By Cindy Loose
Sunday, July 23, 2006; W12
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."
HOW BADLY DOES MELISSA MITCHELL WANT TO BE A DOCTOR? 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 scholarship.
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 scholarships.
MELISSA WAS 7 WHEN SHE DECIDED TO BECOME A DOCTOR. At 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 notion."
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 disillusionment.
"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?"
MELISSA AND THE STUDENTS WITH WHOM SHE'D BE SPENDING THE NEXT SIX YEARS BOARDED A PLANE IN NEW YORK FOR 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 differences.
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."
A SERIES OF GRACEFUL, SPANISH-STYLE BUILDINGS WITH 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 shellshocked.
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 fall.
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.
THE OLD MAN'S EYES LIGHT UP WHEN MELISSA ENTERS HIS 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 says.
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 broadcast.
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 washingtonpost.com/liveonline.