Watching The Well, Late March 2010

This month, it was announced that an island in the Bay of Bengal was swallowed up by the sea, due to rising sea levels caused by climate change. Five other nearby islands are also threatened with submersion.

This month, NASA scientists stated the very high likelihood that this year, 2010 could be the warmest year on record. FYI, 2009 was the warmest year on record in the Southern Hemisphere, and the second warmest year overall.

This month, the U.S. Federal Reserve announced the end of its program of buying U.S. mortgage-backed securities. The buying of these securities by the Fed was a major factor in propping up the U.S. financial system, and was quite possibly the single biggest factor in keeping American home prices elevated.

This year, the U.S. Energy Information Administration finally joined a chorus of official voices from official government and oil industry agencies who are saying that the world could start to see a decline in global oil production...right about now (actually, to be quite precise, starting in 2011). However, neither the EIA nor the U.S. government in general can yet bring themselves to say the words, “Peak Oil.”

This year, none of these pivotal stories has been covered in any meaningful way in mainstream American media. However, Scripps Networks have just launched a new “reality” TV show on their Travel Channel, called, “America's Worst Drivers.” Our media continues to lull us to sleep by petty distractions such as these, and many of us are as a mouse nodding off to the sound of the purr of a nearby cat. So few of us realize that the cat's jaws are about to close on us.

Leaving the Cubicle for the Farm (In The City)

One of the greatest needs of First World society (particularly in the United States) over the next several decades is for a great reskilling, as wealth and concentrated supplies of energy and raw materials dwindle and occupations connected with an energy-intensive society become useless. Farming is a skill that many of us will have to re-learn as the energy required for modern industrial farming becomes unavailable. At present, fewer than two percent of Americans farm for a living. We may be forced to return to a society like that which existed in 1900, in which around 41 percent of Americans were employed in agriculture.

Urban farming is a unique subset of farming in general, and where I live, there is a vibrant community of urban farmers. Urban farming was also on my mind a few weeks ago, as my (now former) office was very slow and I had time on my hands to consider other options for making an honest living. (No worries, I am now working at a different firm.) Thus it was that I found myself calling Josh Volk, urban farming consultant and proprietor of Slow Hand Farm. We got together at Stumptown Coffee in downtown Portland for an exchange of advice about urban farming, and specifically what challenges a person would face in taking up urban farming as a livelihood. Although I recorded the interview, it was very noisy due to the presence of many people and the sound of coffee and espresso makers. Therefore, instead of a podcast, I have only provided a transcript, which I have included below. Today's post is part one of the interview. My questions and comments are in bold type.

What are the first steps for someone who wants to transition into urban farming as a career?

The first thing is to ask what your goals are. In other words, why are you doing this? What do you want to be doing day by day? Second, ask yourself what you need to get out of it, both financially and otherwise. Lastly, there is learning the skills. This depends heavily on how much money and space you have to play with.

When I first started, I met with this guy named Jac Smit, and he had an organization called the Urban Agriculture Network, which I think is still going – he died last year – but he had been working on urban agriculture projects. It turned out that he was not working on things in the United States – there really wasn't much going on in the United States at the time, but in a lot of other countries, they were fairly far along, particularly in a lot of developing countries, partly out of necessity.

He said one of the problems he saw in the United States was that most of the people that were interested in urban agriculture came from an urban background and probably came from a gardening background. They didn't know a whole lot about production, and didn't have the same mindset or skill set as a farmer who is producing goods. They were just growing things for their own consumption. So he said, “If you're really interested in urban agriculture, you should go and you should learn farming – and then bring that back into the urban setting,” because it's an appropriate thing, and that was one of the things that he saw that was working in developing countries – a lot of the people coming into cities were very recent migrants and had an agricultural background already.

So I took that advice and I went and apprenticed on a farm. And I've kind of been stuck in that farming thing for more than ten years now, learning the production end, and I feel like I'm just starting to get back to it [urban farming]. In some ways I'm actually a little less excited about it now, because I know some more of the realities and some of the reasons why it doesn't work as well. But I haven't given up on it, so I'm still looking at it and trying to figure out how I think it fits in best.

It's been about fifteen years since I talked to Jac Smit, and I think in that time period, the landscape has changed a lot, and there are a lot more people who are looking at urban farming, and there are more people coming in and doing urban agriculture projects with a production background, but there are still a lot of people doing it without that background. So that's one place where you could start – go to some production farms, whether in the city or outside the city, and just learn the techniques they're using and try to apply that to a smaller scale.

What were some of the difficulties you encountered that made you less enthusiastic as time passed?

One thing is that I'm excited about growing a lot of different things. If you are trying to do production in an urban environment, land is very expensive – space is very expensive – and water is expensive. There's a very limited subset of crops, I think, that make sense for a limited space. There's a lot of crops that take up a lot of space, so there are some things where I'm not sure how they fit into the urban setting, and I wasn't aware before that there were those differences, or maybe how big those differences were.

For example, the urban agriculture projects that I've seen that have been the most successful generally concentrate on something like salad greens, because you can grow a lot of salad greens in a very small space. And people don't eat as much by pound of salad greens as they eat of something like wheat. In 100 square feet you might be able to get a couple hundred servings of salad greens, whereas with wheat you could get something on the order of ten servings. That's a big difference, and the price of salad greens is probably at least five if not ten or twenty times as high as the price of wheat. So when you think about what you're going to do with an expensive, limited amount of space, there are some limitations there.

What does it take to get access to land in the city? Say Portland, for example?

There's a bunch of different models I see. Some people just outright buy a spot and own it. I have friends who just bought a house that sits on six tenths of an acre. I don't think there's a lot of places like that left in Portland, but there are still places like that. If they really wanted to push it, as a couple, they could certainly make a living off that amount of space. Other people might have a small yard of their own or they might have multiple small yards, and they're bartering that space, either because the people want to see things grown on it, or they want a share of the produce coming from it. And that's questionably legal right now, although the zoning will probably change in the near future to make it legal.

Why is it not quite legal right now?

It's questionable whether the zoning allows you to grow something and sell it on your property. You can probably argue that you can grow it and sell it, but the way that you sell it would have to be off the property. So if you were trying to distribute it directly on the property, that would probably make it illegal. It could probably be argued – although I'm not sure anyone would do this – that it's not even really legal to grow it on your property. Certainly if your neighbors were complaining, they would have a case, although they would probably not win, advocating that you shouldn't be doing what you're doing.

That you shouldn't be growing things on your property?

Not that you shouldn't be growing things, but that you shouldn't be growing them commercially. It's the commercial designation that makes it legal or not legal, because the space is zoned residential; it's not zoned commercial or agricultural. The same thing goes for commercial spaces, because they're zoned for a particular type of commercial use and they're not zoned for agriculture. Contamination is another issue you have to look at, because there are a lot of contaminated soils in urban areas and concentrations of different kinds of chemicals, particularly lead paint.

So another way people get land is more temporary – but land owned by a developer or even publicly owned land has a designated use, yet isn't going to be put to that use for a few years. So the owners may allow that land to be used for a period of time to grow things until they're ready to build their project on the land. I know a few people who are farming on such land; one group in North Portland is doing that with a church property where the church is going to expand, but they're probably not going to do it for another four or five years, so in the interim they're letting folks grow crops on the land.

And the County has a certain amount of tax-foreclosed land, and they make some of that available to organizations that want to do urban agriculture projects. Typically, these are non-profit – but a food production “business” (for lack of a better word) wouldn't necessarily have to be for profit; you could run it in some sense as a non-profit, and in an urban setting, that might actually make more sense, especially as you're not likely to make much of a profit anyway.

How do you find this land? Do you go on real estate websites to find properties like this that people aren't intending to use for a while?

I think one of the things that's an important distinction between urban agriculture and other types of agriculture is that there's a community aspect to it, and I think networking is important. Networking is how those lands and spaces get identified. It's probably more word-of-mouth than anything else. Once you get connected into a community of people that are talking about that and you start putting it out there that you're looking for space or that you have a project you want to do, you start running into people that say, “Oh, I know a spot. You can check with this person,...” or, “I have a spot. How could we work something out?” That's what makes urban agriculture work in a way that rural agriculture isn't working right now.

I think there probably are efforts – I can't recall any off the top of my head – but I think there are people who want to make clearing houses and create lists of available land. There was an effort through the City – I'm forgetting the name – I think it was the “Diggable City” project that tried to identify land a few years ago. But as far as the people I know who are actually doing urban agriculture projects, it's been more word-of-mouth, or people finding each other through existing networks.

You say that rural agriculture is not working that way – is rural agriculture failing in the United States?

In general, I think that it is, because I think what's happened is that the consolidation that's happened in terms of family-scale farms being consolidated into larger and larger industrial corporate factory farms has torn apart the rural community. So there's not a whole lot of “community” in rural communities anymore. That's a big issue, because it has switched the population base in the U.S. from a rural one to an urban population. This has gutted rural communities. It has also disconnected rural communities from urban markets – it has put a couple more layers of distribution systems between the two, because consolidation makes those operations so large that they have to distribute over a wider area in order to make their business work. That has lengthened ties and broken ties in a lot of communities.

If I were to look at the whole picture, I would say that strengthening the rural communities and going back to a rural agriculture that makes more sense is in most ways more important than thinking about how to do urban agriculture appropriately – because there is land there, and it's inexpensive land. If instead of trying to concentrate everybody into a few large urban centers, and figuring out how to make that urban land produce intensively for those people, we could spread those people out more so that the resulting population centers had more of a land base and didn't have to work so intensively, I think that would be ecologically a better model.

* * *

That concludes part one of the interview. Stay tuned for part two, which will be posted next weekend, God willing. And if you want to check out some other sources of information on urban farming, see these links:

• The Urban Agriculture Network

• Diggable City

• And for a video regarding the Diggable City project, check this out on Vimeo, courtesy of Kevin Balmer.

Managing Trees, Stormwater and Hunger in the City

As I mentioned in a recent post, I recently participated in a community tree planting effort. The mass planting took place on the 13^th of March, and was hosted by Friends of Trees, a non-profit group that seeks to revitalize urban environments through planting trees in urban neighborhoods.

This mass planting was part of a larger effort by the City of Portland, known as the “Gray to Green Initiative,” an effort to reduce City stormwater runoff and associated sewage infrastructure costs by the use of natural, living methods. This is an important priority for the City government, which has faced both regulatory requirements and fines from the U.S. Environmental Protection Agency because of inadequate treatment of sewage flows into the Willamette River. The regulatory requirements and lack of adequate treatment led to the “Big Pipe” project and other recent sewage infrastructure modernization efforts.

But the City's Bureau of Environmental Services realizes that technology-heavy infrastructure upgrades are expensive, and that sooner or later the capacity of even an upgraded sewage system can be exceeded through population growth, aging infrastructure and continued urban construction. Thus they have begun to promote living, natural methods of reducing stormwater runoff, and resulting sewage overflows. These living, natural methods include tree plantings and “eco-roofs” – living, literally green roofs whose plants intercept stormwater before it can flow into City gutters and storm drains. The promotion of natural, living methods of dealing with stormwater runoff and sewage will become increasingly important in the near future, as cities lose tax revenue and the ability to maintain expensive sewage treatment systems due to our ongoing economic collapse.

As far as the planting day went, I had a lot of fun. It was a good experience for neighbors to meet each other in the process of doing something that benefited the common good. Also, Friends of Trees were able to address not only stormwater issues, but the issue of local, community-based food production, as this year they began offering low-cost fruit and nut trees to interested homeowners. (I got my very own apple tree!) The fruit trees were so popular that most of them sold out long before the planting day.

For those who want to see what a planting day looks like, I also shot some video of the event, which can be found on Vimeo under this link. Or you can watch it here:

Managing Trees, Stormwater and Hunger in the City from TH in SoC on Vimeo.

An Open Letter To The American Right and the Tea Party

I actually wanted to write a different post for this weekend. But that post involves uploading some video to the Internet, and every time I have tried it, the operation has been a bit like having one's teeth pulled without anesthesia. One of these days, I might just succeed... But in the meantime, I have some questions for the American right in general, and the Tea Party in particular. I am trying to understand you. If you read my blog, you'll doubtless pick up on my general views regarding you – but I'm willing to admit that maybe we don't understand each other, and that I've been unfair in my attitude toward you. So please help me out here, if you would.

Let me just say that it's been quite an experience to watch the rise of the Tea Party and its promoters – groups like Fox News and talk radio hosts, and people like Sarah Palin and Glenn Beck, and rich sponsors like Dick Armey and Steve Forbes. And I see all the books written by your spokespeople and sold in places like the Fred Meyer store just a few blocks away from my house. Moreover, I have met many people who seem to sympathize with you, from some of the people I know at work to some of the people I see on the streets of Portland waving signs. (I am thinking particularly of the sign wavers who want to recall Mayor Sam Adams.) Certainly you all have a lot of energy and zeal.

I must also say that I am more than a little unnerved by what I see of you. I know that both the world in general and our nation in particular are facing tough, uncertain times. However, it seems to me that you are responding to these times in ways that may not be beneficial to all groups of people in the world – especially those who are poor or who come from an ethnic background that is different than yours. It seems to me that many of you would like to take this country (along with the larger world) back to a condition that existed maybe 50 years ago, and that had only slowly begun to change by the 1970's. That condition was very hard on my parents (who are black, as I am), and was rather hard on me as I was growing up. Now I am a Christian, but I must warn you that I refuse to go willingly back to those days without a fight. Also, I perceive larger systemic, environmental, ecological and economic threats for which a return to the thinking of the 1950's and 1960's is just not the answer.

Take the global warming controversy for instance. I really liked science as a kid, and I used to want to be an astronaut. So I read a lot of books on astronomy and particularly the planets of our solar system. One planet, Venus, has an atmosphere that contains a lot of carbon dioxide. Both the U.S. and Russia have sent space probes to Venus, and the Russian probes have actually taken pictures of the surface. Those pictures look like something out of Hell. The surface temperature of Venus is high enough to melt lead. And all those science books, written 40 years ago and more, all said that this was due to the huge amount of carbon dioxide in the atmosphere of Venus. These books also taught me that carbon dioxide is transparent to visible light and short wave infrared radiation, but that it is opaque to long wave infrared radiation. In short, these books explained the greenhouse effect in a way that a little kid could understand (and they were backed up by lots of research done by trustworthy grown-ups). So why is it, now that big money is involved, that we're suddenly not supposed to trust the science behind global warming and manmade climate change?

Or take the subprime crisis (and race relations along with it). I remember the discrimination against minorities that was practiced by banks and realtors during the civil rights struggle. I also remember what it was like for the few minority families that escaped red-lining and were able to move into suburban, traditionally white neighborhoods. I remember the fights I got into almost daily when my dad bought a house in a white neighborhood. And I remember how one of the gains of the Civil Rights Movement was the passage of laws that outlawed discrimination in housing and lending.

But I also remember doing research for this very blog, The Well Run Dry, and finding out how Ronald Reagan and every president after him weakened and gutted those anti-discrimination laws. And I know what the actual causes of the subprime crisis were, and how minorities were deliberately “steered” into subprime loans by banks – against the law – even though many of us could have qualified for conventional loans. And now Fox News is saying that our present financial crisis was caused by the Federal Government outlawing lending discrimination against minorities?! Speaking of race, why is it that whenever there are disasters and people suffering from slow and incompetent responses to those disasters on the part of their government, they are always treated by the media (particularly Fox) as unfortunate sufferers bravely trying to cope as long as they are white, and they are called “looters” if they're not white?

Let's take health care. To me, the present health care debate seems to be about bailing out the health insurance industry. I don't like the Democratic proposal any more than you do. But I would have preferred single-payer health care. Your answer to that is to shout “That's socialism!!! Socialism is evil!!!” I don't get your response. To be sure, single-payer health care would prevent the masters of certain American “industries” from getting any richer – namely, the health care “industry”, the drug “industry,” and particularly, the health insurance “industry.” But you seem to think that preventing these people from getting any richer is the same as preventing you from getting rich.

To me it seems that you think that any restrictions placed on the prerogatives and powers of the rich would hinder anyone else from getting rich. Don't you remember the history of the United States over the last 150 years? Don't you remember that during the 1920's, when there were almost no Government restrictions on businesses, the result was that a few large monopolies emerged which effectively destroyed anyone who tried to compete with them, and that the rich became a club whose members effectively prevented most other people from becoming rich? Oh, sure, there was the stock market, but the stock market was nothing more than a sucker's game to fool the average working-class guy (or gal) that they were playing a rich man's game by which they could also become rich. And then the stock market crashed. Kind of looks like today, doesn't it?

You now seem to think you can play the same game and get rich yourselves, and you don't realize that your chances of scoring it big are about the same as your chances of winning the Lottery (which is to say that you don't have much of a chance). So you scream that you don't want socialized medicine, yet if you break an arm or a leg or have appendicitis and have to visit an emergency room, the health “industry” will bleed you dry. Do you want to be on the hook for a $20,000 emergency room visit?

And that leads to the question of whether or not people should even want to be rich in the first place. Wanting to be rich is an American value – as American as apple pie, blond haired children, NASCAR and “Support Our Troops” bumper stickers. Yet many of you on the right claim to be Christians. Have you never read in the Good Book that “the love of money is the root of all evil”? (1 Timothy 6:10 in case you don't believe me.) Have you ever looked at the lives of the rich and considered the things they did to get rich? Especially the things they did to other people? Do you want to be the kind of people that like doing those sorts of things? You might have Hell to pay afterward.

Or take morality. I think particularly of the “Recall Sam Adams” campaign. I asked a sign-waver why he wanted to recall Adams, and he repeated the true story that Mayor Sam had sex with an 17-year old male and lied about it. Now I have to agree that that's pretty sleazy. Sam Adams is a gross, immoral character. But there are two things to consider. First, the Republicans and the Right also have their share of gross characters – including Larry Craig, Mark Sanford, and Ted Haggard. In fact, there are whole websites dedicated to listing and chronicling the sexual sins of figures on the American Right and its politicians. (The list of sinners on the Right is very long.)

Secondly, for a long time I have believed that the calls on the Right to correct American morality were simply a ploy to rally people around a very different agenda. The candidates we were told to vote for all said that they were very concerned about American morality, yet when they got into office, their real agenda became evident – an agenda designed to promote American economic power at the expense of the rest of the world, and to promote the fortunes of wealthy American and European elites at the expense of ordinary working-class people in America and Europe. Think about it. If the American Religious Right, for instance, had really wanted to end abortion in this country through government action, they had a golden opportunity during the last two years of George W. Bush's presidency. Yet they didn't.

I have come to believe that the sexual morality of a nation can't be fixed by laws. (Anymore, when I vote at all, I vote for people whom I think are most willing to build social safety nets. That's my biggest value these days.) I have also come to believe that those of you on the Right who call yourselves Christians could do far more toward healing the morality of a nation by acting like Christ yourselves. One translation of 1 Peter 1:1 says, “Peter, an apostle of Jesus Christ, to those who reside as aliens, scattered...” We're not called to be earthly patriots or materialists, but to live as resident aliens – in the world, but not of it. Yet what I see especially in the American Religious Right is a bunch of jingoistic flag-wavers who are rabidly willing to send in the troops to kill people in countries that possess things we Americans happen to want.

In short, I see the American Right, both religious and secular, as mere greedy materialists. As has been documented on this blog and on many others, the well of Western and First World prosperity is running dry, due to ecological and energy constraints. One wise response would be to learn to live within limits and to learn to share. Yet the response of American Right seems to be a temper tantrum. This is why you scare me.

As I said at the start, however, I may be wrong about you. If any of you reading this are on the Right or associated with the Tea Party and you have read this far, thank you very much for reading. This entire post arose out of a conversation I had with someone after church today. Now I am reaching out to you all and I would like to know what you think. Correct me if I'm mistaken – please. Please do it calmly and rationally, however; I don't respond well to MESSAGES IN ALL CAPS, FULL OF RANT WORDS AND EXCLAMATION MARKS!!!!, if you get my drift.

A Slightly Late Post, March 2010

To those who are just now joining this blog, I want to say a big “Thank you.” The Well Run Dry is a blog that deals with declines in the energy available to modern industrial society, the environmental destruction caused by this society, and its resulting economic contraction. It is partly a discussion of problems caused by energy decline, environmental degradation and economic collapse. It is also partly a calling-out of some of the rich and powerful people responsible for making our predicament worse than it need be. And it is partly a diary – how one man (me) wakes up to our situation and searches for strategies for coping with all of it. Hopefully in thinking of strategies I can come up with things that help all of you.

Normally, I try to post each weekend (Saturdays preferably, though sometimes I get a post in on a Friday night and sometimes I am delayed until Sunday afternoons). There are also times when I am able to publish two posts per week. This weekend I participated in a tree-planting organized by Friends of Trees, a Portland environmental nonprofit organization. Having recently purchased a very cool “hybrid” camera (one that records both high quality still images and high quality videos), I shot some videos of the tree planting, as well as short interviews with some of the staff. This weekend's post would have featured those videos, as well as a brief explanation of Friends of Trees and the impact of their efforts on building resilient neighborhoods.

Unfortunately, when I tried to upload the videos to Youtube, my computer kept disconnecting from the Web (and the upload process seemed to take forever), so I never completed this weekend's post. I am now looking into other video hosting sites like Vimeo or the Internet Archive. Hopefully, sometime before my next birthday I'll have those videos up on the Web. ;) I've also got to learn how to turn my videos into a more polished production... Meanwhile, if you want to see some other videos I recently shot, look up the “Portland Fix-It Fair” on Youtube. The Fix-It Fair is an annual series of workshops hosted by the City of Portland to promote resilient, sustainable neighborhoods.

I also have more interviews for you all to enjoy. One interview I did last week dealt with urban farming; I'll try to have the transcript up shortly. And I'll be writing a “diary” entry about coping with slow times at my company, and thoughts on appropriate strategies for people dealing with continued underemployment. Stay tuned...

A Safety Net Of Alternative Systems - Providing Community Doctors

Medical care in the United States is insanely expensive. According to several sources, medical bankruptcies account for 60 percent of all personal bankruptcies in America (even though most of those driven into medical bankruptcy have insurance). Moreover, American health care is very technology and drug-driven. This is by design, as American health care has become a capitalist growth “industry” whose masters demand continually increasing profits every quarter. As the global economy continues to shrink, and as the economy of the U.S. in particular continues its collapse, an increasing number of people and communities are being cut off from standard American health care. This trend will only worsen as the industrial economy continues to contract due to the depletion of natural resources such as oil.

Today's post consists of a transcript of a recording I made a couple of weeks ago of an interview with Rachel True, MPH, Academic Program Director for the Medical Education Cooperation With Cuba organization, also known as MEDICC. We discussed the work of the Latin American School of Medicine (ELAM in Spanish) in training primary health care physicians to labor in poor countries and communities, and how disadvantaged American communities could benefit from the initiatives of ELAM. ELAM is now offering scholarships to students from disadvantaged communities in the U.S., for the purpose of training these students as doctors, with the condition that these newly trained doctors be willing to go back to their home communities to help their neighbors. ELAM is a Cuban school which trains Cuban doctors – doctors who have earned a very high reputation for competence and skill. ELAM is therefore an important avenue for communities in the U.S. who want to build their own health care systems.

In the following transcript, my questions and comments are in bold type. If you wan to listen to the interview, you can find it here: “Internet Archive: Free Download: Interview with Rachel True of MEDICC”.

Rachel, what I'd like to ask first is the history and motivation behind the setting up of ELAM. Why did Cuba decide to set up this school? What are their goals? What are they accomplishing?

Cuba has had a very long history of international cooperation in the area of health and human resources for health. For many years they have sent their own trained doctors abroad to countries, mostly in Latin America, but also in Africa and other parts of the world, where they have collaborative and cooperative agreements in solidarity with those countries as they work toward addressing health disparities and the inequities in their own health systems, and addressing the shortage of health care workers in their own countries.

ELAM began as a response to the hurricanes Mitch and George, which devastated much of Central America in the late 1990's. As is often the case, Cuba sent a large number of doctors to the affected areas to address the disaster-related health care concerns of affected communities. Many of those doctors came back from those areas feeling that they had done the best they could, but knowing that when they left, there was no one to take over. They had been manning health posts in remote communities and marginalized areas in Central America where there was no doctor when they arrived and no doctor to take over when they left. So they brought that message back to the leadership in Cuba, saying, “We really need to develop a more sustainable response...we need to bring these countries further along in addressing the shortage of their own health care workers.” So the Cuban government decided to open ELAM as a school to train students from those countries, from Latin America and Africa and Asia to become the kinds of doctors that are needed to work in these remote areas.

The curriculum is offered for free. It is a six-year curriculum. They recruit from marginalized and poor communities with the understanding that those are the students most likely to return to the communities where they're needed most. The curriculum focuses heavily on primary health care, public health and prevention, which have been shown to have the largest impact, especially in communities with large infectious disease burdens.

Regarding primary health care, how does the training of Cuban general practitioners compare and contrast with the training of U.S. general practitioners?

I think that the training offered at ELAM is scientifically very similar to the training offered at U.S medical schools. However, at ELAM, family medicine, which is their basic primary care discipline, is offered as a seven-week block – or rotation – in five of the six years of medical school at ELAM. In the U.S., it is not nearly as well emphasized or encouraged. So in the U.S. the system tends to incentivize sub-specialty and specialized care, and the discipline of family medicine is actually having a very difficult time filling residency slots. I believe last year only 42 percent of residency positions for family medicine were filled by U.S. graduates. The remainder were filled by doctors of osteopathy and by international medical graduates.

So there's a real difference between the two countries in the way primary care is seen and prioritized and encouraged as a prestigious and worthwhile career path. I think that also, integrated into the Cuban model of care and medical education is the idea of prevention and public health. In the United States, clinical medicine and public health are very different disciplines, and there are only a few medical schools that I'm aware of that are trying to bring those two together. In Cuba, it's seamless, it's one and the same; you can't be a doctor without understanding epidemiology and population-based health, or without really understanding and promoting the basic ideas of preventative health.

It sounds like the Cuban system focuses on preventing problems from arising, as much as possible, and the American system focuses on fixing problems after they happen.

Correct. I think that's a pretty good summary. And I think that some of that's out of necessity; I mean, Cuba has very few resources compared with the U.S., and they have decided to put a lot of their resources toward preventative health so that they don't have the exorbitant costs that go with trying to treat things they can't afford to treat at a complicated stage.

That brings up the doctors' response to disasters. I know that Cuban doctors have been very much in the news because of the response of Cuba to the recent earthquake in Haiti. From what I'm reading, it seems that Cuban doctors are extremely well-versed and capable in dealing with disaster medicine. Is that true and is that an emphasis?

Yes, it certainly is true. Disaster medicine is taken very seriously in Cuba; and the Henry Reeve Brigade, which has been around for many years, is a group of first responders from Cuba that have responded to many high-profile disasters. With many of these disasters, especially in Haiti, they [the Brigade] were able to hook up with a large group of Cuban doctors that were already on the ground and who had been working within the public health care infrastructure that already existed. They were thus able to hit the ground running; there wasn't a lot of start-up time, and they already knew the community and knew what was really needed most. They were able to triage well, right off the bat.

It seems that Cuban doctors are able to do a lot with a little. How much do they rely on expensive tests and equipment compared to doctors in the United States?

Very little. I can tell the story from the perspective of a medical student since that's who I have the most contact with at ELAM and in the Cuban medical education system. Students are very regularly asked to make a differential diagnosis based largely on history and physical. They do a much longer and more thorough history and physical than they would do here in the United States, and they are able to make a diagnosis and do testing just to confirm their diagnosis. So they would use radiological or blood testing just to confirm their diagnosis.

When students round with attending physicians in Cuba, they'll be asked to present patients of theirs, and to describe their history and physical work-up – what they did – and then will be asked how they arrived at their diagnoses, as well as the tests they ran to confirm the diagnosis. Then the professors will often ask students, “Now what would you do if you were in a rural village in West Africa? How would you then treat your patients? How would you diagnose them and confirm the diagnosis?” So they're constantly being asked to think about how to best use the resources available to them in Cuba, and then to take it a step further and think, “Now how would you do that if you were in a really remote place?” That's really useful for students who are planning to go back to such places. It's also useful for U.S. students who are planning to come back here and practice in underserved areas, because many of their patients won't have insurance, and won't have ways to pay for diagnostic testing – and they may have to take that into consideration. Others will want to do international work where that may be a consideration.

That leads me to ELAM and its outreach to other countries. How is ELAM funded, since the school is free?

It's a decision that was made by the Cuban government to put resources into this program. Like all things in Cuba, it's funded by the government. Therefore, it's funded in part by the Cuban people. The Cuban people are really proud of this program. They're excited about it and feel that it's the right thing to do.

So the Cubans take pride in exporting this knowledge to the rest of the world?

Yes, that's a nice way to put it.

As far as the outreach to the U.S. students, you mentioned that it was free – I like that price! What are the requirements for U.S. students who want to go? Let's say that someone from an underserved or disadvantaged community in the United States was interested in being a doctor, or someone reached out to them and told them that there was this option; what would be the requirements and what would they have to do to qualify?

The prerequisites are that you have to have at least one year of college-level biology, chemistry, organic chemistry, and physics, which is the basic requirement for medical school here. Many students at ELAM have done an undergraduate degree; it's not a requirement, but you do have to have at least one year of those basic science courses. You have to be under 30 years old. That's a requirement that the Cuban government has, which I think is aimed at trying to get people who will have the longest possible impact in their career.

The way a person would apply is by going through another organization based here in the United States, which has been involved since the very beginning of the ELAM project in terms of the U.S. students. That organization is IFCO – Pastors for Peace. They would go to their [IFCO's] website which is www.ifconews.org, and they could download applications there and get in touch with IFCO personnel to answer any questions and start the interview process.

MEDICC, the organization I work for, is also very much involved, but we're involved on the other end in terms of trying to make sure students have all the resources they need to re-enter the U.S. medical system after they graduate successfully. So we work with students as soon as they get to ELAM to connect them to mentor physicians in the U.S. We have a fellowship program that helps to defray the costs of their board exams, which are a requirement if you want to do a residency in the United States. For this, they need to pass a series of three exams, two of which cost about $750.00. The third costs nearly $1300.00. That can be a real barrier to students who are coming to medical school in Cuba largely because they can't afford the application process or tuition for medical schools in the United States. We have a set of programs to help make sure these students are getting the right support and resources they need in order to be competitive candidates for residency programs and get into the communities they want to work in and really start practicing.

As far as student satisfaction with the program, are U.S. students generally highly satisfied, moderately satisfied, really gung-ho? What's their reaction once they get through it?

I think the students are very excited about their education, and feel that they've gotten an excellent medical education. There is an attrition rate similar to that of U.S. medical schools; there are some students that get there and find that it's not quite for them, and that tends to be in the first one or two years. By the time they're into their more clinical years, which are years three through six, they're really excited, and they've settled in and they feel that it's an excellent opportunity and they have received an excellent education. And like you said, the price is right!

Oh yes, if I was under thirty, I'd be signing up right now! As far as student experiences after graduation, I know that ELAM really prefers that students from disadvantaged communities make a commitment to return to those communities after graduation. What is the general experience of a graduate after returning to the United States?

The first cohort of U.S. students graduated in 2007, and all residency programs are three years long. So we haven't actually seen graduates finish residency and enter practice. The lag is too long, so far. So it's going to take a little while to get enough numbers built up to see how effective this is in terms of being a model and pipeline for disadvantaged and under-represented students to go to medical school for free, as well as whether or not the alleviation of that debt burden [from attending U.S. medical schools] and the elimination of those financial and cultural barriers really are effective in leading toward a high rate of service in underserved communities. I think it will be successful, largely because these students have self-selected to participate in a program that is very geared toward the idea of committing to social service, an ideal that is reinforced throughout their education. The debt burden is really a motivator. People say that family medicine isn't a viable career path because you only make $150,000 a year. But to these students, that is a huge amount of money, and it would be a very comfortable life to live in their communities and do the work they want to do, and have the kind of impact they're looking for.

It seems that if a disadvantaged community in the United States were motivated and aware and doing research on options for taking care of themselves in a time of economic contraction and difficulty, such as this time, what they would be looking at in terms of providing primary health care would involve a long-term commitment...

Right. If they wanted to send one or two of their best and brightest to Cuba, they would be looking at a return ten years down the line. Those students would go through a six year program, then they would need to return to the United States and do a three year residency, and then be able to come back and really practice in their community. But it is an investment that has the potential to pay off in a very deep and sustainable way.

Have communities contacted you in the United States and said, “We want to put some of our students through this program?”

They haven't contacted MEDICC, because, like I said, we're not really involved in the recruitment and application process. They may have done that with IFCO. And I know that many students are supported by their churches – you know, you do need a little bit of money to pay for the plane travel back and forth if you want to come home for the summer, and like I said, there are the exam costs. So there are some incidental expenses that come up. I know that many students are supported by their community-based organizations or religious organizations. So I think there are people making that kind of commitment and investment.

Are there tutoring programs to help U.S. students to get the requisite first-year chemistry and physics requirements down?

You know, I don't know that there is a pipeline program just to get students ready to go to ELAM in particular. There are many pipeline programs to encourage under-represented minority students and students from low-income communities to get into the health profession. MEDICC is beginning to work with these programs and to explore ways that those programs and ELAM can be mutually beneficial and can learn from each other. So I think that's a great idea; I don't know that it's being done yet.

My last question is this: are there any passport or visa or legal issues that students need to know about before they get involved in a program like this?

No. Students who are enrolled in ELAM are able to travel legally and to be in Cuba legally – both from the U.S. and from the Cuban perspective. They get visas to study in Cuba, and they are able to travel freely and legally.

I've been talking with Rachel True of the Medical Education Cooperation with Cuba organization, which partners with the Latin American School of Medicine, known as ELAM. Thank you.

[Note: in the immediate aftermath of Hurricane Katrina, Cuba offered to send over 1500 doctors to New Orleans, along with badly-needed medical supplies. The United States Government under President George W. Bush refused the offer, along with an initial refusal of an offer of aid from France. Instead, the residents of New Orleans were treated to a round of infectious diseases. As President Bush said, “Heckuva job, Brownie!”]