Remarks at the Latin American School of Medicine

Dr Margaret Chan
Director-General of the World Health Organization

Remarks at the Latin American School of Medicine
Havana, Cuba

27 October 2009

Honourable ministers, medical students, present and future colleagues in public health, ladies and gentlemen,

It is a fascinating experience for me, as the head of an international agency, to come to the island of Cuba to address a truly international audience. I understand that Cuba’s Latin American School of Medicine has students from around 30 different nations.

You are receiving a privileged medical education because you come from underprivileged backgrounds and are personally committed to serving underprivileged communities.

I know of no other medical school that offers students so much, at no charge. I know of no other medical school with an admissions policy that gives first priority to candidates who come from poor communities and know, first-hand, what it means to live without access to essential medical care.

For once, if you are poor, female, or from an indigenous population you have a distinct advantage. This is an institutional ethic that makes this medical school unique.

You are also privileged because the curriculum and methods of problem-based, hands-on learning are uniquely equipping you to meet the real challenges of medical practice in the 21st century. The greatest challenge today is not keeping up with the latest techniques using the latest high-tech equipment and procedures. Instead, the greatest challenge is to get essential care to the underserved.

Fairness in health care matters, in life-and-death ways. No one should be denied access to life-saving interventions for unfair reasons, including those with economic or social causes.

And yet the inverse care law, first put forward in 1971, still prevails. The availability of good medical care tends to vary inversely with the need for it in the population served. In other words, the best care goes to the people whose health is already good. We know this is true. With your backgrounds, you have probably seen this nearly every day.

You are a large group of students in a large medical school. But this school is not just turning out thousands of graduates to meet the critical shortage of health care workers, though this is important. Instead, you are being trained to correct an imbalance in the way medical care is distributed. You are being trained to return the practice of medicine to the basic values of people-centred, compassionate care, guided by need, and not by the patient’s ability to pay.

You are being trained in family medicine to deliver primary health care. In many parts of the world, these are disciplines of medicine that have begun to disappear. As a recent editorial in the New England Journal of Medicine noted, primary health care brings huge personal rewards, but less financial gain than work in a specialized branch of medicine.

You are being trained to spot community-wide threats to health linked to living or working conditions, or lifestyles and behaviours, or what people eat, drink, or think. You are being trained to be engaged members of the communities you serve, and not just doctors in white jackets waiting for the problems to show up, preferably by appointment, in your offices.

You will complete your studies well-versed in preventive medicine, equipped with a range of life-saving clinical skills, and able to provide high-quality care in resource-poor settings.

In short, you are being trained in the skills needed to help the underprivileged enjoy good health as a basic human right. You are being trained to serve as a permanent resource for health, and not just part of an emergency team that comes in when disaster strikes.

This is a very welcome trend in capacity building. It is part of Cuba’s long-standing policy of international medical outreach as foreign diplomacy. It is taking the concept of health diplomacy to new levels.

Ladies and gentlemen,

Primary health care is the right way forward, and not just for poor and underprivileged communities. Last year’s report of the Commission on Social Determinants of Health concluded that health systems organized to achieve universal coverage do the most to improve health outcomes.

The Commission endorsed primary health care as a model for a system that deliberately aims for equity, but also acts on the underlying social, economic, and political causes of ill health.

WHO is currently leading a drive to renew the values, principles, and approaches of primary health care. Cuba has long been a centre of excellence for primary health care. Cuba provides solid evidence that factors other than national wealth can produce health outcomes that rival that in the richest nations.

When you begin to practice the many skills you have learned, I have two pieces of advice. First, remain true to the principles and values of your training, that is, the principles and values of primary health care. Second, pay attention to what is happening at the international level.

More and more, health the world over is being shaped by the same powerful global forces. As the economists tell us, the financial crisis has had such a far-reaching impact because it comes at a time of radically increased interdependence among nations. This interdependence also affects health. Too often, health pays the price for bad policies made in other sectors.

Collectively, we have failed to give the systems that govern international relations a moral dimension. The values and concerns of society rarely shape the way these international systems operate. If businesses, like the pharmaceutical industry, are driven by the need to make a profit, how can we expect them to invest in R&D for diseases of the poor, who have no purchasing power?

The international systems that govern economies, financial markets, international trade, and foreign policy rarely make equity an explicit policy goal. In a sense the Millennium Development Goals are a corrective strategy. They aim to compensate for policies and systems that create benefits, but have no rules that guarantee the fair distribution of these benefits.

Too many models for development assumed that living conditions and health status would somehow automatically improve as countries modernized, liberalized their trade, and experienced rapid economic growth. This did not happen. Instead, differences, within and between countries, in income levels, in opportunities, and in health status, are greater today than at any time in recent history.

Around the world, nearly 1 billion people live on the margins of survival. It does not take much to push them over the brink: a fuel crisis, a food crisis, a financial crisis, a changing climate, or an influenza pandemic.

More and more, the crises delivered by our imperfect world are global in their impact, though the consequences are profoundly unfair. Developing countries have the greatest vulnerability and the least resilience. They are hardest hit and take the longest to recover.

In my view, the net result of all our international polices should be to improve the quality of life for as many of the world’s people as possible. Greater equity in the health status of populations, within and among countries, should be regarded as a key measure of how we, as a civilised society, are making progress.

Needless to say, I am honoured to address you, as an international group of very privileged medical students. You are being trained, with noble motives, for a noble vocation, returning to your disadvantaged origins with numerous advantages, as you work for better health.

I wish you every success.

Cuba’s investment in your training is a statement of commitment to greater equity in health, and this, too, earns my full respect.

Thank you.