What if medical school was free? What if every physician had to spend time living among the poor and socially excluded? How would these changes alter the medical profession and the practice of medicine more broadly? The film Salud! (2006) encourages us to ponder the meanings of the universal right to health and, more importantly, the quality of care as it follows Cuban physicians and graduates of ELAM, Cuba’s free medical school.
Though the film explores the global impact of the island nation’s unique medical diplomacy the film steers clear of overt political commentaries by focusing solely on the local and international impact of health care providers. Yet it is not difficult to ruminate on Cuba’s hemispheric and historical impact beyond what is stated in the film. The health care model that emerged in Cuba is as much a product of the revolution as of the sixty-year, US-led embargo of the island. The former, the revolution, laid the ideological foundation for communal care while the latter, the embargo, forced Cubans to develop a health care system based on preventive care. Quite simply Cuba could not afford the challenges and expense of caring for an unhealthy population so it sought to stem illness before it could get started. A vital component to this plan was trained health care professionals.
By 2005 Cuba had 70 594 doctors, about one physician per 159 inhabitants, and more than 447 000 health workers. Given these numbers a large part of Salud! follows neighbourhood clinic doctors, the foundation of Cuban health care, as they make house calls on their patients and neighbours. Physicians address each patient by name, know their clinical history, and detect changes in health because they identify their patients on a professional level but also as members of their smaller community. The ingenuity of making do with very little is front and centre as we see decaying medical equipment that has been repurposed to continue functioning well beyond its serviceable life. We also follow doctors to rural Cuba where we find destitute farmers who, despite their poverty, have access to life-saving surgical procedures. The material poverty, evidenced in waiting rooms with peeling paint, and pen and pencil notations in lieu of computerised records, fades into the background as the viewer realises that on this island everyone has the right to the same care.
We also see Cuban doctors outside Cuba and on the ground in Gambia, the slums of Venezuela, and in Honduras after a devastating hurricane. Each of these examples is different and fascinating for they illustrate how Cuban medical teams adapt to the cultural demands on the ground. The initial response is to provide immediate care in vastly underserved and poor areas. But, ultimately, the Cuban model seeks to train local doctors to take care of their own. For example in Venezuela a young female doctor from the slums of Caracas benefited as a young woman/girl from the services of Cuban doctors and was so inspired by their work that she herself became a doctor trained, of course, in Cuba. She now lives in the same Venezuelan slum but now as the resident physician who cares for her neighbours.
Arguably the most thought-provoking part of the film is the Latin American Medical School or ELAM, a free medical school open to any aspiring physician coming from medically underserved parts of the globe. In addition to students from throughout Latin America and Africa there are dozens from the United States. These students hail from lower-income regions or urban slums and despite excellent grades, even with scholarships, were unable to attend medical schools in the United States. It is in moments such as these – and there are several in the film – when one must pause and question what we have lost and are losing with the high price tag of medical school. For, more important is the question of who is being left out of a medical education for lack of funding or the inability to acquire what would be for many insurmountable debt. It is obvious that freedom from debt allows students to pursue a medical degree that allows them to focus on their individual strengths. While there are certainly Cuban physicians who choose the profession for profit, the film showcases at least one example, the majority of those shown appear to genuinely pursue the profession because they enjoy caring for others. More than 4000 international students have graduated from Cuban medical schools since 1966. All medical students are trained to become doctors devoted to public service.
Cameo appearances by medical anthropologist and physician Paul Farmer, President Jimmy Carter, and several academics and government officials from around the world serve to give global context to the uniqueness of the Cuban health care system.
While inspiring, the film is also sobering. We see very clearly how access to good health care can transform neighbourhoods, regions and even entire countries. But we also must acknowledge that Cuba is an island, a socialist island whose unique geography, history and nationalist pride is built on the idea of community and communal help. It would be difficult to replicate this model elsewhere and the Cuban doctors profiled agreed. In fact, they stress that the Cuban health care model is not one to be reproduced but rather that the ideas of health that focus on the dignity of patients, the idea that each patient no matter how poor or how ill is important, and the obligation of doctors to give back to the community is the foundation of their success.
Though medical students and medical school instructors are the obvious must-see viewers the film will be especially valuable to those who teach history of medicine or public health courses or those interested in questions of development, or models of health care around the world. This film is also recommended for general history of Latin America courses for instructors wishing to highlight the region’s innovative role in medicine and public health. The film is especially important for undergraduates, even those not especially interested in health and medicine, because it brings the discussion of Cuba and our nation’s relationship to the country into perspective.
