MD Pipeline to Community Service—One Student’s Dream

Fourth-year medical student Sarah Hernandez’s ultimate goal is to serve as a family physician in her hometown in Sacramento, California. Re-opening a medical clinic at a neighborhood center— where she and her family have volunteered and received services from—is her dream.  The eldest of three children from a single-parent household, she learned early in life the values of giving back to the community. 

Sarah explained, “I have committed to working in solidarity to create sustainable systems and programs tailored to heal damage suffered from environmental, social, political, and economic health determinants in my community, or wherever there is a need for my services.  I believe that health is a human-right to a harmonious well-being (spiritually, biologically, psychologically, and sociologically) that is achieved on a personal and community level.”

A full scholarship to the Latin American Medical School (ELAM) in Havana offered Sarah a path to becoming a physician.  As a non-traditional medical student, she may not have had this opportunity to train as a doctor.  At ELAM she is receiving a medical education that emphasizes integration of clinical knowledge and skills with public health.  However, Sarah and other US ELAM graduates face formidable obstacles returning home, including their status as foreign medical graduates, extreme financial burdens, and unfamiliarity with residency placement procedures and the workings of fragmented US health care delivery.

Through MEDICC’s MD Pipeline to Community Service program, she has received support in the form of mentors, fellowships for medical exam preparatory courses, and summer placements in US medical facilities.  Through a Kaiser Permanente Community Benefit grant, Sarah and 14 other US ELAM students were matched with healthcare sites throughout Northern California in the summer of 2012 to gain critical US clinical experience. At her observership at Kaiser Permanente San Francisco, she spent a month in rotations, shadowing physicians, practicing note taking and presenting, and working through the differences between the Cuban and US healthcare system, such as style of oral presentations and electronic records systems.

Sarah remarked, “There are a lot of things to learn, but it pushes me to work harder and find those niches where I can apply my excellent Cuban medical education with my US clinical training…exposure to a US clinical setting is essential to my training and possible residency placements.”

MEDICC’s investment in medical students such as Sarah will result in a more diverse physician workforce better equipped to meet the needs of underserved communities around the country.  The social commitment; cultural competency; bilingual fluency; and orientation towards preventive, primary and community health care offered by this outstanding group of young physicians-in-training are precisely the attributes needed to tackle the nation’s profound healthcare and health equity challenges.

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Making the Rounds: Hôpital Universitaire de la Paix

By Conner Gorry in Haiti

It’s not even 7:30 and already it’s hot and close as we board the bus for the circuitous, rubble-pocked ride to Hôpital Universitaire de la Paix. As the crow flies, it’s probably less than a mile from our tent camp to Port-au-Prince’s university teaching hospital, but weaving between vendors and tents pitched in the street, and then caught behind a tractor or backhoe, means it takes almost an hour to get to the front gate.

Canadian surgeon Dr Arthur Porte explains surgical techniques to Dr Valverde (ELAM) and Haitian medical student Xavier Kernizan.

I’m traveling with the Cuban medical team that will staff the ER for the next 24 hours, relieving other members of the Henry Reeve Contingent. My fellow passengers include nurses, lab technicians, family physicians and a few other specialists, like Dr Douglas

Valverde, an energetic orthopedic surgical resident who received his training at Cuba’s Latin American Medical School (ELAM). Costa Rican by birth, Dr Valverde is one of the more than 700 ELAM-trained health professionals making up the Cuban-led international team.

Haitians of all ages are waiting their turn at medical tents pitched in the courtyard when we arrive. Things are fairly well organized, which is a dramatic improvement over the situation in the days following January 12. Hôpital Universitaire de la Paix was at or near capacity when the earthquake struck; it was quickly overwhelmed as the tremors subsided and new patients made their way in droves to the facility.

“The courtyard was filled with wounded people. To cross it we had to step over and around them saying ‘excuse me, excuse me, excuse me’ the whole time,” Dr Wilsos Canton, a Haitian graduate of the ELAM told me. “The building was in decent condition, but there was no light and no water. We delivered babies using the lights on our cell phones. There were patients everywhere,” he tells me in that stoic, but compassionate way Haitians have. This image of the aftermath settles over our conversation.

In the Post Op, Post-Quake

I’m sure what I’ll see today at Hôpital de la Paix won’t compare to those first days and even weeks after the earthquake. Still, coming into the post operative ward where orthopedic resident Dr Valverde and  Cuban colleagues Dr Mariela Rodríguez and Dr Rafael Roque visit with patients, I’m rocked back on my heels.

Dr Rafael Roque of Havana cleans one of many wounds during his shift at the Hopital Universitaire de la Paix.

The heat in the 14-bed unit hovers over amputees of all ages, some moaning in what I imagine is pain mixed with frustration (and undoubtedly fear). This guttural chorus is joined by a clutch of women in the center of the room chanting and undulating, lost in energetic prayer. Daughters, girlfriends, nephews and neighbors wave kerchiefs and swaths of cardboard over their loved ones to keep the flies away. A piercing odor of human waste permeates the scene as an older woman, both legs cut off at the knee, talks to herself in a loud, stricken voice.

The first bed is occupied by one of Dr Valverde’s patients: a beautiful 18-year old who was hit by a car several days ago and presented with a broken femur. Although some of the 84 members of the Henry Reeve team working at this hospital speak Creole, Dr Valverde enlists translating help from one of the women who comes to pray for patients in this hospital several times a week. “She’s in pain and wants to know when you’ll operate,” the woman translates for us. Dr Valverde explains that they can’t operate until her femur is correctly re-aligned, something that without the proper traction equipment, will take a week—or more. The girl lets out a loud wail when this news is translated. Dr Valverde looks at me with wrinkled brow: “We rigged up this manual weight with a cinder block to help the healing process, but she’s obviously in a lot of pain.” He shifts her body a bit and adjusts the height of the block, asking via the translator if that felt better. It did.

We pass along the other beds, occupied by soft-eyed gentlemen

Surgeon Mariela Rodriguez of Holguín lends a hand in the Universitaire de la Paix ER.

paralyzed the instant their houses fell on them in the quake, and young laborers hit by trucks in the disorder that has gripped the Haitian capital since January 12. Trailing behind the trio of surgeons, I learn about complications seen in their daily work here, including infections, phantom limbs (patients feeling pain in their amputated limbs) and depression. Shortages of even basic supplies, despite international donations that continue to roll in, are also a challenge.

A Haitian surgeon and nurse team consults with Dr Rodríguez about another case. Once they’re out of ear shot, I ask about her experience as a female surgeon in this very masculine of settings. She tells me about her two years working in Cap-Haïtien in Cuba’s Comprehensive Health Program—the international program which has bolstered public health systems around the world since 1998, including Haiti’s.

“The hospital I worked in was founded in 1812. In nearly 200 years, I was the first female surgeon they’d ever had,” she explains to me in the laidback manner common to Cubans from the eastern provinces. “It wasn’t a problem that I was a woman, but I had to prove myself in the operating room. Once I did, we got busy.”

Emergency Room Snapshot

With the morning hours dwindling, Rodríguez, Roque, and Valverde shift their attention from the post-op recovery rooms to the hospital’s emergency area. They join colleagues from Nicaragua, Panama, and Cuba’s Villa Clara and Pinar del Río provinces, (all Henry Reeve members), to attend arrivals in the partially screened area with four metal beds. Haitian nurses and medical students lend a hand translating, among their other duties.

There is a steady stream of patients. As in most emergency rooms, (especially post-disaster in the Global South), most patients are extremely sick, including some who won’t see tomorrow. This is the prognosis for the emaciated anemic grandfather and the young woman in a pretty pink dress who has had a high fever for two weeks. Malaria will soon consume her. It’s not only the severity of the conditions these doctors see day after day that is disconcerting; it’s that many of them are preventable. That anguish is written on Dr Adac Mendoza’s face, the ELAM doctor attending the young woman.

Dr Adac Mendoza (ELAM) attends a young patient in the emergency "room" of Hopital Universitaire de la Paix

Accident victims and chronic disease are common in this ER, and between stitching a child’s split chin and taking the blood pressure of Haitian matrons, the doctors treat the aftershocks of natural disaster. A barefoot young boy hops over to the doctors with a badly infected wound on his left calf. Tears stream down his face as the gash is cleaned of dirt, stones, unidentifiable objects (glass? bread crusts? I can’t tell and neither can the attending physician), and finally necrotic tissue. He’s given a shot of antibiotics and told to come back in the evening for another injection, though the doctors admit they probably won’t see him again: transport is too scarce and life too precarious here in post-quake Haiti for many patients to pursue follow-up. Just then, an 18-year old girl staggers in and collapses on one of the metal beds. “She tried to poison herself,” her escort tells me in English. When I ask why, his response is as disturbing as it is vague: “she was sad.”

Improving Health is Collaborative

Like in all disaster response efforts, medical teams from around the world collaborate both formally and informally in Haiti. I’m not surprised then as a blond-haired, blue-eyed woman in hospital scrubs turns up in the emergency area asking to consult on a patient with Dr Valverde. Janice Centurione is a physiotherapist from St Joseph’s Hospital in Ontario, Canada. ‘St Jo’s’, she tells me, has been “sister hospitals” with the Hôpital de la Paix for the past 20 years in a pairing intended to “train Haitians to offer a standard of care.” This extends to specialty services and after examining Janice’s patient, Dr Valverde consults with Dr Arthur Porte, an orthopedic surgeon also from St Jo’s.

“This is my third time in Haiti, but I have no previous disaster response experience, so I was reluctant to come at first,” Dr Porte tells me while looking at an X-ray of the chronically dislocated finger he is about to correct surgically. Dr Valverde, Dr Porte, and Xavier Kernizan, a sixth-year medical student training in Haiti , discuss the incisions to be made and the aluminum finger splint they’ll use to immobilize it following surgery. It’s fascinating to watch the three—from different countries and cultures—collaborate.

“The circumstances are so difficult here in Haiti. Normally I can’t do the operation you’re proposing because we don’t have that type of splint,” Kernizan says to the Canadian surgeon. “Sure you can,” offers Dr Valverde. “You can use anything—sticks, tongue depressors, whatever—to immobilize it.” Dr Porte (who brought the splints, along with other higher-tech tools and materials from Canada) concurs. A Canadian OR nurse enters the anteroom, cutting the conversation short: “We’re ready to go doctor.” And with that, the trio vanishes into the operating theater.

Douglas Valverde prepares to operate.

Following the quick, successful surgery, Dr Valverde tells me: “Working with the international teams here is a great learning experience. I can bounce ideas off the surgeons and they explain their techniques.” Heading back to the ER, Dr Valverde has a near skip in his step. “I love waking up and going to work in the morning.”

We’re met by a boy needing many stitches, including a severed vein that needs sewing, and Dr Valverde sets to work. Night is already falling, but the patients keep coming. “Another one?!” he asks when a young boy hops into the ER. But it’s his young patient from earlier with the infected wound, returning for his second antibiotic shot. The young surgeon compliments the boy for coming back as he finishes mending the vein of his current patient. “This was my most satisfying work in Haiti to date.”

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An Ounce of Prevention: Port-au-Prince Vaccination Campaign

By Conner Gorry in Haiti

At the beginning we were vaccinating around 250 people a day, but it´s tapered off to 70 or so,¨ Raysoly Yacob Flores, a Salvadoran nurse trained in Cuba tells me as we set out for the displaced persons camp where the Henry Reeve Contingent will vaccinate all comers. I´ll admit I´m slightly disappointed that I´m catching the tail end of the action. I´ve heard a lot about the massive vaccinations carried out by the Cubans and their ELAM-trained colleagues in the weeks immediately following the earthquake, when multiple teams fanned out through the sprawling encampments that hundreds of thousands of Haitians now call ¨home.¨

But my disappointment is premature: instead of tagging along with Raysoly or the other team to areas where vaccinations have already been initiated, I´m accompanying Cuban nurse (and head of the Port-au-Prince vaccination effort) Esmeris Atiñol to a camp where no one has yet been vaccinated. It should be interesting to watch the team inaugurate a new location. A recent report filed on the blog Haiti: Operational Biosurveillance by Dr James Wilson describes health actions, including vaccinations, at a displaced persons camp in Petionville: ¨when word spread about sore arms and the occasional post-vaccination fever, very few showed up for the 2nd day of vaccinations. Red Cross left the area, leaving a best estimate of only 20 percent of the population vaccinated.¨ Given the limited experience many Haitians have with health care in general and vaccinations specifically, I´m especially anxious to see the community´s reaction to this basic preventative health measure.

Delmas 15 (as it´s called by the Cubans) is formally known as La Place Dame Carrefour Aeroport in the post-quake language of Port-au-Prince. It´s a postage stamp plaza at the city´s major intersection of Rte de Delmas and Blvd T. Louverture where 1,060 people live in donated tents pitched on bare, blazing hot concrete.

Before we´re even beyond the first line of dust-covered tents, nurse Esmeris is chatting up mothers in lyrical Creole, asking if they´ve been vaccinated. Though she hails from the remote Cuban municipality of Tercer Frente in Santiago de Cuba, Esmeris´ forebearers were Haitian and she has been working in Haiti as part of Cuba´s Integral Health Program for the past year. She traverses the divide between Spanish and Creole easily and I can see the relief etched on the mothers´ faces as they converse in their native tongue. They follow this Cuban nurse to the vaccination post eagerly, small children in tow.

¨Post¨ is an exaggeration. Each time the Henry Reeve Contingent initiates vaccinations in a new location, they have to find an accessible (and hopefully shady/rain-proof) location to set up. Luckily, La Place Dame is anchored by a pastel-colored gazebo that overlooks the fenced in camp. The columns are cracked and crumbling from the quake, the rebar laid bare like an open wound, but no matter: its visibility and staircases at either end provide natural patient flow, plus it´s refreshingly sun-free. From nowhere, a pair of clean cut youths, badges of the camp’s organizing committee dangling from their necks, appear carrying two chairs – each with three legs. Seems everything in Haiti these days is a balancing act.  Once a table materializes (again I’m amazed at Haitian solidarity – that people so destitute and physically and emotionally battered still have the energy to share both among themselves and with us), the team is set to go to work.

The Henry Reeve Disaster Medicine Contingent currently offers three vaccines: a trivalent DPT (diphtheria, petrussis, and tetanus) for babies one-and-a-half months to eight months old; a DPT/measles/mumps combination, paired with Retinol (Vitamin A) for children nine months to seven years old; and a diphtheria-tetanus duo for everyone eight and over. Once again, the supplies used by the Cuban team represent a kaleidoscope of international health cooperation with vaccines from India, Canada and the WHO Essential Medicines Program; disposable syringes from the United Arab Emirates; and nifty collapsible biohazard safety boxes from Finland.

Conducting an effective vaccination campaign in conditions like those in post-quake Haiti is extraordinarily complex. There are issues related to the vaccines themselves (primarily the maintenance of the cold chain and safe disposal of hazardous biowaste), but also to the particular health culture and context of the host country. And Haiti is as intricate and layered as they come. Fortunately, scores of Cuban health professionals – doctors, nurses, specialists, and technicians – in Port-au-Prince have been serving in Haiti for a year or more as part of Cuba’s Comprehensive Health Program. Veterans on these shores, they exhibit a rare affinity for this astonishingly foreign culture. Importantly, nurse Esmeris and several of her colleagues working on the capital’s vaccination campaign were posted in Gonaïves before the earthquake. There, they vaccinated over 40,000 people between October and January 12, meeting the country’s obligation made to the Pan American Health Organization as part of the national immunization program.

Given all this back story, I shouldn’t be surprised when the trickle of people to be vaccinated turns into a stream and eventually a torrent of the Place de Dame community. A teacher lines up her grade-school class for the free vaccines (school still hasn’t started, but this camp is well organized, with young people especially assuming whatever responsibilities required, like this teacher caring for her out-of-school students), and there are grannies and well-dressed men too – even the camp tough guys are rolling up their sleeves, anticipating the jab with a squint and a smile.

But it’s the work of Elvire Constant that really ratchets up the work flow.

Elvire Constant

Once she happens on the scene, people start arriving in droves, from other camps and the street even, belying Raysoly’s 70 or so prediction. A strong, wiry woman with the intricate braids favored by many Haitian women, Elvire is president of the organizing committee of a nearby camp where the Cuban teams previously worked. “Thanks to her, we vaccinated that entire camp,” Esmeris tells me. I can see why there has been such great acceptance: Elvire arrives, picks up a bullhorn, presses ‘talk’ and begins singing in a lovely, lilting Creole about the ‘free vaccinations, available here all morning, given by Cuban doctors.’  She threads her way between tents and out to the street calling vendors, office workers, and passers-by to get vaccinated, like some muezzin of better health.

Each person receives a yellow vaccination card with the seal of the Haitian Ministry of Public Health indicating their name, age, and vaccine administered (and schedule of additional shots in the case of DPT). Everything is in Creole and explained by the Cubans with the help of Haitian volunteers who lend a hand wherever the medical teams are found. Today, Jackson Pierre Louis and Gladimir Alexime, members of the Place de Dame camp organizing committee, appear unsolicited to help fill out the yellow cards and explain the procedure. Given the language barrier and the novelty of the vaccination concept (several people from Place de Dame line up for a second vaccination for example), I ask Esmeris how the program is administered. “We keep detailed records of where we’ve been and how many people of each age group we’ve vaccinated. In two months’ time, we’ll re-visit each area to administer second doses for those requiring them. After that the Haitian health system provides the booster shots.” I raise an eyebrow at this last part, given that the public health system is in such disarray. She tells me that´s the ideal. Still, there is hope: the Haitian government and the Bolivarian Alliance for the People of the Americas (ALBA) presented a plan for reconstructing the Haitian health system to the World Health Organization last week. In today´s Haiti, it´s imperative that such ideals get translated into realities.

Nurse Lucia Zapata vaccinating at Place de Dame

In the meantime, the work of the Cuban teams takes on increasing urgency as the rainy season approaches, says Dr Jorge Pérez, Director of the hospital at Cuba´s Pedro Kourí Institute for Tropical Medicine, Cuba´s reference center for infectious diseases. In Haiti to conduct an epidemiological assessment, Dr Pérez told me vaccination, health promotion and prevention are the most important tasks right now. ¨It´s important to be vigilant. The epidemiological picture is going to get much more complicated when the rains come.¨

With this in mind, the Cuban health professionals, accompanied by graduates of the Latin American Medical School, and innumerable Haitian volunteers, continue their massive vaccination efforts in post-quake Haiti. And Raysoly´s estimate? That day in Place de Dame, the Cuban team vaccinated over 400 people. And the folks keep on coming: Esmeris just visited my tent to report that they broke a record in another camp where the teams are working. ¨We vaccinated over 500 people in Delmas 83 today. We worked from 9 to 2 and had to ask people to come back tomorrow.¨

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From Emergency to Building Health:Hundreds of Cuban-Trained MDs Posted Throughout Haiti

By Conner Gorry in Haiti

The commitment to Haitian health care made by graduates of Havana’s Latin American Medical School (ELAM) after the January 12th earthquake entered a second phase today as more than 250 doctors fanned out to take up their new posts at health centers and hospitals around the country. These Cuban-trained doctors–joining the Cuban medical teams in Haiti–hail form over 25 countries in Africa, North and South America, the Middle East and Asia.

The new assignments for these ELAM grads marks the formal transition from the emergency medical phase of the Cuban-led effort–addressing immediate problems such as wounds, burns and acute respiratory infections–to the next, more sustainable phase of providing long-term health care. The young doctors are being folded into Cuban health teams that have been working in the Haitian public health system without interruption since 1999.

Doctors from Uruguay, Cuba, Colombia, and Brazil - part of the Henry Reeve Emergency contingent.

Each ELAM doctor has chosen to stay in Haiti from 3 months to a year. “I’ve committed to 6 months, but I really want to stay a year,” says Dr. Sindy Gómez from El Salvador (ELAM 2008), “After that,” she told me, “I’ll discuss the possibility with my husband of staying longer. The Haitian people need us.” ELAM doctors from Colombia, Panama and Brazil echoed Dr. Gómez’s sentiments–all the more noteworthy, since many of these young physicians come from low-income families that depend on them.

“All of them were motivated and willing to stay,” said Eladio Balcarcel, Cuban coordinator of the ELAM graduates in Haiti. “Some are now going to more remote communities, but the conditions will be better. Living in tent camps for a couple of months is tolerable, but it’s not sustainable over the long term,” he explained in the midst of the sendoff.  In their new posts, the doctors will be living in houses with electricity and water, and working in health centers and hospitals providing primary care services.

Cuban medical educators are evaluating the possibility that these graduates might carry out part of their residencies in family medicine during their service in Haiti, under the tutelage of Cuban professors. This approach isn’t new: many Guatemalan ELAM graduates working back home are completing family medicine and other specialties under Cuban professors posted in their country. But Haiti’s complex post-disaster context presents new challenges to considering such an option.

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