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O N L I N E   E D I T I O N
Volume 9, Issue 2 Spring 1999

Building Joint Programs With Cuba: The MEDICC Experience

by Gail Reed

Havana—"Coming to Cuba reminds me why I decided to become a doctor". This comment by a Us medical student after rotating for eight weeks through a clinical elective here may be the single best statement of what Cuba's commitment to health brings to US physicians-in-training and to the larger US medical community, which in turn reflects the evolving philosophy of Medical Education Cooperation with Cuba (MEDICC), which sponsors these courses: the best joint program is grounded in real contributions from both sides towards common goals, where there is no single `receiving end'. Axiomatic on paper—as difficult as it is imperative in practice. With Cuba, there is at least a century of US pretensions hovering over the table from the outset.

Historical context is, after all, the place to start. The undisputed equality in which partners sit at this table is in itself a redress of grievances, a recognition that this has not been the norm for official and most unofficial relations between the two nations for the last 100 years, where the Cubans are still fighting for their rightful place.

MEDICC began in 1997 with several essential ideas in mind:
First, that Cuba's practice of universal primary health care, its astounding results in health indicators in the face of devastating economic indicators, and its medical research capability in vaccines and other drugs were exceptional experiences of interest to the US medical community.

Second, that the US embargo had thus far stood in the way of significant institutional collaboration in medicine and public health between the two countries, cooperation the Cubans consider vital because of the undisputed scientific achievements in the United States.

Third, that there was substantial public opinion and humanitarian benefit to be gained from long-term cooperation between the medical communities of the two countries. And finally, that there was much to be learned from each other, but no influences to peddle or promote.

MEDICC is not the first US-Cuba program in medicine: back in the sixties, US-CHE (the US-Cuba Health Exchange) was created by left-of-center physicians and health professionals in the United States, who documented in Cuba their dream of universal medical coverage and made significant material contributions to Cuban medical libraries and other facilities.

Later initiatives proposed across-the-board scientific cooperation. And since the beginning of this decade, the number of US material aid and assistance groups has grown in medicine: DISARM, Global Links, the US-Cuba Medical Project, to name a few.

However, MEDICC was the first constituted as a joint undertaking, its Academic Council made up of prestigious Cuban and US medical educators and practicing physicians, and its Executive Committee of health professionals from both countries . With equal representation, these bodies make policy and operating decisions for MEDICC. Simply stated, but all-important.

It may be worth lingering on this point to place it in context: in 1992, the Cuban Democracy Act became US law. It tightened the already fierce embargo on Cuba, closing virtually its only loophole by banning US foreign subsidiary trade with Cuba and barring ships under any flag from entering US ports for six months after docking in Cuba. As the "carrot", the law also proposed "aid to the Cuban people", better telephone communication with the United States and other measures—all aimed in explicit terms to undermine the Cuban government and social system.

When the enhanced policy was paraded in public two years later by prominent State Department officials—now as lynchpin instead of carrot—Cuban government and domestic opinion received it as tantamount to one more US declaration of war on the revolution.

As so many times in the past, Cuban agencies scrambled to batten down the hatches, and since State had knighted US civil society to ride the Trojan horses into Cuba, US organizations, institutions, universities and the like all fell under suspicion when any approached the island. (Much to their chagrin, since they never asked to be messengers for US foreign policy goals.) Subsequent US policy tinkering has only reinforced such fears that US-based groups come to Cuba with hidden agendas.

Enter the good US doctors proposing MEDICC: even with transparent intentions, they were viewed skeptically—and still are—in many Cuban quarters. The difference today is that the program has won very important defenders, first among them the Cuban leadership in MEDICC, which has gained confidence in their US counterparts from two years of taking joint decisions and implementing practical commitment to a joint program. For them and for the US participants, MEDICC has become a positive model of collaboration.

The Importance of Pilot Courses
Given the legal, travel, educational and cultural complexities of organizing a US student experience in Cuba, MEDICC has put each new elective through a trial run. The program started small, with three pilot courses in 1998: a clinical elective in community medicine for 4th year medical students; an in-depth look at Cuba's national health system for public health master's degree candidates; and a clinical elective for midwifery practitioners.

Based on evaluations from students, faculty, administrators and the Academic Council itself, the first two became established MEDICC electives in 1999. This summer, two more "pilots" are projected: an introduction to the Cuban health system for first-year medical students, and a course on reproductive health in Cuba.

Improving the course contents and general student experience is a constant in MEDICC's development. Based on student and faculty input, the program adapts. For example, a strong cross-cultural component has been introduced into the medical Spanish curriculum; more practice and fewer lectures in clinical electives; and greater attention is being paid to pre-travel orientation. This makes MEDICC a highly labor-intensive program, but it is difficult to imagine it otherwise.

The MEDICC Bridge
The US end of the MEDICC undertaking had its initial home in the American Association for World Health (AAWH), which sponsored the 1996 report on the impact of the embargo on health and nutrition in Cuba. But the program soon outgrew its space there, and became an independent corporation (MEDICC, Inc.) with tax-exempt status.

This change also left MEDICC a freer hand to develop relationships with medical and public health schools (MEDICc students have now come from 41 schools); professional organizations (such as the American Public Health Association, Association of Schools of Public Health, National Medical Association, International Health Medical Education Consortium, and the Hispanic Physicians' Association); and student groups (the American Medical Student Association and the National Student Medical Association). These ties assist MEDICC in outlining interests on the US side of the equation—and helped to identify Cuba's practice of community-based medicine as a key area of interest for the entire health field in the United States.

Such outreach is also indispensable to the institutional links MEDICC hopes to facilitate between the Cuban and Us medical communities. So, too, are spin-off projects that have emerged from priorities jointly identified by MEDICC's Academic Council: thus the program has begun on-line publication of the first medical journal to consistently publish Cuban medical research in English (MEDICC Review) and initiated the Medical Literature Project to equip Cuban health professionals with current subscriptions to US medical journals.

Plans for the near future—which we expect will also help broaden the funding base for the program—include reaching agreements to offer Continuing Medical Education (CME) credits to US physicians attending medical courses and congresses in Cuba (which would substantially increase their participation in medical events on the island); forming an active MEDICc Alumni organization to keep young graduates "plugged in"; setting up a scholarship fund; and facilitating travel to US medical institutions and events by Cuban physicians.

MEDICC is proving that joint programs are possible between US and Cuban institutions, programs which offer respectful models of shared interests and imperatives, and which can produce the confidence necessary for real cooperation.

Gail Reed is a development consultant for several Us foundations and MEDICC Executive Committee member.

MEDICC's Legal Framework
In October 1995, President Clinton made it possible for US students to take courses in Cuba if they receive credit from their home institutions. However, until now travel permission has involved significant red tape, which MEDICC has taken on by applying for individual travel licenses for each participating student. After one year of such licensing, this February the organization received one of Treasury's first "umbrella" licenses, covering all prospective students for the next eight months. Revised regulations are expected momentarily, which should ease this process even further in the future.

On the Cuban side, MEDICC applies for special visas, allowing the visitor to study during their stay in Cuba. And the MEDICC program has been formalized with an official agreement between the US partner (MEDICC, Inc.) and Cuba' s Centro Nacional de Perfeccionamiento Médico (CENAPEM), the island's national post-graduate medical training facility.


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