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GOING WHERE NO DOCTOR HAS GONE BEFORE: the Place Ofcuba's Latin American School Ofmedicine in Building Health Care Capacity for Ecuador

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GOING WHERE NO DOCTOR HAS GONE BEFORE: the Place Ofcuba's Latin American School Ofmedicine in Building Health Care Capacity for Ecuador GOING WHERE NO DOCTOR HAS GONE BEFORE: The Place ofCuba's Latin American School ofMedicine in Building Health Care Capacity for Ecuador. by ROBERT LEE HUISH A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in the Department of GEOGRAPHY © Robert Lee Huish 2008 SIMON FRASER UNIVERSITY Burnaby, British Columbia, Canada Spring, 2008 All rights reserved. This work may not be reproduced in whole or part, by photocopy or other means, without permission ofthe author. APPROVAL Name: Robert Lee Huish Degree: Doctor of Philosophy Title of Thesis: GOING WHERE NO DOCTOR HAS GONE BEFORE: The Place of Cuba's Latin American School of Medicine in Building Health Care Capacity for Ecuador Examining Committee: Chair: Dr. V. Crooks Assistant Professor, Department of Geography, SFU Dr. John A.C. Brohman, Associate Professor Senior Supervisor, Department of Geography, SFU Dr. Michael V. Hayes, Associate Professor Committee Member, Faculty of Health Sciences, SFU Dr. Jerry Spiegel, Associate Professor, Committee Member Liu Institute for Global Issues, Health Care & Epidemiology, UBC Dr. Stacy Pigg, Associate Professor Committee Member, Department of Sociology/Anthropology, SFU Dr. Eric Hershberg, Professor and Director Internal Examiner, Department of Political Science, SFU Dr. Robert Woollard, Royal Canadian Legion Professor External Examiner Department of Family Practice, University of British Columbia Date Approved: April 10, 2008 II SIMON FRASER UNIVERSITY LIBRARY Declaration of Partial Copyright Licence The author, whose copyright is declared on the title page of this work, has granted to Simon Fraser University the right to lend this thesis, project or extended essay to users of the Simon Fraser University Library, and to make partial or single copies only for such users or in response to a request from the library of any other university, or other educational institution, on its own behalf or for one of its users. The author has further granted permission to Simon Fraser University to keep or make a digital copy for use in its circulating collection (currently available to the public at the "Institutional Repository" link of the SFU Library website <www.lib.sfu.ca> at: <http://ir.lib.sfu.ca/handle/1892/112>) and, without changing the content, to translate the thesis/project or extended essays, if technically possible, to any medium or format for the purpose of preservation of the digital work. The author has further agreed that permission for multiple copying of this work for scholarly purposes may be granted by either the author or the Dean of Graduate Studies. It is understood that copying or publication of this work for financial gain shall not be allowed without the author's written permission. Permission for public performance, or limited permission for private scholarly use, of any multimedia materials forming part of this work, may have been granted by the author. This information may be found on the separately catalogued multimedia material and in the signed Partial Copyright Licence. While licensing SFU to permit the above uses, the author retains copyright in the thesis, project or extended essays, including the right to change the work for subsequent purposes, including editing and publishing the work in whole or in part, and licensing other parties, as the author may desire. The original Partial Copyright Licence attesting to these terms, and signed by this author, may be found in the original bound copy of this work, retained in the Simon Fraser University Archive. Simon Fraser University Library Burnaby, BC, Canada Revised: Fall 2007 S [ !Vt 0 N f HA SE H lJ NIV E R SIT Y THINKING OF THE WORLD STATEMENT OF ETHICS APPROVAL The author, whose name appears on the title page of this work, has obtained, for the research described In this work, either: (a) Human research ethics approval from the Simon Fraser University Office of Research Ethics, or (b) Advance approval of the animal care protocol from the University Animal Care Committee of Simon Fraser University; or has conducted the research (c) as a co-investigator, in a research project approved in advance, or (d) as a member of a course approved in advance for minimal risk human research, by the Office of Research Ethics. A copy of the approval letter has been filed at the Theses Office of the University Library at the time of submission of this thesIs or project. The original application for approval and letter of approval are filed with the relevant offices. Inquiries may be directed to those authorities. Bennett Library Simon Fraser University BurnabY,BC,Canada Lil:51 reVISlon- Summel 2007 Abstract Martin Luther King said that "of all the forms of inequality, injustice in health care is the most shocking and inhumane." Today, despite the overwhelming quantity of attention and resources given towards global health, social inequity has never been worse as many in the global South remain perilously marginalized from the receipt of sustainable primary-care services. Amidst this backdrop Cuba developed the Latin American School of Medicine (ELAM) as a response to the global South's lagging supply of human resources for health. The school has received 11,500 students from 29 different countries, including the United States. Every student receives a free, six-year medical education as part of a moral commitment to practice their skills in areas where they are most needed. This dissertation explores how ELAM is building capacity to meet the needs of communities in Ecuador, a country that has endured structural adjustments to its public health sectors. It is about sharing the lived experience of certain ELAM graduates to understand if they are able to reduce health-care inequity in their communities despite personal and structural challenges. This is best understood in how graduates practice community-oriented primary care (COPC) within their communities. This study finds that ELAM's institutional ethics are counter hegemonic to dominant neoliberal tendencies in health-care service provision, but that only with appropriate social and political support will the ethics and skills of these graduates scale up into positive changes in community health. The study conceptualizes ELAM as an alternative-development project grounded in a tradition of Cuban medical internationalism. It offers insight into the program of III study, discusses the nature of public health care in Ecuador, and then explores the professional experiences of several Ecuadorian ELAM graduates. This dissertation serves as a preliminary step in understanding how ELAM impacts the accessibility of vulnerable populations to health-care services in Ecuador. It demonstrates the strengths and challenges of ELAM graduates in seeking to strengthen human resources for health. The ELAM story shows how investing in people can work towards overcoming neoliberal health-care hegemony, which has done a great deal to promote health-care inequality rather than ensure social equity. IV v This one is for Uncle Don, who always fanned the flames. VI - The Delivery - After three days oflabour, the baby still hadn't been born. "He's stuck. The little guy's stuck, " the man said. He had come from a remote farm in the country. The doctor went with him. Valise in hand, the doctor walked under the noonday sun, toward the horizon, into that desolate world where every- thing seems born ofaccursed fate. When he got there he understood. Later, he told Gloria Galvin: "The woman was at death 's door but was still panting and sweating, and her eyes were wide open. I had no experience with situations like that. I was shaking; I hadn't the faintest idea what to do. And then, as I drew back the blanket, I saw a tiny arm sticking outfrom between the woman's spread legs. " The doctor realized that the man had been pulling on it. The little arm was rubbed raw and lifeless: a flap ofskin, black with dried blood. And the doctor thought: There is nothing to be done. And yet, for whatever reason, he caressed the arm. He rubbed the inert limb with his index finger, and when he got to the hand, it suddenly closed, clutching his finger for dear life. Then the doctor asked for boiling water and rolled up his sleeves. Eduardo Galeano (The Book ofEmbraces, 1990: 224) vii Acknowledgements On any beach, in any language, a red flag erected in the sand means, "stay out of the water!" On April 29, 2001, while swimming at Playa Santa Maria, just east of Havana, I missed that message and ran, full speed, into an angry sea. A wave came up on me, threw my feet in the air, and drove my head into the ground shredding my shoulder to pieces. A bloody mess, I dragged myself out of the water, and collapsed on the sand. Within no time two Cubans put me in the back of their old American car, and we drove off to Calixto Garcia Hospital in Vedado. I kept telling them "jNecesisto mi carta de seguridad!" I need my insurance card. "Never mind that," the driver said. We arrived at the hospital. A doctor was lounging by the main entrance reading the daily issue of Granma. He took me, along with another unfortunate Canadian, who sliced open his foot having treaded over a broken beer bottle, into the surgery and immediately two nurses and another doctor appeared. They put the man with the wounded foot on the table, cleaned him up and then, with cat-gut stitches, sowed him up. Then they turned to me. They cleaned my shoulder and treated it with generous mounds ofdisinfectant, iodine, and then some skin cream. We were both treated and out the door in less than 25 minutes. I had $50 USD on me, and I offered the doctors and the nurses the full amount.
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