Monday, July 24, 2006


American Med Students in Cuba

This is another long one. It’s worth reading, esp. if you happen to be a graduate student accumulating debt. It’s also worth reading if you wonder what is wrong with the medical profession in this country.

The Cuban Solution

Melissa Mitchell wants to be a
doctor to tend to the poor. But the Howard Unversity
undergrad was too poor herself to attend med school.
That's when Cuba's maximum leader offered a helping

By Cindy Loose Sunday, July 23, 2006

A single candle casts a faint but warm light on the
dark wood of a dining room table in Havana. The
neighborhood has been hit with one of the rolling
blackouts that occasionally plague the city, but
Melissa Mitchell and Revery Barnes are determined to
cram all night for their final exam in hematology and
endocrinology anyway.

Revery straps a miner-style flashlight onto her head as
Melissa sets up a battery-operated laptop filled with
notes. They pile heavy medical textbooks on the floor,
pull their chairs close together and prop open one
textbook between them.

Back when Melissa was a premed student at Howard
University, studying in the dark was never an issue.
But this isn't Washington. This is Cuba, where Melissa,
Revery and 95 other Americans are studying medicine in
a country that's been an anathema to the United States
for almost five decades. Thanks to Fidel Castro, their
education is free. But that doesn't mean they aren't
paying a price for turning to Cuba in their quest to
become doctors. They've given up creature comforts most
Americans take for granted, struggled to master
hematology and other complicated subjects in a foreign
language, and have no guarantees they will get a chance
to practice medicine in the United States.

Right now, though, Melissa, 25, and Revery, 26, aren't
thinking about any of that. Melissa, a third-year
student, says she has to do well on this test because
the professor is on her case. Cuban doctors place a
premium on basic skills -- interpreting breath sounds
from a stethoscope, for instance -- that have been
deemphasized in the high-tech world of U.S. medicine.
Not long ago during rounds, Melissa's professor
exploded at her when he asked for a diagnosis of a
patient, and she replied that the lab results weren't
back yet.

"Are you planning to become a doctor or a lab analyst?"
he growled. "Tell me what you heard and felt and saw."

To study for the exam, Melissa and Revery have already
walked a couple of miles from the blackout-darkened
dorms at Salvador Allende Hospital in central Havana to
a Cuban friend's house. They were hoping that this
neighborhood near the famous Malecon would still have
electricity. No such luck.

"I reviewed anemia already," Melissa tells Revery.
"I'll teach you anemia if you do diabetes" with me.
Revery tilts her head low to illuminate a page, and
they get to work.

Within a few hours, their last candle sputters out. The
laptop is already dead. Soon the flashlight batteries
lose strength, dimming the light from bright white to
dingy yellow. Before being plunged into pitch
blackness, the two begin packing up, filling backpacks
with notes and books. The plan: walk back to the dorm
because maybe lights have returned to that part of
town. If not, Melissa's Cuban boyfriend has a
flashlight. They'll walk to his house to borrow it.

"We can't complain," says Melissa, whose almond-shaped
eyes make her look a little like a stylized portrait of
Nefertiti. "We knew what it was going to be like when
we signed up."

Badly enough to learn Spanish and commit to living in
Havana for more than six years -- double the time it
would take her to complete medical school in the United
States. Badly enough to live as Cuban students do, in
cramped dorms without air conditioning, eating rice and
beans and little else. (The simplest things -- a phone
call home, a soda or candy bar, checking e-mail -- are
usually out of reach for students living on a monthly
stipend of about $4.) Badly enough to defy a U.S. ban
on travel to Cuba to be here.

Melissa knew when she accepted Castro's offer of room,
board and tuition that relations between her own
government and her benefactor were antagonistic at
best. Last year she and her American classmates were
ordered home by the Bush administration as part of a
series of moves to tighten the 44-year-old embargo
against Cuba. A few students abandoned their medical
studies and returned to the United States, but most,
including Melissa, stayed. Eventually, the
administration relented and agreed to give the students
temporary travel permits, which will be up for renewal
next year.

The Americans are operating on faith that their Cuban
education will prepare them to pass tough U.S.
licensing exams. Even though their medical studies are
in Spanish, they must pass the exams in English.
Melissa has no idea how she will pay for the exams,
which collectively cost more than $2,000, let alone the
review courses that most students, U.S. and foreign,
routinely take to prepare for them. Most of her
classmates are in the same boat.

She and the others face another, longer-term challenge:
winning admission to a U.S. residency program. Because
the first class of Americans studying in Cuba won't
graduate until next year, no one knows how their
education will be viewed back home. And, of course,
there is no guarantee that, if the aging Castro were to
leave office or die, his successor would agree that the
impoverished island should continue to pay for the
education of students from one of the richest nations
on earth.

Castro offered the medical scholarships six years ago,
after hosting a dinner for visiting members of the
Congressional Black Caucus. Rep. Bennie Thompson
(D-Miss.) remembers sitting with Castro in the summer
of 2000 and being impressed at Castro's command of U.S.
statistics on such things as infant mortality and the
number of medically uninsured. Castro talked about the
thousands of Cuban doctors working in Africa and Latin
America, and about training tens of thousands of
foreign medical students.

Medicine has long been Castro's most effective foreign
policy tool. According to Cuba's foreign ministry, this
year alone Cuba is training 20,000 foreigners to be
doctors, nurses and dentists, most free of charge. More
than 2,500 Cuban doctors are treating earthquake
victims in remote parts of Pakistan. In the past two
years, the ministry says, Cuban specialists have
performed eye surgery on 209,103 foreigners, including
157,000 from Venezuela, whose leftist president has
forged close ties to Castro and sells Cuba cheap oil.

Thompson mentioned that some areas of his district in
northwestern Mississippi were woefully underserved by
doctors, and he remembers Castro saying: "We would love
to help you address some of those inequities. If the
Black Caucus can identify students who are willing to
come and attend medical school, we make that offer free
of charge." Soon afterward, Castro announced he was
offering up to 500 scholarships for American students
who were committed to serving impoverished U.S.
communities but were unable to afford medical school.

From the beginning, the program has faced fierce
opposition in the United States. "There were a lot of
naysayers and critics," acknowledges the Rev. Lucius
Walker Jr., head of the New York-based Pastors for
Peace, which, along with the Interreligious Foundation
for Community Organization, selects students and
administers the program stateside.

While the Cuban foreign ministry praises the
scholarships as an example of Castro's humanitarianism,
his opponents contend that the offer was calculated to
embarrass the United States. "This is pure propaganda,
and the students are Castro's propaganda tools," says
Ninoska Perez-Castello, a South Florida radio
personality and a founder of the Cuba Liberty Council,
an anti-Castro group. "I don't believe in the
generosity of a dictator who crushes the skulls of his
own people."

The Bush administration initially sided with the
critics. But when it demanded that the students return
home last year, the Black Caucus erupted. According to
Walker, Colin Powell quietly persuaded the
administration to back off, at least temporarily. "If
our critics are willing to work with us to get more
financial resources for medical care and training, I'm
willing to listen," says Thompson. "Until then, I will
fight to save this opportunity."

Such opportunities are scarce. Most U.S. medical
students are both white and well-off. Only 6 percent of
students entering medical school in 2000 were from
families earning less than $50,000 a year; only 6
percent of doctors in the United States are black,
Hispanic or Native American, according to a 2004 report
by the Sullivan Commission on Diversity in the
Healthcare Workforce.

The United States once had a successful program similar
to the one being offered by Cuba: The National Health
Service Corps Scholarship Program offered thousands of
Americans free tuition and expenses in return for later
practicing in areas that needed more doctors.
Minorities relied heavily on the program: In 1980, one
of every four black medical students had a corps

But the Reagan administration began slashing the
program each budget year. In 1981, the corps offered
6,159 scholarships. In 1982, the number was cut to
2,449. Last year, the corps awarded 90 new

the time, she was watching a favorite aunt -- the one
everyone said she resembled -- waste away from cancer.
Melissa would sit with her for hours, bringing her
water and food.

"Melissa thought that if she were a doctor she could
have saved her aunt," remembers Melissa's grandmother
Rosetta Hughes. "No one could talk her out of that

At her high school in Houston, Melissa loaded up on as
many science courses as possible. She won a full
scholarship to Howard, where she graduated as a premed
student with a 3.2 grade-point average. She'd saved
$1,600 from a part-time job at Howard to pay for the
Medical College Admission Test and a prep course. The
prep course turned out to be a study in

"They recommended we apply to no less than 14 schools,
and each school application costs at least $200. I'd
just spent two years saving the $1,600, and now I need
another $2,800 just to apply to schools? Then, if
you're lucky and a school calls you, you have to fly
there and stay in a hotel. They even had the finite
details about what to wear, and you'd have to buy a
business suit, and everything was more money and more
money and more money, and even then maybe you wouldn't
get in."

Somehow, she figured, she would find the money, even if
she had to delay going. But she worried that she'd be
left with huge loans, which would make it difficult for
her to afford to practice in a poor neighborhood, as
she'd always planned. Besides, the prep class was "a
reality check about the whole medical school thing."
She hated the feeling of exclusivity, the fact that
most of the other students had at least one parent who
was already a doctor, and the chatter about which
specialties paid the best. "One thing sticks in my
head," Melissa says. "A student mentioned she worked in
a cancer clinic, and someone asked what she did. She
said, 'Oh, I just check them in. I give people hope.'
She said it in this joking, dismissive way. But giving
people hope is a beautiful thing."

After graduation from Howard, Melissa took a job at the
nonprofit Youth Law Center in the District.
Occasionally she'd look up medical schools on the Web,
but everything she saw just discouraged her.

Then, one Sunday morning at Rev. Willie Wilson's Union
Temple Church in Southeast Washington, she saw a blurb
in the church bulletin about scholarships to study
medicine in Cuba. She wrote to the Cuban Interests
Section in Washington, and months later a packet of
information arrived. Her mind was made up the moment
she opened it.

"The brochure wasn't fancy," Melissa recalls, "but it
had a lot of feeling to it. You could tell the
resources were really basic, but even that appealed to
me. It had a picture of an entire class of students
gathered around a microscope. There were pictures of
doctors giving physical exams in houses with dirt
floors, with chickens around them. The imagery called
out to me."

There weren't any tests or expensive prep courses
required, just a $100 application fee. Melissa simply
contacted the program administrators in the United
States. A committee of physicians screens the students.
Those who have the drive and education to succeed are
encouraged to apply, and those who apply are usually
accepted by the Cubans.

Melissa says only two things gave her pause: There was
no hot water in the dorms, and there were no toilet
seats. "I knew I'd get used to not having hot water.
But no toilet seats? How does that work?"

CANCUN, where they stayed the night before flying,
without U.S. permission, into Havana. The weeks before
the flight were crazy with packing and shopping and
saying goodbye. It wasn't until they finally landed in
Cuba and were greeted by officials with mojitos that
Melissa felt herself relaxing.

"Transitioning out was harder than transitioning in,"
she says. "I felt I was moving from a complicated,
high-tech life into something very simple."

She'd seen a video about the Latin American School of
Medicine. The main campus, where she would spend her
first 2 1/2 years, is about a 45-minute drive from
downtown Havana and sits along a sandy white beach
pounded by the Atlantic. A series of two-story
buildings ramble around the property lush with flowers
and trees, but life inside is military style. The
walled compound was a naval base that Castro turned
into a medical school to train students from all over
Latin America. There is a separate medical school for
French-speaking Africans and Haitians.

During the week, Melissa and the other students were
confined to the walled compound, with freedom to leave
between Friday afternoon and Sunday evening only if
they'd followed the rules and done well in their
studies. As an adult, Melissa found it hard to "have
people telling you what you could and couldn't do." But
she didn't mind the confinement during the week: She
needed every moment she had to study. That first
semester, she says, she sometimes spent an hour
stumbling through a single page of Spanish.

Most weekends, she took a break from studying by
finding a quiet spot on the beach, her only real escape
from the cramped, overcrowded dorms. Before arriving in
Cuba, Melissa had talked to people who'd visited Cuba,
"but no one had experienced dorm life, which is extreme
even for Cubans."

Melissa shared a room with 20 other American students:
10 bunk beds less than an arm's length from one
another. A small locker held all her belongings, plus
the belongings of the person in another bunk. She
shared a bathroom -- 10 sinks, 10 showers and 10
toilets, san seats -- with 120 other students. Water
was turned off from 8 or 9 p.m. until 6 a.m. When the
Americans first arrived, there were rumors that their
rooms were better, that they had televisions and even
refrigerators. Then a hurricane hit. Students from
other countries around the world were moved into the
American dorm, and everyone realized there were no

Every month each student was allotted two rolls of
toilet paper, two bars of soap and, for the women, a
pack of sanitary napkins. "Even when you had money,
sometimes the school store didn't have toilet paper to
sell," Melissa says. "If they didn't have it, you
didn't have it." She and Revery laugh when repeating a
running joke in the dorm. Anytime a classmate asked
where some missing item might be, someone invariably
replied, "I used it for toilet paper."

Melissa says food represented the hardest adjustment
that first year -- harder even than the struggle with
Spanish. "When I first got there, it was rice and beans
every day. Then after a while they didn't have beans,
and had soup instead, and I'd be like, I'd just die for
some beans. I'd be hungry before lunch, and walk out of
lunch hungry. But after a while your body gets used to
eating less, and you don't want as much." Even now,
though she sometimes dreams about Einstein bagels.
After finishing her second year of medical school,
Melissa moved to the dorms at Salvador Allende
Hospital, where the food is better. "Every Monday is
chicken Monday. You get a piece of chicken, so that's
always fun."

She and Revery have helped each other through all the
challenges of going to medical school in Cuba. They hit
it off from the moment they met, Melissa says: "Our
visions and goals and personalities are very similar."

Revery is one of the few white Americans in the
program. She says she grew up in a tough neighborhood
in San Francisco, with an absent father and a mother
who, at the time, was too ill to work. Revery dropped
out of school when she was 13, but eventually earned a
GED and got a job with a nonprofit as a street outreach
worker. Often her clients, who included crack addicts
and gang members, needed medical care, but it wasn't
available. So Revery decided she'd offer the care, and
started attending a junior college for the science
courses she'd need to apply to a premed program. She
heard about the medical program in Cuba from one of her
teachers. Like Melissa, she didn't hesitate.

Last summer, Revery and Melissa scraped together the
$678 airfare and $695 to take Step 1 of the U.S.
Medical Licensing Exam. Revery's money came from
activist friends in San Francisco, who took up a
collection on her behalf. Melissa's money came from an
aunt, who later lost her home and everything she owned
in Hurricane Katrina. Neither young woman could afford
the usual prep course. But Revery's sister gave her
$300 to sign up for an online drill program. Revery
offered to share the program with Melissa. They spent
the six-week summer break studying together in
Birmingham, Ala., where they lived with Melissa's
84-year-old grandmother, Rosetta.

Being back in the States was weird, Melissa says. She
found herself amazed by how upset people got in the
airport when a flight was delayed -- the sort of thing
that might have upset her in the past, but now seemed
petty, even funny, in the face of everyday realities in
Havana. Most Americans have no idea how the rest of the
world lives, she says.

Medical school administrators had told Melissa and
Revery they should wait another year to take the test,
arguing that the order of information they were
learning was much different from in the United States.
But the two had worried all year about the test and
were determined to get it under their belts. Neither
passed; Melissa missing by a few points, Revery by a
wider margin.

When Melissa found out she'd failed, she began to cry.
For the first time, she felt despair.

"I just crashed," she says. "I barely wanted to get out
of bed in the morning. I started thinking, 'Why am I
torturing myself? I'm 25 years old. I want to get
married; I want to have kids. I have a degree. Anytime,
I could go home and get a job and live comfortably.'"

After a few weeks, she pulled herself together, she
says, "by reminding myself what needs to change in the
American health care system and why I need to play a
role in that process." While she's reluctant to talk
much about Castro or communism, she does admire Cuba's
stated goal of providing medical care to all of its
citizens. Health care, she says, should be a right, not
a privilege. "If you're not going to give a break to
someone when they're sick, when are you ever going to
give them a break?"

During summers with her grandmother in Alabama, she's
volunteered at a free medical clinic, where she says
there's been real appreciation for the skills she's
learned in Cuba. "I've gotten to know a doctor in
Birmingham who has worked all over the world. He worked
in West Africa on disaster relief, and American doctors
were, like, 'I don't have this, I don't have that,' but
the Cuban doctors just went to work," she says.

The doctor, Tom Ellison, a Birmingham cardiologist and
epidemiologist, says Melissa has the makings of a great
doctor. "On rides on our mobile clinic to an
impoverished rural area outside Birmingham, I saw her
dedication, her work ethic, her rapport with patients,"
Ellison says.

One night he took her to an emergency room where he has
privileges, and an ambulance brought in a man whose eye
was hanging from its socket. "Some of the hospital's
students had to leave the room, but she was right in
there, eager to learn and see," says Ellison. He's
hoping that the hospital officials who've seen Melissa
working from the mobile clinic will offer her a
residency in Alabama. Once she clears that hurdle, he
says, "I'd hire her in a minute."

Melissa, who is scheduled to graduate in the spring of
2009, says it should help that she and her classmates
are "not looking for the prestigious residencies; we
want to do work no one else wants to do.

"Besides," she says, "I believe I was born to do this,
so it will happen."

TILED ROOFS, each circled by wide porches, cluster
around a leafy square on the campus of Salvador Allende
Hospital. It's reminiscent of the European hospitals
shown in old World War II movies, where wounded
American soldiers would convalesce -- and usually fall
in love with a nurse -- before heading home.

Melissa, who has just finished her hematology and
endocrinology exam, emerges from one building looking

She and Revery never did find a flashlight last night:
They went to Melissa's boyfriend's house, but he was
out and had taken the flashlight with him. And she
thinks she blew the test. Part of it required matching
diseases to symptoms, and, although some of the choices
made no sense, she tried to match everything. Only
after class did she realize that not all of the
diseases had a match. The professor had talked so fast
that only the Cubans understood the directions. If
she's failed, she'll get a second chance to retake it.
After that, failure would mean the cancellation of her
summer break -- and repetition of the course in the

Narciso Ortiz, a student from New Jersey who is the
elected head of the American student body, fears he
blew the test as well. But Ortiz is the fixer, the
leader, and he focuses on trying to comfort Melissa.
They also discuss whether she can switch from working
in one ward at Salavador Allende to one headed by a
doctor she particularly likes. Narciso promises to set
up a meeting for her with the hospital administrator.

With eyes bloodshot from lack of sleep, Melissa heads
off to take a shower and then a nap.

ROOM. He lies in a white metal, hand-cranked hospital
bed but struggles to sit when she arrives. She helps
him get upright. He jerks when she puts the cold metal
of her stethoscope against his bare chest. They both
giggle for a minute, then chat as she warms the
stethoscope by rubbing it against her palm before
trying again.

As a third-year student, Melissa is assigned two beds
in this ward, where she works six mornings a week
before attending lectures in the afternoon. Once a
week, she also works an overnight shift at the
emergency room. Sundays are free, except when her
emergency room duties fall on that day. Sometimes,
especially on Saturday mornings, she doesn't feel like
getting up. But always, there are the patients to
inspire her to roll out of bed. "I don't want them
getting bounced around among different people," she

The opportunity to work with patients very early in her
training has been the biggest advantage of studying
medicine in Cuba, Melissa says. Often the equipment
available is basic, but, in some ways, that's an
advantage, too, she says. Sometimes, the only needles
available are the big old-fashioned, reusable kind, and
if you can give a painless injection with those, you
can certainly do it with the thin needles used in the
United States. She's looking forward to "playing with
the high-tech toys" available in the States, but
figures she's better off learning to work without them
for now.

She sweats as she makes her way around the ward, 20
rooms that hold 40 beds in a one-story building. There
is no air conditioning, but it's a graceful old
building with high ceilings and white walls with
decorative tiles stretching waist high. Each room has
two doors, one leading to the central hallway, the
other to the porch that wraps around the building.
Beside each bed is a folding beach chair for visitors.

Melissa has a new patient in the bed next to the old
man. Melissa looks at an X-ray of the patient's lungs.
She notes their elongation. It's a sign, she tells me
later, of emphysema.

Once she finishes examining her patients, she joins the
other medical students for rounds, visiting each room
with a supervising doctor. Melissa presents her new
patient, offering her opinion of what's wrong. The
X-rays are passed around and discussed. It's pretty
much like rounds on every TV hospital drama ever

Before she leaves the ward, Melissa fills out her
patients' charts, then heads outside into the sultry
air. After lunch, there will be hours of lectures, then
hours of study. But it's a Monday. So today, she notes
happily, the cafeteria will be serving chicken.

Cindy Loose is a reporter for The Post's Travel
section. She and Melissa Mitchell will be fielding
questions and comments about this article Monday at
noon at (c) 2006 The
Washington Post Company

Comments: Post a Comment

<< Home

This page is powered by Blogger. Isn't yours?