Gail Reed: Where to train the world's doctors? Cuba.

82,344 views ・ 2014-10-01

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00:12
I want to tell you
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how 20,000 remarkable young people
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from over 100 countries
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ended up in Cuba
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and are transforming health in their communities.
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Ninety percent of them would never
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have left home at all
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if it weren't for a scholarship to study medicine in Cuba
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and a commitment to go back
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to places like the ones they'd come from —
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remote farmlands, mountains, ghettos —
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to become doctors for people like themselves,
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to walk the walk.
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Havana's Latin American Medical School:
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It's the largest medical school in the world,
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graduating 23,000 young doctors
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since its first class of 2005,
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with nearly 10,000 more in the pipeline.
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Its mission, to train physicians for the people
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who need them the most:
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the over one billion
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who have never seen a doctor,
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the people who live and die
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under every poverty line ever invented.
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Its students defy all norms.
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They're the school's biggest risk
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and also its best bet.
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They're recruited from the poorest,
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most broken places on our planet
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by a school that believes they can become
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not just the good
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but the excellent physicians
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their communities desperately need,
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that they will practice where most doctors don't,
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in places not only poor
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but oftentimes dangerous,
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carrying venom antidotes in their backpacks
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or navigating neighborhoods
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riddled by drugs, gangs and bullets,
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their home ground.
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The hope is that they will help
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transform access to care,
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the health picture in impoverished areas,
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and even the way medicine itself
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is learned and practiced,
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and that they will become pioneers in our global reach
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for universal health coverage,
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surely a tall order.
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Two big storms and this notion of "walk the walk"
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prompted creation of ELAM back in 1998.
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The Hurricanes Georges and Mitch
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had ripped through the Caribbean
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and Central America,
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leaving 30,000 dead
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and two and a half million homeless.
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Hundreds of Cuban doctors volunteered for disaster response,
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but when they got there,
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they found a bigger disaster:
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whole communities with no healthcare,
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doors bolted shut on rural hospitals
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for lack of staff,
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and just too many babies dying
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before their first birthday.
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What would happen when these Cuban doctors left?
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New doctors were needed to make care sustainable,
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but where would they come from?
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Where would they train?
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In Havana, the campus of a former naval academy
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was turned over to the Cuban Health Ministry
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to become the Latin American Medical School,
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ELAM.
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Tuition, room and board, and a small stipend
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were offered to hundreds of students
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from the countries hardest hit by the storms.
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As a journalist in Havana,
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I watched the first 97 Nicaraguans arrive
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in March 1999,
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settling into dorms barely refurbished
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and helping their professors not only sweep out the classrooms
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but move in the desks and the chairs and the microscopes.
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Over the next few years,
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governments throughout the Americas
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requested scholarships for their own students,
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and the Congressional Black Caucus
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asked for and received hundreds of scholarships
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for young people from the USA.
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Today, among the 23,000
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are graduates from 83 countries
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in the Americas, Africa and Asia,
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and enrollment has grown to 123 nations.
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More than half the students are young women.
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They come from 100 ethnic groups,
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speak 50 different languages.
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WHO Director Margaret Chan said,
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"For once, if you are poor, female,
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or from an indigenous population,
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you have a distinct advantage,
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an ethic that makes this medical school unique."
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Luther Castillo comes from San Pedro de Tocamacho
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on the Atlantic coast of Honduras.
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There's no running water,
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no electricity there,
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and to reach the village, you have to walk for hours
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or take your chances in a pickup truck like I did
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skirting the waves of the Atlantic.
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Luther was one of 40 Tocamacho children
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who started grammar school,
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the sons and daughters of a black indigenous people
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known as the Garífuna,
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20 percent of the Honduran population.
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The nearest healthcare was fatal miles away.
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Luther had to walk three hours every day
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to middle school.
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Only 17 made that trip.
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Only five went on to high school,
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and only one to university:
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Luther, to ELAM,
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among the first crop of Garífuna graduates.
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Just two Garífuna doctors had preceded them
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in all of Honduran history.
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Now there are 69, thanks to ELAM.
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Big problems need big solutions,
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sparked by big ideas, imagination and audacity,
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but also solutions that work.
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ELAM's faculty had no handy evidence base
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to guide them, so they learned the hard way,
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by doing and correcting course as they went.
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Even the brightest students
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from these poor communities
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weren't academically prepared
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for six years of medical training,
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so a bridging course was set up in sciences.
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Then came language:
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these were Mapuche, Quechuas, Guaraní, Garífuna,
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indigenous peoples
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who learned Spanish as a second language,
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or Haitians who spoke Creole.
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So Spanish became part
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of the pre-pre-med curriculum.
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Even so, in Cuba,
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the music, the food, the smells,
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just about everything was different,
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so faculty became family, ELAM home.
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Religions ranged from indigenous beliefs
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to Yoruba, Muslim and Christian evangelical.
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Embracing diversity became a way of life.
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Why have so many countries
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asked for these scholarships?
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First, they just don't have enough doctors,
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and where they do, their distribution
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is skewed against the poor,
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because our global health crisis
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is fed by a crisis in human resources.
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We are short four to seven million health workers
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just to meet basic needs,
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and the problem is everywhere.
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Doctors are concentrated in the cities,
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where only half the world's people live,
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and within cities,
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not in the shantytowns or South L.A.
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Here in the United States,
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where we have healthcare reform,
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we don't have the professionals we need.
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By 2020, we will be short
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45,000 primary care physicians.
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And we're also part of the problem.
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The United States is the number one importer
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of doctors from developing countries.
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The second reasons students flock to Cuba
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is the island's own health report card,
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relying on strong primary care.
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A commission from The Lancet
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rates Cuba among the best performing
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middle-income countries in health.
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Save the Children ranks Cuba
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the best country in Latin America to become a mother.
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Cuba has similar life expectancy
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and lower infant mortality than the United States,
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with fewer disparities,
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while spending per person
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one 20th of what we do on health
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here in the USA.
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Academically, ELAM is tough,
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but 80 percent of its students graduate.
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The subjects are familiar —
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basic and clinical sciences —
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but there are major differences.
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First, training has moved out of the ivory tower
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and into clinic classrooms and neighborhoods,
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the kinds of places most of these grads will practice.
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Sure, they have lectures and hospital rotations too,
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but community-based learning starts on day one.
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Second, students treat the whole patient,
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mind and body,
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in the context of their families, their communities
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and their culture.
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Third, they learn public health:
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to assess their patients' drinking water, housing,
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social and economic conditions.
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Fourth, they are taught
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that a good patient interview
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and a thorough clinical exam
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provide most of the clues for diagnosis,
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saving costly technology for confirmation.
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And finally, they're taught over and over again
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the importance of prevention,
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especially as chronic diseases
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cripple health systems worldwide.
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Such an in-service learning
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also comes with a team approach,
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as much how to work in teams
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as how to lead them,
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with a dose of humility.
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Upon graduation, these doctors share
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their knowledge with nurse's aids, midwives,
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community health workers,
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to help them become better at what they do,
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not to replace them,
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to work with shamans and traditional healers.
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ELAM's graduates:
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Are they proving this audacious experiment right?
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Dozens of projects give us an inkling
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of what they're capable of doing.
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Take the Garífuna grads.
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They not only went to work back home,
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but they organized their communities to build
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Honduras' first indigenous hospital.
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With an architect's help,
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residents literally raised it from the ground up.
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The first patients walked through the doors
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in December 2007,
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and since then, the hospital has received
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nearly one million patient visits.
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And government is paying attention,
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upholding the hospital as a model
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of rural public health for Honduras.
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ELAM's graduates are smart,
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strong and also dedicated.
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Haiti, January 2010.
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The pain.
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People buried under 30 million tons of rubble.
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Overwhelming.
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Three hundred forty Cuban doctors
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were already on the ground long term.
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More were on their way. Many more were needed.
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At ELAM, students worked round the clock
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to contact 2,000 graduates.
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As a result, hundreds arrived in Haiti,
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27 countries' worth, from Mali in the Sahara
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to St. Lucia, Bolivia, Chile and the USA.
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They spoke easily to each other in Spanish
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and listened to their patients in Creole
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thanks to Haitian medical students
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flown in from ELAM in Cuba.
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Many stayed for months,
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even through the cholera epidemic.
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Hundreds of Haitian graduates
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had to pick up the pieces,
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overcome their own heartbreak,
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and then pick up the burden
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of building a new public health system for Haiti.
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Today, with aid of organizations and governments
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from Norway to Cuba to Brazil,
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dozens of new health centers have been built,
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staffed, and in 35 cases, headed
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by ELAM graduates.
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Yet the Haitian story
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also illustrates some of the bigger problems
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faced in many countries.
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Take a look:
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748 Haitian graduates by 2012, when cholera struck,
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nearly half working in the public health sector
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but one quarter unemployed,
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and 110 had left Haiti altogether.
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So in the best case scenarios,
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these graduates are staffing
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and thus strengthening public health systems,
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where often they're the only doctors around.
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In the worst cases, there are simply not enough jobs
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in the public health sector,
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where most poor people are treated,
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not enough political will, not enough resources,
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not enough anything —
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just too many patients with no care.
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The grads face pressure from their families too,
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desperate to make ends meet,
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so when there are no public sector jobs,
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these new MDs decamp into private practice,
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or go abroad to send money home.
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Worst of all, in some countries,
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medical societies influence accreditation bodies
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not to honor the ELAM degree,
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fearful these grads will take their jobs
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or reduce their patient loads and income.
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It's not a question of competencies.
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Here in the USA, the California Medical Board
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accredited the school after rigorous inspection,
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and the new physicians are making good
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on Cuba's big bet,
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passing their boards and accepted
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into highly respected residencies
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from New York to Chicago to New Mexico.
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Two hundred strong, they're coming
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back to the United States energized,
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and also dissatisfied.
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As one grad put it,
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in Cuba, "We are trained to provide quality care
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with minimal resources,
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so when I see all the resources we have here,
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and you tell me that's not possible,
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I know it's not true.
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Not only have I seen it work, I've done the work."
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ELAM's graduates,
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some from right here in D.C. and Baltimore,
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15:04
have come from the poorest of the poor
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to offer health, education
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15:09
and a voice to their communities.
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15:12
They've done the heavy lifting.
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15:15
Now we need to do our part
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2014
15:17
to support the 23,000 and counting,
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15:21
All of us —
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15:22
foundations, residency directors, press,
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15:26
entrepreneurs, policymakers, people —
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15:29
need to step up.
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15:31
We need to do much more globally
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15:33
to give these new doctors the opportunity
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15:36
to prove their mettle.
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15:38
They need to be able
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15:39
to take their countries' licensing exams.
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15:42
They need jobs in the public health sector
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15:45
or in nonprofit health centers
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15:47
to put their training and commitment to work.
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15:51
They need the chance to be
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15:53
the doctors their patients need.
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15:58
To move forward,
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16:00
we may have to find our way back
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16:03
to that pediatrician who would
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2183
16:05
knock on my family's door
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on the South Side of Chicago when I was a kid,
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16:10
who made house calls,
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16:12
who was a public servant.
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16:15
These aren't such new ideas
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1823
16:17
of what medicine should be.
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16:19
What's new is the scaling up
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2725
16:22
and the faces of the doctors themselves:
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16:25
an ELAM graduate is more likely to be a she
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3457
16:29
than a he;
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1930
16:31
In the Amazon, Peru or Guatemala,
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2927
16:33
an indigenous doctor;
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2351
16:36
in the USA, a doctor of color
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16:39
who speaks fluent Spanish.
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16:41
She is well trained, can be counted on,
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16:45
and shares the face and culture of her patients,
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16:49
and she deserves our support surely,
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16:52
because whether by subway, mule, or canoe,
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16:56
she is teaching us to walk the walk.
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16:59
Thank you. (Applause)
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