Cuba's Communist Party newspaper has been publishing unusually frank criticisms of Cuban socialism.
By Nick Miroff
Published: February 9, 2010 06:29 ET
HAVANA, Cuba — Something unusual has been stirring lately in the pages of Granma, this country’s largest newspaper and the official mouthpiece of the Cuban Communist Party.
Lacking commercial advertising and printed entirely in red and black ink, Granma typically carries eight tabloid-style pages devoted to fawning coverage of Cuba’s top officials and the latest iniquities of Yankee imperialism. Its primary function is to promote the Cuban government, rather than cover it, offering an Orwellian chronicle of life on the island as a never-ending series of socialist triumphs.
But in recent months, Granma has become an unlikely forum for a debate that seems to portend much-expected reforms to Cuba’s state-run economy.
A flurry of op-ed columns have appeared lately in the paper’s “letters to the editor” section, staking out positions for and against something Cubans are calling “privatization” — small-scale liberalization measures that might allow more entrepreneurship and private business. At its roots, it is an argument over how to revive Cuba’s anemic economy, which was already woefully inefficient and unproductive before the global recession hit.
Most surprising, at least for the pages of Granma, is that many of the editorials contain rather frank criticisms of Cuba’s economic ills, which include petty corruption, the widespread theft of state goods and a low-wage system that pushes Cubans into black-market activity to make ends meet.
“What would it mean for the State to eliminate the ongoing farce of state-owned property?” asked one letter, signed by D. Gonzalez de la Cruz. Pilfering is so rife at state-run businesses that they’re already being privatized, he argued.
“In our current situation, privatization is already happening” Gonzalez wrote. “Only instead of a rational and well-thought-out process, it’s chaotic and perverse. What kind of social benefits do we get from state-run business and restaurants where the State pays the bills but the profits — obtained fraudulently and illegally — go into the pockets of the those who prey off the people and the State?”
The letters in Granma appear to be part of a broader re-examination of Cuban socialism called for in speeches by President Raul Castro, raising hopes and expectations among Cubans who struggle with constant shortages and a system that officially bans most forms of private commerce. Of course, the debates are bound by certain unspoken parameters, and do not contain calls for free-market capitalism nor any direct political criticism of Cuba’s leaders.
Rather, they are framed as a discussion about the best way to save Cuban socialism and its vaunted social safety net from an underachieving economy choked by excessive centralization and bureaucracy.
“I’m concerned about the future of my country, and it worries me that some still blindly believe that the old economic model we have is perfect,” wrote J. Gonzalez Fernandez in another Granma editorial, saying that he is a 28-year-old whose views are shared by “almost all young people.”
“We can’t keep living in the past. We have to think about the present and future of our country,” he wrote, adding that he believed “adjusting” socialism was needed to ensure its survival.
What’s not clear is when economic reforms may be enacted, nor how extensive they may be. With frustrations running high, many insist changes can’t wait. Even Cuba’s Catholic Church weighed in last week, publishing an editorial written by priest and economist P. Boris Moreno, who warned of “socioeconomic collapse” if reforms aren’t made.
And yet, if “privatization” is being floated in Granma and other official newspapers, does it indicate some package of liberalization measures have already been decided upon by the Castro government?
“I think these are changes that almost everyone supports, including many Communist Party militants, but I don’t know when they may occur” said dissident economist Oscar Espinosa Chepe, who said he has been followed the debates “with great interest.”
“Raul Castro raised a lot of expectations, and people are growing frustrated he hasn’t done anything,” he said.
Since Raul Castro officially took over Cuba’s presidency from his elder brother in 2008, his government has enacted modest reforms to Cuba’s agricultural sector, putting unproductive state land in the hands of private farmers and cooperatives. But many services and small businesses — from watch repair to fast-food restaurants to bakeries — remain in state hands.
And not everyone seems eager for that to change, as other editorials appearing in Granma have urged “not to give capitalism an inch.”
“Now is not the time to create the conditions for the reintroduction of clever and treacherous capitalism into our homeland,” wrote J.L. Valdes Carrasco, exhorting readers to work harder, produce more food, and “place absolute trust in the leaders of the Revolution,” while calling on young people to “lead in the decisive stage of the Revolution,” the term used on the island to refer to the Castros’ socialist system.
One interesting feature of the Granma debates is that many of those who have submitted letters for and against economic reforms try to bolster their arguments by borrowing quotes from Fidel Castro’s speeches. Gonzalez, the 28-year-old, cited Castro’s words from a 2000 May Day speech in making his case: “Revolution is everything that should be changed.”
That partisans on both sides would quote Castro may be a preview of the political debates likely to ensue once he, Raul, and their generation of Cuban leaders is gone, and younger Cubans are left to sort out the island’s problems.
http://www.globalpost.com/dispatch/cuba/100205/privatization-granma-liberalization
Friday, February 12, 2010
Wednesday, February 10, 2010
Cuban Resistance to Reform
Cuba slow to ease its grip on shopkeepers
By Marc Frank in Camagüey
Published: February 10 2010 02:00 | Last updated: February 10 2010 02:00
Three years after Cuba's Rebel Youth newspaper published "The Big Old Swindle" - a scathing series calling for reform of a state-managed retail sector beset by poor management, corruption and abysmal service - debate is still raging over liberalisation. The authorities have yet to act.
Rumours abound in Havana that the state will soon cede control over its thousands of barber shops, cafeterias, bakeries and domestic appliance and car repair businesses, opting to regulate and tax rather than administer, along the lines of the Chinese or Vietnamese model.
Yet the state appears to be doing the opposite, remodelling and opening numerous restaurants, shops and other retail outlets in city after city.
Raúl Castro, president, has insisted that Cuba's Soviet-style command economy needs fixing. He has hinted that ways must be found to reform the retail sector since taking over from his ailing brother, Fidel Castro, two years ago.
"State companies must be efficient and so must have resources to be so. The rest should adapt to more adequate forms of property given the resources available," stated a report by the economy ministry last year soon after Mr Castro replaced the minister and his top deputies.
Mr Castro has been short on specifics. However, commentators, economists and analysts propose raising the small number of family businesses and allowing employees to form co-operatives like those long established in agriculture.
There is apparently fierce resistance within the ruling Communist party, especially in the provinces.
"Cuba is not Havana," a provincial-level party official in eastern Cuba quipped when asked to square the new government-run retail outlets with the idea that the state should get out of the sector.
Pressed, he conceded that the state did not need to run some services, such as every barber shop. But he opposed letting go of larger establishments, such as car repair shops.
"Most cars and trucks in this country are owned by the state," he said.
A mid-level party cadre who administered eateries in the eastern city of Santiago de Cuba insisted the retail sector's poor performance was not systemic but subjective. Fixing it was just a matter of improving party discipline, she said.
Cuba's second city has opened more restaurants, bars, stores and other establishments during the past year than any other.
The administrator, speaking on condition of anonymity, said the province's new party leader, Lazaro Exposito Canto, had improved the sector. "Since his arrival the retail sector has been completely turned round. It is a matter of caring about the people and being demanding with subordinates," she said.
The debate has spilled into the pages of Granma, the Communist party daily, which has carried letters to the editor for and against reform. "We have to shake off the stereotype developed over many years that private property is always evil," González de la Cruz wrote in a recent edition.
"Property, state or private, is valid when it serves a social purpose," he said.
The opposing view was best expressed in Granma by Guerra González, another correspondent.
"The solution of creating new owners and co-operatives and making current employees into supposed collective owners [in the retail sector] will only lead to uncontrolled free competition and capitalism," he wrote, adding, "this would represent not only an economic step backward but a political, social and ideological one".
For the first time since all retail activity - right down to shoe-shine boys - was nationalised in the "revolutionary offensive" of 1968, licences are being handed out to food vendors in the interior who have played cat-and-mouse with police in city streets for decades, saving residents a long walk to state markets.
But that appears to be part of reform already under way in the agriculture sector, where decision-making and food distribution has been decentralised and state lands leased to more than 100,000 farmers.
Authorities, in an apparent concession to popular frustration, are also granting family farms and cooperatives permission to sell a part of what they produce directly using kiosks and horse and bicycle-drawn carts. But not a single state-run retail outlet has been handed over to employees as a co-operative, let alone privatised.
By Marc Frank in Camagüey
Published: February 10 2010 02:00 | Last updated: February 10 2010 02:00
Three years after Cuba's Rebel Youth newspaper published "The Big Old Swindle" - a scathing series calling for reform of a state-managed retail sector beset by poor management, corruption and abysmal service - debate is still raging over liberalisation. The authorities have yet to act.
Rumours abound in Havana that the state will soon cede control over its thousands of barber shops, cafeterias, bakeries and domestic appliance and car repair businesses, opting to regulate and tax rather than administer, along the lines of the Chinese or Vietnamese model.
Yet the state appears to be doing the opposite, remodelling and opening numerous restaurants, shops and other retail outlets in city after city.
Raúl Castro, president, has insisted that Cuba's Soviet-style command economy needs fixing. He has hinted that ways must be found to reform the retail sector since taking over from his ailing brother, Fidel Castro, two years ago.
"State companies must be efficient and so must have resources to be so. The rest should adapt to more adequate forms of property given the resources available," stated a report by the economy ministry last year soon after Mr Castro replaced the minister and his top deputies.
Mr Castro has been short on specifics. However, commentators, economists and analysts propose raising the small number of family businesses and allowing employees to form co-operatives like those long established in agriculture.
There is apparently fierce resistance within the ruling Communist party, especially in the provinces.
"Cuba is not Havana," a provincial-level party official in eastern Cuba quipped when asked to square the new government-run retail outlets with the idea that the state should get out of the sector.
Pressed, he conceded that the state did not need to run some services, such as every barber shop. But he opposed letting go of larger establishments, such as car repair shops.
"Most cars and trucks in this country are owned by the state," he said.
A mid-level party cadre who administered eateries in the eastern city of Santiago de Cuba insisted the retail sector's poor performance was not systemic but subjective. Fixing it was just a matter of improving party discipline, she said.
Cuba's second city has opened more restaurants, bars, stores and other establishments during the past year than any other.
The administrator, speaking on condition of anonymity, said the province's new party leader, Lazaro Exposito Canto, had improved the sector. "Since his arrival the retail sector has been completely turned round. It is a matter of caring about the people and being demanding with subordinates," she said.
The debate has spilled into the pages of Granma, the Communist party daily, which has carried letters to the editor for and against reform. "We have to shake off the stereotype developed over many years that private property is always evil," González de la Cruz wrote in a recent edition.
"Property, state or private, is valid when it serves a social purpose," he said.
The opposing view was best expressed in Granma by Guerra González, another correspondent.
"The solution of creating new owners and co-operatives and making current employees into supposed collective owners [in the retail sector] will only lead to uncontrolled free competition and capitalism," he wrote, adding, "this would represent not only an economic step backward but a political, social and ideological one".
For the first time since all retail activity - right down to shoe-shine boys - was nationalised in the "revolutionary offensive" of 1968, licences are being handed out to food vendors in the interior who have played cat-and-mouse with police in city streets for decades, saving residents a long walk to state markets.
But that appears to be part of reform already under way in the agriculture sector, where decision-making and food distribution has been decentralised and state lands leased to more than 100,000 farmers.
Authorities, in an apparent concession to popular frustration, are also granting family farms and cooperatives permission to sell a part of what they produce directly using kiosks and horse and bicycle-drawn carts. But not a single state-run retail outlet has been handed over to employees as a co-operative, let alone privatised.
Tuesday, February 9, 2010
Americans Learning from Cuban Medical System
Americans Are Learning Medicine the Cuban Way
By Julia Landau, East Bay Express
Posted on February 5, 2010, Printed on February 9, 2010
http://www.alternet.org/story/145523/
Melissa Rose Mitchell was discouraged. After taking the Medical College Admission Test, she was uneasy about applying to medical schools. In prep courses for the exams, she had glimpsed her future as a doctor, and she didn't like the environment she saw. "People were like, 'What kind of doctor do you want to be?' and it was all based on how much money you make," the Oakland resident recalled. "It was a really scary moment, because this thing that all my life I had wanted to do without question, all of a sudden I'm thinking, 'I don't know if I want to do this.'"
Mitchell had scraped together the money to prepare for and take the med-school admissions test, but even as she studied, she had begun to waver. "It had taken me over a year to save the $1,400 for the test and prep course and they said, 'We recommend that you apply to no less than twenty schools,' at about $200 each." And there were still the costs of plane tickets and a proper suit to interview at schools. She did well on the exams, but Mitchell was spending a lot of money to fulfill her goal of serving the poor.
But then her boyfriend saw a blurb in a church newsletter that appeared to assuage her growing worries. It was a unique offer to study in Cuba, the impoverished nation 90 miles from Florida that is internationally known for its training and use of doctors. She applied through the Interreligious Foundation for Community Organization in New York, a group whose mission is to "increase minority participation in medicine" and therefore increase the doctor-patient ratio for underserved areas.
Cuba began educating American medical students after members of the Congressional Black Caucus met with Fidel Castro in 2000. Congressman Bennie Thompson of Mississippi told Castro about areas in his district that suffer from extreme doctor shortages. The Cuban president responded by promising scholarships for 500 Americans to attend medical school in Cuba, under the umbrella of the Latin America School of Medicine. To qualify, the students would have to show aptitude and a commitment to work in underserved communities in the United States. Since then, 34 have graduated, and more than 160 are currently enrolled.
The Bay Area, it turns out, is something of a hub for the Cuba school of thought, where Cuba-trained students, unencumbered by the massive debt that plagues grads from US medical schools, have the luxury to do the kind of medicine that Cuba instructs — family medicine. The island's medical schools focus on nutrition and other preventative approaches. Cuba also is well known for its focus on the "social determinants of health."
The Cuban experience also may provide important lessons for our current health-care crisis. With a fifth of our per capita GDP, Cuba has health statistics comparable to those of industrialized nations. In the shabby, eroding, and commodity-deprived neighborhoods of Old Havana, Cubans also enjoy a better doctor-patient ratio than Americans: 59 doctors per 10,000 people compared to 26 for us.
Cuban life expectancy also matches that of the United States, its infant mortality rate is lower, and the island's HIV/AIDS transmission is among the lowest worldwide. Cuba's aggressive health-care delivery system also costs much less — around $200 per capita annually, compared to our $7,000. And it provides timely and primary care for every citizen — near universal accessibility. To the Cuban government, health care is a right.
This fact highlights a gap in the health-care reform initiative proposed by Congress and President Obama. Those currently without insurance, who will receive coverage with the bill, will feel the lack of family practitioners as basic care continues to be undervalued in favor of more profitable types of medicine.
At a White House forum early last year, the president spelled out the problem bluntly: "We're not producing enough primary-care physicians," he said, pointing to a daunting chain of obstacles. "The costs of medical education are so high that people feel that they've got to specialize."
According to the Association of American Medical Colleges, the average debt for a US medical school graduate in 2008 was $154,607. American doctors, as a result, feel forced to take up specialized practice, because ultimately the higher pay will ease their enormous student debt. Yet without enough primary care doctors, experts say, health-care costs grow exorbitant, end-stage care increases, and thousands of family practice residence positions go unfilled every year.
Doctors graduating in Cuba have no such excuse to specialize, and the island does not graduate members of an elite profession. Instead, it's a veritable doctor-producing machine with more than 70,000 physicians for a population of just 11 million.
And after medical school in Havana, Mitchell would return to the United States debt free.
Many students enter American medical schools wanting to do family care but get discouraged, said Dr. Richard Quint, retired faculty at UC San Francisco and a medical consultant to the Oakland nonprofit group Medical Education Cooperation with Cuba. American medical schools deem primary care as having secondary import, he contends. "The overall structure of our 'non-health system' is fragmented and skewed toward specialty practices," he said. "Faculty in medical schools make comments suggesting you shouldn't go into primary care because it's not stimulating or high-achieving enough." It also no secret that physicians are reimbursed highly for procedures and surgeries rather than for preventive medicine and diagnoses. And the need for primary care in underserved areas often doesn't make it into the textbooks or the classroom.
When it comes to preventative care, the shortcomings in American medical education mirror the failings in our health-care system as a whole. "There's nothing the Cubans are doing that people couldn't think of here — it's just they are looking upstream" at prevention, explained Dr. Lynn Berry, chronic disease program manager at Oakland's Highland Hospital, who has conducted research in Cuba.
Berry pointed out that Alameda County has "pretty strong" community health care. "We have La Clínica de La Raza, the Ethnic Health Institute, Native American Health Services," which emphasize prevention and education to avoid the costs, medical and financial, of end-stage care. But "ours is a market system," Berry said, a system "organized around insurance and payer source, not necessarily the long-term health of the patient."
Cuba redesigned its medical system out of financial necessity following the collapse of the Soviet Union. Faced with a supply crisis brought on by the lack of Soviet funding, Cuba revamped its medical education system towards primary care. By the mid-Nineties, they had established a comprehensive neighborhood-based family medicine standard: a consultario (neighborhood clinic) in every locale, and a revised medical school curriculum to embed family care into the model.
The island's health care starts with a top-down mandate for a "bottom-up" approach to health care. Too poor to rely on high-tech equipment or expensive, invasive procedures, the Cuban model stresses prevention and spreads health-care responsibility beyond doctors — into schools, work sites, and neighborhoods. A national network of polyclinics ensures the mandate. People in all walks of life are expected to cooperate in health publicity campaigns and other measures to prevent disease.
The United States' fifty-year-old embargo on goods to the island also has played a role in shaping Cuba's medical care system. The embargo prohibits or restricts the sale of some medical equipment and punishes other countries that deliver essential cargo. Drugs and medical supplies are sporadic, especially in Cuba's rural areas, where clinics work with outdated X-ray machines. And because US pharmaceutical companies develop most major new drugs, Cuban physicians don't have access to many new medicines on the world market. Countries like Spain and Venezuela donate, but routine medical supplies remain scarce or absent from some Cuban clinics.
Still, Dr. Davida Flattery, an internist at Highland Hospital, was struck by Cuba's "bottom-up" approach when she observed their health system last year. "What really impressed me about Cuba was their focus on the non-medical determinants of health," she said. It's standard in Cuba, she added, to engage the psycho-social factors of a patient — level of sanitation, presence of abuse or addiction, and food habits. Doctors and nurses, in fact, make home visits to evaluate these things personally.
Americans trained in Cuba see firsthand the glaring differences between the two medical education systems. Melissa Rose Mitchell learned, for example, that Cuba highlights rural medicine. "In lots of situations the professor will ask, 'What's the best test?' We'll say 'CT scan, ultrasound.' They'll say 'Well you don't have ultrasound, you're in the middle of nowhere, in the mountains, you have no electricity or phone. ... What are you going to do?'"
Many past and current students of the Latin American School of Medicine in Havana, where Mitchell attended, had lived or worked in poor and underserved neighborhoods in the United States, and were chosen to study in Cuba so they could take what they learned back home. And their Cuban education equipped them to deal with health problems of the poorest communities in the United States far better than if they had gone to Harvard.
Havana medical students, for example, are trained to stabilize people in places with no electricity or potable water. One might think those skills irrelevant in the wealthy United States, but a number of poor American communities have come to resemble sections of Third World countries — especially after a disaster (see Hurricane Katrina).
The lack of doctors in America's neediest communities is exactly what the Interreligious Foundation for Community Organization wanted to remedy as they began recruiting for the Cuban scholarships. The resulting program also is quite diverse — far more diverse group than any US med school. The majority of students in Latin American School of Medicine in Havana are African Americans from New York or California, 85 percent are minorities, and 73 percent are women.
And most of the students are trained as "médicos de la familia," or family practitioners. But, as the students saw, medical supply shortages plague the system, and despite diabetes intervention and screening programs in schools and workplaces across the country, the Cuban national diet remains high in fat and sugar. Like the US poor, Cubans don't have easy access to fresh fruits and vegetables — or the habit of eating them — and this hinders their health. Cuba's food distribution system from the countryside to the cities is substandard. The nation imports more than 50 percent of its food.
Mitchell said the training and experience suited her. "They train us just like they train Cubans," she said. "Every Cuban, regardless of specialty, has to do two years of family medicine. Until you can deal with basic, vital situations, you are not allowed to mess with other parts of the body."
After graduating last summer, Mitchell settled in Oakland to work and prepare for the boards, but she says her calling is rural medicine. She used her summer breaks from medical school, in fact, to work in a mobile health-care clinic serving rural populations outside of Birmingham, Alabama, a conservative city with stark wealth disparities. "Every two weeks or once a month, this clinic on wheels visited parts of the state where some of the houses did not have electricity or indoor plumbing. Not because it couldn't be gotten, but because people didn't have the money to invest in it." When asked if the poverty compared to that of rural Cuba, she responded: "The poverty was more intense" in some areas of rural Alabama than in rural Cuba, she said, "because there were no social services."
Yet back home Mitchell faced disapproval — even hostility — for deciding on a nonspecialized practice. "My first experience going home, my aunt and I had a heated argument — me saying I didn't want to specialize and if I did it would be family medicine or rural medicine. Her argument was anybody who had any sense would become a neurosurgeon or a cardiologist. But my image of a doctor is someone who can handle any situation that comes up."
And having witnessed the obstacles facing Cuba, the returning American doctors are scandalized with the state of health care at home. Mitchell works as a part-time medical assistant at a Bay Area clinic and doesn't have insurance herself. "There have definitely been a couple of times I've been sick and couldn't afford to see a doctor," she said.
"A friend did me a favor by seeing me, but I had to pay $60 for antibiotics — that was with the clinic's discount."
Before moving to Oakland as a teen, Pasha Jackson saw firsthand on the streets of South Central Los Angeles the power of nonmedical, psychosocial factors to spread disease — both physical and mental. Violence, joblessness, and addiction merge with poverty to leave many residents out of the health-care system. "What does primary care mean for the people around me?" he said. "It's self-medication. Junk and drinking. These people really need attention, and insurance will deny them for a list of reasons."
But Jackson didn't know he wanted to study medicine until he sustained a football injury. Recruited from City College of San Francisco by the University of Oklahoma, he went on to play for the San Francisco 49ers and Oakland Raiders. But academic advisors throughout high school and college, he said, actively discouraged his interest in science. "They said it was too hard," and that his best chances were with football.
Reassigned by the Raiders to NFL Europe, Jackson tore his left pectoral — "a huge injury for a linebacker," he noted. "Once I left the NFL my health care ended, and to go to Cuba I needed shots and checkups to travel internationally. I couldn't believe what I had to go through. After calling around to public clinics, I had to wait for weeks and miss a day of work to see a doctor that didn't want to see me."
Jackson spent a year recuperating and getting physical therapy. And during that time, the effects of Hurricane Katrina reminded him of the deep connection between poverty and disease. "I knew I didn't want to play football anymore," Jackson said. "In the NFL there's so much waste, the playing with the money and power. I saw how much a part it was of the capitalist system."
Disgusted with professional football, Jackson went to the Interreligious Foundation for Community Organization's web site and applied. The Cuba program "had me in Cuba, where I could learn Spanish; covered me financially; and got me back to science." With that, Pasha Jackson went socialist.
On summer break from his studies in Cuba, Jackson and more than a dozen other students from the Latin American School of Medicine visited deprived American communities to deliver basic health services and expand their own cultural competency. Los Angeles' Skid Row, a place with "ridiculous numbers of homeless people," was one stop on the trip, Jackson recalled. "Mora County [New Mexico] has hardly any doctors." They stopped at Pajarito Mesa, "where the Pueblo Indians live, with no potable water and no electricity. It shows you," Jackson said. "There's the Third World — right here. There are no national boundaries."
<"When the earthquake hit in Haiti, over 400 Cuban medical personnel were already there - they've been there for years," said Dr. Nelson Valdez, Professor Emeritus of Sociology at the University of New Mexico and Director of Cuba-L, which monitors news related to Cuba. According to Medical Education Cooperation with Cuba, some 700 Haitian medical students in Cuba study at the Santiago de Cuba campus of the Latin American Medical School. Cuba is sending doctors and students in droves to treat tens of thousands Haitians lying wounded in hospitals with zero or few doctors. "No one is reporting on the Cuban presence in Haiti," commented Valdez, though he said he wasn't surprised. "The additional doctors being sent are part of the same team that was offered to the United States by Cuba when hurricane Katrina hit." The assistance was refused. Valdez also said the Cuban doctors, solidly trained in disaster medicine, provide psychological as well as physical attention to victims.
The State Department announced that U.S. aid workers would cooperate with Cubans on the ground in Haiti. Those who've observed what we can learn from the Cuban medical approach -- scholars and physicians, new and veteran -- all agree that cooperation and conversation with Cuba, at least in this respect, might bring us all some relief.
© 2010 East Bay Express All rights reserved.
View this story online at: http://www.alternet.org/story/145523/
By Julia Landau, East Bay Express
Posted on February 5, 2010, Printed on February 9, 2010
http://www.alternet.org/story/145523/
Melissa Rose Mitchell was discouraged. After taking the Medical College Admission Test, she was uneasy about applying to medical schools. In prep courses for the exams, she had glimpsed her future as a doctor, and she didn't like the environment she saw. "People were like, 'What kind of doctor do you want to be?' and it was all based on how much money you make," the Oakland resident recalled. "It was a really scary moment, because this thing that all my life I had wanted to do without question, all of a sudden I'm thinking, 'I don't know if I want to do this.'"
Mitchell had scraped together the money to prepare for and take the med-school admissions test, but even as she studied, she had begun to waver. "It had taken me over a year to save the $1,400 for the test and prep course and they said, 'We recommend that you apply to no less than twenty schools,' at about $200 each." And there were still the costs of plane tickets and a proper suit to interview at schools. She did well on the exams, but Mitchell was spending a lot of money to fulfill her goal of serving the poor.
But then her boyfriend saw a blurb in a church newsletter that appeared to assuage her growing worries. It was a unique offer to study in Cuba, the impoverished nation 90 miles from Florida that is internationally known for its training and use of doctors. She applied through the Interreligious Foundation for Community Organization in New York, a group whose mission is to "increase minority participation in medicine" and therefore increase the doctor-patient ratio for underserved areas.
Cuba began educating American medical students after members of the Congressional Black Caucus met with Fidel Castro in 2000. Congressman Bennie Thompson of Mississippi told Castro about areas in his district that suffer from extreme doctor shortages. The Cuban president responded by promising scholarships for 500 Americans to attend medical school in Cuba, under the umbrella of the Latin America School of Medicine. To qualify, the students would have to show aptitude and a commitment to work in underserved communities in the United States. Since then, 34 have graduated, and more than 160 are currently enrolled.
The Bay Area, it turns out, is something of a hub for the Cuba school of thought, where Cuba-trained students, unencumbered by the massive debt that plagues grads from US medical schools, have the luxury to do the kind of medicine that Cuba instructs — family medicine. The island's medical schools focus on nutrition and other preventative approaches. Cuba also is well known for its focus on the "social determinants of health."
The Cuban experience also may provide important lessons for our current health-care crisis. With a fifth of our per capita GDP, Cuba has health statistics comparable to those of industrialized nations. In the shabby, eroding, and commodity-deprived neighborhoods of Old Havana, Cubans also enjoy a better doctor-patient ratio than Americans: 59 doctors per 10,000 people compared to 26 for us.
Cuban life expectancy also matches that of the United States, its infant mortality rate is lower, and the island's HIV/AIDS transmission is among the lowest worldwide. Cuba's aggressive health-care delivery system also costs much less — around $200 per capita annually, compared to our $7,000. And it provides timely and primary care for every citizen — near universal accessibility. To the Cuban government, health care is a right.
This fact highlights a gap in the health-care reform initiative proposed by Congress and President Obama. Those currently without insurance, who will receive coverage with the bill, will feel the lack of family practitioners as basic care continues to be undervalued in favor of more profitable types of medicine.
At a White House forum early last year, the president spelled out the problem bluntly: "We're not producing enough primary-care physicians," he said, pointing to a daunting chain of obstacles. "The costs of medical education are so high that people feel that they've got to specialize."
According to the Association of American Medical Colleges, the average debt for a US medical school graduate in 2008 was $154,607. American doctors, as a result, feel forced to take up specialized practice, because ultimately the higher pay will ease their enormous student debt. Yet without enough primary care doctors, experts say, health-care costs grow exorbitant, end-stage care increases, and thousands of family practice residence positions go unfilled every year.
Doctors graduating in Cuba have no such excuse to specialize, and the island does not graduate members of an elite profession. Instead, it's a veritable doctor-producing machine with more than 70,000 physicians for a population of just 11 million.
And after medical school in Havana, Mitchell would return to the United States debt free.
Many students enter American medical schools wanting to do family care but get discouraged, said Dr. Richard Quint, retired faculty at UC San Francisco and a medical consultant to the Oakland nonprofit group Medical Education Cooperation with Cuba. American medical schools deem primary care as having secondary import, he contends. "The overall structure of our 'non-health system' is fragmented and skewed toward specialty practices," he said. "Faculty in medical schools make comments suggesting you shouldn't go into primary care because it's not stimulating or high-achieving enough." It also no secret that physicians are reimbursed highly for procedures and surgeries rather than for preventive medicine and diagnoses. And the need for primary care in underserved areas often doesn't make it into the textbooks or the classroom.
When it comes to preventative care, the shortcomings in American medical education mirror the failings in our health-care system as a whole. "There's nothing the Cubans are doing that people couldn't think of here — it's just they are looking upstream" at prevention, explained Dr. Lynn Berry, chronic disease program manager at Oakland's Highland Hospital, who has conducted research in Cuba.
Berry pointed out that Alameda County has "pretty strong" community health care. "We have La Clínica de La Raza, the Ethnic Health Institute, Native American Health Services," which emphasize prevention and education to avoid the costs, medical and financial, of end-stage care. But "ours is a market system," Berry said, a system "organized around insurance and payer source, not necessarily the long-term health of the patient."
Cuba redesigned its medical system out of financial necessity following the collapse of the Soviet Union. Faced with a supply crisis brought on by the lack of Soviet funding, Cuba revamped its medical education system towards primary care. By the mid-Nineties, they had established a comprehensive neighborhood-based family medicine standard: a consultario (neighborhood clinic) in every locale, and a revised medical school curriculum to embed family care into the model.
The island's health care starts with a top-down mandate for a "bottom-up" approach to health care. Too poor to rely on high-tech equipment or expensive, invasive procedures, the Cuban model stresses prevention and spreads health-care responsibility beyond doctors — into schools, work sites, and neighborhoods. A national network of polyclinics ensures the mandate. People in all walks of life are expected to cooperate in health publicity campaigns and other measures to prevent disease.
The United States' fifty-year-old embargo on goods to the island also has played a role in shaping Cuba's medical care system. The embargo prohibits or restricts the sale of some medical equipment and punishes other countries that deliver essential cargo. Drugs and medical supplies are sporadic, especially in Cuba's rural areas, where clinics work with outdated X-ray machines. And because US pharmaceutical companies develop most major new drugs, Cuban physicians don't have access to many new medicines on the world market. Countries like Spain and Venezuela donate, but routine medical supplies remain scarce or absent from some Cuban clinics.
Still, Dr. Davida Flattery, an internist at Highland Hospital, was struck by Cuba's "bottom-up" approach when she observed their health system last year. "What really impressed me about Cuba was their focus on the non-medical determinants of health," she said. It's standard in Cuba, she added, to engage the psycho-social factors of a patient — level of sanitation, presence of abuse or addiction, and food habits. Doctors and nurses, in fact, make home visits to evaluate these things personally.
Americans trained in Cuba see firsthand the glaring differences between the two medical education systems. Melissa Rose Mitchell learned, for example, that Cuba highlights rural medicine. "In lots of situations the professor will ask, 'What's the best test?' We'll say 'CT scan, ultrasound.' They'll say 'Well you don't have ultrasound, you're in the middle of nowhere, in the mountains, you have no electricity or phone. ... What are you going to do?'"
Many past and current students of the Latin American School of Medicine in Havana, where Mitchell attended, had lived or worked in poor and underserved neighborhoods in the United States, and were chosen to study in Cuba so they could take what they learned back home. And their Cuban education equipped them to deal with health problems of the poorest communities in the United States far better than if they had gone to Harvard.
Havana medical students, for example, are trained to stabilize people in places with no electricity or potable water. One might think those skills irrelevant in the wealthy United States, but a number of poor American communities have come to resemble sections of Third World countries — especially after a disaster (see Hurricane Katrina).
The lack of doctors in America's neediest communities is exactly what the Interreligious Foundation for Community Organization wanted to remedy as they began recruiting for the Cuban scholarships. The resulting program also is quite diverse — far more diverse group than any US med school. The majority of students in Latin American School of Medicine in Havana are African Americans from New York or California, 85 percent are minorities, and 73 percent are women.
And most of the students are trained as "médicos de la familia," or family practitioners. But, as the students saw, medical supply shortages plague the system, and despite diabetes intervention and screening programs in schools and workplaces across the country, the Cuban national diet remains high in fat and sugar. Like the US poor, Cubans don't have easy access to fresh fruits and vegetables — or the habit of eating them — and this hinders their health. Cuba's food distribution system from the countryside to the cities is substandard. The nation imports more than 50 percent of its food.
Mitchell said the training and experience suited her. "They train us just like they train Cubans," she said. "Every Cuban, regardless of specialty, has to do two years of family medicine. Until you can deal with basic, vital situations, you are not allowed to mess with other parts of the body."
After graduating last summer, Mitchell settled in Oakland to work and prepare for the boards, but she says her calling is rural medicine. She used her summer breaks from medical school, in fact, to work in a mobile health-care clinic serving rural populations outside of Birmingham, Alabama, a conservative city with stark wealth disparities. "Every two weeks or once a month, this clinic on wheels visited parts of the state where some of the houses did not have electricity or indoor plumbing. Not because it couldn't be gotten, but because people didn't have the money to invest in it." When asked if the poverty compared to that of rural Cuba, she responded: "The poverty was more intense" in some areas of rural Alabama than in rural Cuba, she said, "because there were no social services."
Yet back home Mitchell faced disapproval — even hostility — for deciding on a nonspecialized practice. "My first experience going home, my aunt and I had a heated argument — me saying I didn't want to specialize and if I did it would be family medicine or rural medicine. Her argument was anybody who had any sense would become a neurosurgeon or a cardiologist. But my image of a doctor is someone who can handle any situation that comes up."
And having witnessed the obstacles facing Cuba, the returning American doctors are scandalized with the state of health care at home. Mitchell works as a part-time medical assistant at a Bay Area clinic and doesn't have insurance herself. "There have definitely been a couple of times I've been sick and couldn't afford to see a doctor," she said.
"A friend did me a favor by seeing me, but I had to pay $60 for antibiotics — that was with the clinic's discount."
Before moving to Oakland as a teen, Pasha Jackson saw firsthand on the streets of South Central Los Angeles the power of nonmedical, psychosocial factors to spread disease — both physical and mental. Violence, joblessness, and addiction merge with poverty to leave many residents out of the health-care system. "What does primary care mean for the people around me?" he said. "It's self-medication. Junk and drinking. These people really need attention, and insurance will deny them for a list of reasons."
But Jackson didn't know he wanted to study medicine until he sustained a football injury. Recruited from City College of San Francisco by the University of Oklahoma, he went on to play for the San Francisco 49ers and Oakland Raiders. But academic advisors throughout high school and college, he said, actively discouraged his interest in science. "They said it was too hard," and that his best chances were with football.
Reassigned by the Raiders to NFL Europe, Jackson tore his left pectoral — "a huge injury for a linebacker," he noted. "Once I left the NFL my health care ended, and to go to Cuba I needed shots and checkups to travel internationally. I couldn't believe what I had to go through. After calling around to public clinics, I had to wait for weeks and miss a day of work to see a doctor that didn't want to see me."
Jackson spent a year recuperating and getting physical therapy. And during that time, the effects of Hurricane Katrina reminded him of the deep connection between poverty and disease. "I knew I didn't want to play football anymore," Jackson said. "In the NFL there's so much waste, the playing with the money and power. I saw how much a part it was of the capitalist system."
Disgusted with professional football, Jackson went to the Interreligious Foundation for Community Organization's web site and applied. The Cuba program "had me in Cuba, where I could learn Spanish; covered me financially; and got me back to science." With that, Pasha Jackson went socialist.
On summer break from his studies in Cuba, Jackson and more than a dozen other students from the Latin American School of Medicine visited deprived American communities to deliver basic health services and expand their own cultural competency. Los Angeles' Skid Row, a place with "ridiculous numbers of homeless people," was one stop on the trip, Jackson recalled. "Mora County [New Mexico] has hardly any doctors." They stopped at Pajarito Mesa, "where the Pueblo Indians live, with no potable water and no electricity. It shows you," Jackson said. "There's the Third World — right here. There are no national boundaries."
<"When the earthquake hit in Haiti, over 400 Cuban medical personnel were already there - they've been there for years," said Dr. Nelson Valdez, Professor Emeritus of Sociology at the University of New Mexico and Director of Cuba-L, which monitors news related to Cuba. According to Medical Education Cooperation with Cuba, some 700 Haitian medical students in Cuba study at the Santiago de Cuba campus of the Latin American Medical School. Cuba is sending doctors and students in droves to treat tens of thousands Haitians lying wounded in hospitals with zero or few doctors. "No one is reporting on the Cuban presence in Haiti," commented Valdez, though he said he wasn't surprised. "The additional doctors being sent are part of the same team that was offered to the United States by Cuba when hurricane Katrina hit." The assistance was refused. Valdez also said the Cuban doctors, solidly trained in disaster medicine, provide psychological as well as physical attention to victims.
The State Department announced that U.S. aid workers would cooperate with Cubans on the ground in Haiti. Those who've observed what we can learn from the Cuban medical approach -- scholars and physicians, new and veteran -- all agree that cooperation and conversation with Cuba, at least in this respect, might bring us all some relief.
© 2010 East Bay Express All rights reserved.
View this story online at: http://www.alternet.org/story/145523/
Sunday, February 7, 2010
New Agricultural Reforms
Cuba looks to suburban farms to boost food output
* Plan aims to ring cities and towns with small farms
* Objective is more food production at lower costs
* State monopoly on sales eased a little
By Marc Frank
CAMAGUEY, Cuba, Feb 7 (Reuters) - Cuba has launched an ambitious project to ring urban areas with thousands of small farms in a bid to reverse the country's long agricultural decline and ease its chronic economic woes.
The five-year plan calls for growing fruits and vegetables and raising livestock in 4-mile-wide (6.5 kilometer) rings around 150 of Cuba's cities and towns, with the exception of the capital Havana.
The island's Communist authorities hope suburban farming will make food cheaper and more abundant, cut transportation costs, be less reliant on machinery and encourage urban dwellers to leave bureaucratic jobs for more productive labor.
But the government will continue to hold a monopoly on most aspects of food production and distribution, including its control of most of the land in the Communist-run nation.
The pilot program for the project is being conducted in the central city of Camaguey, which the Cuban agriculture ministry has said eventually will have 1,400 small farms covering 52,000 hectares (128,490 acres), just minutes outside the town.
The farms, mostly in private hands but also including some cooperatives and state-owned enterprises, must grow everything organically, and the ministry expects they will produce 75 percent of the food for the city of 320,000 people, with big state-owned farms providing the rest.
On a recent day, dozens of people were hard at work plowing fields, hoeing earth, posting protective covering for crops and putting up fencing as the sun came up.
"This land they gave to us, the private farmers. I have four hectares (10 acres) and now they have leased me eight (20 acres) more," one of the farmers, Camilo Mendoza, told Reuters.
"Look, on this side and the other side are other plots, and over there another. Here they have given quite a bit of land and support to private farmers," he said.
The project is modeled after the hundreds of urban gardens developed by then-Defense Minister Raul Castro during the deep economic depression of the 1990s that followed the collapse of Communism in eastern Europe.
BEANS, NOT CANNONS
He proclaimed at the time that beans were more important than cannons, marking a strategic shift towards a more domestic focused agenda by Cuban leaders after decades of active support for liberation movements and leftist guerrillas overseas.
The suburban project dovetails with other steps introduced by President Raul Castro since he took over the day-to-day leadership from his ailing elder brother Fidel Castro in 2008.
These have included the leasing of fallow state lands to 100,000 mostly private farmers, raising prices for farm products and allowing farmers to sell part of their crops directly to the people instead of to the state.
On the other side of Camaguey and a few miles up Cuba's central highway, Armando, the head of a cattle cooperative, said his group was persuaded to join the plan by the offer of land to raise garden and root vegetables and the chance for direct sales to the public.
Stands have been set up every mile or so along the city's ring road for the sales, but Armando said they are taking their products to the customers.
"They assigned us a district where we can sell our produce. We are using a mobile system, a bicycle cart, and sell out every day," he said.
"In December we produced around five tonnes. The root vegetables we had to sell to the state, but we were free to sell the garden vegetables directly," he said.
The changes are tweaks to Cuba's centralized socialism, not a major step away from it, keeping with Raul Castro's vow to protect the system put in place after his brother took power in the 1959 Cuban revolution.
He has balked at more sweeping, market-oriented changes that many expected when he took power and without which many economists say Cuba will not significantly increase agricultural output.
Cubans have seen many past government efforts to transform the country's agriculture fail, so the farmers at Camaguey said they were taking a wait-and-see attitude on this latest one.
"For sure there will be more food around here if you come back in a few years," Camilio Mendoza said about his expectations.
"More than that, I can't say." (Editing by Jeff Franks and Paul Simao)
* Plan aims to ring cities and towns with small farms
* Objective is more food production at lower costs
* State monopoly on sales eased a little
By Marc Frank
CAMAGUEY, Cuba, Feb 7 (Reuters) - Cuba has launched an ambitious project to ring urban areas with thousands of small farms in a bid to reverse the country's long agricultural decline and ease its chronic economic woes.
The five-year plan calls for growing fruits and vegetables and raising livestock in 4-mile-wide (6.5 kilometer) rings around 150 of Cuba's cities and towns, with the exception of the capital Havana.
The island's Communist authorities hope suburban farming will make food cheaper and more abundant, cut transportation costs, be less reliant on machinery and encourage urban dwellers to leave bureaucratic jobs for more productive labor.
But the government will continue to hold a monopoly on most aspects of food production and distribution, including its control of most of the land in the Communist-run nation.
The pilot program for the project is being conducted in the central city of Camaguey, which the Cuban agriculture ministry has said eventually will have 1,400 small farms covering 52,000 hectares (128,490 acres), just minutes outside the town.
The farms, mostly in private hands but also including some cooperatives and state-owned enterprises, must grow everything organically, and the ministry expects they will produce 75 percent of the food for the city of 320,000 people, with big state-owned farms providing the rest.
On a recent day, dozens of people were hard at work plowing fields, hoeing earth, posting protective covering for crops and putting up fencing as the sun came up.
"This land they gave to us, the private farmers. I have four hectares (10 acres) and now they have leased me eight (20 acres) more," one of the farmers, Camilo Mendoza, told Reuters.
"Look, on this side and the other side are other plots, and over there another. Here they have given quite a bit of land and support to private farmers," he said.
The project is modeled after the hundreds of urban gardens developed by then-Defense Minister Raul Castro during the deep economic depression of the 1990s that followed the collapse of Communism in eastern Europe.
BEANS, NOT CANNONS
He proclaimed at the time that beans were more important than cannons, marking a strategic shift towards a more domestic focused agenda by Cuban leaders after decades of active support for liberation movements and leftist guerrillas overseas.
The suburban project dovetails with other steps introduced by President Raul Castro since he took over the day-to-day leadership from his ailing elder brother Fidel Castro in 2008.
These have included the leasing of fallow state lands to 100,000 mostly private farmers, raising prices for farm products and allowing farmers to sell part of their crops directly to the people instead of to the state.
On the other side of Camaguey and a few miles up Cuba's central highway, Armando, the head of a cattle cooperative, said his group was persuaded to join the plan by the offer of land to raise garden and root vegetables and the chance for direct sales to the public.
Stands have been set up every mile or so along the city's ring road for the sales, but Armando said they are taking their products to the customers.
"They assigned us a district where we can sell our produce. We are using a mobile system, a bicycle cart, and sell out every day," he said.
"In December we produced around five tonnes. The root vegetables we had to sell to the state, but we were free to sell the garden vegetables directly," he said.
The changes are tweaks to Cuba's centralized socialism, not a major step away from it, keeping with Raul Castro's vow to protect the system put in place after his brother took power in the 1959 Cuban revolution.
He has balked at more sweeping, market-oriented changes that many expected when he took power and without which many economists say Cuba will not significantly increase agricultural output.
Cubans have seen many past government efforts to transform the country's agriculture fail, so the farmers at Camaguey said they were taking a wait-and-see attitude on this latest one.
"For sure there will be more food around here if you come back in a few years," Camilio Mendoza said about his expectations.
"More than that, I can't say." (Editing by Jeff Franks and Paul Simao)
Tuesday, February 2, 2010
Licensing Private Vendors
Cubans Thank God and Communist Party for Small Favors
Cuban Communist Party Makes it Easier to Acquire Food Vending License
By MARC FRANK
Wherever one travels in Cuba
These stealthy hawkers often risk the wrath of the Cuban police who guard the state's monopoly on food distribution in the Communist-run nation. As they haggle over price with passers-by they keep a close eye out for the highway patrol.
The cops in their green Jeeps are usually easy to spot. The 60- mile roadway boasts little traffic.
But around 60 miles outside of eastern Santiago de Cuba
These kiosks are government sanctioned.
The "delinquents," as they are known, proudly sell their fruit and other produce, and customers happily munch while enjoying the spectacular view. The highway patrol attends to what one would hope would be more important matters and the government collects taxes from those it used to persecute at a cost.
Soon after Lazaro Exposito Canto took over the local Communist party in 2009, he ordered the kiosks built and allowed local residents to sell what they produce in their often extensive yards.
"I thank God for this opportunity and also comrade Exposito," said a passionate Edilberto Fernandez, one of a group of young men working a kiosk.
"For a long time when you picked fruit from your patio and went to sell it on the highway, the police would appear, jump all over you, and take it away, when really we were doing nothing wrong," he said.
"You can imagine what it means to be able to bring our fruit here and not have that struggle. The fruit no longer rots on the trees, the animals no longer eat it, Cubans eat it."
Fernandez said his kiosk was open 24 hours a day, and demand was so strong that he and his neighbors were planting as many fruit trees as they could -- good news in this semi-tropical land where nature's bounty is remarkably scarce.
And the idea is catching on.
A former party official in neighboring Granma province said a similar measure recently took affect in the mountains there, followed by Holguin
Farmers in the lowlands of central Cuba said plans were afoot to set up kiosks along roadways around Cuba 's third city, Camaguey
Camilo, the head of a cooperative in the area, said the cooperatives were each assigned a district in and around the city where they could directly sell produce from horse- and bicycle-drawn carts.
Vendors Roam Cities
Similar breakthroughs are occurring in Cuban cities. In a further concession to individual initiative and consumer complaints over the state's monopoly on food distribution Cuban authorities have granted licenses to street vendors of fruits and vegetables who previously risked fines and confiscations.
President Raul Castro has made food production and distribution his top priority since taking over from ailing brother Fidel Castro two years ago, amid an agricultural crisis that has left the cash-strapped country importing between 60 percent and 70 percent of the food it consumes.
Castro decentralized decision-making, raised prices paid to farmers, leased state lands to 100,000 mainly new farmers and urged local officials to improve distribution. As a result, most residents in central and eastern Cuba
After two powerful hurricanes devastated crops in 2008, city produce vendors, illegal but semi-tolerated since they were banned in 1968, were literally driven from Cuba
The state controls more than 90 percent of Cuba
Men and women still prowl Camaguey
"These measures allow me to buy root and garden vegetables at my door, without walking to the market which is far away," retiree Yolanda Santos said.
"The police were always all over us. They didn't let us work," said Ruben, his cart loaded with oranges. "Now, we are at peace. We can sell more without any problems."
Regulations for the licenses include keeping carts and wagons painted and covered, improved dress, healthy animals and paying taxes, he said.
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