MR FEATURES

Profiles in Commitment:
Conversations with ELAM Students

By MEDICC Review Staff

In South Africa, there are 25 doctors for every 100,000 people. In the United States, while there may be 279 doctors for every 100,000 inhabitants, there are also 45 million - one in every six people - without any health insurance. Africa suffers from ‘brain drain,’ sucking homegrown doctors to richer, industrialized markets, and much of Central America threatens to buckle under poverty that makes medical school prohibitively expensive.

Confronting these inequities is precisely why the Latin American Medical School ( ELAM; Escuela Latinoamericana de Ciencias Médicas) was founded. By extending medical school scholarships to students from 27 countries who likely otherwise wouldn’t become doctors, Cuba, and the nations represented at the school, aim to provide health care to some of the world’s neediest communities.

No one is better equipped to talk about the commitment and vision of Cuba’s international medical education program than its students, past and present. What follows are excerpts from interviews with current and recently-graduated ELAM students, wherein they discuss their lives and individual experiences at the school.

Sarpoma Sefa-Boakye is a first generation American, one of three children of immigrant parents from Ghana who moved to Los Angeles several years before she was born. She’s in her third year of medical school.

Why did you decide to become a doctor?

I would say my first experience in Africa when I was 9...I saw kids suffering from beri-beri, their stomachs distended...I had never seen [that] in the U.S. , and I said “What’s going on?” My parents said “you eat everyday but they don’t.” And I couldn’t understand...so I secretly put my clothes inside a (back)pack, and one day there were some kids on the street, kids who had walked from Eastern Ethiopia…It was during the time of the famine over there, and they were all going to Ghana and living in the streets. And I went and gave my clothes and toys to the kids on the street, and I talked to my mother, and I said “Mommy I want to do this every day in my life, I want to give every day of my life, that’s what I want to do…”

When I came back to the U.S. I thought, ‘well, I’m gonna be a doctor.’ But the interesting thing is that I was nine and I didn’t realize that that happens in Africa, but it also happens in Los Angeles - I mean kids with no food. They were talking about a case of beri-beri in Los Angeles, kids with distended bellies because of malnutrition; asthma because of roaches. All these different things going on, so I thought my fight was in Africa, but without realizing it, it’s not only Africa. These rich countries that we’re living in, you know they have these Third World countries within…And that kind of reinstated my desire to make this a lifelong commitment.

What’s different about Cuban medicine from your experience in the States? What do you notice first off?

[Cuban doctors] are very open to what the patients say. The patients say “I’m depressed because x, y and z.” They’re really taught to become doctors...they integrate everything, and so they are physicians, but also psychologists and lawyers…and they really know how to talk, to understand and to listen. And so, we’re really taught how to listen to the patient, to really get to what they want to say.

What about living with students from other countries? What’s that like?

Oh, it has actually been good! Here you learn something every day. You learn that we’re more alike than different. I don’t know how else I could have ever had this experience. I wake up in the morning and I can hear Portuguese, I hear Garifuna, I hear indigenous languages that could have been lost...but that are here. It’s such a beautiful thing, it’s almost like an encyclopedia…What are the Andes Mountains like? I can just go out and ask a student. There’s so much culture here.

Nontembeko, second from left, and fellow South African students at Villa Clara’s medical school, Cuba.

Dr. Nontembeko Sweetness Kunene is from a small town in the Eastern Cape, South Africa, has just graduated after completing her sixth year of medical school at Walter Sisulu University ( formerly UNITRA), as part of the scholarship program that took her to Cuba for her first five years of training. We spoke with her just before she returned home to complete her final year internship.

When you go back to South Africa, do you have any obligations to do any service because you went to school in Cuba?

Oh yes. We have to work for our government for the same amount of time that we’ve been training, which is like five years. We signed a contract with the South African government that we are chosen as students from disadvantaged areas who are willing to work anywhere in South Africa where we are most needed. It’s all about serving the communities. We agreed that we’d do that, [under] whatever conditions...

Being a doctor is not just a profession, it’s a calling...It’s like being a Reverend, you go to where the people need you the most...You have to make sure that [medicine] gets to everyone who needs it. And that is what we have in our minds - medicine and health care and health services for all South Africans.

What do you think is the most important thing you’ve learned studying in Cuba?

When I saw the way Cuba is structured. Their health system and their emphasis on primary health care in all areas...they actually attack the problem before it becomes bigger for them to handle. [In] the South African health system, we tend to attend more to sick patients, to patients who are at different stages of the disease’s development than to attack it at the core, at the base of the problem before it gets to be a problem. Like infectious diseases: if you were to attend to them before they become a bigger problem, before we have a magnitude of people with the same type of infections with parasites and infectious diseases of the lungs or respiratory or digestive [systems], a lot can be done. Simple measures can be done to stop that.

How would you compare medical schools in South Africa to here? What’s the difference in how you’re getting educated?

Here in Cuba, if you are a student having a certain problem, the lecturer will actually tell you “I think you are a good student.” “You‘re doing better,” or “I think you’re having problems, would you like me to help out?” You get to relate more to your lecturers...they’ve more time to help you out [and] if they need more time to help you understand, they will give that time to you. But they will not compromise on good results and things done properly.

I think [the training here] is very good because there are no limits - you get exposed to almost everything, and you do hands on. Like we have done in the hospital today. You are shown patients. You get to see for yourself. ‘This is what you have learnt in the book. This is what we’re talking about. This is how you should treat it. This is how you should relate to a patient.’ You get trained on how to do that. You get to see more and you get to be more confident about what you are doing.

One problem in South Africa is that lots of doctors and nurses leave. They get recruited from other countries or companies which lure them with the opportunity to make a lot of money. Do you think that could ever change?

If we bring more health to the communities, [it] could make ourselves feel more attached to our communities. The more attached we are to our communities, the less we are going to be attracted by all these packages from outside…once we have a connection to our communities, that will overcome the migration of our professionals out of the country to other parts of the world because there’s nothing like being home.

Dr. Luther Castillo is a Garifuna from a small community in the Mosquitia region of Honduras. He is the second oldest of eight children and had to overcome many obstacles (including walking six hours roundtrip to high school), to make it here, as a doctor and ELAM graduate.

Why did you want to become a doctor?

I was searching for an opportunity to study, to prepare myself for life...There’s only one medical school in Honduras and that’s in the capital. So you have to emigrate to Tegucigalpa, and there you have to pay for food and housing and that’s nothing compared to the books. It’s very expensive, you know? So I tried; I did it for one semester, but the cost of anatomy books alone was around 5000 pesos and my monthly income was around 600 pesos, so I had to quit studying.

For me, the idea of studying medicine was closely linked to the situation I saw in my community…some doctors came to other neighboring communities to do their social service. And I noticed some contradictions between these doctors and the people in the communities. Historically, the people in the communities were used to traditional medicine, herbs and such...and the way these doctors approached them - simply saying that what they had been doing for years was wrong or that they were ignorant and what they needed were antibiotics or another drug. And I believed that my efforts could be more helpful since I understood the history, the ideology, the philosophic and moral values of these communities. I thought that I could reach a better understanding of the health problems there and that this could serve the process of the communities’ development, that the doctor could play an important role in the communities.

What are the main health problems in your community?

The main health problems are parasites, malnutrition, acute respiratory infections or diarrhea, seen more frequently in children. Now AIDS is heavily attacking our region. That’s one problem that is not much publicized, but it is also a serious problem in our communities because of some customs that must be tackled.

What services existed in your community for people who needed medical attention?

At that time, [the late 80s], there was no health care center in my community. There was another community close by - four hours away on foot - where there was a religious order of nuns who weren’t doctors…they sold medicines, and they could suture wounds and things like that. So if someone had an accident or was ill, he was carried on a hammock - that was the ambulance service - and taken there on foot, walking four hours until they reached that point where the sisters could at least mitigate the problem, maybe care for a wound, give them some medicine...some people died on their way to that place because it took so long to get there. Now some things have changed. Now there’s a hospital where Cuban doctors work, about 2-1/2 hours from the community; on weekends, the Cuban doctors visit peoples’ homes, and now we have a Cuban doctor in the community who is living in my house (laughing). He is living there and that’s very important for the community.

How do your people see Cuban medicine?

They see it as excellent medicine...the Cuban doctors’ service in these communities has been transcendental...The challenge is for us to offer something comparatively new or better. People have great expectations, they expect us to be like the Cuban doctors, to help them like the Cuban doctors, to have the same training they had but also to take social factors into account, to have the conscience - the human factor - that is so characteristic of the Cuban medicine in which we are being trained.

When I went back on vacation, someone told me “I’m 75 years old and I had never been treated by a doctor without showing disgust for me.” They use this term “disgust” to refer to a kind of rejection, you understand? And he said “No one had ever examined me with such delicacy, sitting by my side, holding my hand…”

In the summer of 2003, 497 Honduran ELAM students worked almost their entire vacation with the team of Cuban doctors in the country, fighting a dengue epidemic. Luther shared this story about the experience:

We were in the Alonso Suazo clinic, where hundreds of mothers brought their children suffering from dengue, some of them already showing signs of hemorrhage, children bleeding…We were classifying the patients in A, B or C according to how serious their condition was, so the doctors knew who to see first because there were so many people…This mother came with her two children and one of them was bleeding, so we took him to the doctor right away. The doctor said the child needed a blood test urgently and sent the mother upstairs with the order. When the woman got there, they told her she had to pay 30 lempiras for the test and she didn’t have the money, so she left with her two children. We were waiting for her in the emergency room and noticed that 10 minutes had passed, and the blood test should have taken 3 or 4 minutes at most. When we went to look for her, the woman was like three blocks away already, taking her child back home because she couldn’t afford the blood test. Our students collected the money among themselves and paid for the test.

That kind of thing made an impact on people. That, and the humane treatment given to patients in the emergency ward, 50 to 80 people there. The presence of a student wearing a white coat with the human quality of our students was important for the mothers psychologically. Our students brought their own thermometers to take the patients’ temperatures and see who needed help first. All this work and the dedication of our students day and night in the struggle against dengue was a great experience for us and besides, it came from real commitment.

Evelyn Erickson, 4th year, is a Dominican-American whose family moved to the Washington Heights area of New York City when she was 11. In addition to a Bachelor’s Degree in Biological Sciences, she holds a Master’s Degree in Education.

Why Cuba?

I think first of all, it was feeling like it was a good match. I had visited the country and felt a connection to it - ever since I came here. But I think it was the feeling that I would come to a place where I would have academic support; that was important for me. I think in the United States, I didn’t feel like that in most of my classes - simply being a woman of color as a biology major. It was quite a struggle to graduate.

In my class, there were several of us, and very few of us graduated, especially in the sciences. So it was the feeling that I would have support here. And it was also about the reputation Cuba has in its health care system, how the health care system works here, how medicine is seen more as a right than a privilege and that the patient is seen kind of more holistically...the doctors here try to be more holistic in the way they see the patient. And there’s more inclusion of alternative medicine. It is just more integrated; it was something I thought I could apply more to the doctor I would want to be in the future.

Have you gotten the academic support you thought you needed?

Absolutely. Here, if you have a question you can go to people. I feel like people here want you to succeed, whereas in the States, I felt people were trying to weed me out so that I wouldn’t make it. I had several encounters with professors that were very discouraging. So that kind of everyday help on a daily basis - I am thankful that I am here. My professor is excellent in the clinical aspect of the career, which is the most exciting part of it. We get to see patients and we apply what we’ve learned in the last three years. So my professor is excellent. She prepares us well, and so I feel I am learning a lot.

And something else: I thought if I came here I would be well prepared, especially thinking about the board exams and the MLE exams. And I am not the best test-taker in the world. I know that these kind of exams are very rigorous. So I knew that if I came here, there would be a support group to help us with the step one exam, that I would get that personalized attention. And that has been great.

What are the needs in your community back home?

There are so many. I think there’s a need, definitely, for more doctors of color, for doctors that can be more culturally sensitive. In my community [ Washington Heights], a lot of people don’t go to the doctor because they don’t feel comfortable…Sometimes they know English, sometimes they don’t, sometimes they cannot find someone to translate for them. Sometimes they cannot miss work. Sometimes it is a situation that even if they can communicate in the language to the doctor, the doctor isn’t culturally sensitive. And if you say, ‘Well, I had a little tea to make this…’ And they say, ‘tea, no; this is what you need to take,’ and they don’t understand they need to work with the patient, with their values. And I think that makes a lot of people not want to go to the doctor.

I know for me, education has always been important, so I think part of the thing I have always wanted to do is to open up schools to young people to have access to science, to have access to medicine.

I remember as a young person of color, it was really difficult. My high school didn’t even have a chemistry department, and so when I went to college I didn’t even have chemistry. And it was so easy at times to just say, ‘I’m going to give up. Forget this, I will major in something else.’ And I didn’t because it was important to look at the long-term goal. And I was lucky that I had people that supported me along the way. But I think it is important to develop ways to educate so that students can say, ‘yes, I can do this.’ So that if you see more doctors like you, maybe you’ll consider being a doctor. If you see more teachers like you, you’ll probably consider being a teacher or learning becomes more acceptable to you.

Wendy Pérez is a 4th year Garifuna student from Limon, Honduras. She is the oldest of five children, raised by a single mother.

What are the most important things you have learned in Cuba?

More than anything, we have learned to be students of science and conscience, to become doctors that are both scientists and conscientious. We are learning to serve people, as it should be, to treat people because of who they are - not because of what they have. We are being trained in the principles of solidarity. We are learning from the Cuban people’s charisma. We’re grateful, and our people are already grateful too. You hear people thanking Cuba for the opportunity it has given us; if this opportunity hadn’t arisen, I wouldn’t be studying medicine. I would have been working during the day as I did before and studying at night.

How did your family react?

At the time [my mother] was the only breadwinner of the household and she told me not to think twice about it, that I should go, that they would make any sacrifice to be able to send me a little something, because it was a once in a lifetime opportunity. She told me that in Honduras I would never be able to study medicine because it demanded full-time study and a lot of money for books and everything…And I feel good because I know that the final result will be great for our people.

What do the clinical years of your studies look like?

I’m in Calixto Garcia Hospital, learning very much, in contact with patients, learning more about diseases because it’s not only theory but also practice. You go to operating rooms, to the wards, there you receive your lessons, you get to know the illnesses. It’s not only the books anymore, it’s reality. Your knowledge is deeper because you’re in touch with reality, not only with theory. And we feel satisfied because the professors give us the attention we need, they know us well, if we have any difficulties they come and ask what’s happening, if we have academic problems, they solve our doubts so that we can do better.

How do patients react when they see a Honduran student treating them?

When the patients ask, I tell them I’m from Honduras and they show surprise but react very well and collaborate with me. And I ask them to help me learn because I want to learn from them, and the relationship is always excellent.