young woman comes in and says, ‘I’m think I’m pregnant. But I don’t know how I got pregnant.’ What do you need to ask her? What do you need to explain to her?”

The program of Integral Community Medicine is designed to mix intensive practical experience and intensive classroom study in each year of the six-year course. In another three years or so, when those students who are now in their third year graduate, we will see if this new course of study has produced a new kind of doctor. For now, from my visit to the first class in the first trimester of study, I can say that special attention is being devoted to the concepts of “integral” and “community.” In this process, both the curriculum and the professors are coordinated in a systematic effort to develop the humanitarian and humanistic potential of this very special vocation.
Dr. Alina provides the broad humanistic perspective without giving an inch on rigorous expectations of her students. They say she's the toughest taskmaster of the Cuban doctors in Sanare, all of whom demand the strictest attention and professionalism from the students whether they are in the classroom or assisting in the medical offices. After the class, however, she was all smiles and invited me to come visit her at her morning job, the Barrio Adentro clinic in one of the poorest neighborhoods of Sanare.

Who can aspire to this vocation?
Anyone who passes the preliminary exam and the six-month premedical training course is admitted. One of the first-year students in Sanare is José, a fairly old guy -- according to his fellow classmates, he's either seventy-one years old right now, or will be seventy one when he graduates in six years. He told me that forty-five years ago he was a supporter of the revolutionary guerrillas and was carrying supplies to them in their hideouts in the mountains in this region. “I was born a socialist,” he said as we walked away from the classroom building, “so this is a good way for me to finish out my life.”

The younger students say they are proud of him and glad he got a chance to qualify for the training in spite of his age. He says, with a big grin, that he hopes to practice medicine til he’s one hundred.

José wanted to know what was new with the primary elections in the United States, and I replied that Obama appeared to be edging out Hillary. “That’s good,” José said, “but do you think he wants to end that insane war in Iraq?”

“I wish I could say yes, but I really don’t know,” I said.

“Well, if he gets elected and says he’s going to pull the troops out, he had better watch his back. I am afraid they’ll try to assassinate him within five months.”