Resilience, Healthcare and Cooperation

Here is a link to a post I did over five years ago concerning the Cuban health care system and the ways in which it is both different from and better than the U.S. health care system.  That post also contains an audio interview I conducted with Rachel True, who is a member of the staff at MEDICC, a health care education cooperative group which has partnered with Cuba to train doctors for the developing world and for underserved communities in the United States.  In that interview we discuss the Latin American School of Medicine, a medical school founded by the Cuban government under Fidel Castro to provide free medical education to prospective students from poor countries and communities who would not be able to afford tuition at medical schools in developed countries such as the U.S.

The Cuban medical system is a prime example of the good that can arise in a society that is founded on cooperation and collaboration and not on ruthless Calvinist cut-throat competition.  For that reason, such an arrangement is not likely to arise in mainstream Anglo-American society unless that society undergoes a radical change.  Until then, we in the U.S. will have to content ourselves with window-shopping (or, for the richest among us, with medical tourism.)

The Breakup of Pathological Spaces

To summarize last week's post, present-day American narcissism stands on the following legs:

• A 1700-year legacy of the preaching of national exceptionalism in Europe by state churches who tried to justify the disconnect between the words of the New Testament and the actions of the states in which these churches were embedded.

• Exceptionalism “taken to the next level” through Calvinism: first, the belief that some people were predestined from before the womb to eternal salvation, and others predestined from before the womb to eternal damnation, this election being completely independent of the choice of any of those so predestined. Second, the belief that all that happens in the world happens because God has willed it; therefore, all that happens must have been approved by God. This morphed into “social Calvinism”: the belief that the sign that one was a member of God's elect was material prosperity and success in earthly business, the belief that those who were not successful or who were poor were so because they were not of God's elect but were under God's curse, and the belief that whatever “God's elect” got away with doing to the rest of the people in the world was approved by God and a sign of His “Providence.”

As I said in last week's post, this is the foundation of American narcissism, the belief that this nation is above all nations in that it has a special mission from God (a mission which conveniently lines up with American imperial ambitions), that Americans (specifically, white Americans) are a special, chosen people, and the belief that both Scripture, Providence and nature bear this out.

The effect that such beliefs, combined with a long string of seeming “successes” has had on the Anglo-American psyche is that this has become the unconscious foundation of national identity and the unconscious justification of white privilege. Americans know they are special just because they are. Therefore many of them have begun to compete with each other to see who is most “special.” (“Mirror, mirror, on the wall...”)

Today's post will consider the environment which narcissists create for themselves and in which they operate. That environment is the narcissist's Pathological Space: “the network of relationships in their home, extended families, workplace, and neighborhood.” (Krajco, 2004-2007). Its purpose is to feed the narcissist by providing victims and mirrors who reflect back the narcissist's grandiose self. Garden-variety narcissists don't care about anything outside their pathological space, even though they know that there is a world full of people who live outside that space. Therefore they don't trouble themselves with that outside world unless someone mentions it to them, in which case they disparage the outside world and turn back to contemplating their own glory. Within the pathological space, everyone else is either a victim or a mirror. A person can choose to be a victim or a mirror, although sometimes mirrors are turned into victims apart from their own choice.

A mirror is an adoring lackey or sycophant, who always gives the right answer when asked the All-Important Question: “Mirror, mirror on the wall, who's the fairest one of all?” A victim is anyone who contradicts the narcissist. Contradicting is extremely easy to do. You can give the wrong answer to the All-Important Question – first, by pointing out someone (other than the narcissist) whom you admire or look up to, second, by being someone of obviously praiseworthy virtue or competence yourself, or third, simply by being obviously different in any way from the narcissist – especially if your “difference” makes you “vulnerable” in the narcissist's eyes.

So what happens to you if you contradict or refuse to validate the grandiose self constructed by a narcissist? You become the target of attack while you are in the narcissist's pathological space. The attack is designed to destroy you, for a contradiction to the narcissist's grandiose self must not be allowed to survive, as the contradiction is an existential threat to the narcissist's identity. If you fight back or defend yourself, you simply provoke a drastic multiplication of the narcissist's rage – he has to be right and victorious, or his grandiose self will suffer an intolerable injury. Therefore, it will be a no-holds-barred, knock-down and drag-out fight from his point of view. Even if you win a round, you'll have to be forever on your guard, because the narcissist will never quit – even if at times he seems to surrender. The only way to rid yourself of the narcissist is to cut off all contact with him, and that introduces an entirely different set of dynamics and risks into the situation.

What happens when a narcissist or narcissistic nation manages to turn the world into a Pathological Space? I think when that happens, you get the sort of foreign policy which the United States has enacted from the late 1800's until now (with more than a little help from England, another nation ruled by narcissists). The war against “contradictions” has involved the following nations:

• Haiti, a former slave colony which obtained its independence by revolting from France in 1804. In the aftermath of the revolution, the United States sided with France in trying to economically isolate Haiti in order to destroy its self-determination and its government. France imposed a fine on Haiti in order to recoup the losses to its earning power resulting from the loss of its African slaves in Haiti, and the United States assisted France in its economic punishment of Haiti. Moreover, the United States has invaded the country numerous times during the 20th and 21st centuries. (For an example, see this.)

• The Philippines during the Filipino-American War, where the United States inflicted casualties to the tune of at least 220,000 and possibly over 300,000 people, according to some historians.

• The Dominican Republic, which was invaded four times by the United States from 1900 to 1965.

• Vietnam, whose citizens fought a war of independence against France from 1946 to 1954. The French had become involved at the behest of the British government after World War 2. During that war, the United States supported the French with arms, intelligence, and funding. However, the French lost the war. Once the French were kicked out of the country, the United States brokered a partition of the country into North and South Vietnam. When the South Vietnamese government proved itself to be inept and corrupt, the Vietnamese people began fighting to overthrow it, thus triggering the American involvement of the 1960's and early 1970's which ended when Nixon negotiated a “peace with honor” that enabled America to walk away without having to admit defeat.

• The sabotaging of the attempts of Central and South American nations to escape from “banana republic” status (note the overthrow of Salvador Allende , the Iran-Contra Affair, the 2009 coup in Honduras (a contributing factor in the current child refugee crisis on the southern border of the United States), and other meddlings).

• Both Gulf Wars, ISIS, Syria, and Afghanistan, where American intervention has caused from 1,200,000 to possibly 2,000,000 (yes, that's two million) civilian deaths so far, according to several sources (such as this one);

• And many, many more!

In People of the Lie, M. Scott Peck wrote a chapter on the Vietnam War titled, “My Lai: An Examination of Group Evil,” in which he states that we fought so hard to conquer that country because psychologically we just had to be right, even though the facts on the ground contradicted us. We would rather have destroyed the contradiction entirely than admit that we had been wrong. Our zeal in fighting therefore shows our narcissism. It can be argued that this nation has never truly backed down from a war which it has started as an attempt to conquer a nation whose citizens plainly showed that they did not want to be ruled by the United States. After the U.S. was forced militarily out of Indochina, it used economic policies to enforce a partial subjugation of the region. And the U.S. has never truly left Iraq.

When the “good angels” in a narcissist's pathological space get together to compare notes, often the result is an exodus of people from the pathological space. Many writers describe this as “going No Contact (NC)” with the narcissist. Narcissists are enraged by contradiction, but they are made desperate by No Contact. Under No Contact, people who were mirrors to the narcissist, or who were used as sources of supply by the narcissist, are no longer there to reflect the narcissist's glory or power or influence back to him. Without such people, the narcissist faces an existential crisis even worse than the crisis provoked when he is contradicted by someone, for under No Contact, the narcissist sees his former victims and mirrors living meaningful lives completely independent of him, and he sees that his formerly grandiose self can no longer have any effect on them. This is the ultimate contradiction of his Grandiose Self.

Over the last thirteen to fifteen years, other nations have begun to go No Contact with the U.S. The diminishing of contact has taken place in the economic arena, as nations have sought to build trade agreements with each other independently from the United States, and to move away from the dollar as the world's reserve currency. This move was provoked initially by the American use of sanctions to subjugate Iraq after the first Gulf War. This move has accelerated in response to the unilateral American military and economic acts of aggression which have taken place since 2001. This move has not been without risk, as Saddam Hussein and Muammar Gaddafi found out. Nevertheless, in spite of economic and military warfare waged by the United States, the U.S. dollar as a percentage of all foreign exchange holdings droppped from 55 percent in 2001 to 33 percent in 2013.  Further, new bilateral and multilateral trade agreements and trade zones continue to be enacted throughout the world, independently of the United States, which is not being invited to enter these agreements. American attempts to wreck foreign economies through sanctions are backfiring, as targeted nations are learning that one can indeed survive without the U.S. dollar.

I think it's safe to say that we are witnessing the emergence of a new world order, but not one that is pleasing to the United States. What is emerging is a multipolar world, in which everyone must be polite, wait his or her turn, and say “Please” and “Thank you,” and in which no one nation will get to enjoy outlandishly “special” prerogatives or privileges over any other nation. The holders of concentrated privilege and power in the United States fear and hate the emergence of such a world, but increasingly, there doesn't seem to be a thing they can do to stop it. The long-term response of the United States to that emergence is likely to be some form of “decompensation.” That “decompensation” will be in part comically stupid, and in part dangerously ugly in many parts of this country, and in many sectors of American society. I'll talk about that in a future post.

A last note: when narcissists lose most of their current sources of supply, one sign of their resulting desperation is that they go back to former sources of supply and try to re-establish relationships with these people, in the hope of rebuilding a pathological space of mirrors and victims. Going back to former sources is called “hoovering” by many writers. As I think about hoovering, I think about the recent news that the United States is seeking to normalize relations with Cuba. Cuba – a nation which was ostracized by the United States over a span of 55 years – from the overthrow of the Batista regime until now. Cuba – a nation which has discovered that it is possible to live a meaningful and worthy life independent of the United States. Cuba – a nation which is now famous for having a first-rate medical system and which exports medical expertise and medical technology to the rest of the world. Cuba – a nation which is only 90 miles away from the American coastline. Cuba – a nation now being “hoovered”?  ¡Ten cuidado, Raul Castro!

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!”]

Primary Health Care in the U.S. and Partnership With the Latin American School of Medicine (ELAM) - An Interview with MEDICC

This week, President Obama is hosting a “health care summit” with leaders of the Republican Party in order to facilitate passage of a national health care plan. The President's proposals are basically a copy of the Senate health reform bill recently passed. That bill would require all Americans to purchase a health insurance policy, with the Federal Government providing subsidies for people with low incomes to purchase health insurance. However, the bill would do nothing to rein in health care costs arising from explosive growth of health insurance fees, as well as excessive growth in pharmaceutical and medical technology costs. This is not surprising, as the fundamental problem with health care in the U.S. is that it is a for-profit “industry,” and the leaders of this industry seek continual profit growth. These leaders are controlling the present health care “debate” in this country.

However, there are resources for implementing alternative models of health care for communities in the U.S. that are interested in setting up their own systems of effective, truly affordable care. One such resource is the medical outreach program of the Latin American School of Medicine (ELAM) in Cuba. ELAM is a renowned medical school that produces top-notch doctors skilled in disaster medicine and promotion of community health with limited resources. (In fact, Cuba itself has become a renowned source of medical expertise.) ELAM has an outreach program in which students from disadvantaged countries as well as disadvantaged communities in the U.S. are invited to study medicine at the ELAM campus in Cuba, free of charge. Afterward, these students become board-certified primary care physicians. All that is asked of them in return is that they make a commitment to return to their communities to provide low-cost, high-quality health care to their fellow citizens.

I recently had the privilege of interviewing Rachel True, MPH, Academic Program Director for the Medical Education Cooperation with Cuba (MEDICC), a non-profit organization that facilitates Cuba's medical outreach to other countries. We discussed the work of ELAM, the unique competencies and emphasis of Cuban medicine and the doctors trained at ELAM, and lessons that could be applied to the United States. We also talked about how disadvantaged communities in the United States could sponsor their own young people to become students at ELAM, in order to build a network of primary health care providers in American communities. This is very important for the times we are now facing, in which the profit-driven U.S. model of health care (and education of health care professionals) is becoming ever more unsustainable. ELAM offers an exceptional education free of charge, and produces doctors who can deliver effective health care solutions at low cost.

I was able to save an audio file of my interview, which can be found at http://www.archive.org/details/InterviewWithRachelTrueOfMedicc. It should be accessible to computers running on either Windows or Linux operating systems. I will also be creating a transcript of the interview for a future blog post. And I am planning on interviewing a student who is currently enrolled at ELAM. God willing, I hope to post that interview in the next few weeks. Stay tuned!